NCLEX Trainer Test 1
Question 1 of 5.
The nurse has received her assignment for the day and is to care for the following clients. Which client should the nurse go to first?
A. A 56-year-old who was admitted last evening vomiting blood; the night nurse says he has had no emesis for the last four hours
B. A 65-year-old who had hip replacement surgery two days ago
C. A 68-year-old who fell yesterday and is scheduled for hip surgery later this morning
D. A 69-year-old who was admitted last evening with severe right upper quadrant and right scapular pain
Explanation: The client with recent hematemesis is at risk for recurrent bleeding, requiring immediate assessment to ensure stability, prioritizing over stable surgical or presurgical clients.
Question 2 of 5.
The nurse is caring for an adult for whom phenytoin (Dilantin) has been prescribed. Which is of greatest concern to the nurse?
A. The client's urine has a pinkish tinge to it.
B. The client has enlarged gums.
C. The client's serum Dilantin level is 14 mcg/mL.
D. The client says, 'I usually go to Happy Hour every Friday.'
Explanation: Gingival hyperplasia is a significant side effect of phenytoin, requiring dental care and possible dose adjustment, more concerning than normal urine discoloration or social drinking.
Question 3 of 5.
An adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also.adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also complains of tingling around the mouth and in the fingers and toes. What should the nurse expect to do initially?
A. Administer oxygen
B. Have the client breathe into a paper bag
C. Call the physician immediately
D. Encourage the client to do deep breathing exercises
Explanation: Tachypnea and tingling suggest hyperventilation causing respiratory alkalosis; breathing into a paper bag restores CO2 levels, correcting pH.
Question 4 of 5.
An adult male had a myocardial infarction six weeks ago. He asks the nurse if it is safe for him to have sex. What should the nurse include when replying?
A. Taking nitroglycerin before sexual activity is often helpful.
B. Taking drugs for erectile dysfunction in addition to nitroglycerin is advised.
C. The client should rest for several hours before engaging in sexual activity.
D. Sexual activity should be avoided for six months after a heart attack.
Explanation: Nitroglycerin before sexual activity can prevent angina, and sexual activity is generally safe 6 weeks post-MI if the patient is stable.
Question 5 of 5.
A client with pernicious anemia is admitted. What would the nurse expect the admitting assessment to reveal?
A. Ecchymoses on the trunk
B. Bilateral neuropathy of the legs
C. Decreased platelet count
D. Decreased appetite
Explanation: Pernicious anemia, a vitamin B12 deficiency, often causes neurological symptoms like bilateral leg neuropathy due to nerve demyelination.