NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 80 bpm, and urine output 50 mL/hour indicate stability.
Question 2 of 5
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
Question 3 of 5
The nurse is caring for a client who was in a motor vehicle accident. His blood pressure is dropping rapidly. What should the nurse observe the client for before placing the client in shock position?
Correct Answer: C
Rationale: Shock position (legs elevated) is contraindicated in head injury due to increased intracranial pressure risk. Observing for head injury ensures safety before positioning.
Question 4 of 5
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse.
Correct Answer: A
Rationale: A blood sugar of 50 mg/dL indicates hypoglycemia, characterized by confusion, cold, clammy skin, and tachycardia (pulse 110) due to sympathetic activation. Hyperglycemia causes hot, dry skin and rapid respirations, while normal or fluid overload symptoms do not apply.
Question 5 of 5
The nurse is caring for a client with a history of depression.
Correct Answer: A
Rationale: Feeling like their old self indicates improved mood and function, a positive response to antidepressants. Stopping medication prematurely, excessive sleep, or persistent sadness suggest inadequate response or side effects.