NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
A multipara client who delivered a female infant one hour ago. The nurse observes that the client's breasts are soft; the uterus is boggy, to the right of the midline, and 2 cm below the umbilicus; moderate lochia rubra.
Question 1 of 5
It is MOST important for the nurse to take which of the following actions?
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) encourage the client to void before catheterizing (2) correct-boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder
Extract:
Question 2 of 5
Because a client is taking rifampin (Rimactane), what must the nurse include when discussing medications with the client?
Correct Answer: D
Rationale: Rifampin commonly causes red-orange discoloration of urine and sweat, a harmless side effect clients should be informed about to avoid alarm.
Question 3 of 5
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving prednisone 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Weight gain of 5 pounds in a month suggests a side effect of prednisone, such as fluid retention or increased appetite, requiring evaluation to prevent complications like hypertension. Options A, B, and D are less concerning: headaches and fatigue are nonspecific, and taking with food is appropriate.
Question 4 of 5
The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following symptoms should the nurse report immediately?
Correct Answer: C
Rationale: Suicidal thoughts are a medical emergency in clients on SSRIs like sertraline. Options A, B, and D are common side effects.
Extract:
A man is presently employed as a night watchman. When he comes to the clinic for a visit, he tells the nurse he is having difficulty sleeping and is fatigued much of the time.
Question 5 of 5
Which of the following responses by the nurse is BEST?
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assessment, open-ended, encourages discussion (2) judgment based on inadequate information, nontherapeutic (3) generalization with no factual basis, closed communication (4) closed communication, generalization