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
A client who is withdrawing from alcohol says to the nurse, 'There are snakes on the wall.' Which action should the nurse take initially?
Correct Answer: C
Rationale: Acknowledging the hallucination (delirium tremens) as perceived but clarifying reality reduces agitation without confrontation. Reassurance or lighting changes are less effective.
Question 3 of 5
The nurse is caring for a client who is receiving intravenous fluid therapy. Which observation needs to be reported to the charge nurse?
Correct Answer: D
Rationale: A cool, blanched infusion site suggests infiltration or extravasation, requiring immediate reporting to prevent tissue damage. Cool fluid sensation, tape, or ambulation are normal.
Question 4 of 5
The nurse is caring for a client receiving chemotherapy.
Correct Answer: B
Rationale: A temperature of 100.8°F indicates possible infection, a life-threatening complication in chemotherapy patients due to immunosuppression. Nausea, fatigue, and alopecia are expected side effects but less urgent.
Question 5 of 5
Prior to suctioning a tracheotomy, the nurse should:
Correct Answer: B
Rationale: Administering oxygen pre-suctioning prevents hypoxia, as suctioning can reduce oxygen levels. Oropharyngeal suctioning, cannula changes, or bed elevation are not primary pre-suction steps.