NCLEX-PN Practice Exam Graded A

NCLEX-PN Practice Exam Graded A+

Question...A 62 year old woman who lives alone tripped on a rug in her home and fractured her hip at the proximal end of the femur. Which predisposing factor should the PN identify that most likely contributed to the fracture? - Answer... osteoporosis resulting from declining hormone levels.

Question... While caring for a client with trigeminal neuralgia the PN observes the client experience facial spasms. What action should the PN implement? - Answer... Notify the charge nurse of the finding

Question...A client with cancer who has been receiving fentanyl (Duragesic) for several weeks reports to the PN that the medication is not effectively controlling the pain. Which intervention should the PN take? - Answer...Notify the RN or health care provider of the need for dose adjustment.

Question...When turning an immobile bedfast client without assistance, which action by the PN best ensures client safety? - Answer...Put the bed rails up on the opposite side of the bed.

Question... A mother is being discharged following the birth of her second child. The mother tells the PN that her first child dies at 6 weeks of age due to SIDS, and she fears that this infant will also develop SIDS. Which response is best for the PN to provide this mother? - Answer...The fear of losing another child to SIDS is very realistic. Have you thought about what you are going to do?

Question... A client is admitted to the hospital after an injury in a motor vehicle collision and has the right knee in skeletal traction. The PN reviews the plan of care and identifies the client's priority nursing diagnosis is "potential for impairment of skin integrity related to immobility from traction." Which nursing intervention should the PN implement for this nursing diagnosis?

• Answer... Provide back and skin care while maintaining the traction.

Question... The PN is reinforcing discharge instructions for a 22-year old male client diagnosed with Beurger disease (thromboangitis obliterans). Which referral is most important for this client? - Answer... Smoking cessation program

Question... Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The PN inserts the catheter, but no urine is seen in the tubing. What action should the PN take next? - Answer... Leave the catheter in place and reattempt with another catheter.

Question... During the admission process, the PN determines that a male client who is scheduled for surgery in the morning has a blood pressure of 160/85. He is drinking coffee and says his blood pressure has never been that high. The PN plans to retake the blood pressure in 30 minutes. This action indicates that the PN recognizes that the elevated blood pressure is likely due to which factor? - Answer... Preoperative anxiety

Question... The PN is caring for a client with symptoms of paranoia and psychosis. Which intervention is most important for the PN to implement for the nursing diagnosis, "Impaired social interactions related to inability to trust?" - answer... Greet the client by first name during each social interaction.

Question... An adolescent female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the PN take? - Answer...Suggest another way for this client to participate in the unit's activities.

Question... A client in a long-term care facility reports to the PN that he has not had a bowel movement in 2 days. Which intervention should the PN implement first? - Answer... Access the client's medical records to determine the client's normal bowel pattern.

Question... What types of medications should the PN expect to administer to a client during an acute respiratory distress episode? - Answer... Bronchodilators and steroids

Question... A mother who is breastfeeding her baby receives instructions from the PN. Which instruction is most effective in preventing nipple soreness? - Answer... Ensure the baby is positioned correctly for latch-on

Question... The PN observes that a male client has removed the covering from the ice pack applied to his knee. What action should the PN take first? - Answer... Observe the appearance of the skin under the ice pack.

Question... A primipara presents to the perinatal unit describing spontaneous rupture of the membranes (SROM) that occurred 12 hours before coming to the hospital. 8 hours after admission, the client's contractions are irregular and mild. What vital sign should the PN monitor with greater frequency that the typical protocol? - Answer... Maternal temperature

Question... Which statement reflects the highest priority nursing diagnosis that the PN should identify for an elderly client recently admitted to the hospital for a new onset cardiac dysrhythmia? - Answer... Risk for injury related to syncope and confusion

Question... During a well-child clinic visit, the PN is teaching the parents of a toddler about prevention of accidental poisonings. What information should the PN reinforce? - Answer...Store all toxic agents and medicines in locked cabinets

Question... In assessing a client for complications of total parenteral nutrition, it is important for the PN to monitor which lab value regularly? - Answer... Glucose

Question... What is the nursing priority that the PN should identify for a client who is admitted for a possible kidney stone? - Answer... Straining all urine

Question... A woman whose mother dies of pancreatic cancer asks the PN how she can avoid this disease. Which lifestyle change is most important for the PN to suggest to avoid developing pancreatic cancer? - Answer... Cease cigarette smoking

Question... Which statement describes the process of external respiration? - Answer... Exchange of oxygen and carbon dioxide occurs at the alveolar level between gas concentrations of inspired air volumes and pulmonary capillary blood.

Question... The PN is reviewing preoperative instructions with a 14 year old female client scheduled for surgery to correct spinal curvature. Which statement by the client best demonstrates that learning has taken place? - Answer... "Let me show you the method of turning I will use after surgery."

Question... The PN is providing morning care to a newly admitted child with bacterial meningitis. What is the most important intervention for the PN to implement? - Answer... Use designated isolation precautions.

Question... The PN is assessing a client's oxygenation status. Which pulse oximeter finding is critical for the PN to report to the registered nurse or health care provider? - Answer... 88% saturation while sitting in a chair.

Question... An adult client is admitted with a possible kidney tumor and is scheduled for an intravenous pyelogram in the morning. The PN should prepare the client before the IVP by implementing which protocol? - Answer... NPO after midnight

Question... A female client has been particularly restless and the PN finds her trying to leave the psychiatric unit. She tells the PN, "Please let me go! I must leave because the secret police are after me." What response is best for the PN to make? - Answer... "Come with me to your room and I will sit with you."

Question... In completing a client's preoperative routine, the PN finds that the operative permit is not signed. The Client begins to ask more questions about the surgical procedure. What action should the PN take next? - Answer... Inform the charge nurse that the operative permit is not signed and the Pt. has questions about the surgery

Question... Which statement by a client should indicate to the PN that the client understands how HIV is transmitted? - Answer... Anyone can contact HIV if high risk behaviors are practiced.

Question... A 46 year old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test should the PN review to determine the best indicator of adequate glomerular filtration? - Answer... Serum Creatinine

Question... A client is receiving drug therapy for a postoperative infection. Which complaint should alert the PN to the possibility that the client has contracted a superinfection? - Answer..."My mouth is sore" Note: stomatitis, which can cause mouth pain, is a sign of a thrush superinfection.

Question... After feeding a newborn, how should the PN position the infant in the crib? - Answer... On the right side (facilitates gastric emptying)

Question... Ten minutes after signing an operative permit for a fractured hip, an elderly client states, "The aliens will coming to get me soon!" and falls asleep. Which action should the PN implement next? - Answer... Assess the client's neurological status

Question... A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the PN offer to attempt to alleviate her anxiety? - Answer..."there's a strong, tough membrane that protects the baby, so you can wash the scalp and comb the hair without injury."

Question... The PN is obtaining a lie-sit-stand blood pressure reading on a male client. Which action is most important for the PN to implement? - Answer... Stay with the client while he is in a standing position.

Question... The PN should implement droplet precautions for a client admitted with which diagnosis/ - Answer... Meningococcal pneumonia

Question... A 63 year old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with conventional wound care. The PN observes that the entire left foot is darker in color than the right foot. Which additional symptom should the PN expect to find? - Answer... pedal pulses will be weak or absent in the left foot.

Question...The PN is assigned to care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours of hospital admission. - Answer...Maintain safety in the client's milieu.

Question... the PN is assessing the umbilical cord of a newborn. Which finding constitutes a

normal finding? - Answer... Three vessels: 2 arteries and 1 vein

Question... A child is brought to the emergency room with burns over 50% of the body. Using a modified rule of nines to estimate the % of the body surface burned, the PN considers that which part of the child's body is proportionally larger than the adult's? - Answer... head and neck

Question... The PN is interacting with a young adult female client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering form loss and depression. - Answer... "I'm not very pretty or likeable."

Question... The PN is caring for a hospitalized client with depression. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. What outcome is most important for the client to meet by discharge? - Answer... Reports feeling better and less depressed