NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
Four clients have signaled with their call bell for the nurse. Who should the nurse observe first?
Correct Answer: C
Rationale: A client recently given penicillin is at risk for an allergic reaction, including anaphylaxis, requiring immediate observation. Bathroom assistance, pain, or chair positioning are less urgent.
Question 2 of 5
A client with MRSA is receiving Vanomycin (Vancocin) IV. If the client experiences 'red man' syndrome, the nurse should:
Correct Answer: A
Rationale: Red man syndrome is caused by rapid vancomycin infusion, leading to histamine release. Slowing the infusion and monitoring blood pressure manage symptoms. It's not normal, and discontinuing is unnecessary.
Question 3 of 5
The nurse is caring for a client with heart failure.
Correct Answer: A
Rationale: A weight gain of 2 pounds in 24 hours indicates fluid retention, a sign of worsening heart failure. Decreased blood pressure may occur but is less specific, clear lung sounds suggest stability, and improved exercise tolerance indicates improvement.
Question 4 of 5
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
Question 5 of 5
A client who is about to be discharged from the acute care facility is receiving warfarin (Coumadin). The nurse should plan to teach the client which of the following?
Correct Answer: B
Rationale: Warfarin interacts with many over-the-counter medications, risking bleeding or reduced efficacy, so physician consultation is essential. Full stomach, aspirin, or sun exposure are not primary concerns.