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NCLEX PN Practice Questions Questions

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Question 1 of 5

The nurse is performing tracheal suctioning and notes a previously used bottle of saline at the client's bedside. The nurse should:

Correct Answer: B

Rationale: A new, sterile saline bottle is required for suctioning to prevent infection. Reusing or relabeling an opened bottle is unsafe.

Question 2 of 5

The nurse is to observe the client for shock. The client's admitting vital signs are blood pressure (BP)=116/70, pulse=86, and respirations=24. Which finding, if observed, would be most suggestive of shock?

Correct Answer: B

Rationale: Increased pulse (tachycardia) is a hallmark of shock, compensating for reduced volume. Stable or slightly varied BP and low pulse are less indicative.

Question 3 of 5

A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit. The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse. Which action by the nurse is appropriate?

Correct Answer: D

Rationale: Persistent VT causing altered mental status requires synchronized cardioversion to restore normal rhythm.

Question 4 of 5

The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect?

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic, so a normal potassium level indicates it is counteracting the potassium loss from hydrochlorothiazide.

Question 5 of 5

The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?

Question Image

Correct Answer: C

Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation

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