NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
Question 1 of 5
A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to
Correct Answer: A
Rationale: Notify the primary care provider immediately. The client’s suicidal intent and plan require immediate intervention by the healthcare team.
Question 2 of 5
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
Correct Answer: D
Rationale: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.
Question 3 of 5
The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?
Correct Answer: D
Rationale: The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.
Question 4 of 5
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results should the nurse report immediately?
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) from furosemide increases arrhythmia risk in heart failure. Options B, C, and D are normal.
Question 5 of 5
A 38-year-old woman, mother of two, has a mastectomy for breast cancer.
Correct Answer: B
Rationale: Frequent crying and difficulty coping one month post-mastectomy reflect a normal grieving process for the loss of a body part. Helping family cope is premature, social withdrawal indicates abnormal adjustment, and immediate return to normal activities suggests denial, which is too early for integration.