NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?
Correct Answer: B
Rationale: For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client's choice to sign it.
Question 2 of 5
Which of the following findings is consistent with a diagnosis of congestive heart failure?
Correct Answer: A
Rationale: Jugular vein distention reflects increased fluid volume and right-sided heart failure, a hallmark of congestive heart failure. Other options are not specific to this condition.
Question 3 of 5
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min via nasal cannula. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: A temperature of 101°F suggests infection, a serious complication in COPD that can exacerbate respiratory distress. Options A, B, and D are acceptable: oxygen saturation 90% is adequate for COPD, respiratory rate 20 is normal, and heart rate 80 bpm is normal.
Question 4 of 5
The nurse is caring for a client who was in a motor vehicle accident. His blood pressure is dropping rapidly. What should the nurse observe the client for before placing the client in shock position?
Correct Answer: C
Rationale: Shock position (legs elevated) is contraindicated in head injury due to increased intracranial pressure risk. Observing for head injury ensures safety before positioning.
Question 5 of 5
A woman with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which of the following orders?
Correct Answer: D
Rationale: Propranolol, a non-selective beta-blocker, can cause bronchoconstriction, worsening COPD. Options A, B, and C are appropriate: theophylline bronchodilates, tetracycline treats infections, and ipratropium reduces bronchospasm.