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NCLEX Practice Test PN Questions

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Question 1 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 2 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 3 of 5

During the admission bath, the nurse notes a region of impaired skin under a large sacral dressing. Which of the following actions by the nurse are appropriate? Select all that apply.

Question Image

Correct Answer: A,C,D,E

Rationale: A nutrient-rich diet (
A) supports wound healing. Cleansing with saline (
C) prevents infection. A hydrophilic dressing (
D) promotes a moist healing environment. Frequent repositioning (E) reduces pressure on the impaired skin.

Question 4 of 5

An older adult is seen in clinic. During the assessment process, all of the following are expressed or noted. Which is of most immediate concern to the nurse?

Correct Answer: B

Rationale: A productive cough suggests a respiratory infection, potentially serious in an older adult, requiring immediate evaluation. Forgetfulness, slow ambulation, or presbyopia are less urgent.

Question 5 of 5

An adult who has hepatitis A asks the nurse why her skin is yellow. The nurse should include which information when replying?

Correct Answer: A

Rationale: Hepatitis A impairs liver function, reducing bilirubin conjugation and excretion, leading to its accumulation in the blood, causing jaundice. The virus does not produce pigment, nor does the liver overproduce bilirubin or excrete waste through skin.

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