NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
A 70-year-old man with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question?
Correct Answer: C
Rationale: contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension
Extract:
A client after a bronchoscopy.
Question 2 of 5
The nurse would be MOST concerned if which of the following was observed?
Correct Answer: C
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) would cause a complication if client is given fluids before the gag reflex has returned (2) common for a few days after a biopsy (3) correct-client should be assessed for symptoms of respiratory distress from swelling due to the procedure; signs of respiratory distress include tachypnea, tachycardia, respiratory stridor, and retractions (4) expected after this procedure
Extract:
Question 3 of 5
A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma.
Correct Answer: B
Rationale: Morphine sulfate, a narcotic analgesic, causes CNS and respiratory depression, which is contraindicated in head injuries because it masks signs of increased intracranial pressure, such as altered consciousness or pupil changes. Promethazine is an antiemetic, docusate is a stool softener, and ranitidine prevents stress ulcers, none of which pose the same risk.
Question 4 of 5
A baby girl is born with a meningomyelocele. To prevent trauma to the sac, the nurse should place the infant:
Correct Answer: B
Rationale: Placing the infant prone with hips slightly elevated protects the meningomyelocele sac from trauma and pressure.
Extract:
A client is receiving heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal.
Question 5 of 5
Which of the following actions by the nurse is MOST appropriate?
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer. (1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (3) prothrombin time (PT) Test is useful for assessing warfarin (Coumadin) therapy (4) correct-expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage