NCLEX-PN
NCLEX Trainer Test 4 Questions
Extract:
A client is being treated for hypovolemia.
Question 1 of 5
Which of the following observations should the nurse identify as the desired response to fluid replacement?
Correct Answer: D
Rationale: Strategy: Determine the significance of each answer choice and how it relates to hypovolemia. (1) indicates a hypovolemic state (2) indicates a hypovolemic state (3) indicates acidosis (4) correct-normal range for CVP is 3-8 cm water pressure (or 2-6 mm Hg); reading of 8 cm water pressure would indicate a desired response to fluid replacement
Extract:
Question 2 of 5
A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider?
Correct Answer: C
Rationale: Continue the same analgesic dosage. Dying patients who have been in chronic pain will probably continue to experience pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if effective.
Question 3 of 5
The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: B
Rationale: A temperature of 100.4°F suggests worsening infection or inadequate antibiotic coverage, requiring immediate evaluation. Options A, C, and D are less concerning: WBC 12,000/mm^3 is expected, urine output 50 mL/hour is normal, and blood pressure 120/80 mmHg is stable.
Extract:
A client has been brought into the emergency room for treatment of a suspected drug overdose. The client appears to be highly agitated, fearful, and may be hallucinating.
Question 4 of 5
The nurse should anticipate the client's need for
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate at this time because the client is not in contact with reality (2) may agitate the client further (3) correct-sensory stimulation would only increase agitation and could potentially lead to aggressive behavior and injury (4) not the priority at this time
Extract:
Question 5 of 5
Which of the following should the nurse include in his teaching plan for the client taking Vasopressin (Lypressin)?
Correct Answer: D
Rationale: Vasopressin is often administered nasally or by injection, so teaching the proper administration method is essential.