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.
Question 2 of 5
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the 'unfreezing' phase of change. With this approach the nurse manager should:
Correct Answer: B
Rationale: Explain to the unit staff why change is necessary. The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it.
Question 3 of 5
Delirium tremens could best be described as
Correct Answer: C
Rationale: An excited state accompanied by disorientation, hallucination and tachycardia. Delirium tremens involves severe withdrawal symptoms, including confusion, hallucinations, and autonomic hyperactivity.
Extract:
The nurse is performing teaching for a client being discharged on clozapine (Clozaril).
Question 4 of 5
Which of the following client statements indicates to the nurse that teaching has been successful?
Correct Answer: B
Rationale: Strategy: 'Teaching has been successful' indicates a correct response. (1) follow routine schedule (2) correct-Clozaril causes agranulocytosis; requires weekly WBC; teach client to report early signs of infection (3) check with physician before taking any OTC medication (4) check with physician before ingesting alcohol
Extract:
Question 5 of 5
The nurse is caring for a client who is postoperative day 1 after a pancreaticoduodenectomy (Whipple procedure). Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-Whipple procedure due to extensive surgery, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.