NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
A client receives morphine sulfate after being admitted to the emergency room in acute respiratory distress. He is very anxious, edematous, and cyanotic. Which of the following should the nurse recognize as the desired response to the medication?
Correct Answer: B
Rationale: morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema
Question 2 of 5
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.
Question 3 of 5
The nurse is caring for a client in a manic phase of bipolar affective disorder. It is MOST important for the nurse to offer which of the following meals?
Correct Answer: A
Rationale: Manic clients need portable, nutritious finger foods due to high energy and distractibility. Tuna salad sandwich and orange slices provide balanced nutrition. Options B, C, and D are less suitable: bologna is processed, milkshakes lack variety, and fried chicken is messy.
Question 4 of 5
The nurse is caring for a client with heart failure.
Correct Answer: A
Rationale: A weight gain of 2 pounds in 24 hours indicates fluid retention, a sign of worsening heart failure. Decreased blood pressure may occur but is less specific, clear lung sounds suggest stability, and improved exercise tolerance indicates improvement.
Question 5 of 5
Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints?
Correct Answer: B
Rationale: assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained