NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously every 12 hours. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A platelet count of 100,000/mm^3 suggests thrombocytopenia, a serious complication of heparin therapy, increasing bleeding risk and possibly indicating heparin-induced thrombocytopenia. Options B, C, and D are normal or less concerning: INR and PTT are not significantly affected by subcutaneous heparin, and hemoglobin 14 g/dL is normal.
Question 3 of 5
The nurse is caring for a client with a history of peripheral artery disease.
Correct Answer: B
Rationale: Intermittent claudication (leg pain with activity, relieved by rest) is a hallmark of peripheral artery disease due to reduced blood flow. Warm skin and swelling suggest venous issues, and arm numbness is unrelated.
Question 4 of 5
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin detemir (Levemir) 15 units SC daily. Which of the following symptoms should the nurse report immediately?
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin detemir. Options A, C, and D are less urgent: fatigue is nonspecific, thirst is expected, and headache is common.
Question 5 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of nitroglycerin for chest pain. Which of the following findings should the nurse report immediately?
Correct Answer: A
Rationale: Hypotension (100/60 mmHg) is a serious nitroglycerin side effect, risking inadequate perfusion. Options B, C, and D are normal findings.