NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
A client hospitalized with acute glomerulonephritis has a positive ASO titer. The nurse understands that the client's current illness is due to a:
Correct Answer: B
Rationale: A positive antistreptolysin titer indicates infection with Group A β-hemolytic Streptococcus, a bacterial infection. Answers A, C, and D are not associated with acute glomerulonephritis so they are incorrect.
Question 2 of 5
Which action is most likely to ensure the safety of the nurse while making a home visit?
Correct Answer: C
Rationale: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee nurses' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards. Observe surroundings when parking, walking to the client's door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.
Question 3 of 5
The nurse is to insert an indwelling catheter in a male. Which action is appropriate?
Correct Answer: B
Rationale: Washing hands before catheter insertion is critical to maintain a sterile field and prevent infection. Cleansing the meatus occurs after hand washing, a 45-degree angle is incorrect (90 degrees is typical), and the balloon is inflated post-insertion.
Question 4 of 5
A fluid challenge of 250 cc of normal saline infused over 15 min is ordered for a client with possible acute renal failure. The nurse understands that the fluid challenge is given to
Correct Answer: A
Rationale: expected response after a fluid challenge on normally functioning kidneys is an increase in urine output; will occur if low urine output is due to dehydration; if it is due to acute renal failure, there will continue to be oliguria
Question 5 of 5
The client with multiple myeloma is admitted and prescribed cyclophosphamide (Cytoxan). During the treatment, the nurse should instruct the client to:
Correct Answer: B
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, so reporting hematuria is critical. Fiber, antacids, and activity are not directly related to this medication's side effects.