NCLEX-PN
NCLEX Practice Test PN Questions
Extract:
Question 1 of 5
A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority?
Correct Answer: B
Rationale: Assess for neonatal withdrawal syndrome. These symptoms indicate possible opioid withdrawal, requiring immediate assessment.
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 2 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
Extract:
Question 3 of 5
A client diagnosed with pneumonia is experiencing shortness of breath, chest pain, and orthopnea. The chest x-ray reveals a very large right pleural effusion. Which intervention should the nurse anticipate for this client?
Correct Answer: C
Rationale: Thoracentesis removes fluid from the pleural space, relieving pressure on the lung and improving breathing in a large pleural effusion.
Question 4 of 5
The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting is:
Correct Answer: C
Rationale: Suction pressure of 80-120 mm Hg is recommended for adult tracheostomy suctioning to effectively remove secretions without causing trauma.
Question 5 of 5
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
Correct Answer: C
Rationale: oliguria. Kidneys maintain fluid volume through adjustments in urine volume.