NCLEX-PN
NCLEX Trainer Test 1 Questions
Extract:
Question 1 of 5
Which of the following infants is in need of additional growth assessment?
Correct Answer: B
Rationale: Baby B has gained only 1 oz. in 2 weeks, indicating poor growth (normal is 0.5-1 oz./day). Others show appropriate weight gain.
Question 2 of 5
The nurse is caring for a client who is postoperative day 1 after a gastrectomy. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-gastrectomy due to risk of anastomotic leak, requiring immediate evaluation. Options B, C, and D are expected: incision pain, NG tube output, and urine output 40 mL/hour are normal on day 1.
Question 3 of 5
The nurse is teaching a client with a new diagnosis of depression about fluoxetine (Prozac). Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: Suicidal thoughts are a serious fluoxetine side effect, requiring immediate reporting. Options A, C, and D are incorrect.
Question 4 of 5
A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
Correct Answer: C
Rationale: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate's skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.
Extract:
A client experiencing hallucinations.
Question 5 of 5
Which of the following behaviors by a client should the nurse record to indicate that the client is experiencing hallucinations?
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct-hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety