NCLEX-PN
PN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client is admitted with diabetic ketoacidosis (DKA). Which laboratory finding requires immediate intervention by the nurse?
Correct Answer: C
Rationale: This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation.
Question 2 of 5
A client on the oncology unit is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The client weighs 105.6 lbs. How many units should the client receive in a 24-hour period?
Correct Answer: C
Rationale: The client weighs 48 kg and should receive 5 units/kg, or 240 units every 4 hours. This would be 1440 units in 24 hours. The answers in A, B, and D are incorrect calculations.
Question 3 of 5
The nurse is caring for a client who was admitted for treatment of schizoaffective disorder with visual hallucinations. He tells the nurse that he sees extraterrestrials that are coming to get him. What is the best nursing response?
Correct Answer: D
Rationale: Reflecting the client's statement validates his experience without reinforcing the hallucination, promoting therapeutic communication.
Question 4 of 5
The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
Correct Answer: C
Rationale: Distended neck veins. Cardiac tamponade causes venous congestion, leading to distended neck veins.
Question 5 of 5
A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?
Correct Answer: B
Rationale: Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.