NCLEX-PN
NCLEX Trainer Test 10 Questions
Extract:
Question 1 of 5
The nurse is caring for an 11-year-old girl being treated for a fractured right femur with balanced suspension traction with a Thomas ring and Pearson attachment. The physician orders 2 liters to be instilled with a dwell time of 40 minutes. The nurse measures the outflow and finds it to be 1,800 cc. During the nurse's shift, the client drinks 700 cc of fluids and voids 400 cc. The nurse should record which of the following on the client's intake and output sheet?
Correct Answer: B
Rationale: intake and output
Question 2 of 5
The nurse is preparing to administer digoxin (Lanoxin) to a client. The client's apical pulse is 56 beats per minute. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: digoxin is held if the apical pulse is below 60 beats per minute in adults to prevent toxicity
Question 3 of 5
The nurse is caring for a client who is postoperative day 1 following a total knee replacement. Which of the following findings should the nurse report to the physician immediately?
Correct Answer: B
Rationale: swelling and warmth may indicate infection or a deep vein thrombosis, which requires immediate attention
Question 4 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: the pouch should be emptied when one-third to one-half full, not on a fixed schedule
Question 5 of 5
The nurse is caring for a client receiving mechanical ventilation. The high-pressure alarm sounds. Which of the following actions should the nurse take FIRST?
Correct Answer: A
Rationale: high-pressure alarms are often caused by obstructions such as kinks in the tubing or mucus in the airway