NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is postoperative day 1 after a nephrectomy. Which of the following findings should the nurse report immediately?
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-nephrectomy complication. Options A, C, and D are normal or expected.
Question 2 of 5
A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
Correct Answer: C
Rationale: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate's skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.
Question 3 of 5
The nurse is caring for a client with a history of atrial fibrillation who is receiving digoxin (Lanoxin) 0.125 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) increases the risk of digoxin toxicity, which can cause life-threatening arrhythmias in atrial fibrillation. Options B, C, and D are normal: sodium 140 mEq/L, magnesium 2.0 mEq/L, and calcium 9.0 mg/dL do not affect digoxin.
Question 4 of 5
The mother of a 2-month-old child asks the nurse when she should start her son on solids. He is taking about 30 oz of formula per day. How should the nurse respond?
Correct Answer: C
Rationale: Solids are typically introduced between 4-6 months when infants have better head control and digestive maturity, not at 2 months or based on formula volume.
Question 5 of 5
An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.