NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a 14-year-old girl admitted with an acute exacerbation of ulcerative colitis.
Correct Answer: D
Rationale: Involving the adolescent in planning her daily schedule promotes autonomy and control, which is developmentally appropriate and therapeutic for managing chronic illness. Rooming in, school programs, and friend visits are supportive but less empowering for self-management.
Question 2 of 5
The nurse is administering terbutaline (Brethine) to a client in labor.
Correct Answer: A
Rationale: Terbutaline causes maternal tachycardia, and a pulse of 144 indicates a significant side effect. Withholding the medication is the priority to prevent further complications like pulmonary edema. Reducing the dose, administering, or delaying without action is unsafe.
Extract:
During the first 24 hours after total parenteral nutrition (TPN) therapy is started.
Question 3 of 5
The nurse should
Correct Answer: C
Rationale: Strategy: Determine how each assessment relates to TPN. (1) inappropriate (2) inappropriate (3) correct-total parenteral nutrition (TPN), or hyperalimentation, has a high glucose content; important to monitor glucose levels (4) appropriate, but not a priority
Extract:
Question 4 of 5
The nurse is caring for a client who had a cholecystectomy. Which of the following observations is MOST important for the nurse to report to the next shift?
Correct Answer: D
Rationale: Decreased breath sounds suggest atelectasis or pneumonia, serious post-cholecystectomy complications due to reduced ventilation from pain. Options A, B, and C are routine: resting is expected, absent bowel sounds are normal post-surgery, and IV rate is standard.
Question 5 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.