NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
Question 1 of 5
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
Question 2 of 5
The nurse is caring for a client with a history of heart failure who is receiving lisinopril (Prinivil) 10 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.5 mEq/L) is a serious complication of lisinopril, an ACE inhibitor, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
Question 3 of 5
A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?
Correct Answer: C
Rationale: Obtain an interview guide from human resources for consistency in interviewing each candidate. An interview guide used for each candidate enables the nurse manager to be more objective in the decision making. The nurse should use resources available in the agency before attempts to develop one from scratch. Certain personal questions are prohibited, and HR can identify these for novice managers.
Extract:
A 28-year-old woman at 39-weeks gestation in active labor screams, 'I have to push, I have to push.' The nurse notes that the client is 8 cm dilated.
Question 4 of 5
The nurse should
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) pushing should be discouraged until the second stage of labor (2) would increase discomfort (3) is inappropriate at this time; this is a short, intense period of labor (4) correct-describes transition phase of labor, breathing technique allows patient to control pain and urge to push and promotes adequate oxygenation of fetus
Extract:
Question 5 of 5
An adult is receiving lithium carbonate 600 mg tid. Which of the following observations is of greatest concern to the nurse?
Correct Answer: B
Rationale: A low-sodium diet increases lithium retention, risking toxicity, a serious concern requiring immediate education or intervention.