NCLEX-PN
NCLEX PN Test Questions Questions
Extract:
Question 1 of 5
In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?
Correct Answer: C
Rationale: Check the client for bladder distention and the client's urinary catheter for kinks. These are findings of autonomic dysreflexia, typically initiated by a noxious stimulus below the level of injury such as a full bladder.
Question 2 of 5
The nurse answers a call light on a client not assigned to the nurse. The client, who was just admitted from the emergency department, requests a cup of coffee. What is the appropriate intervention?
Correct Answer: D
Rationale: Suggesting water (
D) is safe until dietary orders are confirmed. Coffee (A,
C) may be contraindicated, and waiting (
B) doesn't address the request.
Question 3 of 5
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (
C) prevents allergic reactions by identifying triggers, making it the priority. Cost (
A), finger foods (
B), and cow's milk (D, not recommended before 12 months) are secondary.
Question 4 of 5
The nurse is screening pediatric clients for developmental dysplasia of the hip (DDH). Which of the following findings would be consistent with DDH in a 3-week-old client?
Correct Answer: C
Rationale: Extra gluteal folds (
C) are a sign of DDH. The affected leg appears shorter, not longer (
A). Narrowing of the perineum (
B) and pelvic tilt (
D) are not typical.
Question 5 of 5
Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the provider examine first?
Correct Answer: A
Rationale: An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.' This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured, based on the history of the pain suddenly stopping over three hours ago. Elderly clients have less functional reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also, however given that they fall in younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen.