NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings should the nurse report immediately?
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are less urgent or normal.
Question 2 of 5
The home health nurse visits a client who is six-weeks postpartum.
Correct Answer: C
Rationale: Painful sexual intercourse six weeks postpartum is abnormal and may indicate infection, episiotomy complications, or other issues requiring immediate evaluation. Hot flashes, pinkish discharge, and fatigue are common during the postpartum period as the body recovers.
Question 3 of 5
A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident.
Correct Answer: D
Rationale: A decreased level of consciousness (e.g., confusion, stupor) is the initial symptom of increased intracranial pressure from a subdural hematoma, reflecting cerebral compression. Unequal pupils, posturing, and seizures are later signs of severe brain damage.
Question 4 of 5
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A creatinine of 2.5 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
Question 5 of 5
A baby girl is born with a meningomyelocele. To prevent trauma to the sac, the nurse should place the infant:
Correct Answer: B
Rationale: Placing the infant prone with hips slightly elevated protects the meningomyelocele sac from trauma and pressure.