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 insulin for diabetic ketoacidosis. Which of the following laboratory results should the nurse report immediately?
Correct Answer: B
Rationale: Hypokalemia (3.0 mEq/L) risks arrhythmias during insulin therapy for DKA. Options A, C, and D are less urgent.
Question 2 of 5
The newborn infant of an HIV-positive mother is admitted to the nursery.
Correct Answer: A
Rationale: Standard precautions are the immediate priority to protect staff and others from potential HIV transmission. HIV Test ing and AZT may be considered later, and transfer is unnecessary without clinical indication.
Question 3 of 5
Following a coronary artery bypass, a client develops a temperature of 102°. The nurse should notify the doctor because an elevation in temperature:
Correct Answer: B
Rationale: A fever increases metabolic demand, which can decrease cardiac output in a post-bypass patient, potentially straining the heart.
Question 4 of 5
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
Correct Answer: A
Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway.
Therefore, the obstruction has increased or worsened.
Question 5 of 5
The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
Correct Answer: B
Rationale: Place the client in a sitting position with legs dangling. This reduces venous return, alleviating pulmonary edema symptoms.