NCLEX Trainer Test 4
Question 1 of 5.
The nurse is performing a post-op assessment of an elderly client with a total hip repair. Although he has not requested medication for pain, the nurse suspects that the client's discomfort is severe and prepares to administer pain medication. Which of the following signs would not support the nurse's assessment of acute post-op pain?
A. Increased blood pressure
B. Inability to concentrate
C. Dilated pupils
D. Decreased heart rate
Explanation: Acute pain typically increases heart rate, blood pressure, and pupil dilation. Decreased heart rate is not consistent with acute pain.
Question 2 of 5.
The nurse is caring for an adult who is enrolled in a study involving an experimental drug. The client says to the nurse, 'I don't think I can stand the vomiting anymore. I think it is due to the drug I am taking. If only I could get out of this study I signed up for. That was a really stupid thing I did when I signed up for the study.' What information must the nurse include when responding to the client?
A. If the client signed the proper forms, the client is committed to the study.
B. Persons who have signed up for a study may opt out of the study at any time.
C. The person should discuss his/her concerns with the researchers.
D. Inform the client that there are drugs that can control nausea.
Explanation: Participants can withdraw from research studies at any time, per ethical research guidelines, ensuring autonomy and safety.
Question 3 of 5.
Lithium carbonate is prescribed for an adult. The nurse knows the client is most likely to have which condition?
A. Depression
B. Mania
C. Schizophrenia
D. Paranoia
Explanation: Lithium carbonate is primarily used to stabilize mood in bipolar disorder, particularly for mania.
Question 4 of 5.
An adult is admitted in diabetic ketoacidosis. What observation by the nurse is consistent with the diagnosis?
A. Deep respirations
B. Foul breath
C. Constipation
D. Red rash
Explanation: Deep, rapid (Kussmaul) respirations are a compensatory mechanism in diabetic ketoacidosis to eliminate excess CO2, correcting acidosis.
Question 5 of 5.
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
A. Alteplase (tPA) is given to relieve the pain of a heart attack.
B. Alteplase (tPA) dissolves the clot that is blocking a coronary artery.
C. Alteplase (tPA) prevents new clots from forming and existing clots from getting bigger.
D. Alteplase (tPA) helps the heart muscle to repair itself.
Explanation: Alteplase (tPA) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.