NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is preparing to administer an injection of haloperidol decanoate (Haldol D).
Correct Answer: B
Rationale: Haloperidol decanoate is highly irritating to subcutaneous tissue, requiring deep IM injection into a large muscle mass to ensure proper absorption and minimize irritation. Massaging the site, using a small-gauge needle, or dividing doses is inappropriate.
Question 2 of 5
The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results should the nurse report immediately?
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious valproic acid side effect. Options B, C, and D are normal.
Extract:
A client is receiving heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal.
Question 3 of 5
Which of the following actions by the nurse is MOST appropriate?
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer. (1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (3) prothrombin time (PT) Test is useful for assessing warfarin (Coumadin) therapy (4) correct-expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage
Extract:
An eight-year-old receiving chemotherapy for six months.
Question 4 of 5
Which of the following responses by the nurse is BEST?
Correct Answer: A
Rationale: Strategy: Remember therapeutic communication. (1) correct-encourages ventilation of thoughts and feelings regarding the concern (2) inappropriate (3) ignores the child's concern with dying (4) ignores the child's concern with dying
Extract:
Question 5 of 5
The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
Correct Answer: A
Rationale: Stating his name indicates orientation, a positive sign post-head injury. Options B, C, and D are less reassuring: reaching for a toy is nonspecific, opisthotonos suggests meningeal irritation, and withdrawal may occur in unconscious states.