NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.
Extract:
An infant is admitted for vomiting and diarrhea. The infant's anterior fontanelle is depressed, and he has a fever of 103.2°F (39.5°C).
Question 2 of 5
Which of the following nursing actions would be MOST appropriate?
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) assessment, correct information, but is not what the question asks for (2) correct-assessment, will assist in determining if hydration can be done through oral fluids alone (3) implementation, does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee that the infant is taking fluids (4) implementation, would be implemented later
Extract:
Question 3 of 5
A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST?
Correct Answer: D
Rationale: symptoms of pulmonary edema; requires immediate attention
Extract:
A five-year-old boy in the playroom.
Question 4 of 5
The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a five-year-old boy?
Correct Answer: B
Rationale: Strategy: Picture the child. (1) play begins to be cooperative at this age (2) correct-imitative behavior seen at this age (3) too advanced for this age (4) too regressed for this age
Extract:
At an inpatient psychiatric unit, a 40-year-old woman insists on staying in her room and repeatedly comments to the nurse: 'Special agents are here. Maybe you are one.'
Question 5 of 5
Which of the following responses, if made by the nurse, is BEST?
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication. (1) nontherapeutic, fails to respond to feeling tone, trust builds through interactions (2) correct-patient experiencing delusion (persistent false belief), responds to feeling tone, acknowledges that patient believes it to be true, represents reality (3) statement of reassurance, but denies acceptance of patient's feelings (4) should not encourage patient to explain delusions, would serve to reinforce them