NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
A client has been receiving chlorpromazine (Thorazine) 400 mg/day for four weeks. He experiences an oral temperature of 105°F (40.5°C), severe rigidity, oculogyric crisis, and severe hypertension. It is MOST important for the nurse to take which of the following actions?
Correct Answer: B
Rationale: Symptoms indicate neuroleptic malignant syndrome, a life-threatening reaction to chlorpromazine. Holding the drug and notifying staff is critical. Options A, C, and D address symptoms but not the cause.
Question 2 of 5
While a client is receiving TPN, it is MOST important for the nurse to monitor
Correct Answer: C
Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.
Question 3 of 5
An adult client who had major abdominal surgery is returned to her room on the surgical nursing unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. She has a nasogastric tube in place that is attached to intermittent suction. How should the nurse position the client?
Correct Answer: B
Rationale: Semi-sitting facilitates breathing, reduces aspiration risk with a nasogastric tube, and promotes comfort post-abdominal surgery. Supine or dorsal recumbent increases aspiration risk, and prone is contraindicated.
Question 4 of 5
The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Chest tube drainage of 150 mL/hour is excessive post-CABG, suggesting hemorrhage, requiring immediate evaluation. Options A, B, and D are less concerning: heart rate 100 bpm and temperature 100.8°F are common, and blood pressure 130/80 mmHg is normal.
Question 5 of 5
The nurse is monitoring the fluid status of a 63-year-old woman receiving IV fluids following surgery.
Correct Answer: B
Rationale: Fluid volume overload is characterized by symptoms such as a bounding pulse, elevated blood pressure, respiratory crackles (due to pulmonary edema), and distended neck veins. Cool skin and respiratory crackles with a bounding pulse are indicative of this condition. The other options suggest dehydration, non-specific symptoms, or normal findings unrelated to fluid overload.