NCLEX Trainer Test 9
Question 1 of 5.
Extract:The nurse's aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck.
Which of the following observations, if made by the nurse, would require an intervention?
A. The woman removes her dentures and gives them to her husband.
B. The woman's vital signs are: BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C).
C. The woman has a nitroglycerine patch on her right chest area.
D. The woman has red nail polish on her fingers and toes.
Explanation: Strategy: 'Require an intervention' indicates an incorrect action. (1) should be removed before the Test (2) results are within normal limits (3) correct-should be removed before the Test (4) unnecessary to check capillary refill
Question 2 of 5.
The nurse is caring for an older adult in his home. Which of the following factors increase the client's risk for falls? Select all that apply.
A. The client is 78 years old.
B. The home is a one-story home.
C. There are several scatter rugs on the hardwood floors.
D. The client's wife does all of the housework.
E. There are handrails in the bathroom.
F. There are several plants in the living room.
Explanation: Age over 65, scatter rugs, and obstacles like plants increase fall risk. A one-story home, handrails, and the wife's housework reduce risk.
Question 3 of 5.
An adult is hospitalized for heart failure. Hydrochlorothiazide and digoxin are prescribed. What laboratory test(s) should the nurse monitor because the client is taking these medications?
A. CBC and differential
B. Serum creatinine and BUN
C. Cardiac enzymes
D. Serum electrolytes
Explanation: Hydrochlorothiazide and digoxin can cause electrolyte imbalances (e.g., hypokalemia), increasing digoxin toxicity risk, necessitating serum electrolyte monitoring.
Question 4 of 5.
An adult is admitted through the outpatient department for elective surgery today. The client is coughing and sneezing and has a temperature of 100.6°F. What should the nurse do next?
A. Prepare the client for surgery as scheduled
B. Explain to the client that a cold increases risks during surgery and ask if he/she is willing to assume those risks
C. Call the physician before continuing preparations for surgery
D. Ask what type of anesthesia the client is receiving
Explanation: Infection increases surgical risks; notifying the physician allows for evaluation and possible postponement.
Question 5 of 5.
An adult is taking digoxin and furosemide. Which laboratory value is of greatest concern to the nurse?
A. Serum digoxin of 1.2 ng/mL
B. Serum K+ of 3.0 mEq/L
C. BUN of 12 mg/dL
D. Serum Mg of 1.6 mEq/L
Explanation: Furosemide, a diuretic, can cause hypokalemia (low potassium), increasing the risk of digoxin toxicity. A serum K+ of 3.0 mEq/L is below normal (3.5-5.0 mEq/L), posing a significant risk. The digoxin level is therapeutic (0.5-2.0 ng/mL), and BUN and Mg are within normal ranges.
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