NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of heart failure who is receiving metoprolol (Lopressor) 50 mg PO bid. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A heart rate of 50 bpm indicates bradycardia, a serious side effect of metoprolol, a beta-blocker, requiring immediate evaluation to prevent reduced cardiac output. Options B, C, and D are normal: blood pressure 130/80 mmHg, respiratory rate 18 breaths/min, and oxygen saturation 95% are stable.
Question 2 of 5
The nurse is administering terbutaline (Brethine) to a client in labor.
Correct Answer: A
Rationale: Terbutaline causes maternal tachycardia, and a pulse of 144 indicates a significant side effect. Withholding the medication is the priority to prevent further complications like pulmonary edema. Reducing the dose, administering, or delaying without action is unsafe.
Question 3 of 5
The client who is receiving hydantoin (Dilantin) tells the nurse his urine is pink-colored. What action should the nurse take?
Correct Answer: C
Rationale: Pink urine may result from dietary factors like cranberry juice or red gelatin, which should be ruled out before assuming a Dilantin-related issue.
Question 4 of 5
The greatest threat during the immediate post-burn period results from burn shock. Which of the following statements best describes why burn shock occurs?
Correct Answer: A
Rationale: Burn shock occurs due to histamine release causing vasodilation and increased capillary permeability, leading to fluid loss from the vascular to interstitial space.
Question 5 of 5
The nurse assesses an 18-month-old child brought to the well child clinic for a routine check-up. Which finding would be of most concern to the nurse?
Correct Answer: C
Rationale: Dropping objects handed to him suggests motor or neurological issues at 18 months, requiring evaluation. Creeping , not being toilet trained , and stranger anxiety are normal.