NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Thoughts of self-harm indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on sertraline. Options A, B, and D are common side effects of SSRIs (fatigue, insomnia, dry mouth) and less urgent.
Question 2 of 5
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the 'unfreezing' phase of change. With this approach the nurse manager should:
Correct Answer: B
Rationale: Explain to the unit staff why change is necessary. The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it.
Question 3 of 5
In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must
Correct Answer: B
Rationale: Breathe once every 5 compressions. For a 5 year-old, the nurse should give 1 breath for every 5 compressions.
Question 4 of 5
A low-sodium, high-potassium diet is ordered for a client. Which food selection made by the client indicates understanding of the prescribed diet?
Correct Answer: A
Rationale: Orange juice and vegetables are high in potassium and low in sodium, aligning with the prescribed diet, unlike milk, beef, or fried foods.
Question 5 of 5
The registered nurse has just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses?
Correct Answer: D
Rationale: Safety. A depressed client is at acute risk for self-destructive behavior, making safety the priority.