NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is postoperative day 1 after a pancreaticoduodenectomy (Whipple procedure). Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-Whipple procedure due to extensive surgery, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.
Question 2 of 5
A client is admitted to the outpatient oncology unit for his routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm³, RBC 5.1 ml/mm³, and calcium 5 mEq/L. Based on these assessments, which of the following should be the priority nursing diagnosis?
Correct Answer: B
Rationale: clients with a low WBC count are susceptible to infection
Extract:
A child who received meperidine (Demerol) IM one hour ago.
Question 3 of 5
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM one hour ago?
Correct Answer: D
Rationale: Strategy: Think about what the words mean. (1) contains correct information, but is not a priority; child could deny pain out of fear of getting another injection (2) indicates discomfort, anxiety (3) indicates a need to decrease the amount of medication (4) correct-when pain is decreased, child will be better able to breathe deeply and improve the outcome of use of the incentive spirometer
Extract:
Question 4 of 5
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
Question 5 of 5
Delirium tremens could best be described as
Correct Answer: C
Rationale: An excited state accompanied by disorientation, hallucination and tachycardia. Delirium tremens involves severe withdrawal symptoms, including confusion, hallucinations, and autonomic hyperactivity.