NCLEX-PN
NCLEX Trainer Test 9 Questions
Extract:
Question 1 of 5
The nurse is administering lidocaine (Xylocaine) to a client with a myocardial infarction. Which of the following assessment findings requires the nurse's immediate action?
Correct Answer: C
Rationale: One of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest (this drug should never be administered without continuous EKG monitoring).
Question 2 of 5
The nurse is caring for an older adult in his home. Which of the following factors increase the client's risk for falls? Select all that apply.
Correct Answer: A,C,F
Rationale: Age over 65, scatter rugs, and obstacles like plants increase fall risk. A one-story home, handrails, and the wife's housework reduce risk.
Question 3 of 5
The multidisciplinary team decides to implement behavior modification with a client.
Correct Answer: A
Rationale: Consistency in applying the behavior modification plan is critical for success. Confirming that all staff members understand and comply ensures consistent implementation, reducing manipulation by the client or staff. While setting goals, choosing rewards, and scheduling reinforcement are important, they are secondary to ensuring staff alignment.
Question 4 of 5
The nurse is reviewing the chart of a 1-day-old infant. Which of the following data requires further action?
Correct Answer: B
Rationale: A respiratory rate of 72 is elevated for a newborn (normal 30-60 breaths/min), suggesting potential respiratory distress requiring further evaluation.
Question 5 of 5
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.