NCLEX-PN
NCLEX-PN Practice Questions Free Questions
Extract:
The nurse assesses a patient's IV site and finds that it is red, hot, and tender to touch.
Question 1 of 5
The most appropriate first nursing action is:
Correct Answer: A
Rationale: Signs of phlebitis or infection require stopping the infusion and removing the IV to prevent further complications.
Extract:
Question 2 of 5
A nurse is caring for a patient in the first stage of labor. Which of the following interventions should the nurse implement to promote comfort? (Select all that apply)
Correct Answer: A,B,C,E
Rationale: Walking, ice chips, warm showers, and breathing techniques reduce discomfort and promote relaxation in early labor. Enemas are outdated and not routine.
Extract:
The patient with ascites has a paracentesis and 1500 ml of fluid is removed.
Question 3 of 5
Immediately following the procedure it is most important for the nurse to observe for:
Correct Answer: A
Rationale: A rapid, thready pulse indicates hypovolemia or shock post-paracentesis, a critical complication.
Extract:
Question 4 of 5
The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?
Correct Answer: D
Rationale: A fixed and dilated pupil is a neurological emergency, often indicating increased intracranial pressure (ICP) or brain herniation. Immediate physician notification is critical for timely intervention. Reassessing in five minutes delays care, checking visual acuity is irrelevant, and lowering the bed could worsen ICP.
Question 5 of 5
The nurse is caring for a client with a nasogastric tube in place. Assessment of the aspirate reveals a pH of 2.0. Which is the appropriate action?
Correct Answer: A
Rationale: This finding is within normal range for gastric aspirate of 0-4. Answers B, C, and D would not be appropriate or necessary due to the normal reading, so they're incorrect.