NCLEX-PN
NCLEX Trainer Test 6 Questions
Extract:
Question 1 of 5
While caring for a child who had a revision of a ventriculoperitoneal shunt, the nurse notes clear drainage from the incision. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Clear drainage may indicate cerebrospinal fluid (CSF) leak; checking for glucose with a Dextrostik confirms CSF, which requires immediate action.
Question 2 of 5
The nurse assesses the use of coping mechanisms by an adolescent 1 week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be displayed?
Correct Answer: B
Rationale: Helplessness and hopelessness may contribute to regressive, dependent behavior which often occurs at any age with hospitalization. Denying or minimizing the seriousness of the illness is used to avoid facing the worst situation. Recall that denial is the initial step in the process of working through any loss.
Question 3 of 5
If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
Correct Answer: C
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site to prevent bleeding and complications.
Question 4 of 5
The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: D
Rationale: An oxygen saturation of 90% is low, indicating hypoxemia, a serious complication of propofol due to respiratory depression, requiring immediate intervention. Options A, B, and C are acceptable: respiratory rate 12 breaths/min, blood pressure 100/60 mmHg, and heart rate 80 bpm are stable.
Extract:
Before administering calcium gluconate 10% 500 mg IV stat.
Question 5 of 5
It is MOST important that the nurse assess the
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant