NCLEX-PN
NCLEX PN Test Questions
Extract:
Question 1 of 5
The nurse is observing client care activities on the unit. It would require completion of an incident report if
Correct Answer: B
Rationale: Administering escitalopram within 24 hours of phenelzine, a monoamine oxidase inhibitor, risks serotonin syndrome, a life-threatening condition, requiring an incident report. Holding clozapine for low neutrophils, holding isosorbide for low blood pressure, and giving warfarin for a normal INR are appropriate actions.
Question 2 of 5
Which of the following observations indicates the possibility of a birth injury related to forceps delivery?
Correct Answer: A
Rationale: Asymmetry of the mouth may indicate facial nerve injury, a potential complication of forceps delivery due to pressure on the facial nerve.
Question 3 of 5
A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child?
Correct Answer: C
Rationale: Prolonged hypoxemia. Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia, requiring specialized monitoring.
Question 4 of 5
A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation?
Correct Answer: C
Rationale: Inspiratory wheezes in bilateral lower lung fields is a specific, objective finding that accurately describes the client's condition. The other entries are vague, lack detail, or are subjective without supporting data.
Question 5 of 5
The nurse is performing a dressing change for a client with an infected wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply.
Correct Answer: A,C
Rationale: Encasing the dressing in a glove and washing hands before and after glove use prevent contamination. Saving sterile supplies compromises sterility, and wrapping in paper towels before regular trash disposal risks infection spread; biohazard disposal is required.