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
Following a typanoplasty, the nurse should maintain the client in which position?
Correct Answer: C
Rationale: After tympanoplasty, the client should be positioned flat with the head turned to the side and the operative ear facing up to promote healing and prevent pressure on the surgical site. Answer A is incorrect because the operative ear should face up, not down. Answer B is incorrect because low Trendelenburg is not indicated. Answer D is incorrect because a neck roll may not ensure proper positioning of the operative ear.
Question 3 of 5
The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse?
Correct Answer: C
Rationale: Petechiae indicate thrombocytopenia, a serious adverse effect of methotrexate, risking bleeding and requiring immediate reporting for dose adjustment or discontinuation.
Question 4 of 5
A nurse is reinforcing appropriate interventions with the parent of an infant who had a febrile seizure. Which instruction is appropriate to review?
Correct Answer: A
Rationale: Administering acetaminophen or ibuprofen every 6-8 hours helps control fever, reducing the risk of recurrent febrile seizures in infants.
Extract:
Intake and output record
Time Oral intake Parenteral intake Output
0700 180 mL juice
0800 1 L 0.9% sodium chloride IV 150 mL liquid stool
1000 75 mL vancomycin
1200 240 mL tea 250 mL metronidazole IV
1500 360 mL water
1600 1300 mL urine from collection bag
Question 5 of 5
The nurse is calculating a client's intake and output for the shift. How many mL should the nurse record as the client's net fluid balance? Record your answer using a whole number.
Correct Answer: 655 mL
Rationale: 1. Intake:
Oral: 180 + 240 + 360 = 780 mL
IV: 1000 + 75 + 250 = 1325 mL
Total Intake = 780 + 1325 = 2105 mL
2. Output:
Stool: 150 mL
Urine: 1300 mL
Total Output = 1450 mL
3. Net Balance:
2105 − 1450 = 655 mL net positive balance