NCLEX-PN
NCLEX Trainer Test 9 Questions
Extract:
Question 1 of 5
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.
Question 2 of 5
The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.
Question 3 of 5
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving salmeterol (Serevent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Shakiness suggests systemic beta-agonist effects, a concerning side effect of salmeterol in COPD, requiring evaluation to prevent tachycardia or arrhythmias. Options A, B, and D are less concerning: twice-daily use is standard, dry mouth is common, and rinsing is appropriate.
Question 4 of 5
A 15-month old is admitted in sickle crisis. The parents ask why the child did not have any symptoms until now. What should be included in the nurse's response?
Correct Answer: D
Rationale: High fetal hemoglobin (HbF) in infants inhibits sickling, delaying sickle cell anemia symptoms until HbF decreases around 6-12 months, replaced by adult hemoglobin.
Extract:
A client taking phenelzine (Nardil) eating another client's lunch, then complaining of headache, nausea, rapid heartbeat, and vomiting.
Question 5 of 5
The nurse anticipates administering which of the following medication?
Correct Answer: D
Rationale: Strategy: Think about the action of each medication. (1) antianxiety; side effects include light-headedness, confusion, hypotension, palpitations (2) SSRI antidepressant; side effects include palpitation, bradycardia, nausea and vomiting (3) antiemetic; side effects include drowsiness, orthostatic hypotension (4) correct-antihypertensive; client experiencing hypertensive crisis due to ingesting tyramine; side effects include dizziness, headache, nervousness