NCLEX-PN
NCLEX Trainer Test 9 Questions
Question 1 of 5
The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.
Question 2 of 5
A symptom of impending cardiac decompensation in a pregnant client with heart disease is:
Correct Answer: A
Rationale: Increasing dyspnea signals worsening cardiac function and potential decompensation, a critical symptom in pregnant clients with heart disease. Other symptoms are less specific.
Question 3 of 5
The nurse is auscultating the chest of a client with heart failure. The nurse should assess for which finding as an early sign of volume overload?
Correct Answer: A
Rationale: S3 heart sound. This is an early sign of volume overload due to fluid in the ventricles during diastole.
Question 4 of 5
The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client?
Correct Answer: D
Rationale: Complete all of the antibiotic even if your findings decrease. Finishing the full antibiotic course prevents recurrence and resistance.
Question 5 of 5
The nurse is teaching a client who has short-term memory loss how to use the call light. Which factor is least essential for the nurse to assess when teaching this client?
Correct Answer: B
Rationale: Ambulatory difficulty is least relevant, as call light use relies on vision, orientation, and language comprehension, not mobility.