NCLEX-PN
NCLEX PN Practice Questions Questions
Extract:
Question 1 of 5
The client is unable to adequately bathe himself because he has dressings on his hands that cannot get wet. What is the most appropriate nursing diagnosis for this assessment finding?
Correct Answer: D
Rationale: Inability to bathe due to hand dressings indicates a self-care deficit in bathing, the most specific nursing diagnosis.
Question 2 of 5
The nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube and a gastric residual volume of 75 mL. Which of the following actions should the nurse take? Select all that apply.
Correct Answer: A,C,D
Rationale: A residual of 75 mL is typically acceptable to proceed with feeding. High-Fowler position and flushing are standard. Residual is returned, not discarded, and pH >5 is not concerning.
Question 3 of 5
An infant with Tetralogy of Fallot is discharged with a prescription for Lanoxin (digoxin) elixir. The nurse should instruct the mother to:
Correct Answer: B
Rationale: The calibrated dropper ensures accurate dosing of digoxin, which is critical due to its narrow therapeutic range. Other methods risk incorrect dosing.
Question 4 of 5
The nurse assists with data collection during a routine prenatal visit for a client at 36 weeks gestation. Which statement by the client is most concerning to the nurse?
Correct Answer: B
Rationale: Decreased fetal movement may indicate fetal distress and requires immediate evaluation.
Question 5 of 5
The nurse is caring for a client admitted 3 days ago with bacterial pneumonia who has become short of breath, restless, and difficult to rouse. Which additional finding indicates to the nurse that the client may be developing sepsis?
Correct Answer: A
Rationale: Prolonged capillary refill time suggests poor perfusion, a sign of sepsis, requiring immediate intervention.