NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is postoperative day 1 after a total knee replacement. Which of the following actions is the PRIORITY?
Correct Answer: C
Rationale: Applying the CPM machine is the priority to prevent stiffness and promote joint mobility post-knee replacement. Options A, B, and D are important but secondary: incentive spirometry prevents pneumonia, pain management supports recovery, and dressing checks monitor bleeding.
Question 2 of 5
A client hospitalized with bipolar disorder, manic phase, begins to talk loudly, pace the floor, and shout commands to others in the day room as he quickly changes the TV channels. The nurse's first action should include:
Correct Answer: B
Rationale: Escorting the client from the day room de-escalates the situation by removing them from a stimulating environment, reducing agitation.
Question 3 of 5
The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following statements by the client indicates a need for further teaching?
Correct Answer: D
Rationale: Stopping metformin when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: taking with meals reduces GI upset, nausea is a side effect, and alcohol increases lactic acidosis risk.
Question 4 of 5
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck.
Correct Answer: B
Rationale: Biperiden, an antiparkinsonian agent, counteracts extrapyramidal side effects (e.g., dystonia, stiffness) caused by antipsychotics like perphenazine. Promazine, thiothixene, and haloperidol are antipsychotics that could worsen these side effects.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: Chest pain may indicate vasoconstriction, a serious sumatriptan side effect. Options A, C, and D are incorrect.