NCLEX-PN
NCLEX Practice Test PN Questions
Extract:
Vital signs
Temperature 98.2 F (36.7 C)
Blood pressure 108/72 mm Hg
Heart rate 62/min
Respirations 16/min
SpO2 96% on room air
Question 1 of 5
A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply.
Correct Answer: A,B,E
Rationale: Taking pulse (
A), monitoring weight (
B), and reducing sodium (E) help manage heart failure by tracking symptoms, detecting fluid retention, and preventing exacerbation.
Extract:
Question 2 of 5
While the nurse is preparing medications, a code occurs. One of the nursing assistants offers to help by administering the medications. What is the best response by the nurse?
Correct Answer: B
Rationale: Holding medications prioritizes the code response, as CNAs cannot administer medications, ensuring patient safety and appropriate task delegation.
Question 3 of 5
The nurse is feeding a 3-month-old client with tetralogy of Fallot. During the feeding, the client becomes cyanotic and has difficulty breathing. Which action should the nurse take first?
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance and reduces right-to-left shunting in tetralogy of Fallot, immediately improving oxygenation during a tet spell.
Question 4 of 5
The nurse is caring for a hospitalized adult who is receiving a blood transfusion. Twenty minutes after the start of the transfusion, the client complains of feeling cold and is shivering. What is the best first action for the LPN to take?
Correct Answer: D
Rationale: Shivering and feeling cold during a transfusion suggest a possible transfusion reaction, requiring immediate cessation of the transfusion to prevent further complications, followed by vital signs and physician notification.
Question 5 of 5
The nurse hears another staff member talking in a crowded elevator about a client on the unit. The client is identified by name and details of illness. What action should the practical nurse take at this time?
Correct Answer: D
Rationale: Speaking to the staff member privately after the elevator ride addresses the HIPAA violation discreetly, promoting education and correction without immediate escalation.