NCLEX-PN
NCLEX Trainer Test 10 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of fentanyl for pain management. Which of the following findings should the nurse report immediately?
Correct Answer: A
Rationale: A respiratory rate of 10 breaths/min indicates respiratory depression, a serious fentanyl side effect. Options B, C, and D are normal findings.
Question 2 of 5
A client is scheduled for a cardiac catheterization, and the nurse teaches him about the procedure. What statements, if made by the client, would indicate to the nurse that he understands the teaching?
Correct Answer: C
Rationale: peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then every 4 h
Question 3 of 5
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
Correct Answer: C
Rationale: A teenager with 50% body burns is at high risk for infection due to loss of skin barrier. Maintaining aseptic technique during procedures is the highest priority to prevent life-threatening infections. Counseling, precautions, and peer visits are important but secondary to infection control.
Question 4 of 5
The nurse is caring for a client who is postoperative day 1 following a total knee replacement. Which of the following findings should the nurse report to the physician immediately?
Correct Answer: B
Rationale: swelling and warmth may indicate infection or a deep vein thrombosis, which requires immediate attention
Question 5 of 5
The nurse is caring for a client with a history of congestive heart failure.
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early, a key indicator of worsening heart failure. Extra diuretics require medical orders, high-sodium diets worsen fluid retention, and exercise is encouraged within limits.