NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
A client is receiving heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal.
Question 1 of 5
Which of the following actions by the nurse is MOST appropriate?
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer. (1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (3) prothrombin time (PT) Test is useful for assessing warfarin (Coumadin) therapy (4) correct-expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage
Extract:
Question 2 of 5
A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to
Correct Answer: B
Rationale: The nurse must initially assist in stabilizing the patient prior to performing the other tasks related to radiologic contamination.
Extract:
A young female with recent ileostomy due to ulcerative colitis. A middle-aged male with elevated temperature and chronic pancreatitis. A teenager in hypovolemic shock following a crushing injury to the chest. A child with compound fracture of the right femur and massive laceration of the left arm.
Question 3 of 5
The nurse would identify which of the following patients as a likely candidate for developing acute renal failure?
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to acute renal failure. (1) usually ileostomy clients do not experience severe hypovolemia, which would lead to renal failure problems (2) this type of infection and inflammation does not lead to acute renal failure (3) correct-common cause of acute renal failure is renal ischemia precipitated by hypovolemia or heart failure (4) femoral fractures are more likely to lead to fat embolism than acute renal failure
Extract:
Question 4 of 5
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease (PID). The nurse recognizes that this condition most frequently follows which type of infection?
Correct Answer: B
Rationale: Chlamydia. Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.
Question 5 of 5
The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client prior to removing the drain?
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the wound. Normal breathing , deep breaths , or slow breathing may increase complications.