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 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.
Question 3 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 4 of 5
The parents of a child with cystic fibrosis discuss nutritional requirements and the need for vitamin supplements with the nurse. The nurse explains that it is necessary to give daily supplements of vitamins A, D, E, and K because:
Correct Answer: C
Rationale: Cystic fibrosis impairs fat absorption, leading to deficiencies in fat-soluble vitamins (A, D, E, K), necessitating supplementation.
Question 5 of 5
The nurse is caring for a client with a history of hemophilia.
Correct Answer: A
Rationale: Factor replacement therapy stops bleeding in hemophilia, relieving joint pain from hemarthrosis. Cold compresses are used, exercise worsens bleeding, and analgesics are supportive.