NCLEX-PN
2023 NCLEX-PN Practice Questions Questions
Extract:
Question 1 of 5
A nurse is caring for a client with a Sengstaken-Blakemore tube for esophageal varices. Which complication should the nurse monitor for?
Correct Answer: B
Rationale: The Sengstaken-Blakemore tube can obstruct the airway if it migrates or the balloon inflates improperly, requiring close monitoring.
Question 2 of 5
In which of the following positions is it best for the nurse to place the client with suspected heart failure?
Correct Answer: C
Rationale: The high Fowler's position (sitting upright) reduces preload on the heart by promoting venous pooling in the lower extremities, easing breathing in heart failure.
Question 3 of 5
During a home health visit, the nurse asks the parents of a 7-year-old to describe how they give the child's medication through a gastrostomy and the which responses by the parents to the additional teaching?
Correct Answer: C
Rationale: Mixing medication with tube feeding formula can alter drug absorption and clog the tube, requiring additional teaching to administer medications separately with proper flushing.
Question 4 of 5
A nurse is caring for a client with a temporary pacemaker. Which observation requires immediate intervention?
Correct Answer: A
Rationale: A heart rate of 60 beats/min may indicate pacemaker failure to capture or sense, requiring immediate intervention to prevent bradycardia.
Question 5 of 5
The physician performs a vaginal examination on a client in labor and states that the client is completely effaced and fully dilated. At this time, the nurse correctly plans to assess the need to the client who is entering which stage of labor?
Correct Answer: B
Rationale: Complete effacement and full dilation indicate the end of the first stage and the start of the second stage of labor, where the client begins pushing to deliver the baby.