NCLEX-PN
NCLEX PN Practice Test Questions
Extract:
Question 1 of 5
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
Correct Answer: A
Rationale: Decreased breath sounds in the right lower lobe may indicate aspiration or pneumonia, a serious complication requiring immediate intervention to ensure airway patency and prevent further respiratory compromise.
Question 2 of 5
The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?
Correct Answer: C
Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (
C). Auditory hallucinations (
A) involve hearing voices, not reference. Tactile hallucinations (
B) involve false sensations, and persecutory delusions (
D) involve belief in harm without reference to neutral stimuli.
Question 3 of 5
The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?
Correct Answer: B
Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (
A) may confuse or alienate the client. Promising medication will resolve it (
C) oversimplifies treatment, and distracting with games (
D) dismisses the client’s distress.
Question 4 of 5
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the 'evil eye.' The nurse should communicate to other personnel that the appropriate approach is to
Correct Answer: A
Rationale: In many cultures, an 'evil eye' is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.
Question 5 of 5
A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker 'force feed' the client. What is the priority nursing action?
Correct Answer: A
Rationale: Explaining that anorexia is normal in dying (
A) addresses family distress and aligns with hospice goals. Exploring concerns (
B) is secondary, feeding tubes (
C) are inappropriate, and choking warnings (
D) may escalate distress.