NCLEX-PN
NCLEX-PN Free Practice Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?
Correct Answer: D
Rationale: Using a trapeze reduces shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis), which increase the risk of pressure ulcer development. They can occur as clients slide down in bed or when they're pulled up in bed.
To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees. The risks of friction, impaired circulation, and localized pressure aren't decreased with trapeze use.
Question 2 of 5
The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: 'We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).' In order to take appropriate action, the nurse must understand that
Correct Answer: D
Rationale: 95% of SIDS cases occur before 6 months of age. Peak age of SIDS occurrence is 2 to 4 months and 95% of cases occur by 6 months of age. It is the leading cause of death in infants 1 month to 1 year of age.
Question 3 of 5
A client with a history of seizures is prescribed phenytoin (Dilantin) 100 mg tid. The nurse should instruct the client to
Correct Answer: B
Rationale: Alcohol can lower phenytoin levels, increasing seizure risk, so avoidance is critical. Taking with meals (
A) is unnecessary, calcium (
C) is unrelated, and stopping for a rash (
D) requires physician consultation due to potential Stevens-Johnson syndrome.
Question 4 of 5
A patient is prescribed digoxin for heart failure. Which of the following findings should prompt the nurse to withhold the medication and notify the healthcare provider?
Correct Answer: A
Rationale: Digoxin slows heart rate, and a rate below 60 beats per minute indicates potential toxicity or bradycardia, requiring withholding the dose and provider notification. Other findings are within normal limits or unrelated.
Extract:
When changing Ms. Wilson's postoperative dressing, the nurse is careful not to introduce microorganisms into the surgical incision.
Question 5 of 5
This is an example of:
Correct Answer: C
Rationale: Intact skin is the first line of defense against entry of microorganisms. A surgical incision is a portal of entry, so a technique that requires the absence of all microorganisms (surgical asepsis) is essential.