NCLEX-PN
NCLEX PN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube and a gastric residual volume of 75 mL. Which of the following actions should the nurse take? Select all that apply.
Correct Answer: A,C,D
Rationale: A residual of 75 mL is typically acceptable to proceed with feeding. High-Fowler position and flushing are standard. Residual is returned, not discarded, and pH >5 is not concerning.
Question 2 of 5
The nurse monitoring a newborn after birth observes a bluish discoloration of the hands and feet. The trunk is pink. What is the nurse's initial action?
Correct Answer: D
Rationale: Acrocyanosis is normal in newborns. Skin-to-skin contact promotes thermoregulation and bonding.
Question 3 of 5
The nurse is reinforcing teaching to a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Caffeine, tobacco, and cold exposure can trigger Raynaud episodes. Yoga/tai chi and gloves help prevent attacks. Cold water immersion exacerbates symptoms.
Question 4 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 5 of 5
The nurse is caring for a newborn with jaundice who is being treated with phototherapy. What action by the nurse would require the charge nurse to intervene?
Correct Answer: B
Rationale: Clothing during phototherapy reduces skin exposure to light, decreasing treatment efficacy.