NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
Correct Answer: B
Rationale: When the client threatens self-harm and harm to others. Confidentiality can be breached to ensure safety, per legal precedents like the Tarasoff decision.
Question 2 of 5
An 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which of the following actions by the nurse is BEST?
Correct Answer: A
Rationale: Observing mealtime assesses feeding behaviors and parental interactions, identifying causes of poor weight gain. Options B, C, and D are less direct or premature.
Question 3 of 5
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
Question 4 of 5
A client in the intensive care unit is overheard telling his wife, 'It's impossible to get any sleep in this place with all the noise and lights on all the time.' After talking with the client, the nurse determines that the client is bothered by sensory disturbance related to being in the ICU. Which laboratory finding would confirm the nurse's assessment of sensory disturbance?
Correct Answer: A
Rationale: Sensory disturbance and stress in the ICU increase catecholamines (e.g., epinephrine), detectable in urine. Other labs are unrelated to sensory disturbance.
Question 5 of 5
The nurse is preparing to discharge a client with a new diagnosis of asthma.
Correct Answer: D
Rationale: Daily peak flow monitoring helps the client detect early changes in lung function, enabling timely intervention to prevent asthma exacerbations. Using a spacer, proper medication sequencing, and exercise management are important but secondary to ongoing monitoring.