NCLEX-PN
NCLEX PN Exam 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 right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.
Question 2 of 5
The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate? Click the exhibit button for additional information.
Correct Answer: B
Rationale: Skin discoloration in the buttock and lumbar area of a newborn is often due to Mongolian spots (also called congenital dermal melanocytosis). These are benign, flat, bluish-gray patches typically found on the lower back or buttocks. They are more common in infants with darker skin tones and are not harmful, but they can be mistaken for bruises, which raises concern for abuse later on.
The appropriate nursing action is to measure and document the size, shape, and location of the spots in the medical record. This ensures that there is a clear, dated record of the findings to avoid confusion in the future.
Question 3 of 5
The nurse is talking with a client's spouse who insists on being present in the room while the client is receiving CPR. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Allowing the spouse to stay with a staff member to explain reduces distress and supports family presence, which is often permitted during CPR.
Question 4 of 5
A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?
Correct Answer: B
Rationale: Community-acquired pneumonia poses the least infection risk to an immunocompromised client with AIDS, unlike C. difficile or fever of unknown origin.
Question 5 of 5
The nurse is evaluating the security of the client's tracheostomy ties. Which of the following methods is used to assess for tie tightness?
Correct Answer: A
Rationale: Placing one finger between the tie and neck ensures ties are secure but not overly tight, preventing tissue damage or airway obstruction.