NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously every 12 hours. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A platelet count of 100,000/mm^3 suggests thrombocytopenia, a serious complication of heparin therapy, increasing bleeding risk and possibly indicating heparin-induced thrombocytopenia. Options B, C, and D are normal or less concerning: INR and PTT are not significantly affected by subcutaneous heparin, and hemoglobin 14 g/dL is normal.
Extract:
A 52-year-old woman has an appendectomy for a ruptured appendix. The nurse observes a student nurse perform a wet-to-dry dressing change on the 2-in incision.
Question 2 of 5
Which of the following behaviors, if performed by the student nurse, would require an intervention by the nurse?
Correct Answer: A
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) correct-should be removed dry so wound debris and necrotic tissue are removed with old dressing (2) done to protect clothing and bedding (3) purpose of wet-to-dry dressing (4) appropriate procedure
Extract:
Question 3 of 5
Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce information about cancers to a group of young adults?
Correct Answer: A
Rationale: It is recommended that only red meat be limited for the prevention of stomach cancer. All of the other statements offer correct information.
Question 4 of 5
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client.
Correct Answer: C
Rationale: Prochlorperazine (Compazine) is incompatible with other medications in the same syringe, so it must be drawn and administered separately from Stadol. Monitoring vital signs (e.g., blood pressure for orthostatic hypotension) is important but not the priority before administration. Dilution and route verification are unnecessary.
Question 5 of 5
A client recently diagnosed with bipolar disorder expresses concern over taking Eskalith (lithium carbonate) because 'a lot of people have problems getting too much of it.' The nurse should explain that lithium toxicity typically occurs when the client has an insufficient intake of:
Correct Answer: D
Rationale: Lithium toxicity occurs with insufficient sodium and fluids, as low sodium increases lithium reabsorption in kidneys, and fluids aid excretion. Other nutrients are less directly related.