NCLEX-PN
NCLEX PN Exam Practice Test Questions
Extract:
Question 1 of 5
The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
Correct Answer: A
Rationale: The phlebostatic axis is the reference point for accurate central venous pressure measurement, as it corresponds to the right atrium's level. The point of maximum impulse, Erb's point, and Tail of Spence are not used for this purpose, so answers B, C, and D are incorrect.
Question 2 of 5
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
Correct Answer: A
Rationale: Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.
Question 3 of 5
The nurse is caring for a newborn shortly after birth. Which of the following findings would be a priority to follow up?
Correct Answer: D
Rationale: A tuft of hair at the spine base may indicate spina bifida occulta, requiring follow-up. Vernix, caput succedaneum, and Mongolian spots are normal newborn findings.
Question 4 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.
Question 5 of 5
The nurse is auscultating an elderly bedridden client's breath sounds and hears crackles. What is the best interpretation of this finding?
Correct Answer: C
Rationale: Crackles in a bedridden elderly client suggest fluid in the lungs or atelectasis, which deep breathing can help clear. It's not normal, not immediately life-threatening, and oxygen is premature without further assessment.