NCLEX-PN
Free NCLEX-PN Practice Questions Questions
Extract:
Question 1 of 5
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage, indicating a rupture of the meninges, which poses a risk of meningitis or other complications in a head injury. This must be reported immediately. Eyelid edema (
A) and minor bleeding (
C) are less urgent, and withdrawal to pain (
D) is consistent with the initial assessment.
Question 2 of 5
A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma. Although the client complains of a severe headache, he is alert and answers questions appropriately. The nurse would question which of the following orders?
Correct Answer: B
Rationale: Morphine sulfate, a narcotic analgesic, causes central nervous system (CNS) and respiratory depression. In patients with head injuries, it is contraindicated because it masks signs of increased intracranial pressure (ICP), such as changes in level of consciousness, which are critical for monitoring neurological status. Promethazine is an antiemetic, docusate is a stool softener, and ranitidine prevents stress ulcers, none of which pose the same risk in this context.
Question 3 of 5
The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM. Two hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?
Correct Answer: A
Rationale: Dark, greenish-yellow drainage is expected bile post-T-tube removal, and a saturated dressing indicates ongoing drainage until the wound seals. Replacing with a more absorbent dressing keeps the site clean and dry, preventing infection. Culturing (
B) is unnecessary without infection signs, dehiscence (
C) is unlikely, and reinforcing (
D) risks infection.
Question 4 of 5
The nurse is caring for a client with a colostomy. The client reports that the colostomy bag is leaking. The nurse should
Correct Answer: C
Rationale: A leaking colostomy bag may indicate poor fit, skin irritation, or stoma changes, so assessing the stoma and peristomal skin is the first step to determine the cause and plan interventions. Taping (
A) is temporary, emptying/reapplying (
B) may not address the issue, and physician notification (
D) is premature.
Extract:
This is a 70-year-old male patient admitted due to hiccups, confusion, right arm & right leg weakness, facial droop and slurred speech. He has an Hx of CAD & had the 2nd CABG about 4 years ago.
Question 5 of 5
The nurse is aware that clinical manifestations differentiate right CHF from left CHF. Symptoms of right CVA would include:
Correct Answer: A
Rationale: Right-sided symptoms like jugular vein distension are unrelated to CVA; question likely meant right CHF.