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 cirrhosis.
Correct Answer: C
Rationale: Asterixis and confusion indicate hepatic encephalopathy, a life-threatening complication of cirrhosis due to ammonia buildup, requiring immediate intervention. Ascites, jaundice, and melena are concerning but less acute.
Question 3 of 5
An adult is admitted with deep partialthickness and full-thickness burns on both lower legs, the anterior chest, and the anterior and posterior aspects of the right arm. Using the Rule of Nines, calculate the percentage of body burned.
Correct Answer: B
Rationale: Using the Rule of Nines: both lower legs (18%), anterior chest (9%), right arm anterior and posterior (9%) = 18 + 9 + 9 = 36% total body surface area burned.
Question 4 of 5
A client is admitted to the hospital with findings of liver failure with ascites. The health care provider orders spironolactone (Aldactone). What is the pharmacological effect of this medication?
Correct Answer: A
Rationale: Spironolactone promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. It has no effect on ammonia levels.
Question 5 of 5
A Hispanic client in the postpartum period refuses the hospital food because it is 'cold.' The best initial action by the nurse is to
Correct Answer: B
Rationale: Ask the client what foods are acceptable or are unacceptable. Understanding cultural food preferences ensures appropriate dietary support.