NCLEX-PN
NCLEX Practice Test PN Questions
Extract:
Question 1 of 5
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
Correct Answer: D
Rationale: All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However, the worst result is heart failure with lung congestion, so the auscultation of the lungs is the priority action.
Question 2 of 5
Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor glycemic control?
Correct Answer: A
Rationale: The American Diabetes Association (AD
A) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care for clients with poor glycemic control.
Question 3 of 5
A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
Correct Answer: C
Rationale: Raising all four side rails is a restraint and can increase fall risk if the client attempts to climb over them. It also violates standards of care unless specifically prescribed.
Question 4 of 5
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
Correct Answer: B
Rationale: Explain that this behavior is expected. Fear of strangers is normal in toddlers and extends into the preschool period.
Question 5 of 5
During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
Correct Answer: C
Rationale: All the pants have become tight around the waist. Increased abdominal girth is an early sign of Wilm's tumor.