NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
A patient is being treated in the telemetry unit for cardiac disease. The patient is to receive propranolol hydrochloride (Inderal) 20 mg PO at 9 AM. The nurse finds him wheezing with a nonproductive cough and shortness of breath.
Question 1 of 5
INITIALLY, the nurse should
Correct Answer: A
Rationale: Strategy: Determine the outcome of each answer choice. (1) correct-side effects include increased airway resistance, patient is experiencing bronchospasm, should assess then call the physician (2) should assess the patient's condition first (3) experiencing a side effect, medication should not be given (4) medication should be held, experiencing a side effect
Extract:
Question 2 of 5
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
Correct Answer: C
Rationale: Psychomotor retardation or agitation. These are common physiologic symptoms of depression.
Question 3 of 5
In addition to standard precautions, a nurse should implement contact precautions for which client?
Correct Answer: A
Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.
Extract:
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 cc 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity.
Question 4 of 5
It is MOST important for the nurse to take which of the following actions?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antibiotic should be administered within one hour (2) unnecessary for safe infusion (3) correct-when using a gravity drip, piggyback fluid level needs to be higher than primary infusion (4) unnecessary for safe infusion
Extract:
A client with a perforated bowel secondary to a bowel obstruction.
Question 5 of 5
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done