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
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
Question 3 of 5
A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include
Correct Answer: C
Rationale: suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies
Question 4 of 5
Which characteristic is most likely to be present in persons who abuse others?
Correct Answer: C
Rationale: Substance abuse is strongly associated with abusive behavior due to impaired judgment and aggression. Financial security, self-image, or illness are less predictive.
Question 5 of 5
A baby is delivered following a pregnancy complicated by gestational diabetes. What should the nurse observe the baby for?
Correct Answer: D
Rationale: Infants of mothers with gestational diabetes are at risk for hypoglycemia due to high fetal insulin levels from maternal hyperglycemia, requiring close monitoring.