NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
Correct Answer: D
Rationale: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse's notes.
Question 2 of 5
The nurse is caring for a client with a history of peptic ulcer disease who is receiving ranitidine (Zantac) 150 mg PO bid. Which of the following symptoms should the nurse report immediately?
Correct Answer: C
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious complication in peptic ulcer disease. Options A, B, and D are less urgent.
Extract:
A 20-year-old woman with a fracture of the left femur is placed in Buck's traction with a 7-lb weight. The patient keeps sliding down in bed.
Question 3 of 5
The nurse should
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not prevent patient from sliding down; may change pull of traction (2) correct-will keep leg straight and counter the pull of the weights (3) will bend the leg and alter the pull of the traction (4) not effective way of preventing the patient from sliding down in bed
Extract:
Question 4 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 5 of 5
A client with MRSA is receiving Vanomycin (Vancocin) IV. If the client experiences 'red man' syndrome, the nurse should:
Correct Answer: A
Rationale: Red man syndrome is caused by rapid vancomycin infusion, leading to histamine release. Slowing the infusion and monitoring blood pressure manage symptoms. It's not normal, and discontinuing is unnecessary.