NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of deep vein thrombosis who is receiving warfarin (Coumadin) 5 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: An INR of 3.5 is above the therapeutic range (2.0–3.0) for DVT, increasing bleeding risk, requiring dose adjustment. Options B, C, and D are normal: PTT is unaffected, platelet count 200,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.
Question 2 of 5
The nurse is caring for a client who is postoperative day 1 after a prostatectomy. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-prostatectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, high urinary output, and blood-tinged urine are normal on day 1.
Question 3 of 5
The client with multiple myeloma is admitted and prescribed cyclophosphamide (Cytoxan). During the treatment, the nurse should instruct the client to:
Correct Answer: B
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, so reporting hematuria is critical. Fiber, antacids, and activity are not directly related to this medication's side effects.
Extract:
A client who is receiving a tube feeding around the clock.
Question 4 of 5
Which of the following nursing actions is MOST appropriate?
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-there is an increased growth of organisms after four hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis
Extract:
A client who has been complaining of dysuria, urinary frequency, and discomfort in the suprapubic area.
Question 5 of 5
After evaluating the results, the nurse should order a repeat urinalysis based on which of the following findings?
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates a bladder infection. (1) glucose increases during the inflammation process; it is not a primary component in determining urinary tract infections (2) not as complete a response as answer choice #3 (3) correct-with the client's complaints, WBCs and RBCs should be present; WBCs are a response to the inflammation process and irritation of the urethra; RBCs are increased when bladder mucosa is irritated and bleeding (4) indicates the concentration of the urine