NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of myasthenia gravis.
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, critical in myasthenia gravis due to immunosuppressive therapy. Pyridostigmine is taken with food, activity is encouraged, and blood pressure monitoring is not primary.
Question 2 of 5
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.
Question 3 of 5
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
Question 4 of 5
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is
Correct Answer: A
Rationale: Eat a balanced diet for your age. There are no recommended additions and subtractions from the diet for acne management.
Question 5 of 5
The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client's progress, the nurse recognizes that the most revealing resistant behavior is
Correct Answer: B
Rationale: Continuing drug use. Persistent substance use indicates lack of commitment to recovery and ongoing addiction.