NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
Question 1 of 5
The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to
Correct Answer: D
Rationale: Assess airway breathing and circulation. The nurse must first assess the client to determine the appropriate next step. In this case the first step the nurse must take is to evaluate the A, B, C’s.
Question 2 of 5
The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspects of this care is/are
Correct Answer: C
Rationale: humidified air and increased oral fluids. The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids in mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing.
Extract:
A client is diagnosed with bipolar disorder and is in a manic phase with combative behavior.
Question 3 of 5
An INITIAL nursing priority is to
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression (3) this action is inappropriate at this time (4) correct-is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents
Extract:
Question 4 of 5
The nurse is caring for a client with a history of alcoholism.
Correct Answer: A
Rationale: A serum potassium of 3.2 mEq/L indicates hypokalemia, a life-threatening complication in chronic alcoholism due to poor nutrition and diuretic effects of alcohol, risking arrhythmias. Elevated AST reflects liver damage, but hypokalemia is more immediately dangerous.
Question 5 of 5
The nurse is caring for a client receiving warfarin (Coumadin) 5 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: Ibuprofen, an NSAID, increases bleeding risk when taken with warfarin, a significant concern due to potential for hemorrhage. Options A, C, and D are less critical: spinach (vitamin K) may require dose adjustment, moderate wine is generally safe, and walking is beneficial.