NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
A 68-year-old man is diagnosed with myasthenia gravis. The nurse instructs the client about his disease. Which of the following statements, if made by the client to the nurse, indicates the need for further teaching?
Correct Answer: D
Rationale: Hot tubs cause heat exposure, which can exacerbate myasthenia gravis symptoms, indicating a need for further teaching. Options A, B, and C are correct: alcohol worsens symptoms, crowds increase infection risk, and stress can trigger exacerbations.
Extract:
A client with a perforated bowel secondary to a bowel obstruction.
Question 2 of 5
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done
Extract:
Question 3 of 5
The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client should be assigned to the nursing assistant?
Correct Answer: B
Rationale: A nursing assistant can provide basic care such as hygiene and vital signs for stable clients. A client with viral pneumonia, if stable, requires less complex care compared to post-surgical , potential emergency , or cardiac clients, which require licensed staff.
Question 4 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
Question 5 of 5
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units at bedtime. Which of the following symptoms should the nurse report immediately?
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin. Options A, C, and D are less urgent.