NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
A nurse is teaching a client about self-administration of Haldol 15 mg po hs. For which side effect/s must the client seek medical attention?
Correct Answer: B
Rationale: Muscle spasms and restlessness are side effects of Haldol.
Extract:
A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client has received 80 mg of furosemide (Lasix).
Question 2 of 5
Which of the following nursing observations is MOST important to report to the next shift?
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read the answers for clues. (1) further signs and symptoms of right-sided heart failure; not a priority (2) correct-furosemide is diuretic, which warrants close observation of the client's urine output (3) further signs and symptoms of right-sided heart failure; not a priority (4) may occur as a result of volume loss, but is not a priority over answer choice #2
Extract:
The nurse is aware that Rh immune globulin (RhoGAM) is administered.
Question 3 of 5
The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) if both mother and baby are Rh-negative, there is no problem (2) correct-RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when baby has a negative Coombs' Test (3) medication is not given if the mother has been sensitized by a previous pregnancy (4) there is no incompatibility here, but the mother needs to be evaluated regarding sensitization in the incomplete pregnancy
Extract:
A 28-year-old woman at 39-weeks gestation in active labor screams, 'I have to push, I have to push.' The nurse notes that the client is 8 cm dilated.
Question 4 of 5
The nurse should
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) pushing should be discouraged until the second stage of labor (2) would increase discomfort (3) is inappropriate at this time; this is a short, intense period of labor (4) correct-describes transition phase of labor, breathing technique allows patient to control pain and urge to push and promotes adequate oxygenation of fetus
Extract:
Question 5 of 5
Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?
Correct Answer: D
Rationale: Papilledema, or swelling of the optic disc, is a specific sign of increased intracranial pressure due to pressure on the optic nerve. Nausea, vomiting, headache, and dizziness are less specific symptoms, so answers A, B, and C are incorrect.