NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
Question 2 of 5
A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push.
Correct Answer: B
Rationale: Severe hypotension is a serious side effect of procainamide, requiring the dose to be withheld to prevent cardiovascular collapse. PVCs and atrial tachycardia are arrhythmias the drug treats, and a normal sedimentation rate is irrelevant.
Question 3 of 5
A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
Correct Answer: C
Rationale: Playing with cars on the pavement near burning leaves. Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.
Question 4 of 5
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 80 bpm, and urine output 50 mL/hour indicate stability.
Question 5 of 5
The nurse is caring for clients in the prenatal clinic. The nurse would be MOST concerned if a diabetic client in the third trimester makes which of the following statements?
Correct Answer: A
Rationale: Decreased insulin needs in the third trimester suggest placental dysfunction, as placental hormones typically increase insulin resistance. Options B, C, and D are appropriate: bedtime snacks prevent hypoglycemia, exercise after meals manages glucose, and postprandial checks monitor hyperglycemia.