NCLEX-PN
PN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, HPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying?
Correct Answer: A
Rationale: The majority of reactions occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization.
Question 2 of 5
The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?
Correct Answer: B
Rationale: There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.
Question 3 of 5
The nurse is assisting in caring for a client who had a transsphenoidal hypophysectomy 48 hours ago and has developed diabetes insipidus. Which of the following prescriptions should the nurse clarify?
Correct Answer: D
Rationale: Desmopressin treats diabetes insipidus by replacing vasopressin. Checking urine osmolarity and serum sodium monitors the condition. Trendelenburg position is inappropriate as it may increase intracranial pressure post-hypophysectomy.
Question 4 of 5
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago. She is 8 weeks pregnant. Which description of her obstetric history is written correctly?
Correct Answer: C
Rationale: Gravida 3 para 1. Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
Question 5 of 5
The nurse is inserting an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? Select all that apply.
Correct Answer: A,B,D
Rationale: Spreading labia aids visualization. Sterile gloves and drape maintain sterility. Proper positioning facilitates insertion. Advancing only 2 inches is insufficient (should be 5-7 cm) before balloon inflation. Cleansing should start with the meatus , not labia.