NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?
Correct Answer: C
Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.
Question 2 of 5
The nurse and unlicensed assistive personnel (UAP) are caring for a client who is experiencing an acute episode of Ménière disease. Which action by the UAP would require the nurse to intervene?
Correct Answer: C
Rationale: Raising all side rails during an acute Ménière's episode (vertigo, nausea) increases fall risk if the client attempts to climb over them. Other actions (assisting to commode, dimming lights, turning off TV) reduce stimulation and promote safety.
Question 3 of 5
A nurse receives report on a group of clients. Which client should the nurse assess first?
Correct Answer: B
Rationale: The toddler with circumoral cyanosis, distress, and inability to speak suggests a potential airway obstruction, a life-threatening emergency requiring immediate assessment. Other clients show less acute symptoms.
Question 4 of 5
The nurse is talking with the parent of a 2-year-old client who has a sunburn across the back and shoulders. Which of the following statements by the parent would indicate a correct understanding of sunburn care? Select all that apply.
Correct Answer: A,C,D
Rationale: Extra fluids prevent dehydration, cool compresses soothe skin, and outdoor play with protection (sunscreen, clothing) is safe. Aspirin is avoided in children due to Reye's syndrome risk. Hydrocortisone isn't standard for sunburn; aloe or moisturizers are preferred.
Question 5 of 5
During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the well in the wheelchair. What is the priority nursing action?
Correct Answer: C
Rationale: Multiple bruises in various stages raise suspicion for elder abuse, requiring reporting to the HCP for investigation. Further questioning may cause distress, and hygiene/nutrition assessments are secondary. Discussing with family risks alerting potential abusers.