NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant's mother made which of the following statements?
Correct Answer: A
Rationale: An eight-month-old should have doubled birth weight by 5–6 months; 'almost doubled' suggests growth delay, requiring evaluation. Options B, C, and D are normal behaviors.
Extract:
A client who has overdosed on a large quantity of diazepam (Valium).
Question 2 of 5
Which of the following nursing actions should take priority during the first several days of this client's inpatient treatment?
Correct Answer: C
Rationale: Strategy: Think Maslow. (1) psychosocial, can be done after the client has been medically stabilized (2) psychosocial, can be done after the client has been medically stabilized (3) correct-physical, because of potentially life-threatening complications of depressant overdose such as respiratory failure, pulmonary edema, and seizures, nurse's priority is observation and documentation of vital signs (4) psychosocial, can be done after the client has been medically stabilized
Extract:
Question 3 of 5
The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding, the nurse should plan to
Correct Answer: A
Rationale: restrict visitors to immediate family. Maintaining a quiet environment will assist in minimizing cerebral rebleeding. When family visit, the client should not be disturbed. If the client is awake, topics of a general nature are better choices for discussion than topics that result in emotional or physiological stimulation.
Question 4 of 5
The nurse is to remove an indwelling urinary catheter from an adult client. Which step should be done first?
Correct Answer: B
Rationale: Withdrawing fluid from the balloon deflates it, allowing safe catheter removal without urethral trauma. Cutting, clamping, or pulling without deflation risks injury.
Question 5 of 5
The nurse is caring for a client with a history of bipolar disorder who is receiving lithium 300 mg PO tid. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A lithium level of 2.0 mEq/L is toxic (therapeutic range 0.6–1.2 mEq/L), risking seizures or coma, requiring immediate intervention. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and creatinine 1.0 mg/dL do not indicate complications.