NCLEX-PN
NCLEX Trainer Test 9 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.
Question 2 of 5
The nurse and a nursing assistant are preparing to move an elderly immobile client up in the bed using a sheet. The staff should be standing on opposite sides of the bed even with the client's:
Correct Answer: C
Rationale: Positioning at the shoulders aligns staff with the client's upper body, ensuring safe and effective movement.
Question 3 of 5
The nurse discovers that a hospitalized client is not breathing and has no pulse. After calling for help, what should the nurse do next?
Correct Answer: A
Rationale: Per CPR guidelines, after calling for help, provide two rescue breaths if trained, followed by compressions. Fetching the cart or defibrillating delays resuscitation.
Extract:
A client with an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L has digoxin (Lanoxin) ordered.
Question 4 of 5
Which of the following actions if taken by the nurse is BEST?
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) although the pulse is normal, level of potassium must be considered (2) notify physician about low potassium (3) correct-hypokalemia can precipitate digoxin toxicity; physician should be called to obtain order for potassium supplement (4) notify physician about the potassium level
Extract:
Question 5 of 5
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Dizziness may indicate systemic absorption or hypoxia, a serious concern in COPD requiring evaluation. Options A, B, and D are less concerning: four times daily is standard, dry mouth is a common side effect, and rinsing is appropriate.