NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
A patient before administration of morphine sulfate 8 mg IM q 3-4 hours for pain PRN.
Question 1 of 5
In which of the following situations should the nurse consider withholding the medication until further assessment is done?
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to morphine. (1) morphine used for moderate to severe pain, medication should be given (2) BP slightly elevated, respirations elevated, may be the result of pain, medication should be given (3) correct-morphine depresses CNS, especially respiratory center in medulla (4) may be the result of pain
Extract:
Question 2 of 5
A woman who was recently widowed says to the nurse, 'I just can't believe he's gone. Sometimes I even think I see him standing there.' What does this comment indicate about the client?
Correct Answer: A
Rationale: Disbelief and transient perceptions of the deceased are normal in early grief. Hallucinations, illusions, or depression require more persistent or severe symptoms.
Question 3 of 5
Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
Correct Answer: B
Rationale: Transferring into and out of a wheelchair is essential for a paraplegic to perform ADLs independently, enabling mobility and access to other tasks. Shaving, maneuvering the wheelchair, and cooking are important but less critical if transfer ability is impaired.
Question 4 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 5 of 5
A client with acute leukemia has developed oral ulcerations. The nurse can increase the client's comfort by suggesting that he:
Correct Answer: B
Rationale: Normal saline rinses are gentle and help keep the mouth clean without irritating oral ulcerations.