NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
A client who is receiving hydralazine (Apresoline) q6h has a blood pressure of 90/60.
Question 1 of 5
Which of the following nursing actions would be MOST appropriate?
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of the implementations. (1) correct-BP of 90/60 is too low for an additional dose of medication, withholding the medication and checking with the doctor is appropriate (2) assessment, appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance (3) unnecessary (4) appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance
Extract:
Question 2 of 5
An adult is admitted to the unit with a fractured femur and will be in Buck's extension traction for several days. The client tells the nurse that she has all of the following. Which is likely to cause the client the most problems at this time?
Correct Answer: B
Rationale: Hiatal hernia can be exacerbated by prolonged immobility in traction, increasing reflux and discomfort. Hypertension, finger osteoarthritis, and high cholesterol are less directly impacted by traction.
Question 3 of 5
A 16-year-old client is admitted for elective surgery. The LPN is asked to have the child's mother sign the operative permit. Which action by the nurse is most appropriate?
Correct Answer: A
Rationale: For minors, a parent or guardian must sign the operative permit, as they provide legal consent for the procedure.
Question 4 of 5
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of 'suppression'?
Correct Answer: A
Rationale: I don't remember anything about what happened to me. Suppression is willfully putting an unacceptable thought or feeling out of one's mind, used to protect one's self-esteem.
Question 5 of 5
Promethazine hydrochloride (Phenergan) 25 mg IV push has been ordered for a patient. Before administering this medication to the patient, the nurse should check the
Correct Answer: D
Rationale: is very important to determine absolute patency of the vein; extravasation will cause necrosis