NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
Extract:
The doctor writes an order for piperacillin (Pipracil) 3 g IV q6h for an adult client.
Question 2 of 5
Before administering this drug, the nurse should
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-assessment, piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) assessment, not relevant for administration of this medication (3) implementation, not relevant for administration of this medication (4) assessment, not relevant for administration of this medication
Extract:
Question 3 of 5
The nurse is caring for a client with a history of sickle cell disease.
Correct Answer: A
Rationale: Oxygen therapy improves oxygenation, reducing sickling and tissue hypoxia during a sickle cell crisis. Ambulation is limited, cold compresses worsen vasoconstriction, and fluids are encouraged to prevent dehydration.
Question 4 of 5
A woman is admitted to the labor and delivery unit in a sickle cell crisis.
Correct Answer: C
Rationale: Adequate hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and improve blood flow, reducing the risk of complications. Oxygen, repositioning, and antibiotics may be supportive but are not the primary intervention.
Question 5 of 5
The nurse in a long-term care facility wants to help a resident become continent of stools. Which is likely to be most helpful when planning care for the resident? Select all that apply.
Correct Answer: A,C,D
Rationale:
Toileting after meals leverages the gastrocolic reflex, fluids soften stool, and walking stimulates peristalsis, all promoting continence. Limiting fiber, listing foods, or discouraging snacking are less effective or counterproductive.