NCLEX-PN
NCLEX Practice Test PN Questions
Extract:
Question 1 of 5
A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
Correct Answer: C
Rationale: Raising all four side rails is a restraint and can increase fall risk if the client attempts to climb over them. It also violates standards of care unless specifically prescribed.
Question 2 of 5
The nurse is caring for a client who is confused and is in soft wrist restraints. Which tasks can the nurse safely assign to unlicensed assistive personnel? Select all that apply.
Correct Answer: A,C,D,E
Rationale: UAP can assist with bedpan use (
A), perform range-of-motion exercises (
C), report skin changes (
D), and reposition the client (E). Checking circulation and sensation (
B) requires nursing assessment skills.
Question 3 of 5
A 9-year-old with type 1 diabetes takes insulin glargine and NPH regularly. While at school, the client becomes shaky, diaphoretic, and pale. What is the most appropriate action by the nurse?
Correct Answer: D
Rationale: Shakiness, diaphoresis, and pallor indicate hypoglycemia. Providing 15 grams of fast-acting carbohydrates, such as 4 oz of a regular soft drink, is the first-line treatment.
Question 4 of 5
A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first?
Correct Answer: B
Rationale: A teenager who got a singed beard while camping. This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.
Question 5 of 5
The nurse in the outpatient clinic is talking with the spouse of a client with borderline personality disorder. The client's spouse states, 'My spouse self-inflicts lacerations on the arms to stop me from traveling for business. My spouse's actions are not a serious attempt at self-harm.' Which of the following responses would be appropriate for the nurse to make?
Correct Answer: B
Rationale: Self-inflicted lacerations, even if not suicidal, indicate significant distress in borderline personality disorder and require professional assessment to ensure safety and address underlying issues.