NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Question 1 of 5
Which of the following responses by the nurse is the BEST?
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
Extract:
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 cc 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity.
Question 2 of 5
It is MOST important for the nurse to take which of the following actions?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antibiotic should be administered within one hour (2) unnecessary for safe infusion (3) correct-when using a gravity drip, piggyback fluid level needs to be higher than primary infusion (4) unnecessary for safe infusion
Extract:
Question 3 of 5
Which diet selection contains the most potassium and should be removed from the tray of the client with renal failure?
Correct Answer: B
Rationale: Baked potatoes are high in potassium, which is restricted in renal failure to prevent hyperkalemia. Peach , marshmallows , and bread have lower potassium content.
Question 4 of 5
The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:
Correct Answer: B
Rationale: Outcome criteria need to be specific, measurable, and realistic. Talking for 10 minutes meets all of these conditions.
Question 5 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Facial flushing and itching suggest red man syndrome, a serious reaction to vancomycin, requiring immediate slowing of the infusion or antihistamine administration. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 90 bpm, and urine output 50 mL/hour are stable.