NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
Question 2 of 5
The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?
Correct Answer: C
Rationale: Maternal hypertension. Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.
Question 3 of 5
A client who has a strong family history of breast cancer tells the nurse that she is taking a drug to prevent breast cancer. The nurse expects the drug that she is receiving is:
Correct Answer: A
Rationale: Tamoxifen is used for breast cancer prevention in high-risk individuals due to its anti-estrogenic effects. Cyclophosphamide and Doxorubicin are chemotherapy drugs, not preventive, so B and D are incorrect. Estrogen can increase breast cancer risk, making C incorrect.
Question 4 of 5
The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is
Correct Answer: A
Rationale: You think that someone wants to poison you? This acknowledges the client's perception, opening discussion and expressing doubt.
Extract:
A client who has overdosed on a large quantity of diazepam (Valium).
Question 5 of 5
Which of the following nursing actions should take priority during the first several days of this client's inpatient treatment?
Correct Answer: C
Rationale: Strategy: Think Maslow. (1) psychosocial, can be done after the client has been medically stabilized (2) psychosocial, can be done after the client has been medically stabilized (3) correct-physical, because of potentially life-threatening complications of depressant overdose such as respiratory failure, pulmonary edema, and seizures, nurse's priority is observation and documentation of vital signs (4) psychosocial, can be done after the client has been medically stabilized