NCLEX-PN
NCLEX PN Test Questions
Extract:
Question 1 of 5
A 15-year-old client with iron deficiency anemia and a ruptured ectopic pregnancy needs a blood transfusion prior to surgery. The client's mother is a Jehovah's Witness and refuses to sign the blood permit. Which nursing action is most appropriate?
Correct Answer: D
Rationale: The nurse must respect the mother's refusal due to religious beliefs and notify the physician to discuss alternatives or legal options, such as court intervention for a minor in a life-threatening situation. Giving blood without permission is unethical and illegal. Coaxing may be coercive, and a 15-year-old typically cannot provide legal consent.
Question 2 of 5
A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?
Correct Answer: A
Rationale: Checking the catheter and tubing first ensures there are no kinks, blockages, or improper placements causing the leak, which is a non-invasive and logical initial step. Irrigation or removal requires further assessment, and notifying the RN is premature without initial troubleshooting.
Question 3 of 5
The nurse is observing a staff member perform open suctioning for a client who has a tracheostomy tube. The nurse should intervene if the staff member is observed
Correct Answer: C
Rationale: Applying suction while inserting the catheter can cause tracheal mucosa damage and hypoxia. Flushing the catheter with saline maintains patency, and semi-Fowler position aids breathing and reduces aspiration risk during suctioning.
Question 4 of 5
The nurse is caring for a client with suspected tracheoesophageal fistula and esophageal atresia. The nurse is most likely to observe
Correct Answer: A
Rationale: Tracheoesophageal fistula and esophageal atresia prevent normal swallowing, leading to pooling of saliva and excessive salivation. Abdominal distension or vomiting may occur in some cases, but salivation is the most consistent sign. Diminished lung sounds are less specific.
Question 5 of 5
At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a month. What is the nurse's best response?
Correct Answer: B
Rationale: How long has this been occurring? Nighttime control is expected by age 4 but may not occur until age 5. Assessing the duration helps determine if further evaluation is needed.