NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
For which of the following mother-baby pairs should the nurse review the Coombs' test in preparation for administering Rh0 (D) immune globulin within 72 hours of birth?
Correct Answer: A
Rationale: Rh negative mother with Rh positive baby. Rh0 (
D) immune globulin is administered to prevent Rh sensitization in an Rh-negative mother who may have been exposed to Rh-positive fetal blood during delivery. The Coombs' test helps determine if the baby is Rh-positive, confirming the need for the injection.
Extract:
A male client's behavior begins to escalate into aggressive behavior.
Question 2 of 5
The nurse is caring for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct-as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion
Extract:
Question 3 of 5
A cooling blanket is ordered for an adult client who has a temperature of 106°F. What nursing action is essential because the client has a cooling blanket?
Correct Answer: B
Rationale: Turning every two hours prevents skin breakdown from prolonged cooling blanket contact.
Tongue blades, ice, or heavy coverings are inappropriate.
Question 4 of 5
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
Question 5 of 5
A post-operative client is admitted to the post-anesthesia recovery room (PACU). The anesthetist reports that malignant hyperthermia occurred during surgery. The nurse recognizes that this complication is related to what factor?
Correct Answer: C
Rationale: Malignant hyperthermia is a rare, potentially fatal adverse reaction to inhaled anesthetics. There is a genetic predisposition to this disorder.