NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
Question 2 of 5
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: A temperature of 100.4°F suggests infection, a serious complication in TPN due to catheter-related bloodstream infections. Options A, C, and D are less urgent: hyperglycemia is common and manageable, rapid weight gain may indicate fluid overload, and potassium 3.8 mEq/L is normal.
Question 3 of 5
A client receiving Gentamycin (garamycin) IVPB has a morning peak level of 12 μg/mL. The nurse should:
Correct Answer: A
Rationale: The nurse should notify the physician because the level is too high (therapeutic range for Garamycin is 4-10 μg/mL). Answers B and C are incorrect because they would increase the peak level. Answer D refers to the time for drawing a trough level, making it incorrect.
Question 4 of 5
The nurse notes that the client has a pulse deficit. What is the most appropriate action for the nurse?
Correct Answer: C
Rationale: A pulse deficit indicates irregular heartbeats, requiring immediate physician notification to assess for arrhythmias.
Question 5 of 5
A 3-year-old with coarctation of the aorta is scheduled for corrective surgery. Which preoperative lab result should be reported to the physician?
Correct Answer: B
Rationale: A WBC of 14,000 suggests possible infection, which should be reported before surgery, so B is correct. HCT 48% , platelet count 200,000 , and RBC 5.3 are within normal ranges.