NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is performing a post-op assessment of an elderly client with a total hip repair. Although he has not requested medication for pain, the nurse suspects that the client's discomfort is severe and prepares to administer pain medication. Which of the following signs would not support the nurse's assessment of acute post-op pain?
Correct Answer: D
Rationale: Acute pain typically increases heart rate, blood pressure, and pupil dilation. Decreased heart rate is not consistent with acute pain.
Question 2 of 5
An adult client who has a fractured tibia is ordered to take one baby aspirin a day. He says to the nurse, 'I don't think the aspirin is doing any good. I still have pain.' What should the nurse include when replying to this client?
Correct Answer: A
Rationale: Low-dose aspirin is used to prevent thrombus formation in immobilized clients with fractures. It's not primarily for fever, pain, or inflammation in this context.
Question 3 of 5
The nurse is caring for a client with a history of anxiety who is receiving lorazepam (Ativan) 0.5 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Dizziness upon standing suggests orthostatic hypotension, a serious side effect of lorazepam, increasing fall risk and requiring evaluation. Options A, B, and D are less concerning: drowsiness and dry mouth are common, and taking with food is acceptable.
Question 4 of 5
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.
Question 5 of 5
Which of the following should the nurse include in his teaching plan for the client taking Vasopressin (Lypressin)?
Correct Answer: D
Rationale: Vasopressin is often administered nasally or by injection, so teaching the proper administration method is essential.