NCLEX-PN
2023 NCLEX-PN Practice Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a client with a gastrostomy tube. Which action ensures proper care?
Correct Answer: A
Rationale: Flushing the gastrostomy tube with 30 mL of water after feedings prevents clogging and maintains patency.
Question 2 of 5
The nurse is assessing for side effects from the administration of a dose of penicillin (Bicillin). Which assessment finding best justifies withholding the I.M. administration of penicillin until consulting the prescribing physician?
Correct Answer: B
Rationale: A red, itchy rash is a sign of a possible allergic reaction to penicillin, which could progress to anaphylaxis, necessitating immediate consultation with the physician.
Question 3 of 5
A pregnant client is admitted to the labor and delivery area with vaginal bleeding. The physician's routine admission orders include the administration of an enema. Which action by the nurse is most appropriate?
Correct Answer: B
Rationale: Vaginal bleeding in pregnancy may indicate a serious condition like placenta previa or abruption, where an enema could exacerbate bleeding or cause complications, so it should be withheld until clarified.
Question 4 of 5
A client had a hysterectomy 10 hours ago. The nurse assesses the client and finds that her blood pressure has fallen abruptly. Which action by the nurse is most appropriate at this time?
Correct Answer: C
Rationale: A sudden drop in blood pressure post-hysterectomy may indicate internal bleeding or hypovolemia, requiring immediate notification of the surgeon for evaluation and intervention.
Question 5 of 5
A nurse is caring for a client with a chest tube. Which observation requires immediate intervention?
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which could compromise lung re-expansion and requires immediate investigation.