NCLEX-PN
PN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is very demanding. She frequently rings the bell and asks to have her pillow fluffed or the water glass filled. Which response by the nurse will likely be most effective?
Correct Answer: D
Rationale: Acknowledging potential underlying concerns invites the client to express needs, reducing demands. Constant responses reinforce behavior, and dismissive or confrontational responses escalate tension.
Question 2 of 5
The nurse checks the lab values of a newly admitted client. RBC: 4.0 million/mm³, WBC: 1500/mm³, Platelets: 40,000/mm³. What nursing actions are indicated because of these lab values?
Correct Answer: B
Rationale: Low WBC (neutropenia) requires protective isolation, and low platelets (thrombocytopenia) contraindicate injections to prevent bleeding and infection.
Question 3 of 5
The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?
Correct Answer: B
Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.
Question 4 of 5
Which incidence should be documented on an unusual incident report?
Correct Answer: D
Rationale: A fall is an unusual incident requiring documentation due to potential injury and liability. Leaving AMA, transfusion fever, or upset stomach are notable but less likely to require an incident report.
Question 5 of 5
A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure is 170/100 mm Hg. How should the nurse respond initially?
Correct Answer: D
Rationale: Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.