NCLEX Trainer Test 8

NCLEX Trainer Test 8 Related

Review NCLEX Trainer Test 8 related questions and content

A client on suicide precautions is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members.

Based on this data, which of the following nursing actions is MOST appropriate?

  • A. Recommend that the physician decrease the client's medication dosage.
  • B. Recommend that the treatment team reevaluate the client's treatment plan.
  • C. Give the client privileges to walk around the hospital by himself.
  • D. Ask the family to begin planning for the client's discharge.
Correct Answer: B

Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may reverse the client's progress (2) correct-data suggests that client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually based on a full-data picture (3) may be the team's decision, but not until a thorough review of the case is completed (4) premature

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The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results would be of GREATest concern to the nurse?

  • A. PTT of 90 seconds.
  • B. INR of 1.0.
  • C. Platelet count of 150,000/mm^3.
  • D. Hemoglobin of 13 g/dL.
Correct Answer: A

Rationale: A PTT of 90 seconds is above the therapeutic range for heparin (60–80 seconds), increasing bleeding risk, requiring immediate adjustment. Options B, C, and D are normal: INR is unaffected, platelet count 150,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.

The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?

  • A. 11 months of age.
  • B. 14 months of age.
  • C. 17 months of age.
  • D. 20 months of age.
Correct Answer: D

Rationale: by 24 months may be able to achieve daytime bladder control

Which of the following positions is best for a client with preeclampsia who is in labor?

  • A. Left Sims
  • B. High Fowler's
  • C. Trendelenburg
  • D. Supine
Correct Answer: A

Rationale: The left Sims position promotes placental perfusion and reduces pressure on the vena cava in preeclampsia, improving maternal and fetal outcomes. Other positions are less optimal.

An upset client says to the nurse, 'Where did you learn to be a nurse? You don't know anything.' How should the nurse respond?

  • A. I'm sorry you feel that way.'
  • B. I went to a fine nursing school.'
  • C. You sound upset.'
  • D. Please don't speak to me that way.'
Correct Answer: C

Rationale: Reflecting the client's emotions ('You sound upset') opens therapeutic dialogue, addressing feelings without defensiveness. Other responses escalate or dismiss.

The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?

  • A. Irritability
  • B. Slight edema at site
  • C. Local tenderness
  • D. Seizure activity
Correct Answer: D

Rationale: Seizure activity. Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.

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