NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings?
Correct Answer: A
Rationale: signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pains, tachycardia, and hypotension
Extract:
An HIV-positive infant to receive an oral polio immunization.
Question 2 of 5
Which of the following nursing actions is MOST appropriate?
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the identified problem of the compromised immune system (2) does not address the identified problem of the compromised immune system (3) correct-polio vaccine contains live virus and should not be given to children who are immunocompromised (4) does not address the identified problem of the compromised immune system
Extract:
Question 3 of 5
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.
Extract:
A client presents with confusion, mood lability, impaired communication, and lethargy.
Question 4 of 5
The nurse should question which of the following orders?
Correct Answer: D
Rationale: Strategy: Think about each Test . (1) may be ordered to determine the presence of major depression (2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made (3) may be ordered to see if the client's symptoms are caused by excessive use of medications or alcohol (4) correct-Test is used with a client who may have varicose veins, no relationship to the symptoms described in this situation
Extract:
Question 5 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 laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.8 mEq/L) is a serious complication of spironolactone, a potassium-sparing diuretic, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.