NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
Question 1 of 5
In addition to routine vital signs, what should the nurse assess because the client had a lumbar laminectomy?
Correct Answer: B
Rationale: Lumbar laminectomy affects lower spine nerves; assessing foot strength evaluates neurological function in the legs. Hand grasps, swallowing, and abdominal strength are unrelated.
Question 2 of 5
The nurse is caring for a client with a history of epilepsy who is receiving carbamazepine (Tegretol) 200 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A white blood cell count of 3,000/mm^3 indicates leukopenia, a serious side effect of carbamazepine, increasing infection risk and requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
Question 3 of 5
The nurse is performing a sterile dressing change. Which action is essential?
Correct Answer: D
Rationale: Wearing sterile gloves maintains a sterile field, essential for preventing infection during a sterile dressing change.
Question 4 of 5
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
Correct Answer: D
Rationale: Seizure activity. Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.
Question 5 of 5
A newly admitted client is exhibiting signs of severe anxiety. She is pacing back and forth and has difficulty concentrating on the nurse's questions. What nursing action is most appropriate at this time?
Correct Answer: D
Rationale: Directing the client to a quiet area reduces stimuli, helping manage severe anxiety. Commands, leaving, or whispering are ineffective or dismissive.