NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: A temperature of 100.4°F suggests worsening infection or inadequate antibiotic coverage, requiring immediate evaluation. Options A, C, and D are less concerning: WBC 12,000/mm^3 is expected, urine output 50 mL/hour is normal, and blood pressure 120/80 mmHg is stable.
Extract:
A two-year-old who is one-day postoperative.
Question 2 of 5
The mother of a two-year-old who is one-day postoperative tells the nurse, 'My child is so restless and overactive.' The nurse should
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. (1) no indication that there are any problems (2) passing the buck (3) implementation, should first assess (4) correct-young children typically become restless and overactive if in pain, grimacing, clenching teeth, rocking, and aggressive behavior may also be observed
Extract:
During auscultation of the fetal heart rate during labor, the nurse assesses a rate of 59 beats per minute.
Question 3 of 5
The FIRST action the nurse should take is
Correct Answer: B
Rationale: Strategy: 'FIRST' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should be placed on left side to increase blood flow to the uterus (2) correct-persistent fetal bradycardia may indicate cord compression or separation of the placenta, but always indicates fetal distress, left side reduces compression of vena cava and aorta (3) should be done after positioning patient (4) this position is used only if there is cord prolapsed
Extract:
Question 4 of 5
A pregnant diabetic client, who is 37 weeks gestation, is scheduled for an amniocentesis. The client asks the nurse the purpose of the test. The nurse should explain that the primary reason for performing an amniocentesis is:
Correct Answer: C
Rationale: At 37 weeks, amniocentesis primarily assesses fetal lung maturity via lecithin/sphingomyelin ratio, critical for delivery planning. Diabetes effects , skeletal age , and genetic issues are less common indications.
Question 5 of 5
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
Correct Answer: B
Rationale: Alteplase (tP
A) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.