NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
One hour after receiving 7 U of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. The priority nursing action would be to
Correct Answer: C
Rationale: Diaphoresis, pallor, and tachycardia indicate hypoglycemia, a medical emergency. Milk and crackers provide fast-acting carbohydrates. Options A, B, and D delay treatment or are reserved for severe cases.
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 2 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 3 of 5
A client with a cholesterol level of $240 \mathrm{mg}$ is instructed to modify his diet. Which of the following diets provides a low-cholesterol, low-saturated fat breakfast?
Correct Answer: A
Rationale: Oatmeal, skim milk, and margarine are low in cholesterol and saturated fat, unlike bacon, sausage, or cream cheese.
Question 4 of 5
The nurse is teaching a client with a new diagnosis of ulcerative colitis about mesalamine (Asacol). Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: Fever or sore throat may indicate bone marrow suppression, a serious mesalamine side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks relapse, and it can be taken with meals.
Question 5 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.