NCLEX-PN
NCLEX PN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is observing a client who had a left total knee replacement using a cane to descend stairs. It would demonstrate correct technique if the client descends the stairs by placing the
Correct Answer: A
Rationale: For descending stairs, the cane and affected leg move together after the unaffected leg, providing stability.
Question 2 of 5
The nurse finds a person unresponsive on the floor. What is the initial nursing action?
Correct Answer: B
Rationale: Assessing respirations and pulse determines if CPR is needed, per ACLS guidelines. Compressions, positioning, or breathing are premature without confirming unresponsiveness and absence of pulse/breathing.
Question 3 of 5
Triazolam (Halcion) 0.25 mg is ordered for a client at bedtime. When the nurse goes to give the medication, the client asks the nurse to leave it at the bedside because she wants to finish reading a book. What is the best action for the nurse to take?
Correct Answer: B
Rationale: Returning in an hour ensures medication administration while respecting the client's request, adhering to safety protocols. Leaving medication or delaying indefinitely risks errors.
Question 4 of 5
The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
Correct Answer: A
Rationale: Extreme fatigue. Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.
Question 5 of 5
The nurse is observing client care situations. Which of the following situations would require an order for physical restraints? Select all that apply.
Correct Answer: D,E
Rationale: Belt and ankle restraints require a provider's order due to their restrictive nature. Immobilizers, mummy restraints, and padded rails are typically used for specific purposes without restraint orders.