NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
A mentally retarded, nonverbal, ambulatory client is found sitting on the floor unable to get up. The LPN/LVN notes the client appears to be in great pain, and his right leg is out of alignment. What is the most important action for the nurse to take as the client is readied for ambulance transport?
Correct Answer: B
Rationale: Immobilizing the leg prevents further injury in a suspected fracture, the priority action before transport.
Question 2 of 5
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: A temperature of 101°F suggests infection, a serious complication in COPD that can exacerbate respiratory distress. Options A, B, and D are acceptable: oxygen saturation 90% is adequate for COPD, respiratory rate 20 is normal, and heart rate 80 bpm is normal.
Question 3 of 5
A client in the intensive care unit is overheard telling his wife, 'It's impossible to get any sleep in this place with all the noise and lights on all the time.' After talking with the client, the nurse determines that the client is bothered by sensory disturbance related to being in the ICU. Which laboratory finding would confirm the nurse's assessment of sensory disturbance?
Correct Answer: A
Rationale: Sensory disturbance and stress in the ICU increase catecholamines (e.g., epinephrine), detectable in urine. Other labs are unrelated to sensory disturbance.
Question 4 of 5
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously q12h. The nurse should monitor for which of the following as a side effect?
Correct Answer: B
Rationale: Heparin can cause bruising at injection sites due to its anticoagulant effect. Options A, C, and D are not typical side effects.
Question 5 of 5
A child is admitted with acute glomerulonephritis. Which finding in the client's history is most consistent with the diagnosis?
Correct Answer: B
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis by 1-3 weeks, due to immune complex deposition in glomeruli. Tick bites, mosquito bites, or uric acid are unrelated.