“NCLEX Question Trainer Test 5 with
Explanations | Verified Questions, Correct
Answers & Detailed Rationales for Guaranteed
Success”
1
, A client is started on doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should
recommend a change in the client’s therapy if which of the following occurs?
1. The client refuses to speak and sits quietly in the room.
2. The client becomes excitable and develops tremors.
3. The client refuses to eat breakfast.
4. The client sleeps 18 hours a day.
Strategy: Think about the cause of each assessment and how it relates to Sinequan.
(1) not relevant to this medication
(2) correct–doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include
excitability and tremors
(3) not relevant to this medication
(4) not relevant to this medication
2. Which of the following guidelines is appropriate for the nurse to give a mother concerning the
developmental stage of her seven-year-old daughter?
1. The child’s periods of shyness are to be expected.
2. Nightmares are not characteristic of this age and should be investigated.
3. The child should be encouraged to care for her younger sister.
4. Punishment may be necessary for acts of independence.
Strategy: Remember growth and development.
(1) correct–normal for developmental stage, beginning to show independence from parents
(2) nightmares are frequently experienced at this age
(3) should be encouraged to be independent, not responsible for sibling, inappropriate for this
age group
(4) should allow child to be increasingly independent without punishment
3. A client is scheduled for a cardiac catheterization, and the nurse teaches him about the
procedure. What statements, if made by the client, would indicate to the nurse that he
understands the teaching?
1. “I’m going to feel cold during the procedure.”
2. “I can get up and walk to the bathroom immediately after the procedure.”
3. “The nurse will be checking my foot pulses after the procedure.”
4. “I won’t be able to eat for 24 hours before the procedure.”
Strategy: “Understands teaching” indicates that you are looking for a true statement.
(1) may feel burning sensation when dye injected
(2) on bedrest 8–12 h after procedure with pressure dressing applied over catheter insertion site
(3) correct–peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then
every 4 h
(4) NPO midnight prior to procedure
2
,4. A client had an aortic aneurysm resection two days ago. A complete blood count reveals a
decreased red blood cell count. The nursing assessment is MOST likely to reveal which of the
following?
1. Fatigue, pallor, and exertional dyspnea.
2. Nausea, vomiting, and diarrhea.
3. Vertigo, dizziness, and shortness of breath.
4. Malaise, flushing, and tachycardia.
Strategy: Remember the “comma, comma, and rule”. Each part of the answer choice must be
correct in order for the answer to be correct.
(1) correct–these “constitutional symptoms” are characteristic of most types of anemia and are
predominantly the result of tissue hypoxia secondary to inadequate red blood cells
(2) are not as indicative of the loss of red blood cells
(3) are not as indicative of the loss of red blood cells
(4) are not as indicative of the loss of red blood cells
5. The physician orders meperidine (Demerol) 50 mg IM every 3–4 h PRN for pain for a client. The
client asks the nurse for the medication at bedtime. Prior to administering the pain medication,
the nurse should
1. take measures to determine if the pain is psychological.
2. check to see if the man has a history of addiction.
3. try several other comfort and pain relief measures.
4. learn the location, character, and intensity of the pain.
Strategy: Answers are a mix of assessments and implementations. Does this situation require
assessment? Yes. Is there an appropriate assessment? Yes.
(1) should assess patient first
(2) not highest priority, should assess patient first
(3) need to assess before implementing action
(4) correct–assessment first step in nursing process
6. The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart
failure (CHF). Which of the following in the client’s history would have a direct correlation with her
current problem?
1. History of rheumatic fever four years ago.
2. Presence of ventricular septal defect as an infant.
3. Heart disease in both the maternal and the paternal families.
4. Persistent ear infections and mastoiditis as a child.
Strategy: Think about each answer choice.
(1) correct–most common cause of mitral valve problems is a history of rheumatic fever with a
subsequent complication of carditis, which affects the valve
(2) does not contribute to mitral valve disease
(3) does not contribute to mitral valve disease
(4) does not contribute to mitral valve disease
3
, 7. The nurse is preparing a 56-year-old woman for a paracentesis. It is MOST important for the
nurse to take which of the following actions?
1. Keep the woman NPO 12 hours before the procedure.
2. Have the woman void just before the procedure.
3. Initiate a bowel preparation program 24 hours before the procedure.
4. Place the woman supine during the procedure.
Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it
desired?
(1) does not need to be NPO
(2) correct–prevents puncture of bladder
(3) bowel preparation unnecessary
(4) would make it more difficult to drain fluid, patient should be positioned sitting upright at side
of bed with feet supported
8. The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished via a Swan-
Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following
information?
1. Measures the circulatory volume in the coronary arteries.
2. Indirectly measures the pressure in the ventricles.
3. Analyzes the adequacy of pulmonary circulation.
4. Directly measures the adequacy of CO2 exchange.
Strategy: Think about each answer choice.
(1) not a function of this catheter, and does not reflect hemodynamic monitoring
(2) correct–CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter
measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure
in the left ventricle
(3) not a function of this catheter, and does not reflect hemodynamic monitoring
(4) not a function of this catheter, and does not reflect hemodynamic monitoring
9. A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the
maxillary branch of the affected nerve. When performing client teaching, it is MOST important for
the nurse to include which of the following instructions?
1. Report an increase in blurred vision.
2. Eat soft, warm foods.
3. Change positions slowly.
4. Chew food on the affected side.
Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it
desired?
(1) unnecessary, does not occur with this condition
(2) correct–intense facial pain experienced along nerve tract is characteristic of this condition;
nursing care should be directed toward preventing stimuli to the area and decreasing pain
(3) intervention for Ménière’s disease
(4) chewing food on unaffected side less likely to trigger an attack
4
Explanations | Verified Questions, Correct
Answers & Detailed Rationales for Guaranteed
Success”
1
, A client is started on doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should
recommend a change in the client’s therapy if which of the following occurs?
1. The client refuses to speak and sits quietly in the room.
2. The client becomes excitable and develops tremors.
3. The client refuses to eat breakfast.
4. The client sleeps 18 hours a day.
Strategy: Think about the cause of each assessment and how it relates to Sinequan.
(1) not relevant to this medication
(2) correct–doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include
excitability and tremors
(3) not relevant to this medication
(4) not relevant to this medication
2. Which of the following guidelines is appropriate for the nurse to give a mother concerning the
developmental stage of her seven-year-old daughter?
1. The child’s periods of shyness are to be expected.
2. Nightmares are not characteristic of this age and should be investigated.
3. The child should be encouraged to care for her younger sister.
4. Punishment may be necessary for acts of independence.
Strategy: Remember growth and development.
(1) correct–normal for developmental stage, beginning to show independence from parents
(2) nightmares are frequently experienced at this age
(3) should be encouraged to be independent, not responsible for sibling, inappropriate for this
age group
(4) should allow child to be increasingly independent without punishment
3. A client is scheduled for a cardiac catheterization, and the nurse teaches him about the
procedure. What statements, if made by the client, would indicate to the nurse that he
understands the teaching?
1. “I’m going to feel cold during the procedure.”
2. “I can get up and walk to the bathroom immediately after the procedure.”
3. “The nurse will be checking my foot pulses after the procedure.”
4. “I won’t be able to eat for 24 hours before the procedure.”
Strategy: “Understands teaching” indicates that you are looking for a true statement.
(1) may feel burning sensation when dye injected
(2) on bedrest 8–12 h after procedure with pressure dressing applied over catheter insertion site
(3) correct–peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then
every 4 h
(4) NPO midnight prior to procedure
2
,4. A client had an aortic aneurysm resection two days ago. A complete blood count reveals a
decreased red blood cell count. The nursing assessment is MOST likely to reveal which of the
following?
1. Fatigue, pallor, and exertional dyspnea.
2. Nausea, vomiting, and diarrhea.
3. Vertigo, dizziness, and shortness of breath.
4. Malaise, flushing, and tachycardia.
Strategy: Remember the “comma, comma, and rule”. Each part of the answer choice must be
correct in order for the answer to be correct.
(1) correct–these “constitutional symptoms” are characteristic of most types of anemia and are
predominantly the result of tissue hypoxia secondary to inadequate red blood cells
(2) are not as indicative of the loss of red blood cells
(3) are not as indicative of the loss of red blood cells
(4) are not as indicative of the loss of red blood cells
5. The physician orders meperidine (Demerol) 50 mg IM every 3–4 h PRN for pain for a client. The
client asks the nurse for the medication at bedtime. Prior to administering the pain medication,
the nurse should
1. take measures to determine if the pain is psychological.
2. check to see if the man has a history of addiction.
3. try several other comfort and pain relief measures.
4. learn the location, character, and intensity of the pain.
Strategy: Answers are a mix of assessments and implementations. Does this situation require
assessment? Yes. Is there an appropriate assessment? Yes.
(1) should assess patient first
(2) not highest priority, should assess patient first
(3) need to assess before implementing action
(4) correct–assessment first step in nursing process
6. The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart
failure (CHF). Which of the following in the client’s history would have a direct correlation with her
current problem?
1. History of rheumatic fever four years ago.
2. Presence of ventricular septal defect as an infant.
3. Heart disease in both the maternal and the paternal families.
4. Persistent ear infections and mastoiditis as a child.
Strategy: Think about each answer choice.
(1) correct–most common cause of mitral valve problems is a history of rheumatic fever with a
subsequent complication of carditis, which affects the valve
(2) does not contribute to mitral valve disease
(3) does not contribute to mitral valve disease
(4) does not contribute to mitral valve disease
3
, 7. The nurse is preparing a 56-year-old woman for a paracentesis. It is MOST important for the
nurse to take which of the following actions?
1. Keep the woman NPO 12 hours before the procedure.
2. Have the woman void just before the procedure.
3. Initiate a bowel preparation program 24 hours before the procedure.
4. Place the woman supine during the procedure.
Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it
desired?
(1) does not need to be NPO
(2) correct–prevents puncture of bladder
(3) bowel preparation unnecessary
(4) would make it more difficult to drain fluid, patient should be positioned sitting upright at side
of bed with feet supported
8. The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished via a Swan-
Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following
information?
1. Measures the circulatory volume in the coronary arteries.
2. Indirectly measures the pressure in the ventricles.
3. Analyzes the adequacy of pulmonary circulation.
4. Directly measures the adequacy of CO2 exchange.
Strategy: Think about each answer choice.
(1) not a function of this catheter, and does not reflect hemodynamic monitoring
(2) correct–CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter
measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure
in the left ventricle
(3) not a function of this catheter, and does not reflect hemodynamic monitoring
(4) not a function of this catheter, and does not reflect hemodynamic monitoring
9. A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the
maxillary branch of the affected nerve. When performing client teaching, it is MOST important for
the nurse to include which of the following instructions?
1. Report an increase in blurred vision.
2. Eat soft, warm foods.
3. Change positions slowly.
4. Chew food on the affected side.
Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it
desired?
(1) unnecessary, does not occur with this condition
(2) correct–intense facial pain experienced along nerve tract is characteristic of this condition;
nursing care should be directed toward preventing stimuli to the area and decreasing pain
(3) intervention for Ménière’s disease
(4) chewing food on unaffected side less likely to trigger an attack
4
