NCLEX-PN
Free PN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The output from a client's indwelling catheter is 500 mL for the past 10 hours. The nurse should:
Correct Answer: A
Rationale: Urine output of 500 mL in 10 hours (50 mL/hour) is within normal limits (30-50 mL/hour). No intervention is needed.
Question 2 of 5
Steam inhalation is prescribed for a client. Which of the following safety precautions should the nurse include in the client's instructions?
Correct Answer: C
Rationale: Turning off the humidifier when not in use prevents electrical hazards and bacterial growth. Distilled water is ideal but not critical, overfilling is unnecessary, and cleaning frequency depends on use.
Question 3 of 5
Because the client is thought to have Cushing's syndrome, the nurse should assess the client for the presence of which of the following? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Cushing's syndrome causes hyperglycemia, easy bruising, immunosuppression, and fluid retention due to excess cortisol. Hypertension, not low blood pressure, and acne are common, but pitting is not specific.
Question 4 of 5
A client with retinal detachment of the right eye has a scleral buckling with instillation of silicone oil. Post-operatively the client should be positioned:
Correct Answer: D
Rationale: Following a scleral buckling with instillation of silicone oil or gas, the client should be positioned prone with the head turned so that the operative eye is facing upward. Answers A, B, and C would displace the oil and prevent it from enhancing a seal between the retina and choroid.
Question 5 of 5
A 5-month-old infant is admitted to the ER with a temperature of 103.6° and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical sign in bacterial meningitis.