NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
A laboring woman who has dystocia is receiving oxytocin. The nurse observes a contraction lasting 90 seconds. What should the nurse do first?
Correct Answer: D
Rationale: Contractions longer than 60-90 seconds risk fetal hypoxia; stopping oxytocin immediately reduces uterine stimulation, prioritizing fetal safety.
Extract:
A client with dementia.
Question 2 of 5
The nurse knows that which of these plans would be MOST successful in caring for a client with dementia?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unable to learn new skills (2) correct-client with dementia does not have cognitive abilities to learn new skills or to adapt, environment must be adapted for client with attention to safety and predictability (3) requires skills the client with dementia does not have (4) requires skills the client with dementia does not have
Extract:
A client who has clear lung sounds and unlabored breathing is receiving aminophylline IV.
Question 3 of 5
Which of the following would be the MOST appropriate nursing action if the client's IV infiltrates?
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) continued IV medication may not be necessary based on the current assessment (2) physician should be notified if IV medications are not infusing as scheduled (3) client has improved breathing, so IV medications may not be indicated (4) correct-before a new IV is started on this client, physician should be called and PO medications recommended
Extract:
Question 4 of 5
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone.
Correct Answer: B
Rationale: Decreased tissue oxygenation from impaired circulation in hemiparesis is the leading cause of skin breakdown, making this the priority nursing diagnosis. Mobility and immobility are concerns, but tissue perfusion is more critical, and communication issues are more relevant to right-sided CVA.
Question 5 of 5
The nurse is caring for a client with a history of glaucoma who is receiving timolol (Timoptic) eye drops. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bradycardia, and a slower heart rate is concerning, requiring evaluation to prevent cardiovascular complications. Options A, C, and D are less urgent: burning is common, headaches are nonspecific, and watery eyes are not significant.