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
When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by
Correct Answer: B
Rationale: An imbalance between red cell destruction and production. Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from 120 days to 12-20 days).
Question 3 of 5
The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.
Correct Answer: C,D,E
Rationale: Orthostatic pulse change (
C) indicates cardiovascular instability, increasing fall risk. Osteoarthritis of knees (
D) impairs mobility and stability. Carbidopa/levodopa (E) for Parkinson’s can cause orthostatic hypotension or dyskinesia, heightening fall risk. Age 50 (
A) is not a significant risk factor alone, ovarian cancer (
B) is unrelated to falls, and cane use (F) reduces risk if used correctly.
Question 4 of 5
The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
Correct Answer: D
Rationale: Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorte
the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a
herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the
body even when active lesions are healed; however, it is still contagious, even when dormant. The infection
can be spread to other people or other parts of the body via skin-to-skin contact; therefore, gloves should be
used when applying topical antiviral or analgesic (eg, lidocaine) medications. There is no cure for genital
herpes; treatment is aimed at relieving symptoms and preventing the spread of infection
Question 5 of 5
A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?
Correct Answer: A
Rationale: Cessation of contractions with maternal tachycardia (
A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (
B) is concerning but less specific, anxiety (
C) is expected, and regular contractions (
D) are normal.