NCLEX Questions, NCLEX PN Exam Practice Test Questions, NCLEX-PN Questions, Nurselytic

Questions 163

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NCLEX-PN Test Bank

NCLEX PN Exam Practice Test Questions

Extract:


Question 1 of 5

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately?

Correct Answer: D

Rationale: A thicker tongue may indicate angioedema, a rare but life-threatening side effect of enalapril (an ACE inhibitor), requiring immediate reporting. A (dry cough) and C (dizziness) are common side effects that warrant monitoring but are less urgent. B indicates suboptimal blood pressure control, which requires follow-up but is not immediately life-threatening.

Question 2 of 5

The nurse is talking with a 74-year-old client with previously well-controlled hypertension. The client currently has a blood pressure of 190/88 mm Hg and has had a cold with nasal congestion for the past 3 days. Which of the following questions would be most important for the nurse to ask?

Correct Answer: B

Rationale: OTC cold medications (e.g., decongestants) can elevate blood pressure, explaining the sudden increase, making this the most important question.

Question 3 of 5

The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate? Click the exhibit button for additional information.

Question Image

Correct Answer: B

Rationale: Skin discoloration in the buttock and lumbar area of a newborn is often due to Mongolian spots (also called congenital dermal melanocytosis). These are benign, flat, bluish-gray patches typically found on the lower back or buttocks. They are more common in infants with darker skin tones and are not harmful, but they can be mistaken for bruises, which raises concern for abuse later on.
The appropriate nursing action is to measure and document the size, shape, and location of the spots in the medical record. This ensures that there is a clear, dated record of the findings to avoid confusion in the future.

Extract:

Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L)
Hematocrit
Male: 42%–52%
(0.42-0.52)

Female: 37%–47%
(0.37–0.47)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
Troponin T (cTnT)
<0.1 ng/mL
(<0.1 mcg/L)
B-type natriuretic peptide
<100 pg/mL
(<28.9 pmol/L)


Question 4 of 5

The nurse is reviewing laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires immediate action by the nurse?

Correct Answer: D

Rationale: Elevated troponin T (0.7 ng/mL) indicates myocardial injury, requiring immediate action for possible myocardial infarction. Other values are less critical.

Extract:


Question 5 of 5

The nurse has just received report on 4 clients. Which of the following reported information is the most concerning?

Correct Answer: B

Rationale: Back pain shortly after coronary angiography may indicate retroperitoneal bleeding, a life-threatening complication requiring immediate investigation. The other conditions are less acute or expected.

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