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 preparing the room of a client returning from a subtotal thyroidectomy. Which item should be placed at the bedside of a client with a subtotal thyroidectomy?
Correct Answer: B
Rationale: A tracheostomy set is essential post-thyroidectomy due to the risk of airway obstruction from swelling or hematoma. Other equipment is less immediately relevant.
Question 3 of 5
A mother telephones the clinic and says 'I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding.' The nurse's best response would be which of these?
Correct Answer: A
Rationale: In breast-fed infants, stools are frequent and yellow to golden, and vary from soft to thick liquid in consistency. No change in feedings is indicated.
Question 4 of 5
A client in the medical-surgical unit has an indwelling urinary catheter. Which actions should the nurse implement to reduce the incidence of catheter-associated urinary tract infections? Select all that apply.
Correct Answer: B,C,E
Rationale: Using a separate container prevents cross-contamination. Keeping the bag below the bladder prevents urine backflow, reducing infection risk. E: Sterile technique minimizes pathogen introduction during specimen collection. A is incorrect as routine antiseptic cleansing can disrupt natural flora, increasing infection risk. D is incorrect as routine irrigation is not recommended unless medically indicated, as it can introduce pathogens.
Question 5 of 5
While caring for a client with a pulmonary embolus, the nurse notes several petechiae on his chest and abdomen. Which action should the nurse take first?
Correct Answer: C
Rationale: Petechiae may indicate a coagulopathy or emboli-related complication, requiring prompt reporting to the physician for further evaluation. Recording and monitoring are secondary, and ice packs are inappropriate.