NCLEX-PN
NCLEX Trainer Test 10 Questions
Extract:
An elderly client receiving IV fluids of 0.9% NaCl at 125 cc/h into her left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases.
Question 1 of 5
The nurse should
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) correct-KVO (20 cc/h) will keep access open (2) need to notify physician, rate still too much since patient is in fluid overload (3) IV line may be necessary, diuretics may be ordered (4) description indicates circulatory overload, not infiltration
Extract:
Question 2 of 5
The nurse is caring for a client with a long history of alcohol and drug dependence. It would be MOST important for the nurse to include which of the following as a part of his discharge planning?
Correct Answer: C
Rationale: self-help groups have greatest success rate as a sustained support system in the community
Question 3 of 5
A client has an order for a low-sodium, low-cholesterol diet. The nurse knows that which of the following selections reflects the client's compliance?
Correct Answer: C
Rationale: fresh fruits and vegetables are low sodium, roasted chicken is low cholesterol
Question 4 of 5
A client is started on doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should recommend a change in the client's therapy if which of the following occurs?
Correct Answer: B
Rationale: doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include excitability and tremors
Question 5 of 5
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space