NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?
Correct Answer: A
Rationale: Risk for injury. Impaired judgment from substance abuse significantly increases the risk of accidents and injuries.
Question 2 of 5
An adult had major abdominal surgery this morning under general anesthesia. When the client arrives in the recovery room, she is very lethargic and restless. Her BP is 150/98; pulse is 110 and irregular; and respirations are 30 breaths per minute and shallow. Postoperative orders include meperidine (Demerol) 75 mg IM for operative site pain; reinforce dressings PRN; oxygen at 6 L/min PRN; irrigate nasogastric tube every 2 hours and PRN; IV 2500 cc D5W in 24 hours. What should the nurse do next?
Correct Answer: D
Rationale: Tachypnea, tachycardia, and restlessness suggest hypoxia. Administering oxygen at 6 L/min addresses this critical need. Dressings, nasogastric irrigation, and pain medication are secondary to stabilizing oxygenation.
Question 3 of 5
A spansule is ordered twice a day for a client in the outpatient clinic. What should the nurse teach the client about taking a spansule?
Correct Answer: C
Rationale: Spansules are time-release capsules, requiring 12-hour intervals for consistent drug release. Opening, cutting, or meal-based timing disrupts their mechanism.
Question 4 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of midazolam (Versed) for sedation. Which of the following findings should the nurse report immediately?
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious midazolam side effect. Options A, B, and C are acceptable: respiratory rate is low but stable, BP is mildly low, and heart rate is normal.
Question 5 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: D
Rationale: An oxygen saturation of 90% is low, indicating hypoxemia, a serious complication of propofol due to respiratory depression, requiring immediate intervention. Options A, B, and C are acceptable: respiratory rate 12 breaths/min, blood pressure 100/60 mmHg, and heart rate 80 bpm are stable.