NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
Correct Answer: C
Rationale: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate's skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.
Question 2 of 5
The nurse is caring for a client with a history of dementia.
Correct Answer: B
Rationale: Using simple, clear sentences enhances comprehension in dementia patients with cognitive impairment. Loud speaking is unnecessary, open-ended questions overwhelm, and written instructions are ineffective.
Question 3 of 5
Which of the following electrolytes must be maintained in a steady state for a client receiving lithium?
Correct Answer: A
Rationale: Sodium levels must be stable in clients taking lithium, as fluctuations can affect lithium levels and toxicity risk.
Question 4 of 5
As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The serum glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time?
Correct Answer: C
Rationale: Repeat the test in 2 hours. This blood sugar is within the normal range for a full-term newborn. Normal values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L, Neonate: 30-60 mg/dl or 1.7-3.3 mmol/L, Infant: 40-90 mg/dl or 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a Newborn: <30 and >300 mg/dl. Because of the increased birth weight which can be associated with diabetes mellitus, repeated blood sugars will be drawn.
Question 5 of 5
Which assessment is most essential before administering digoxin to an adult?
Correct Answer: B
Rationale: Taking an apical pulse ensures the heart rate is above 60 bpm, as digoxin can cause bradycardia, a critical safety check.