NCLEX-PN
NCLEX-PN Practice Questions Free Questions
Extract:
The patient has been receiving 2500 ml of IV fluid and 300 to 400 ml of oral intake daily for 2 days. The patient's urine output has been decreasing and now has been less than 40 ml per hour for the past 3 hours.
Question 1 of 5
The nurse should immediately:
Correct Answer: B
Rationale: The imbalance in intake and output, with decreasing urinary output, may indicate renal failure or fluid overload, potentially leading to congestive heart failure. Assessing breath sounds and vital signs is the first step.
Extract:
Which statement is best to document a patient's behavior in an unbiased way?
Question 2 of 5
The patient's hostility created difficulties for the nursing staff.'
Correct Answer: C
Rationale: Nursing documentation must be objective, describing specific actions without subjective judgments.
Extract:
Question 3 of 5
The nurse is talking with a group of young people who are preparing to spend a weekend camping in the woods. Which information is essential to include in the discussion?
Correct Answer: A
Rationale: Long pants and sleeves prevent tick bites, reducing Lyme disease risk, a critical precaution. Sunscreen is needed, salt tablets are outdated, and poison ivy reacts quickly.
Question 4 of 5
Light therapy can be effective for:
Correct Answer: D
Rationale: Light therapy is effective for regulating circadian rhythms and treating sleep disorders, like seasonal affective disorder. It is not primarily used for weight, allergies, or general alternative treatments. Nonpharmacological Therapies
Question 5 of 5
A client who is 12 hour post-op becomes confused and says: 'Giant sharks are swimming across the ceiling.' Which assessment is necessary to adequately identify the source of this client's behavior?
Correct Answer: C
Rationale: Pulse oximetry. A sudden change in mental status in any post-op client should trigger a nursing intervention directed toward respiratory evaluation. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate gas exchange which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these findings which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations, and loss of consciousness.