NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a patient admitted two days ago with a diagnosis of closed head injury. If the patient develops diabetes insipidus, the nurse would observe which of the following symptoms?
Correct Answer: B
Rationale: signs of dehydration, increased output, low specific gravity, normal 1.010-1.030
Extract:
A client with a perforated bowel secondary to a bowel obstruction.
Question 2 of 5
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done
Extract:
Question 3 of 5
As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid
Correct Answer: B
Rationale: Scuba diving. The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to collapse again.
Question 4 of 5
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
Correct Answer: A
Rationale: Bradycardia. The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).
Question 5 of 5
A client receiving Eskalith (lithium carbonate) has a level of 4.5 mEq/L. The nurse should prepare the client for immediate:
Correct Answer: B
Rationale: A lithium level of 4.5 mEq/L indicates severe toxicity, requiring hemodialysis to rapidly remove lithium from the body.