NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration and electrolyte imbalance in cirrhosis. Options A, B, and D are normal or expected: ammonia 40 mcg/dL is controlled, potassium 3.5 mEq/L is normal, and sodium 140 mEq/L is normal.
Question 2 of 5
The nurse is administering digoxin to a 6-month-old infant. Which finding would cause the nurse to withhold the medication and notify the charge nurse or the physician?
Correct Answer: A
Rationale: An apical heart rate below 100 in infants indicates bradycardia, a contraindication for digoxin due to toxicity risk, requiring withholding and reporting.
Question 3 of 5
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of 'suppression'?
Correct Answer: A
Rationale: I don't remember anything about what happened to me. Suppression is willfully putting an unacceptable thought or feeling out of one's mind, used to protect one's self-esteem.
Question 4 of 5
The nurse is caring for a client following removal of the thyroid. Immediately post-op the nurse should:
Correct Answer: A
Rationale: Semi-Fowler's position reduces swelling and supports the surgical site post-thyroidectomy. Turning the head or flexing the neck risks wound dehiscence. Supine with sandbags is unnecessary and uncomfortable.
Question 5 of 5
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
Correct Answer: D
Rationale: Decreased appetite. Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, and dysrhythmias.