NCLEX-PN
NCLEX PN Test Questions
Extract:
Question 1 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 2 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.
Question 3 of 5
When performing an assessment on the client with emphysema, the nurse finds that the client has a barrel chest. The alteration in the client's chest is due to:
Correct Answer: B
Rationale: Clients with emphysema develop a barrel chest due to the trapping of air in the lungs, causing them to hyperinflate. Answers C and D are common in those with emphysema but do not cause the chest to become barrel shaped. Answer A does not occur in emphysema.
Question 4 of 5
The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?
Correct Answer: A
Rationale: Activity intolerance caused by fatigue related to chronic tissue hypoxia. This reflects the client's reduced capacity for physical activity due to COPD.
Question 5 of 5
A woman reports to the physician's office complaining of urinary frequency and pain and burning on urination. The nurse expects that which procedures will be ordered for this client?
Correct Answer: A
Rationale: Urinary frequency, pain, and burning suggest a urinary tract infection. A urine culture and sensitivity identifies the causative organism and appropriate antibiotics, making it the most likely test. CBC, BUN, creatinine, or routine urinalysis are less specific.