NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment findings would suggest the complication of autonomic dysreflexia?
Correct Answer: B
Rationale: severe headache results from rapid onset of hypertension
Extract:
A postoperative appendectomy client who is complaining of incisional pain. A diabetic client who had a cardiac catheterization in the early AM. A postoperative cholecystectomy client who is complaining of incisional pain. A client with congestive heart failure who underwent diuresis in the hospital.
Question 2 of 5
The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
Correct Answer: D
Rationale: Strategy: Determine the least stable client. Remember the ABCs. (1) expected outcome, treat with analgesics (2) instruct no bending, straining, or lifting heavy objects for 24 hours, observe for bleeding, swelling, new bruising at puncture site (3) expected outcome, treat with analgesics (4) correct-assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia
Extract:
Question 3 of 5
The nurse is caring for a client with a history of bipolar disorder who is receiving lithium 300 mg PO tid. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A lithium level of 2.0 mEq/L is toxic (therapeutic range 0.6–1.2 mEq/L), risking seizures or coma, requiring immediate intervention. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and creatinine 1.0 mg/dL do not indicate complications.
Extract:
The nurse is caring for clients in the diabetic clinic.
Question 4 of 5
Which of the following clients should the nurse see FIRST?
Correct Answer: A
Rationale: Strategy: Determine the least stable client. (1) correct-indicates diabetic ketoacidosis; treat with normal saline and regular insulin (2) suggestive of intermittent claudication, not an emergency situation (3) suggestive of hyperglycemia, should assess blood sugar (4) psychosocial issues, physical takes priority
Extract:
Question 5 of 5
An infant is suspected of having coarctation of the aorta. Which assessment finding is most related to coarctation of the aorta?
Correct Answer: B
Rationale: Coarctation of the aorta causes aortic narrowing, leading to higher blood pressure in the upper extremities compared to the lower, a hallmark sign.