NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?
Correct Answer: C
Rationale: Intussusception causes intestinal obstruction, often leading to 'currant jelly' stools (blood and mucus). Black, sticky stools suggest upper GI bleeding. Greasy stools indicate malabsorption. Ribbon-like stools suggest rectal narrowing.
Question 2 of 5
The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?
Correct Answer: C
Rationale: Advise the parents to ignore breath holding because breathing will begin as a reflex. Breath-holding is benign and self-resolving in toddlers.
Question 3 of 5
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
Correct Answer: C
Rationale: Significant bleeding (600 mL), pallor, diaphoresis, and dizziness suggest hypovolemia. Lowering the head of the bed improves cerebral perfusion, stabilizing the client. Notification, labs, and documentation follow stabilization.
Question 4 of 5
Which of these findings indicate that a pump set to deliver a basal rate of 10 ml per hour plus PRN morphine drip for breakthrough pain is not working?
Correct Answer: C
Rationale: The minimal dose is 10 ml per hour, which would mean 40 mls are given in a 4 hour period. Only 60 mls should be left at noon. The pump is not functioning when more than expected medicine is left in the container.
Question 5 of 5
Which findings reflect vital signs that are concerning and require further nursing monitoring and intervention? Select all that apply.
Correct Answer: C,D,E
Rationale: Hypotension (90/60 mm Hg) with nifedipine risks severe hypotension. Transfusion-related hypotension and tachycardia suggest a reaction. Fetal heart rate deceleration post-contraction indicates potential distress. Albuterol's tachycardia/tremor and hydromorphone's mild BP drop are expected.