NCLEX-PN
NCLEX Trainer Test 10 Questions
Extract:
A client with internal radiation.
Question 1 of 5
Which of the following actions, if taken by the nurse, is MOST important?
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) all visitors are restricted with regard to the distance they should be from the client (2) not relevant to the situation (3) correct-principles for radiation therapy are time, distance, shielding; nurse should decrease the time spent in close proximity to the client (4) appropriate shielding (lead aprons) is to be used when the nurse has to spend any length of time at a close distance, not just for routine care
Extract:
An elderly client receiving IV fluids of 0.9% NaCl at 125 cc/h into her left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases.
Question 2 of 5
The nurse should
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) correct-KVO (20 cc/h) will keep access open (2) need to notify physician, rate still too much since patient is in fluid overload (3) IV line may be necessary, diuretics may be ordered (4) description indicates circulatory overload, not infiltration
Extract:
Question 3 of 5
The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST important for the nurse to ask?
Correct Answer: A
Rationale: client given general anesthesia for ECT; NPO after midnight
Question 4 of 5
A client admitted four days ago for treatment of alcohol dependence is now displaying the following symptoms: slurred speech, ataxia, uncoordinated movements, and headache. Which of the following nursing actions should be taken FIRST?
Correct Answer: B
Rationale: best way to identify possible physical complications of alcohol dependence is through a complete physical assessment
Question 5 of 5
The nurse is preparing to administer digoxin (Lanoxin) to a client. The client's apical pulse is 56 beats per minute. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: digoxin is held if the apical pulse is below 60 beats per minute in adults to prevent toxicity