NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
At 11 AM a patient returned to the nursing unit from the postanesthesia care unit (PACU) following a hemorrhoidectomy. At noon the patient complains of pain. The physician has ordered meperidine (Demerol) 50 mg IV q 3-4 hrs. The chart indicates that the patient was given Demerol 50 mg IV at 9:15 AM.
Question 1 of 5
The nurse should
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no reason to call the physician (2) can't change amount of medication ordered by physician (3) medication is ordered every 3 to 4 hours, should not wait if patient needs medication after 3 hours (4) correct-give patient the medication as ordered
Extract:
Question 2 of 5
The mother of a 10-year-old boy with IDDM (insulin-dependent diabetes mellitus) calls to discuss the child’s self-monitoring blood glucose (SMBG) home readings. He is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past two mornings his blood sugar readings were 220 mg/dL and 210 mg/dL. The nurse should advise the mother to
Correct Answer: B
Rationale: High morning blood sugars suggest rebound hyperglycemia (Somogyi effect) from nocturnal hypoglycemia, requiring nighttime glucose checks. Options A, C, and D are premature: continuing the regimen ignores the issue, and adjusting insulin or snack timing requires confirmation.
Extract:
A client has returned to the floor from thyroidectomy surgery.
Question 3 of 5
After a client has returned to the floor from thyroidectomy surgery, it is MOST important for the nurse to take which of the following actions?
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Determine what assessment is being made in each answer choice. (1) assessment is not specific to this surgery (2) assessment, method used to monitor for postoperative hemorrhage in a tonsillectomy client (3) correct-assessment, after surgery, swelling can occur, which causes respiratory distress (4) implementation, head of the bed should be elevated
Extract:
Question 4 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 client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Muscle cramps suggest hyperkalemia, a serious side effect of spironolactone, a potassium-sparing diuretic, requiring immediate evaluation to prevent arrhythmias. Options A, B, and D are less concerning: fatigue and dry mouth are nonspecific, and taking with food is acceptable.
Question 5 of 5
The nurse's neighbor complains to the nurse that he feels tired all the time. Which comment suggests to the nurse that the man may have a serious sleep disorder?
Correct Answer: A
Rationale: Snoring may indicate sleep apnea, a serious disorder causing fatigue, unlike napping, early waking, or muscle jerks, which are less concerning.