NCLEX-PN
NCLEX Practice Test PN Questions
Extract:
Question 1 of 5
The nurse is preparing to assist a client to ambulate to the bathroom. The client rises from the chair at the bedside and immediately reports feeling dizzy. It would be a priority for the nurse to
Correct Answer: D
Rationale: Dizziness upon standing suggests orthostatic hypotension or other instability. Assisting the client back to a sitting position prevents falls and ensures immediate safety.
Question 2 of 5
A nurse in the pediatric unit is preparing a 16-year-old for a surgical procedure and observes that the client has signed the informed consent for surgery. What should be the first action by the nurse?
Correct Answer: B
Rationale: Minors typically cannot provide legal consent unless they are emancipated or meet specific legal criteria. The nurse must first determine if the 16-year-old is legally able to sign the consent.
Question 3 of 5
A child's burn is debrided each day with hydrotherapy to remove the eschar. The child's parents ask why this immersion is necessary. What is the most appropriate response for the nurse to make?
Correct Answer: A
Rationale: Hydrotherapy removes eschar to prevent infection and prepare for grafting, accurately explaining the procedure's purpose.
Question 4 of 5
Following a typanoplasty, the nurse should maintain the client in which position?
Correct Answer: C
Rationale: After tympanoplasty, the client should be positioned flat with the head turned to the side and the operative ear facing up to promote healing and prevent pressure on the surgical site. Answer A is incorrect because the operative ear should face up, not down. Answer B is incorrect because low Trendelenburg is not indicated. Answer D is incorrect because a neck roll may not ensure proper positioning of the operative ear.
Question 5 of 5
The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider?
Correct Answer: D
Rationale: A vancomycin trough of 23 mg/L is above the therapeutic range (10-20 mg/L), indicating potential toxicity. Elevated creatinine (1.5 mg/dL) suggests renal impairment, which increases the risk of vancomycin accumulation and nephrotoxicity.