NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
Question 1 of 5
The nurse notes that the client has a pulse deficit. What is the most appropriate action for the nurse?
Correct Answer: C
Rationale: A pulse deficit indicates irregular heartbeats, requiring immediate physician notification to assess for arrhythmias.
Question 2 of 5
One hour after receiving 7 U of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. The priority nursing action would be to
Correct Answer: C
Rationale: Diaphoresis, pallor, and tachycardia indicate hypoglycemia, a medical emergency. Milk and crackers provide fast-acting carbohydrates. Options A, B, and D delay treatment or are reserved for severe cases.
Question 3 of 5
The nurse is caring for a client with a history of peptic ulcer disease who is receiving ranitidine (Zantac) 150 mg PO bid. Which of the following symptoms should the nurse report immediately?
Correct Answer: C
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious complication in peptic ulcer disease. Options A, B, and D are less urgent.
Question 4 of 5
The nurse is caring for a client who is 4 days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty his colostomy pouch. What is the best response by the nurse?
Correct Answer: D
Rationale: Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget that they have mastered the skill of emptying the pouch. The client should show the nurse how the pouch is emptied.
Question 5 of 5
The nurse is caring for an adult who had a cervical laminectomy this morning. After an uneventful stay in the postanesthesia care unit, the client is returned to the nursing care unit. How should the client be positioned immediately upon return?
Correct Answer: C
Rationale: Semi-reclining reduces neck strain and swelling post-cervical laminectomy, promoting comfort and healing. Supine or prone may increase pressure, and side-lying is less optimal.