NCLEX Trainer Test 7

NCLEX Trainer Test 7 Related

Review NCLEX Trainer Test 7 related questions and content

A primigravida client, 10-days postpartum, who is anxious about caring for her newborn. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.

The homecare nurse is scheduling clients for the day. Which of the following clients should the nurse visit FIRST?

  • A. A primigravida client, 10-days postpartum, who is anxious about caring for her newborn.
  • B. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision.
  • C. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin.
  • D. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.
Correct Answer: C

Rationale: Strategy: Identify the least stable client by eliminating the more stable clients. (1) psychosocial need, physical issues take priority (2) complaints require follow-up, but not the most unstable client (3) correct-describes subcutaneous emphysema, which is indication of pneumothorax; observe client for respiratory distress, contact physician (4) postural hypotension a side effect of diuretic therapy, change position slowly

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Which of the following interventions is appropriate when caring for a client who has lost function of cranial nerve $\mathrm{V}$ on the left side?

  • A. Helping the client select foods that are easy to swallow
  • B. Speaking to the client on his right side
  • C. Applying an eye patch to the left eye
  • D. Speaking to the client on his left side
Correct Answer: C

Rationale: Cranial nerve V (trigeminal) loss may impair corneal sensation, increasing risk of eye injury; an eye patch protects the left eye. Swallowing and hearing are unrelated.

The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain.

Which of the following observations is MOST important for the nurse to report to the next shift?

  • A. The client indicates the need to use the bathroom.
  • B. Blood pressure has decreased from 140/80 to 90/60.
  • C. Respiratory rate has increased from 16 to 24.
  • D. The client indicates that the chest pain has subsided.
Correct Answer: B

Rationale: Strategy: The topic of the question is unstated. Read answer choices for clues. (1) not a side effect of this medication (2) correct-hypotension is significant side effect of nitroglycerin; although effect may be transient, BP should be closely observed to ensure that it does not continue to decrease (3) not a side effect of this medication (4) an expected outcome

The nurse is caring for a client who is postoperative day 1 after a nephrectomy. Which of the following findings would be of GREATest concern to the nurse?

  • A. Temperature of 100.8°F (38.2°C).
  • B. Pain at the incision site.
  • C. Urine output of 30 mL/hour.
  • D. Blood pressure of 130/80 mmHg.
Correct Answer: A

Rationale: A temperature of 100.8°F suggests infection, a serious complication post-nephrectomy requiring immediate evaluation. Options B, C, and D are expected or normal: incision pain is typical, urine output 30 mL/hour is adequate for one kidney, and blood pressure 130/80 mmHg is stable.

The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?

  • A. The blood pressure
  • B. The vital signs
  • C. The pulse oximeter
  • D. The EEG
Correct Answer: B

Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.

A diabetic client is taking Lantus insulin for regulation of his blood glucose levels. The nurse should know that this insulin will most likely be administered:

  • A. Prior to each meal
  • B. At night
  • C. Midday
  • D. Prior to the evening meal
Correct Answer: B

Rationale: Lantus is a long-acting insulin typically administered at night to provide basal coverage. Options A, C, and D are incorrect for its dosing schedule.

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