NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who was admitted following a motor vehicle accident. The client's blood pressure one hour ago was 118/76, and pulse was 80; now the blood pressure is 90/60, and pulse is 98. What action should the nurse take initially?
Correct Answer: D
Rationale: A significant drop in blood pressure with increased pulse suggests shock or bleeding, requiring immediate physician notification. Monitoring, rechecking, or leg elevation delays care.
Question 2 of 5
A 15-month-old child has just been diagnosed with sickle cell anemia. The mother is pregnant and asks if the child she is carrying will also have sickle cell anemia. She says that neither she nor her husband has sickle cell anemia. The nurse's reply should be based on which understanding?
Correct Answer: B
Rationale: Sickle cell anemia is autosomal recessive; if both parents are carriers (trait), there's a 25% (1 in 4) chance per child of inheriting the disease, independent of gender or prior children.
Extract:
A two-year-old who is one-day postoperative.
Question 3 of 5
The mother of a two-year-old who is one-day postoperative tells the nurse, 'My child is so restless and overactive.' The nurse should
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. (1) no indication that there are any problems (2) passing the buck (3) implementation, should first assess (4) correct-young children typically become restless and overactive if in pain, grimacing, clenching teeth, rocking, and aggressive behavior may also be observed
Extract:
Question 4 of 5
The nurse is caring for a client with a history of anxiety who is receiving lorazepam (Ativan) 0.5 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Dizziness upon standing suggests orthostatic hypotension, a serious side effect of lorazepam, increasing fall risk and requiring evaluation. Options A, B, and D are less concerning: drowsiness and dry mouth are common, and taking with food is acceptable.
Question 5 of 5
An adult has completed an alcohol detoxification program and is being discharged with disulfiram (Antabuse). Which statement that the client makes indicates a need for more teaching?
Correct Answer: A
Rationale: Planning to drink alcohol (even minimally) while on disulfiram indicates misunderstanding, as it causes severe reactions with alcohol. Other statements show proper understanding.