NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
Question 2 of 5
The nurse is teaching the client with an ileal conduit regarding skin care to prevent excoriation. In addition to applying a well-fitted collection bag the client should be told to empty the collection bag:
Correct Answer: D
Rationale: The client should be told to empty the collection bag when it is one-third full. Answer A isn't necessary or feasible, so it is incorrect. Waiting until the collection bag is half full or more as suggested in answers B and C increases the likelihood of skin exposure to urine thereby contributing to excoriation.
Question 3 of 5
The nurse observes the certified nursing assistant doing all of the following. Which action needs correction?
Correct Answer: A
Rationale: Changing dressings requires nursing judgment and sterile technique, outside a CNA's scope. Other actions are within their role.
Question 4 of 5
A client with acromegaly will most likely experience which symptom?
Correct Answer: A
Rationale: Acromegaly, caused by excess growth hormone, often leads to bone pain due to bone overgrowth. Infections , fatigue , and weight loss are less specific symptoms.
Question 5 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: D
Rationale: An oxygen saturation of 90% is low, indicating hypoxemia, a serious complication of propofol due to respiratory depression, requiring immediate intervention. Options A, B, and C are acceptable: respiratory rate 12 breaths/min, blood pressure 100/60 mmHg, and heart rate 80 bpm are stable.