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 is making a home visit to an adult who had a cataract extraction yesterday. Which observation indicates that the client needs more instruction?
Correct Answer: C
Rationale: Bending over post-cataract surgery increases intraocular pressure, risking complications; this indicates a need for further instruction on activity restrictions.
Question 3 of 5
The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention should the nurse anticipate?
Correct Answer: D
Rationale: Vancomycin requires therapeutic drug monitoring to ensure efficacy and prevent toxicity. Obtaining a serum trough level 15-30 minutes before the fourth dose (
D) is standard to guide dosing adjustments. A new IV line (
A) is unnecessary unless the current line is compromised. Antiemetics (
B) are not routinely needed. Infusion over 60 minutes (
C) is typical to prevent red man syndrome, not 30 minutes.
Question 4 of 5
A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?
Correct Answer: C
Rationale: Pale skin in the hand (
C) suggests vascular compromise, risking fistula failure or ischemia, requiring immediate reporting. Edema (
A) is common, a swooshing sound (
B) indicates patency, and mild pain (
D) is expected.
Question 5 of 5
A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?
Correct Answer: A
Rationale: Cessation of contractions with maternal tachycardia (
A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (
B) is concerning but less specific, anxiety (
C) is expected, and regular contractions (
D) are normal.