NCLEX-PN
PN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
Correct Answer: A
Rationale: Normal ICP is less than 15. 66 is a high reading, and the RN and the physician should be notified. Answer B would be the action if the reading was normal, so it is incorrect. Answers C and D would not be appropriate actions, so they are wrong.
Question 2 of 5
The nurse is observing a nursing assistant providing care. Which action indicates that the nursing assistant understands universal precautions?
Correct Answer: C
Rationale: Wearing a gown for soiled linen contact adheres to universal precautions, preventing contamination. Limited hand washing, excessive gloves, or no hand washing post-gloves are incorrect.
Question 3 of 5
The nurse is inserting an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? Select all that apply.
Correct Answer: A,B,D
Rationale: Spreading labia aids visualization. Sterile gloves and drape maintain sterility. Proper positioning facilitates insertion. Advancing only 2 inches is insufficient (should be 5-7 cm) before balloon inflation. Cleansing should start with the meatus , not labia.
Question 4 of 5
Which of the following beverages is most appropriate for a client with renal failure?
Correct Answer: C
Rationale: Apple juice is most appropriate for a client with renalrape juice has a lower potassium content, which is crucial for renal failure patients who need to limit potassium intake. Prune, grape, and apricot juices are high in potassium, which can be harmful in renal failure.
Question 5 of 5
All of the following clients are on the unit. Which one is most likely to develop urinary retention?
Correct Answer: C
Rationale: Abdominal hysterectomy involves pelvic manipulation, increasing urinary retention risk due to bladder trauma or nerve disruption. Other surgeries pose lower risk.