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
The nurse is observing client care activities on the unit. It would require completion of an incident report if
Correct Answer: B
Rationale: Administering escitalopram within 24 hours of phenelzine, a monoamine oxidase inhibitor, risks serotonin syndrome, a life-threatening condition, requiring an incident report. Holding clozapine for low neutrophils, holding isosorbide for low blood pressure, and giving warfarin for a normal INR are appropriate actions.
Question 3 of 5
The nurse is reinforcing discharge instructions for the parents of a 4-year-old client with heart failure. What statement made by the parents indicates a need for further teaching?
Correct Answer: A
Rationale: Holding heart failure medication (e.g., digoxin) for a heart rate above 90/min is incorrect for a 4-year-old, as their normal heart rate is 80-120/min; the threshold is typically lower (e.g., <60/min). Not repeating a dose after vomiting, avoiding mixing with food, and reporting nausea/vomiting are correct.
Question 4 of 5
The nurse is discussing health concerns with a group of adolescent girls. When discussing genital warts caused by condyloma acuminata (HPV), the nurse should emphasize that the organism increases the risk of which condition?
Correct Answer: C
Rationale: Certain HPV strains, including those causing genital warts, are linked to cervical cancer, necessitating regular screening. Infertility, anomalies, or prolapse are not directly related.
Question 5 of 5
The health care provider is starting an elderly client on terazosin to treat benign prostatic hyperplasia. Which information should be included when reinforcing teaching to this client about the new medication?
Correct Answer: A
Rationale: Terazosin can cause orthostatic hypotension, so changing positions slowly prevents dizziness or falls, especially in the elderly. Grapefruit juice, morning dosing, and stool color changes are not specific concerns with terazosin.