NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially?
Correct Answer: A
Rationale: Asking for symptom details helps assess urgency without violating privacy, as the spouse initiated contact. Privacy rules don't preclude initial fact-gathering, but direct client contact or an appointment may follow based on severity.
Question 2 of 5
The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? Select all that apply.
Correct Answer: A,C,E,F
Rationale: The Valsalva maneuver increases intracranial pressure (head injury), cardiac strain (post-MI), intra-abdominal pressure (portal hypertension), and intraocular pressure (post-cataract surgery), risking complications. Mammoplasty and pancreatic cancer have less direct risks.
Question 3 of 5
The home care nurse is observing the client's spouse performing a colostomy irrigation. Which action needs correction?
Correct Answer: D
Rationale: Petroleum jelly is not suitable for lubricating colostomy irrigation catheters, as it may degrade materials or harbor bacteria; water-soluble lubricant is preferred. The height, volume, and position are appropriate.
Question 4 of 5
The nurse is caring for a client who had a total thyroidectomy. What should the nurse plan to observe the client for immediately after his return to the nursing care unit?
Correct Answer: B
Rationale:
Total thyroidectomy risks parathyroid gland damage, leading to hypocalcemia (not hypercalcemia). However, the question likely intends hypocalcemia signs (tetany, spasms), which are critical to monitor immediately post-surgery. Hoarseness, reflexes, or confusion are less urgent.
Question 5 of 5
The nurse is caring for a man who had a transsphenoidal hypophysectomy earlier today. He says he has to spit a lot. What nursing action is essential?
Correct Answer: B
Rationale: Excessive spitting may indicate cerebrospinal fluid (CSF) leak, which contains glucose; testing secretions confirms this serious complication.