NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings should the nurse report immediately?
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication. Options A, B, and D are normal.
Extract:
A client is receiving heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal.
Question 2 of 5
Which of the following actions by the nurse is MOST appropriate?
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer. (1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (3) prothrombin time (PT) Test is useful for assessing warfarin (Coumadin) therapy (4) correct-expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage
Extract:
Question 3 of 5
An adult is on a clear liquid diet. Which food should the nurse offer him?
Correct Answer: D
Rationale: Apple juice is a clear liquid, appropriate for a clear liquid diet. Milkshakes and sherbet contain dairy, and fruited gelatin may have solids, making them unsuitable.
Extract:
The nurse observes the student nurse enter wearing a gown, gloves, and a mask.
Question 4 of 5
The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients?
Correct Answer: D
Rationale: Strategy: Determine the precautions required for each disease. (1) requires contact precautions, no mask (2) requires contact precautions, no mask (3) standard precautions (4) correct-droplet precautions used for organisms that can be transmitted by face-to-face contact, door may remain open
Extract:
Question 5 of 5
A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma.
Correct Answer: B
Rationale: Morphine sulfate, a narcotic analgesic, causes CNS and respiratory depression, which is contraindicated in head injuries because it masks signs of increased intracranial pressure, such as altered consciousness or pupil changes. Promethazine is an antiemetic, docusate is a stool softener, and ranitidine prevents stress ulcers, none of which pose the same risk.