NCLEX-PN
NCLEX PN Test Questions Questions
Extract:
Vital signs
Blood pressure 105/60 mm Hg
Heart rate 80/min
Respirations 22/min
SpO2 90% on room air
Nurse notes
The client has a history of coronary artery disease and peripheral vascular disease. Nursing assessment reveals crackles in middle & lower lung fields, moderate jugular venous distension, and 3+ pedal edema.
Medications
Enoxaparin: 30 mg subcutaneous once daily
Metoprolol: 50 mg PO twice a day
Furosemide: 40 mg PO twice daily
Atorvastatin: 20 mg PO once daily
Question 1 of 5
The nurse is preparing to administer medications to a client with acute decompensated heart failure. Which of the following medications should the nurse hold for clarification prior to administering?
Correct Answer: D
Rationale: Metoprolol (
D) may worsen acute decompensated heart failure by reducing cardiac output, requiring clarification. Furosemide (
C) treats fluid overload, enoxaparin (
B) prevents thrombosis, and atorvastatin (
A) manages lipids.
Extract:
Question 2 of 5
The nurse is caring for a newborn who has a large myelomeningocele. It would be a priority for the nurse to
Correct Answer: B
Rationale: A myelomeningocele requires a sterile, moist dressing (
B) to prevent infection and drying. Checking anus tone (
A), measuring head circumference (
C), and supine positioning (
D) are secondary or contraindicated.
Question 3 of 5
The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?
Correct Answer: D
Rationale: This type of identification band easily tracks the client's movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.
Question 4 of 5
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?
Correct Answer: C
Rationale: Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Letting tap water run for several minutes will diminish the lead contamination.
Question 5 of 5
The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?
Correct Answer: B
Rationale: Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Sudden cessation of wheezing is an ominous sign that indicates an emergency -- the small airways are now collapsed.