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
The nurse is walking through a crowded waiting room when the respiratory therapist approaches the nurse and asks, 'How is the client in room 312?' Which of the following responses would be most appropriate for the nurse to make?
Correct Answer: D
Rationale: Discussing client information in a crowded area risks breaching confidentiality. Moving to a private area ensures compliance with HIPAA and protects client privacy.
Question 3 of 5
A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first?
Correct Answer: B
Rationale: A teenager who got a singed beard while camping. This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.
Question 4 of 5
A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client?
Correct Answer: C
Rationale: Frothy, pink-tinged sputum and dyspnea indicate pulmonary edema, a complication of myocardial infarction. Diffuse bilateral crackles are heard due to fluid in the alveoli.
Question 5 of 5
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
Correct Answer: B
Rationale: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Gonorrhea does not present as a lesion but is exhibited by a yellow discharge, so answer C is incorrect. Condylomata lesions are painless warts, so answer D is incorrect.