NCLEX-PN
NCLEX PN Test Questions
Extract:
Question 1 of 5
A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply.
Correct Answer: A,B,E
Rationale: Dedicated equipment, hand hygiene, and an isolation gown prevent the spread of vancomycin-resistant enterococcus. A 'No Visitors' sign is unnecessary, and a face mask is not required unless droplet precautions are indicated.
Question 2 of 5
The nurse monitors a client who has followed a vegan diet for several years. Which client statement would indicate a possible complication resulting from a vegan diet?
Correct Answer: A
Rationale: Night vision disturbances suggest vitamin A deficiency, common in vegan diets lacking sufficient beta-carotene sources. Insomnia, scaly skin, and tingling are less specific to vegan diet complications, potentially relating to other causes like stress or neuropathy.
Question 3 of 5
A spouse brings a client with a history of previous suicide attempts to the emergency department due to erratic behavior and expressions of hopelessness. When the triage nurse asks if the client is having suicidal thoughts, the client shrugs their shoulders. What action should the triage nurse take?
Correct Answer: C
Rationale: Given the history of suicide attempts and current hopelessness, a noncommittal response like shrugging suggests a high suicide risk. One-to-one observation ensures safety. Documenting no suicidality is inaccurate, frequent observation is insufficient, and returning to the waiting room is unsafe.
Question 4 of 5
Which of the following interventions is most helpful in determining the need for oxygen therapy for a client with COPD?
Correct Answer: D
Rationale: Pulse oximetry objectively measures oxygen saturation, guiding the need for oxygen therapy in COPD. Subjective reports and hemoglobin levels are less direct.
Question 5 of 5
Which of the following observations indicates the possibility of a birth injury related to forceps delivery?
Correct Answer: A
Rationale: Asymmetry of the mouth may indicate facial nerve injury, a potential complication of forceps delivery due to pressure on the facial nerve.