NCLEX-PN
NCLEX Practice Test PN Questions
Extract:
Question 1 of 5
The nurse is caring for a 31-year-old gravida 2, para 1 woman who is in labor. The woman calls the nurse and says, 'My water has broken and I feel something between my legs.' The nurse looks and sees a loop of umbilical cord at the vaginal outlet. After signaling for help, what should the nurse do?
Correct Answer: B
Rationale: Knee-chest position relieves pressure on the prolapsed umbilical cord, maintaining fetal oxygenation until emergency delivery. Replacing the cord or pressing the fundus worsens the situation.
Question 2 of 5
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
Correct Answer: D
Rationale: All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However, the worst result is heart failure with lung congestion, so the auscultation of the lungs is the priority action.
Question 3 of 5
The nurse hears another staff member talking in a crowded elevator about a client on the unit. The client is identified by name and details of illness. What action should the practical nurse take at this time?
Correct Answer: D
Rationale: Speaking to the staff member privately after the elevator ride addresses the HIPAA violation discreetly, promoting education and correction without immediate escalation.
Question 4 of 5
The mother of a boy who has recently been diagnosed with sickle cell anemia is pregnant and asks the nurse if her unborn baby will have sickle cell anemia. What information should the nurse include in the answer?
Correct Answer: B
Rationale: Sickle cell anemia is autosomal recessive; if both parents are carriers, each child has a 25% chance of inheriting the disease, regardless of sex or birth order.
Question 5 of 5
The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?
Correct Answer: A
Rationale: Black, tarry stool (melena) indicates upper gastrointestinal bleeding, a serious complication in cirrhosis due to portal hypertension or varices, requiring immediate intervention.