NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 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 2 of 5
The nurse is caring for a client with a history of breast cancer.
Correct Answer: B
Rationale: A new lump in the axillary region may indicate lymph node metastasis, requiring immediate evaluation. Fatigue, nausea, and hair loss are expected chemotherapy side effects.
Question 3 of 5
An African-American client is admitted with full thickness burns over 40% of his body. In addition to the CBC and complete metabolic panel, the physician is likely to request which additional lab work?
Correct Answer: D
Rationale: Sickle cell anemia and sickle cell trait are more prevalent in African American clients. The Sickledex test detects the presence of sickle cell anemia and sickle cell trait. Trauma can trigger a sickle cell crisis, which would complicate the treatment of the client. Answers A and C indicate inflammation, so they are incorrect. Answer B is incorrect because it detects circulating antibodies against RBCs.
Question 4 of 5
Because a client is taking rifampin (Rimactane), what must the nurse include when discussing medications with the client?
Correct Answer: D
Rationale: Rifampin commonly causes red-orange discoloration of urine and sweat, a harmless side effect clients should be informed about to avoid alarm.
Question 5 of 5
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
Correct Answer: C
Rationale: Providing oral fluids is a routine task with predictable outcomes, suitable for a UAP, while the other tasks require clinical judgment or assessment skills.