NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
An adult is admitted in diabetic ketoacidosis. What observation by the nurse is consistent with the diagnosis?
Correct Answer: A
Rationale: Deep, rapid (Kussmaul) respirations are a compensatory mechanism in diabetic ketoacidosis to eliminate excess CO2, correcting acidosis.
Extract:
The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
Question 2 of 5
After determining the client's vital signs, which of the following activities should the nurse perform next?
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
Extract:
Question 3 of 5
When suctioning a client's tracheostomy, the nurse should instill saline in order to
Correct Answer: D
Rationale: remove a mucus plug. While no longer recommended for routine suctioning, saline may thin and loosen viscous secretions that are very difficult to move, perhaps making them easier to suction.
Question 4 of 5
A client recently diagnosed with bipolar disorder expresses concern over taking Eskalith (lithium carbonate) because 'a lot of people have problems getting too much of it.' The nurse should explain that lithium toxicity typically occurs when the client has an insufficient intake of:
Correct Answer: D
Rationale: Lithium toxicity occurs with insufficient sodium and fluids, as low sodium increases lithium reabsorption in kidneys, and fluids aid excretion. Other nutrients are less directly related.
Question 5 of 5
The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse?
Correct Answer: B
Rationale: 1 in 4 risk for each child to have the disease. Cystic fibrosis is autosomal recessive, with a 25% chance of the disease per pregnancy if both parents are carriers.