NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The serum glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time?
Correct Answer: C
Rationale: Repeat the test in 2 hours. This blood sugar is within the normal range for a full-term newborn. Normal values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L, Neonate: 30-60 mg/dl or 1.7-3.3 mmol/L, Infant: 40-90 mg/dl or 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a Newborn: <30 and >300 mg/dl. Because of the increased birth weight which can be associated with diabetes mellitus, repeated blood sugars will be drawn.
Question 2 of 5
The nurse is teaching a client with a new diagnosis of epilepsy about phenytoin (Dilantin). Which of the following statements by the client indicates a need for further teaching?
Correct Answer: D
Rationale: Stopping phenytoin when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: oral hygiene prevents gingival hyperplasia, rashes may indicate hypersensitivity, and grapefruit juice does not significantly affect phenytoin.
Question 3 of 5
The nurse is caring for a client who had a cystoscopy earlier in the day. Which symptom from the client is of greatest concern to the nurse?
Correct Answer: A
Rationale: Back pain post-cystoscopy may indicate complications like renal injury or infection, requiring urgent evaluation. Hematuria (tea/pink urine) is expected, and leg cramps are less concerning.
Question 4 of 5
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
Correct Answer: D
Rationale: Abruptio placentae causes hemorrhage, leading to fluid volume deficit, a major nursing concern. The other options are incorrectly stated or irrelevant: infection is not typical, ‘potential’ diagnoses are not standard, and fibrinogen depletion is not the primary issue.
Question 5 of 5
The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?
Correct Answer: C
Rationale: Wash and rinse the bed linens in hot water. For asthma clients sensitive to house dust-mites, washing bed linens in hot water above 130 degrees Fahrenheit is necessary to kill dust-mites.