NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
A client arrives at the emergency room with an HR of 120, an RR of 48, and hemoptysis. The nurse should give priority to:
Correct Answer: B
Rationale: Hemoptysis and tachypnea suggest respiratory distress, so oxygen administration is the priority to stabilize the client.
Question 2 of 5
An adolescent is to be admitted to the orthopedic floor with several fractures. The client has been taking hallucinogens this evening. What should the nurse expect on admission because the client is using hallucinogens?
Correct Answer: B
Rationale: Hallucinogens can cause agitation or violent behavior due to altered perceptions, especially in a stressful hospital setting. Depression, respiratory distress, or convulsions are less common.
Question 3 of 5
The nurse is caring for a client with a suspected myocardial infarction. Which of the following actions should the nurse perform FIRST?
Correct Answer: B
Rationale: Applying oxygen is the priority to improve myocardial oxygenation in a suspected myocardial infarction, addressing the immediate threat of hypoxia. Options A, C, and D are important but secondary: aspirin prevents clot progression, ECG confirms diagnosis, and IV access supports medication delivery.
Question 4 of 5
The nurse is caring for a client with a history of schizophrenia.
Correct Answer: B
Rationale: Improved ability to focus on tasks indicates reduced psychotic symptoms and better cognitive function, a positive response to antipsychotics. Withdrawal, hallucinations, and agitation suggest poor response.
Question 5 of 5
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings should the nurse report immediately?
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration. Options A, B, and D are normal.