NCLEX-PN
Free NCLEX-PN Practice Questions Questions
Extract:
Question 1 of 5
Assessment of the client with an arteriovenous fistula for hemodialysis should include:
Correct Answer: B
Rationale: Palpating a thrill confirms the patency of an AV fistula. Visible pulsation is not typical, percussion is irrelevant, and blood pressure is not auscultated in the fistula limb. Physiological Adaptation
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
A nurse is caring for a pregnant patient in her third trimester. Which of the following findings should be reported immediately?
Correct Answer: C
Rationale: Severe headache and visual disturbances may indicate preeclampsia, a life-threatening condition requiring immediate reporting. Mild edema, heartburn, and frequent urination are common in the third trimester.
Question 4 of 5
The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed?
Correct Answer: A
Rationale:
To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear or all of the solution has been used. After the irrigation, the nurse should dry the area around the wound; moistening it promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a sterile dressing, rather than a wet-to-dry dressing. The nurse always should instill the irrigating solution gently; rapid or forceful instillation can damage tissues.
Question 5 of 5
The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client's blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client's left arm. Which of these statements is most immediately accurate?
Correct Answer: D
Rationale: The UAP is responsible for carrying out the activity correctly once directions have been clearly communicated especially if given verbally and in writing.