NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal or less concerning: heart rate 80 bpm, blood pressure 120/80 mmHg, and temperature 99.5°F are stable.
Question 2 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: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
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.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: A skin rash may indicate a hypersensitivity reaction to allopurinol, requiring immediate reporting. Options A, C, and D are incorrect.