NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
A client in labor is receiving magnesium sulfate IV.
Question 1 of 5
Which assessment is MOST important to give during report to the nurse on the next shift?
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to magnesium sulfate. (1) not a concern because the respirations are increasing (2) not relevant to the medication (3) not relevant to the medication (4) correct-magnesium sulfate is a central nervous system depressant; side effect is oliguria
Extract:
Question 2 of 5
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room.
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage due to a meningeal rupture, a serious complication that risks meningitis and requires immediate reporting. Eyelid edema, minor bleeding, and withdrawal to pain are less urgent or expected findings.
Question 3 of 5
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
Correct Answer: A
Rationale: Bradycardia. The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).
Question 4 of 5
The nurse assesses an 18-month-old child brought to the well child clinic for a routine check-up. Which finding would be of most concern to the nurse?
Correct Answer: C
Rationale: Dropping objects handed to him suggests motor or neurological issues at 18 months, requiring evaluation. Creeping , not being toilet trained , and stranger anxiety are normal.
Question 5 of 5
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units subcutaneously at bedtime. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Sweating and irritability indicate hypoglycemia, a serious complication of insulin glargine, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 100 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.