NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings should the nurse report immediately?
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious propofol side effect. Options A, B, and C are acceptable.
Question 2 of 5
The nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about tiotropium (Spiriva). Which of the following statements by the client indicates a need for further teaching?
Correct Answer: D
Rationale: Using tiotropium as a rescue inhaler is incorrect, as it is a long-acting maintenance medication for COPD, not for acute symptoms. Options A, B, and C are correct: rinsing prevents oral thrush, daily use is standard, and eye pain may indicate glaucoma.
Question 3 of 5
The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?
Correct Answer: C
Rationale: Maternal hypertension. Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.
Question 4 of 5
A client on assisted ventilation develops a right-sided tension pneumothorax. Which of the following signs is associated with a right-sided tension pneumothorax?
Correct Answer: A
Rationale: Tension pneumothorax causes lung collapse, reducing breath sounds on the affected side (right). Tracheal deviation is toward the unaffected side (left).
Extract:
A client with a perforated bowel secondary to a bowel obstruction.
Question 5 of 5
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done