NCLEX-PN
NCLEX PN Exam Practice Test Questions
Extract:
Medication administration record
Allergies: No known allergies
Sliding-Scale Blood Glucose Levels Regular Insulin Dose
<150 mg/dL (<8.3 mmol/L) 0 units
150-199 mg/dL (8.3-11.0 mmol/L) 3 units
200-249 mg/dL (11.1-13.8 mmol/L) 6 units
250-299 mg/dL (13.9-16.6 mmol/L) 9 units
300-349 mg/dL (16.7-19.4 mmol/L) 12 units
>350 mg/dL (>19.4 mmol/L) 15 units and notify the health care provider
Question 1 of 5
A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL (12.2 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take?
Correct Answer: D
Rationale: Regular insulin is drawn up first to prevent NPH contamination, and both can be mixed in one syringe for a blood glucose of 220 mg/dL, assuming a sliding scale of 6 units. Administering after the meal or using separate injections is incorrect.
Extract:
Question 2 of 5
The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate? Click the exhibit button for additional information.
Correct Answer: B
Rationale: Skin discoloration in the buttock and lumbar area of a newborn is often due to Mongolian spots (also called congenital dermal melanocytosis). These are benign, flat, bluish-gray patches typically found on the lower back or buttocks. They are more common in infants with darker skin tones and are not harmful, but they can be mistaken for bruises, which raises concern for abuse later on.
The appropriate nursing action is to measure and document the size, shape, and location of the spots in the medical record. This ensures that there is a clear, dated record of the findings to avoid confusion in the future.
Question 3 of 5
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
Correct Answer: B
Rationale: Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.
Question 4 of 5
The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is:
Correct Answer: C
Rationale: The arrival of the imperfect child that the mother had not envisioned places the mother in a situational crisis.
Question 5 of 5
The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first?
Correct Answer: D
Rationale: Symptoms suggest supine hypotensive syndrome; turning the client to a lateral position relieves uterine pressure on the vena cava, improving blood flow.