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.
Question 2 of 5
The client with cancer of the larynx is admitted to the unit with Acute Respiratory Distress Syndrome. Which nursing diagnosis should receive priority?
Correct Answer: A
Rationale: Acute Respiratory Distress Syndrome causes severe hypoxemia, making alteration in oxygen perfusion the priority nursing diagnosis to ensure adequate oxygenation. Pain , mobility , and sensory perception are secondary in this life-threatening condition.
Question 3 of 5
A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving aminophylline, 25 mg/hour. Which one of the following findings by the nurse would require immediate intervention?
Correct Answer: C
Rationale: Restlessness and palpitations. Side effects of Aminophylline include restlessness and palpitations.
Question 4 of 5
The nurse is teaching a client with a new diagnosis of atrial fibrillation about diltiazem (Cardizem). Which of the following statements by the client indicates a need for further teaching?
Correct Answer: C
Rationale: Taking diltiazem with grapefruit juice is incorrect, as it increases drug levels, risking toxicity. Options A, B, and D are correct: pulse monitoring detects bradycardia, leg swelling may indicate heart failure, and avoiding driving with dizziness prevents accidents.
Question 5 of 5
A nurse is assessing a patient that has undergone a recent CABG. The nurse notices a mole with irregular edges with a bluish color. The nurse should:
Correct Answer: C
Rationale: Contacting the attending physician via the medical record is appropriate due to the possibility of melanoma.