NCLEX-PN
NCLEX PN Practice Test Questions
Extract:
Question 1 of 5
A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.
Correct Answer: C,D
Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.
Question 2 of 5
The nurse is caring for a client who has a single-chamber atrial pacemaker. Which of the following findings would the nurse expect to observe on the client’s electrocardiogram strip?
Correct Answer: B
Rationale: A single-chamber atrial pacemaker paces the atrium, producing a spike before the P wave (
B), followed by normal conduction. Spikes on T waves (
A) are abnormal, wide QRS (
C) suggests ventricular issues, and prolonged PR (
D) is unrelated to pacing.
Question 3 of 5
A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?
Correct Answer: C
Rationale: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.
Question 4 of 5
A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply.
Correct Answer: A,B,D
Rationale: Hypothyroidism in infants causes lethargy (
A), dry skin (
B), and hoarse cry (
D) due to slowed metabolism. Loose stools (
C) and tachycardia (E) are more typical of hyperthyroidism.
Question 5 of 5
The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
Correct Answer: A,C,D
Rationale: The varicella vaccine may cause a low-grade fever (
A) or a rash at the injection site (
C) as common side effects. A second dose (
D) is required at 4-6 years for full immunity. Aspirin (
B) is contraindicated in children due to Reye’s syndrome risk. Other vaccines (E) can be given concurrently, per CDC guidelines, unless contraindicated.