NCLEX-PN
NCLEX Trainer Test 3 Questions
Extract:
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
Question 1 of 5
The nurse would be MOST concerned by which of the following?
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
Extract:
Question 2 of 5
Which of the following statements is both a correctly stated nursing diagnosis and a high priority for a 65-year-old client immediately following a modified radical mastectomy and axillary dissection?
Correct Answer: C
Rationale: immediately after surgery, the priority is optimizing the client's comfort
Extract:
A 10-year-old for a cardiac catheterization.
Question 3 of 5
Which of the following plans would be MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization?
Correct Answer: C
Rationale: Strategy: Think about the developmental stage of a 10-year-old. (1) video will provide correct information but is not best preparation for a school-age child (2) pamphlet will contain correct information but is not best preparation for a school-age child (3) correct-this plan will best prepare the child for the procedure (4) would be more appropriate for a younger child
Extract:
A client describing seeing snakes on the walls of his room in a psychiatric facility.
Question 4 of 5
Based on this information, the nurse should identify a nursing diagnosis of
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist (2) not relevant to the data (3) not relevant to the data (4) not relevant to the data
Extract:
Question 5 of 5
The nurse is teaching a client with a new diagnosis of type 2 diabetes about insulin detemir (Levemir). Which of the following statements by the client indicates a need for further teaching?
Correct Answer: D
Rationale: Taking insulin detemir when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, rotation prevents lipodystrophy, and refrigeration preserves insulin.