NCLEX-PN
NCLEX PN Exam Practice Test Questions
Extract:
Question 1 of 5
The nurse is caring for a 6-month-old client who has a new tracheostomy. Which of the following findings would indicate that the client's airway requires suctioning? Select all that apply.
Correct Answer: A,C,D
Rationale: Audible gurgling, irritability, and low oxygen saturation (88%) indicate airway obstruction or secretions requiring suctioning. Normal heart rate (110/min) and respiratory rate (30/min) for a 6-month-old do not necessitate suctioning.
Question 2 of 5
A client with a embolus has an order for a continuous infusion of heparin. The doctor has ordered 1,200 units per hour. If the solution contains 1,250 units in $250 \mathrm{~mL}$, the nurse should administer how many $\mathrm{mL}$ per hour?
Correct Answer: B
Rationale: Calculation: (1,200 units/hour ÷ 1,250 units) × 250 mL = 24 mL/hour. This ensures the correct heparin dose is delivered.
Question 3 of 5
The nurse has just completed a dressing change on an elderly client who is allowed bathroom privileges. Which action is most essential for the nurse to take before leaving the client's bedside?
Correct Answer: A
Rationale: Hand washing prevents infection transmission post-dressing change, a critical step. Lowering the bed, toileting, or pain assessment are secondary.
Question 4 of 5
The nurse in the emergency department is caring for assigned clients. The nurse should recognize that which of the following clients meets the criteria for involuntary admission to the mental health unit? Select all that apply.
Correct Answer: A,C
Rationale: Refusal of food and fluids for 4 days indicates imminent risk of harm to self due to dehydration and malnutrition, meeting involuntary admission criteria. 3: Threats of violence suggest potential harm to others, justifying involuntary admission. 2 does not indicate immediate risk, as the client is medication-compliant. 4 reflects unusual behavior but not immediate danger. 5 does not inherently indicate a psychiatric emergency requiring involuntary admission.
Question 5 of 5
The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is:
Correct Answer: C
Rationale: The arrival of the imperfect child that the mother had not envisioned places the mother in a situational crisis.