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 preoperative client is from a different country and tells the nurse that his family will be coming for a prayer service. Eighteen persons arrive and start chanting in the client's semiprivate room. What is the best response for the nurse?
Correct Answer: D
Rationale: Arranging for a private space respects cultural practices while minimizing disruption to the roommate, balancing sensitivity and practicality.
Question 3 of 5
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
Correct Answer: A
Rationale: Clopidogrel is an antiplatelet medication that can increase the risk of bleeding, such as epistaxis (nosebleeds). Abdominal distention, nausea, and hyperactivity are not typical adverse effects of clopidogrel, so answers B, C, and D are incorrect.
Extract:
A student nurse caring for a client while wearing a gown and gloves in addition to following standard precautions.
Question 4 of 5
The nurse should determine that care is appropriate if the student nurse performs which of the following activities?
Correct Answer: D
Rationale: Strategy: Determine how the organism of each disease is spread. (1) requires airborne precautions, particulate respirator (2) requires droplet precautions, nurse should wear a mask (3) requires standard precautions (4) correct-requires contact precautions
Extract:
Question 5 of 5
A client with tuberculosis is started on Rifampin. Which one of the following statements by the nurse would be appropriate to include in teaching? 'You may notice:
Correct Answer: A
Rationale: Discoloration of the urine and other body fluids may occur. It is a harmless response to the drug, but the patient needs to be aware it may happen.