NCLEX-PN
NCLEX Practice Questions PN Questions
Extract:
Question 1 of 5
The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
Correct Answer: B, C, E
Rationale: High-pitched cry (
B), poor feeding (
C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (
A) suggests dehydration, not meningitis, and Babinski sign (
D) is normal in infants.
Question 2 of 5
The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply.
Correct Answer: A, C, E, F
Rationale: Guiding to the floor (
A), clearing objects (
C), positioning laterally (E), and observing (F) ensure safety.
Tongue blades (
B) are dangerous, and restraining (
D) increases injury risk.
Question 3 of 5
The nurse is caring for a client who has congestive heart failure. Which finding indicates that her condition is getting worse?
Correct Answer: B
Rationale: A decrease in blood pressure suggests worsening cardiac output in congestive heart failure, indicating decompensation.
Question 4 of 5
A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?
Correct Answer: C
Rationale: Obtain a sitter for the client while restrained. The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm caused by removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as aspiration, then a sitter should be requested. These are to be provided by the facility in the event the family cannot do so. This client needs to cough and be watched rather than restricted. Suctioning will not prevent aspiration in this situation. Cough suppressants should be avoided for this client.
Question 5 of 5
The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply.
Correct Answer: B, C, D
Rationale: Crushing separately (
B) prevents interactions, liquid forms (
C) are preferred, and flushing (
D) ensures patency. Combining all medications (
A) or mixing with formula (E) can cause clogs or interactions.