NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range for heparin (60–80 seconds), increasing bleeding risk, requiring immediate adjustment. Options B, C, and D are normal: INR is unaffected, platelet count 150,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.
Question 2 of 5
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
Correct Answer: D
Rationale: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.
Extract:
An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home.
Question 3 of 5
Which of the following statements, if made by the mother to the nurse, would require further teaching by the nurse?
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents increased pressure on area (2) should check level of consciousness and orientation every 3-4 hours (3) avoid use of sedatives, sleeping pills, alcohol with head injuries (4) correct-no strenuous activity for 48 hours
Extract:
A client has severe second- and third-degree burns over 75% of his body.
Question 4 of 5
The nurse would be MOST concerned if which of the following was observed?
Correct Answer: C
Rationale: Strategy: Determine how each answer relates to burns. (1) insignificant for burn client (2) may be due to pain (3) correct-body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain
Extract:
An adult male developed diabetes insipidus following a craniotomy.
Question 5 of 5
Which of the following statements, if made by the client, would indicate that further teaching is needed?
Correct Answer: C
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) disorder or water metabolism caused by deficiency of ADH (antidiuretic hormone) by pituitary gland, symptoms are increased urinary output (4-30 L/24 h), dilute urine with specific gravity less than 1.005 (2) normal specific gravity 1.003-1.030 (3) correct-weight gain should be reported to physician, may need medication adjusted (4) desmopressin (DDAVP) nasally or SQ required for remainder of life