NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
Prior to suctioning a tracheotomy, the nurse should:
Correct Answer: B
Rationale: Administering oxygen pre-suctioning prevents hypoxia, as suctioning can reduce oxygen levels. Oropharyngeal suctioning, cannula changes, or bed elevation are not primary pre-suction steps.
Question 2 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
Question 3 of 5
The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment findings would suggest the complication of autonomic dysreflexia?
Correct Answer: B
Rationale: severe headache results from rapid onset of hypertension
Question 4 of 5
A client is to begin taking Fosamax. The nurse must emphasize which of these instructions to the client when taking this medication? 'Take Fosamax
Correct Answer: A
Rationale: Fosamax should be taken first thing in the morning with 6-8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of Fosamax. The client must be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.
Question 5 of 5
A diabetic client has been maintained on Glucophage (metformin) for regulation of his blood glucose levels. Which teaching should be included in the plan of care?
Correct Answer: A
Rationale: Metformin can affect kidney function, so changes in urinary patterns should be reported. Optimal effects occur sooner than six weeks , carbohydrates should be balanced, not increased , and itching is not a common side effect .