NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
A client is diagnosed with bipolar disorder and is in a manic phase with combative behavior.
Question 1 of 5
An INITIAL nursing priority is to
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression (3) this action is inappropriate at this time (4) correct-is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents
Extract:
Question 2 of 5
The nurse is caring for a client with a history of renal failure.
Correct Answer: B
Rationale: A serum potassium of 6.2 mEq/L indicates hyperkalemia, a life-threatening condition in renal failure due to impaired excretion, risking cardiac arrhythmias. Elevated creatinine, BUN, and low hemoglobin are expected but less urgent.
Extract:
A client with signs of increased intracranial pressure (ICP).
Question 3 of 5
In planning care for a client with signs of increased intracranial pressure (ICP), the nurse would include which of the following?
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) increases intracranial pressure (2) increases intracranial pressure (3) head of the bed should be elevated 15 to 30° to promote venous drainage (4) correct-assessment, cough or gag reflex and the swallowing reflex may be affected by the increased pressure; increases the incidence of aspiration
Extract:
A client develops severe, crushing chest pain radiating to the left shoulder and arm.
Question 4 of 5
Which of the following PRN medications should the nurse administer?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not an appropriate medication in this situation; antianxiety medication (2) Demerol is less commonly used because it may induce vomiting and initiate a vagal response (3) correct-morphine sulfate is given to reduce pain, anxiety, and cardiac workload; reduces the preload and afterload pressures (4) although a client at home may have taken NTG SL, the nurse would administer it IV to reduce pain and decrease overload
Extract:
Question 5 of 5
Following a CT scan with contrast medium, the nurse should give attention to:
Correct Answer: B
Rationale: Forcing fluids promotes excretion of contrast medium, reducing risk of renal toxicity. Bed rest and hemorrhage monitoring are not typically required.