NCLEX-PN
NCLEX Practice Test PN Questions
Extract:
Question 1 of 5
The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting is:
Correct Answer: C
Rationale: Suction pressure of 80-120 mm Hg is recommended for adult tracheostomy suctioning to effectively remove secretions without causing trauma.
Question 2 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.
Question 3 of 5
A client with a below-the-knee amputation is experiencing phantom limb pain. Which action by the nurse would be most effective in relieving the pain?
Correct Answer: C
Rationale: Applying a TENS unit can help relieve phantom limb pain by stimulating nerves and reducing pain signals. Acknowledging the pain is supportive but does not directly relieve it. Elevating the stump may help with swelling but not specifically phantom pain. Rewrapping the stump may provide comfort but is less effective than TENS for pain relief.
Question 4 of 5
A client hospitalized with mania is racing wildly about the unit trying to organize the other clients into a game of Ping-Pong. The nurse should:
Correct Answer: B
Rationale: Taking the client for a walk redirects energy safely and reduces stimulation. Art therapy may not engage, continuing the activity risks escalation, and video exercises lack supervision.
Question 5 of 5
A client complaining of severe shortness of breath is diagnosed with congestive heart failure. The nurse observes a falling pulse oximetry. The client's color changes to gray and she expectorates large amounts of pink frothy sputum. The first action of the nurse would be which of the following?
Correct Answer: D
Rationale: Administer oxygen. In a medical emergency, airway and breathing are prioritized. Oxygen administration addresses the immediate respiratory distress.