NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units at bedtime. Which of the following symptoms should the nurse report immediately?
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin. Options A, C, and D are less urgent.
Question 2 of 5
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
Correct Answer: A
Rationale: Bradycardia. The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).
Question 3 of 5
A client on assisted ventilation develops a right-sided tension pneumothorax. Which of the following signs is associated with a right-sided tension pneumothorax?
Correct Answer: A
Rationale: Tension pneumothorax causes lung collapse, reducing breath sounds on the affected side (right). Tracheal deviation is toward the unaffected side (left).
Extract:
The nurse is caring for a client with organic brain syndrome in a long-term care facility.
Question 4 of 5
Which of the following actions by the nurse is BEST?
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) may not remember who or where he is (2) not as important as answer choice #4 (3) even with orientation, the client soon forgets (4) correct-geriatric client should be encouraged to talk about his life and important things in the past because he has recent memory loss
Extract:
Question 5 of 5
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room.
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage due to a meningeal rupture, a serious complication that risks meningitis and requires immediate reporting. Eyelid edema, minor bleeding, and withdrawal to pain are less urgent or expected findings.