NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of seizures.
Correct Answer: C
Rationale: Turning the client to the side during a seizure maintains an open airway, preventing aspiration and ensuring oxygenation, which is the priority. Restraining limbs risks injury, tongue blades are contraindicated, and medication administration follows airway management.
Question 2 of 5
When admitting a client who has acute glomerulonephritis, the nurse expects that the client will report which information?
Correct Answer: C
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis. Bladder/kidney infections or sexual partners are less directly related.
Question 3 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication in diabetic ketoacidosis treatment, as insulin drives potassium into cells, risking arrhythmias. Options A, C, and D are less urgent: glucose 200 mg/dL is improving, pH 7.30 is near normal, and sodium 135 mEq/L is normal.
Question 4 of 5
The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: A temperature of 100.4°F suggests worsening infection or inadequate antibiotic coverage, requiring immediate evaluation. Options A, C, and D are less concerning: WBC 12,000/mm^3 is expected, urine output 50 mL/hour is normal, and blood pressure 120/80 mmHg is stable.
Question 5 of 5
The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client prior to removing the drain?
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the wound. Normal breathing , deep breaths , or slow breathing may increase complications.