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
The nursing care plan for a toddler diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
Correct Answer: D
Rationale: Coronary artery aneurysms. Kawasaki disease can lead to inflammation and aneurysms in coronary arteries.
Question 3 of 5
A low-sodium, high-potassium diet is ordered for a client. Which food selection made by the client indicates understanding of the prescribed diet?
Correct Answer: A
Rationale: Orange juice and vegetables are high in potassium and low in sodium, aligning with the prescribed diet, unlike milk, beef, or fried foods.
Question 4 of 5
The nurse is caring for a client who is postoperative day 1 after a total knee replacement. Which of the following actions should the nurse prioritize?
Correct Answer: C
Rationale: Applying the CPM machine prevents stiffness and promotes mobility post-knee replacement. Options A, B, and D are secondary.
Question 5 of 5
The nurse is caring for a client with a history of sickle cell disease.
Correct Answer: A
Rationale: Oxygen therapy improves oxygenation, reducing sickling and tissue hypoxia during a sickle cell crisis. Ambulation is limited, cold compresses worsen vasoconstriction, and fluids are encouraged to prevent dehydration.