NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The client who is receiving hydantoin (Dilantin) tells the nurse his urine is pink-colored. What action should the nurse take?
Correct Answer: C
Rationale: Pink urine may result from dietary factors like cranberry juice or red gelatin, which should be ruled out before assuming a Dilantin-related issue.
Question 2 of 5
The nurse is caring for a client who has been placed on a hypothermia blanket. What should the nurse include in the care plan?
Correct Answer: A
Rationale: Frequent vital signs monitor for hypothermia or cardiovascular instability, and skin assessments prevent pressure injuries or cold burns. Direct blanket contact, prolonged use, or alcohol sponges risk skin damage or ineffective cooling.
Question 3 of 5
A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?
Correct Answer: C
Rationale: Children with celiac disease should eat a gluten free diet. Potato chips are naturally gluten-free, unlike the other options which contain wheat-based ingredients.
Question 4 of 5
The nurse is caring for a client who is 6 hours postoperative after an appendectomy. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: A temperature of 100.8°F 6 hours post-appendectomy suggests infection, possibly from perforation or abscess, requiring immediate evaluation. Options A, C, and D are expected: heart rate 88 is normal, absent bowel sounds are typical post-surgery, and moderate pain is common.
Question 5 of 5
The nurse is caring for a client who is receiving intravenous fluid therapy. Which observation needs to be reported to the charge nurse?
Correct Answer: D
Rationale: A cool, blanched infusion site suggests infiltration or extravasation, requiring immediate reporting to prevent tissue damage. Cool fluid sensation, tape, or ambulation are normal.