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.
Question 2 of 5
The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is
Correct Answer: A
Rationale: You think that someone wants to poison you? This acknowledges the client's perception, opening discussion and expressing doubt.
Question 3 of 5
The nurse is caring for a client who is receiving intravenous fluid therapy. Which observation needs to be reported to the charge nurse?
Correct Answer: D
Rationale: A cool, blanched infusion site suggests infiltration or extravasation, requiring immediate reporting to prevent tissue damage. Cool fluid sensation, tape, or ambulation are normal.
Question 4 of 5
The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:
Correct Answer: B
Rationale: Outcome criteria need to be specific, measurable, and realistic. Talking for 10 minutes meets all of these conditions.
Question 5 of 5
A client receiving Eskalith (lithium carbonate) has a level of 4.5 mEq/L. The nurse should prepare the client for immediate:
Correct Answer: B
Rationale: A lithium level of 4.5 mEq/L indicates severe toxicity, requiring hemodialysis to rapidly remove lithium from the body.