NCLEX-PN
NCLEX Practice Questions PN Questions
Extract:
Question 1 of 5
A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply.
Correct Answer: A, B, D
Rationale: Applying to upper arm/chest (
A), folding patches (
B), and rotating sites (
D) ensure safe use. Removing for dizziness (
C) requires medical consultation, and shaving (E) can irritate skin.
Question 2 of 5
The nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 6 inches (15.2 cm), the nurse notes a small amount of urine in the tubing. Which of the following actions should the nurse take next?
Correct Answer: D
Rationale: Advancing to the bifurcation (
D) ensures proper placement in the bladder before inflating the balloon. Measuring output (
A), inflating early (
B), or securing (
C) are premature.
Question 3 of 5
The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which, if occurred, would be reported to the charge nurse immediately due to the toxic effects of this drug?
Correct Answer: A
Rationale: This drug can cause cardiotoxicity exhibited by changes in the ECG and congestive heart failure. Rales and distended neck veins are clinical manifestations of congestive heart failure, so answer A is correct. A reddish discoloration to the urine is a harmless side effect, so answer B is incorrect. An elevated BUN and dry, flaky skin are not specific to this drug, so answers C and D are incorrect.
Question 4 of 5
The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?
Correct Answer: B
Rationale: Activity intolerance related to oxygen supply and demand imbalance. This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and fatigue.
Question 5 of 5
The nurse is assisting with care of a client with blunt head injury admitted for observation, including hourly neurologic checks. At 1:00 AM, the client reports a headache; the neurologic check is normal, and the nurse administers acetaminophen prn. At 2:00 AM, the client appears to be sleeping. What action does the nurse anticipate taking?
Correct Answer: A
Rationale: Hourly neurologic checks require arousing the client to assess orientation (
A). Checking paresthesia (
B), assuming relief (
C), or only verifying respiratory rate (
D) do not meet monitoring requirements.