NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?
Correct Answer: B
Rationale: Sense of impending doom. The feeling of overwhelming and uncontrollable doom is characteristic of a panic attack.
Question 2 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: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
Extract:
A postoperative appendectomy client who is complaining of incisional pain. A diabetic client who had a cardiac catheterization in the early AM. A postoperative cholecystectomy client who is complaining of incisional pain. A client with congestive heart failure who underwent diuresis in the hospital.
Question 3 of 5
The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
Correct Answer: D
Rationale: Strategy: Determine the least stable client. Remember the ABCs. (1) expected outcome, treat with analgesics (2) instruct no bending, straining, or lifting heavy objects for 24 hours, observe for bleeding, swelling, new bruising at puncture site (3) expected outcome, treat with analgesics (4) correct-assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia
Extract:
Question 4 of 5
The nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse perform FIRST?
Correct Answer: C
Rationale: Hypoglycemia can mimic stroke symptoms; checking blood glucose is the first step to rule out treatable causes. Options A, B, and D are secondary.
Extract:
A client is admitted with irritable bowel syndrome.
Question 5 of 5
The nurse would anticipate the client's history to reflect which of the following?
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-condition is often called spastic bowel disease; no inflammation is present (2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (4) bloody stools do not occur