NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
After the anesthesiologist administers an epidural to a woman in labor, which of the following nursing actions has the HIGHEST priority?
Correct Answer: D
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring the priority to detect complications. Options A, B, and C are secondary or incorrect.
Question 2 of 5
An adult has the following blood gasses: pH=7.52, pCO2=50, HCO3=35, and pO2=90. What is most likely to be in the client's history of presenting signs and symptoms?
Correct Answer: B
Rationale: High pH and HCO3 indicate metabolic alkalosis, commonly caused by frequent vomiting, losing gastric acid.
Question 3 of 5
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
Correct Answer: B
Rationale: Potential complication hemorrhage. Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
Question 4 of 5
A client arrives at the emergency room with an HR of 120, an RR of 48, and hemoptysis. The nurse should give priority to:
Correct Answer: B
Rationale: Hemoptysis and tachypnea suggest respiratory distress, so oxygen administration is the priority to stabilize the client.
Question 5 of 5
The nurse is caring for a client who is postoperative day 1 after a pancreaticoduodenectomy (Whipple procedure). Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-Whipple procedure due to extensive surgery, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.