NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
Correct Answer: D
Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.
Question 2 of 5
The nurse is preparing to administer phenytoin oral suspension via nasogastric tube to a client with a seizure disorder. The client is receiving continuous enteral feedings. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Phenytoin binds to enteral feedings, reducing absorption. Holding feedings for 1 hour before and after administration ensures efficacy. Tube placement should be verified before, not after, administration. Blood pressure and pancreatic enzymes are unrelated.
Question 3 of 5
An adult who has osteoarthritis tells the clinic nurse that her joints have been more painful lately and her head aches and her ears are 'making funny buzzing sounds.' What question should the nurse ask the client?
Correct Answer: D
Rationale: New symptoms with increased joint pain suggest possible medication side effects (e.g., NSAIDs causing tinnitus), making medication history critical.
Question 4 of 5
The nurse is caring for a client who has no pulse and is experiencing the cardiac rhythm in the ECG strip shown below. The client has a do not attempt resuscitation directive. The health care provider (HCP) orders initiation of resuscitative measures. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: A client with a Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) directive has legally chosen not to receive resuscitative measures, such as CPR or defibrillation, in the event of cardiac arrest. The nurse has an ethical and legal obligation to honor the client's advanced directive.
Question 5 of 5
Which client would be at greatest risk for a fat emboli following a fracture?
Correct Answer: C
Rationale: Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults age 20-30. Answers A, B, and D are not high-risk incidents and do not fall in the greater risk category, so they are incorrect.