NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
Question 1 of 5
The nurse is providing home care to a confused older adult. The family members have tied the client in a chair with a large leather belt. They say the client wanders if he isn't restrained. What initial nursing action is most appropriate?
Correct Answer: C
Rationale: Helping the family create a safer environment addresses wandering non-restrictively, promoting safety and autonomy. Reporting, praising, or prohibiting are less constructive.
Question 2 of 5
The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: A temperature of 100.4°F suggests worsening infection or inadequate antibiotic coverage, requiring immediate evaluation. Options A, C, and D are less concerning: WBC 12,000/mm^3 is expected, urine output 50 mL/hour is normal, and blood pressure 120/80 mmHg is stable.
Question 3 of 5
The nurse is teaching a woman the normal changes of pregnancy. Which statement by the woman indicates correct understanding?
Correct Answer: C
Rationale: Pregnancy increases blood volume by about 50% to support fetal circulation, a correct understanding. Oxygen consumption and metabolic rate increase, and peristalsis slows.
Question 4 of 5
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
Correct Answer: B
Rationale: Alteplase (tP
A) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.
Question 5 of 5
A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider?
Correct Answer: C
Rationale: Continue the same analgesic dosage. Dying patients who have been in chronic pain will probably continue to experience pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if effective.