NCLEX-PN
NCLEX PN Practice Test Questions
Extract:
Question 1 of 5
The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse?
Correct Answer: D
Rationale: A vest restraint in the high-Fowler position (
D) poses a risk of strangulation or asphyxiation due to the restraint slipping upward, requiring immediate intervention. Belt restraint in semi-Fowler (
A), mitten restraints in side-lying (
B), and wrist restraints in supine (
C) are safer positions, assuming proper application and monitoring.
Question 2 of 5
A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2 hour-old newborn, which clinical finding requires the nurse to intervene?
Correct Answer: C
Rationale: Jitteriness (
C) in a newborn of a diabetic mother suggests hypoglycemia, a common complication due to maternal hyperglycemia causing fetal hyperinsulinism. Immediate intervention (e.g., glucose testing) is needed. Acrocyanosis (
A) is normal, heart rate 165/min while crying (
B) is within range, and respirations of 60/min (
D) are normal for a newborn.
Question 3 of 5
The nurse is preparing to administer IV cefazolin to a newly admitted client with cellulitis. The nurse notes the client is allergic to amoxicillin. Which of the following actions should the nurse take next?
Correct Answer: D
Rationale: Clients with an allergy to penicillin antibiotics (eg, amoxicillin) can experience a cross-sensitivity reaction
to cephalosporin antibiotics (eg, cefazolin) because the medication molecules are structurally similar. The
nurse should first obtain more information by asking about the type of reaction the client experienced because
allergic reactions can range from mild to severe (Option 4)
Cephalosporins can be safely administered to clients with a history of mild allergic reaction to penicillin (eg,
rash) but are contraindicated for clients with a history of anaphylaxis.
Question 4 of 5
Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom?
Correct Answer: C
Rationale: Persistent vomiting (
C) suggests shunt malfunction or increased intracranial pressure, requiring immediate reporting. Normal temperature (
A), memory lapses (
B), and palpable shunt (
D) are not concerning.
Question 5 of 5
The nurse is reinforcing teaching of proper foot care to a client with diabetes mellitus. Which statement by the client indicates the need for further teaching?
Correct Answer: D
Rationale: Sandals (
D) expose feet to injury, increasing infection risk in diabetes. Lanolin (
A), avoiding heating pads (
B), and testing water (
C) are correct to prevent skin breakdown and burns.