NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a man who had a transsphenoidal hypophysectomy earlier today. He says he has to spit a lot. What nursing action is essential?
Correct Answer: B
Rationale: Excessive spitting may indicate cerebrospinal fluid (CSF) leak, which contains glucose; testing secretions confirms this serious complication.
Question 2 of 5
The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.
Correct Answer: B,C,D,E
Rationale: Elevating the head of the bed (≥30 degrees) reduces reflux, proper cuff pressure seals the airway, monitoring distension detects feed intolerance, and cautious sedation prevents respiratory depression. Residual checks every 4-6 hours are standard, not 12.
Question 3 of 5
The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Avoiding NSAIDs (ibuprofen), excess coffee/cola, smoking, and alcohol reduces ulcer irritation and promotes healing. Whole wheat foods are beneficial for digestion and not contraindicated.
Question 4 of 5
The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?
Correct Answer: A
Rationale: Shoulder pain radiating down the arm post-amputation suggests a possible cardiac event (e.g., angina), a life-threatening condition requiring immediate assessment. Other pains, while severe, are more likely related to known conditions.
Question 5 of 5
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
Correct Answer: D
Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.