NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
Correct Answer: B
Rationale: Emptying the pouch every morning is a rigid schedule that does not account for individual bowel patterns; it should be emptied when one-third to one-half full. Options A, C, and D are correct: changing when one-third full prevents leaks, high-fiber diets promote regularity, and skin checks prevent breakdown.
Question 2 of 5
A 48-year-old woman is diagnosed with a tumor of the pituitary gland and has a transsphenoidal hypophysectomy. The nurse plans care for the patient two days after surgery. It is MOST important for the nurse to monitor the patient's
Correct Answer: C
Rationale: Transsphenoidal hypophysectomy risks diabetes insipidus from ADH disruption, detected by low urine specific gravity. Options A, B, and D are less specific.
Question 3 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.
Question 4 of 5
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
Correct Answer: A
Rationale: Clopidogrel is an antiplatelet medication that can increase the risk of bleeding, such as epistaxis (nosebleeds). Abdominal distention, nausea, and hyperactivity are not typical adverse effects of clopidogrel, so answers B, C, and D are incorrect.
Question 5 of 5
A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?
Correct Answer: C
Rationale: Children with celiac disease should eat a gluten free diet. Potato chips are naturally gluten-free, unlike the other options which contain wheat-based ingredients.