NCLEX-PN
NCLEX PN Exam Practice Test Questions
Extract:
Question 1 of 5
A client wanders away from home and is found 48 hours later sleeping on a park bench. The client is awake, alert, and oriented but cannot recall name, address, or events that occurred in the past 2 days. What is the priority nursing action?
Correct Answer: C
Rationale: Measuring vital signs is the priority to ensure physiological stability in a client with amnesia, which may indicate a medical emergency like transient global amnesia.
Question 2 of 5
The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
Correct Answer: A
Rationale: The phlebostatic axis is the reference point for accurate central venous pressure measurement, as it corresponds to the right atrium's level. The point of maximum impulse, Erb's point, and Tail of Spence are not used for this purpose, so answers B, C, and D are incorrect.
Question 3 of 5
A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?
Correct Answer: B
Rationale: Community-acquired pneumonia poses the least infection risk to an immunocompromised client with AIDS, unlike C. difficile or fever of unknown origin.
Question 4 of 5
The nurse is caring for a 6-month-old client who has a new tracheostomy. Which of the following findings would indicate that the client's airway requires suctioning? Select all that apply.
Correct Answer: A,C,D
Rationale: Audible gurgling, irritability, and low oxygen saturation (88%) indicate airway obstruction or secretions requiring suctioning. Normal heart rate (110/min) and respiratory rate (30/min) for a 6-month-old do not necessitate suctioning.
Question 5 of 5
A mother telephones the clinic and says 'I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding.' The nurse's best response would be which of these?
Correct Answer: A
Rationale: In breast-fed infants, stools are frequent and yellow to golden, and vary from soft to thick liquid in consistency. No change in feedings is indicated.