NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
Delirium tremens could best be described as
Correct Answer: C
Rationale: An excited state accompanied by disorientation, hallucination and tachycardia. Delirium tremens involves severe withdrawal symptoms, including confusion, hallucinations, and autonomic hyperactivity.
Extract:
A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client has received 80 mg of furosemide (Lasix).
Question 2 of 5
Which of the following nursing observations is MOST important to report to the next shift?
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read the answers for clues. (1) further signs and symptoms of right-sided heart failure; not a priority (2) correct-furosemide is diuretic, which warrants close observation of the client's urine output (3) further signs and symptoms of right-sided heart failure; not a priority (4) may occur as a result of volume loss, but is not a priority over answer choice #2
Extract:
Question 3 of 5
A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following?
Correct Answer: C
Rationale: approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation
Extract:
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
Question 4 of 5
The nurse would be MOST concerned by which of the following?
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
Extract:
Question 5 of 5
The nurse is caring for a 78-year-old woman in a long-term care facility. The client is sitting in a geriatric chair with the attached tray in place. The client is agitated and appears to be sliding down in the chair. What is the best action for the nurse to take?
Correct Answer: D
Rationale: Foam wedges stabilize the client safely and comfortably, preventing sliding without restrictive measures. Restraints (jacket or sheet) increase agitation and risk, and consulting the supervisor delays action.