NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of heart failure who is receiving lisinopril (Prinivil) 10 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a serious complication of lisinopril, an ACE inhibitor, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
Question 2 of 5
A client with bipolar disorder receives Eskalith (lithium carbonate) bid. Which observation is associated with lithium toxicity?
Correct Answer: C
Rationale: Ataxia , or impaired coordination, is a sign of lithium toxicity. Hyporeflexia is not typical. Akathesia is restlessness, often linked to antipsychotics. Petechiae indicate bleeding issues, not lithium toxicity.
Extract:
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
Question 3 of 5
The nurse would be MOST concerned by which of the following?
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
Extract:
Question 4 of 5
A woman is admitted to the labor and delivery unit in a sickle cell crisis.
Correct Answer: C
Rationale: Adequate hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and improve blood flow, reducing the risk of complications. Oxygen, repositioning, and antibiotics may be supportive but are not the primary intervention.
Question 5 of 5
An adult is admitted with suspected urolithiasis. Which nursing diagnosis is of highest priority when planning nursing care for this client immediately after admission?
Correct Answer: A
Rationale: Kidney stones cause severe pain, making acute pain the priority diagnosis for immediate relief and comfort. Other diagnoses are secondary.