NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
Correct Answer: A
Rationale: Steadily increasing vital signs (e.g., heart rate, blood pressure) indicate progression toward delirium tremens, a life-threatening complication of alcohol withdrawal, necessitating additional sedation. Mild tremors, decreased respirations, or gastroinTest inal symptoms are expected or contraindicate more sedation.
Question 2 of 5
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse.
Correct Answer: A
Rationale: A blood sugar of 50 mg/dL indicates hypoglycemia, characterized by confusion, cold, clammy skin, and tachycardia (pulse 110) due to sympathetic activation. Hyperglycemia causes hot, dry skin and rapid respirations, while normal or fluid overload symptoms do not apply.
Question 3 of 5
An adult had major abdominal surgery this morning under general anesthesia. When the client arrives in the recovery room, she is very lethargic and restless. Her BP is 150/98; pulse is 110 and irregular; and respirations are 30 breaths per minute and shallow. Postoperative orders include meperidine (Demerol) 75 mg IM for operative site pain; reinforce dressings PRN; oxygen at 6 L/min PRN; irrigate nasogastric tube every 2 hours and PRN; IV 2500 cc D5W in 24 hours. What should the nurse do next?
Correct Answer: D
Rationale: Tachypnea, tachycardia, and restlessness suggest hypoxia. Administering oxygen at 6 L/min addresses this critical need. Dressings, nasogastric irrigation, and pain medication are secondary to stabilizing oxygenation.
Question 4 of 5
A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push.
Correct Answer: B
Rationale: Severe hypotension is a serious side effect of procainamide, requiring the dose to be withheld to prevent cardiovascular collapse. PVCs and atrial tachycardia are arrhythmias the drug treats, and a normal sedimentation rate is irrelevant.
Question 5 of 5
A mentally retarded, nonverbal, ambulatory client is found sitting on the floor unable to get up. The LPN/LVN notes the client appears to be in great pain, and his right leg is out of alignment. What is the most important action for the nurse to take as the client is readied for ambulance transport?
Correct Answer: B
Rationale: Immobilizing the leg prevents further injury in a suspected fracture, the priority action before transport.