NCLEX Trainer Test 6
Question 1 of 5.
Extract:A student nurse obtaining an infant's vital signs.
Which of the following actions should the student nurse complete FIRST?
A. Take an axillary temperature to minimize use of invasive procedures.
B. Count respirations for 15 seconds and multiply the number by 4.
C. Count respirations for a minute prior to arousing the infant.
D. Use a stethoscope with a one-and-a-half-inch diaphragm to count the apical pulse.
Explanation: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate to use probe to take axillary temperature (2) should count for a full minute (3) correct-respirations should be counted for one full minute prior to arousing the infant with a temperature probe or stethoscope (4) after infant is stimulated, crying may interfere with accurate evaluation of respirations
Question 2 of 5.
A registered nurse (RN) asks the licensed practical nurse (LPN) to hang blood on a client. What is the best response by the LPN?
A. Carefully check the order and the client identification and hang the unit if all is in order.
B. Ask the RN to verify the order and then administer as ordered.
C. Hang the blood after taking baseline vital signs.
D. Refuse to administer the blood.
Explanation: LPN scope of practice typically excludes initiating blood transfusions due to the need for specialized monitoring, requiring RN administration.
Question 3 of 5.
Digoxin has been prescribed for a 70-year-old man who has atrial fibrillation. Which behavior indicates that the client understands the nurse's instructions about taking digoxin?
A. The client states that he will not spend much time in the sun.
B. The client says to the nurse, 'Is this the correct way to check my pulse? I want to do it right.'
C. The client tells the nurse he will be very careful to sit on the edge of the bed for a few moments before standing up.
D. The client says, 'I will not take Cialis while I am taking this medicine.'
Explanation: Checking pulse before taking digoxin prevents administration if bradycardia is present, indicating understanding of toxicity monitoring.
Question 4 of 5.
An 87-year-old woman is admitted to the acute care hospital for heart failure. The nurse asks about the client's signs and symptoms and obtains vital signs. Considering the client's age, what additional question is most important for the nurse to ask?
A. How do you manage your bowels?
B. When was your last menstrual period?
C. What are your favorite foods?
D. When was your last tetanus shot?
Explanation: Elderly patients are at risk for tetanus due to waning immunity; assessing vaccination status is critical for infection prevention.
Question 5 of 5.
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
A. Check pedal pulses.
B. Check legs for pitting edema.
C. Upper extremity neuro checks.
D. Auscultate lung sounds.
E. Observe respirations.
F. Observe for gait disturbances.
Explanation: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
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