NCLEX-PN
PN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The nurse in the pediatric unit is collecting data from several newly admitted clients. Which finding should the nurse follow up for possible abuse and mandatory reporting?
Correct Answer: A
Rationale: A 2-month-old cannot roll, and lethargy after a fall suggests possible non-accidental head trauma, requiring abuse investigation. Bluish buttock marks may be Mongolian spots (benign), and splatter burns are consistent with an accident.
Question 2 of 5
The nurse is caring for assigned clients. The nurse should first check the client with
Correct Answer: A
Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.
Question 3 of 5
A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure is 170/100 mm Hg. How should the nurse respond initially?
Correct Answer: D
Rationale: Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.
Question 4 of 5
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
Correct Answer: B
Rationale: Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication.
Question 5 of 5
A laboring woman prefers to lie in the supine position during labor. The nurse teaches her that this is not a good position for which reason?
Correct Answer: C
Rationale: Supine position can compress the vena cava, causing maternal hypotension and reduced fetal perfusion, leading to fetal heart rate drops.