NCLEX Trainer Test 9
Question 1 of 5.
Extract:The nurse is caring for clients on a psychiatric unit and is suddenly faced with multiple issues.
Which of the following situations require the nurse's IMMEDIATE attention?
A. A client with bipolar disorder walks into the dayroom in her underwear and begins dancing.
B. A client with depression says to the nurse, 'My plan is complete, and I'm ready to go for it.'
C. A client recovering from substance abuse says to the nurse, 'My plan is complete, and I'm ready to go for it.'
D. A client with schizophrenia tells the nurse that it's 'God's will' that he destroy the 'evil TV'.
Explanation: Strategy: 'Require IMMEDIATE intervention' indicates that you are looking for the least stable situation. (1) should remove to quiet area, decrease environmental stimuli (2) correct-could indicate impending suicide, requires immediate follow-up (3) potential suicide is more immediate concern (4) command hallucination, potential suicide takes priority
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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