NCLEX-PN
NCLEX Trainer Test 7 Questions
Extract:
Question 1 of 5
The nurse’s INITIAL priority when managing a physically assaultive client is to
Correct Answer: C
Rationale: Restoring the client’s self-control is the initial priority to ensure safety and prevent escalation. This involves assessing the situation, using psychological or chemical interventions, and possibly physical control. Room restriction, supervision, or clearing the area are secondary or impractical during rapid escalation.
Question 2 of 5
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.8 mEq/L) is a serious complication of spironolactone, a potassium-sparing diuretic, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
Extract:
A primigravida client, 10-days postpartum, who is anxious about caring for her newborn. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.
Question 3 of 5
The homecare nurse is scheduling clients for the day. Which of the following clients should the nurse visit FIRST?
Correct Answer: C
Rationale: Strategy: Identify the least stable client by eliminating the more stable clients. (1) psychosocial need, physical issues take priority (2) complaints require follow-up, but not the most unstable client (3) correct-describes subcutaneous emphysema, which is indication of pneumothorax; observe client for respiratory distress, contact physician (4) postural hypotension a side effect of diuretic therapy, change position slowly
Extract:
Question 4 of 5
Which of the following indicates that a client is beginning to develop a trusting relationship with the nurse?
Correct Answer: B
Rationale: Sharing feelings indicates trust, a key to therapeutic relationships. Options A, C, and D are less direct indicators.
Question 5 of 5
While a client is receiving TPN, it is MOST important for the nurse to monitor
Correct Answer: C
Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.