NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention?
Correct Answer: C
Rationale: Respiratory rate of 32. Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are tachypnea, dyspnea, and chest pain.
Question 2 of 5
The nurse is caring for clients on the neurology unit.
Correct Answer: D
Rationale: A fixed and dilated pupil is a neurological emergency, often indicating increased intracranial pressure or brain herniation. Immediate physician notification is critical to initiate interventions. Reassessing later delays care, checking visual acuity is irrelevant, and lowering the bed could worsen intracranial pressure.
Question 3 of 5
One hour after receiving 7 U of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. The priority nursing action would be to
Correct Answer: C
Rationale: Diaphoresis, pallor, and tachycardia indicate hypoglycemia, a medical emergency. Milk and crackers provide fast-acting carbohydrates. Options A, B, and D delay treatment or are reserved for severe cases.
Question 4 of 5
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of 'suppression'?
Correct Answer: A
Rationale: I don't remember anything about what happened to me. Suppression is willfully putting an unacceptable thought or feeling out of one's mind, used to protect one's self-esteem.
Question 5 of 5
A client who is about to be discharged from the acute care facility is receiving warfarin (Coumadin). The nurse should plan to teach the client which of the following?
Correct Answer: B
Rationale: Warfarin interacts with many over-the-counter medications, risking bleeding or reduced efficacy, so physician consultation is essential. Full stomach, aspirin, or sun exposure are not primary concerns.