NCLEX-PN
PN NCLEX Practice Exam Questions
Extract:
Question 1 of 5
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?
Correct Answer: C
Rationale: Low urine output (200 mL/8 hr) in heart failure suggests worsening fluid retention, requiring immediate reporting to the RN (
C). Auscultation (
A), fluids (
B), and IV diuretics (
D) require RN direction.
Question 2 of 5
A 62-year-old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority?
Correct Answer: D
Rationale: Tenderness and warmth suggest deep vein thrombosis, so a neurovascular check (
D) is the priority to assess for complications. History (
A), ECG (
B), and vitals (
C) are secondary.
Question 3 of 5
The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.
Correct Answer: A,B,C,E
Rationale: Lubricating the tube (
A), left lateral positioning (
B), retaining the enema (
C), and pausing for cramping (E) are correct for safe administration. Refrigerating the solution (
D) is incorrect; it should be at body temperature.
Question 4 of 5
Which nursing diagnosis is most appropriate for a client who has Cushing's syndrome?
Correct Answer: A
Rationale: Cushing's syndrome causes cortisol excess, leading to osteoporosis and increased fracture risk, making 'Risk for injury related to osteoporosis' the most appropriate diagnosis.
Question 5 of 5
The nurse is caring for a client who had a portable water seal chest drainage system inserted today. Which observation indicates that the client's drainage system is working properly?
Correct Answer: A
Rationale: No bubbles in the water seal bottle indicates a stable system without air leaks, confirming proper function post-insertion.