NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
A nurse is working in an outpatient orthopedic clinic. During the patient's history the patient reports, 'I tore 3 of my 4 Rotator cuff muscles in the past.' Which of the following muscles cannot be considered as possibly being torn?
Correct Answer: B
Rationale: Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis make up the Rotator Cuff.
Question 2 of 5
The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: A temperature of 100.4°F suggests worsening infection or inadequate antibiotic coverage, requiring immediate evaluation. Options A, C, and D are less concerning: WBC 12,000/mm^3 is expected, urine output 50 mL/hour is normal, and blood pressure 120/80 mmHg is stable.
Question 3 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of nitroglycerin for chest pain. Which of the following findings should the nurse report immediately?
Correct Answer: A
Rationale: Hypotension (100/60 mmHg) is a serious nitroglycerin side effect, risking inadequate perfusion. Options B, C, and D are normal findings.
Question 4 of 5
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings should the nurse report immediately?
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication. Options A, B, and D are normal.
Extract:
A client is being treated for hypovolemia.
Question 5 of 5
Which of the following observations should the nurse identify as the desired response to fluid replacement?
Correct Answer: D
Rationale: Strategy: Determine the significance of each answer choice and how it relates to hypovolemia. (1) indicates a hypovolemic state (2) indicates a hypovolemic state (3) indicates acidosis (4) correct-normal range for CVP is 3-8 cm water pressure (or 2-6 mm Hg); reading of 8 cm water pressure would indicate a desired response to fluid replacement