NCLEX-PN
PN NCLEX Practice Exam Questions
Extract:
Question 1 of 5
Thirty-six hours after major surgery, a client has a temperature of 100°F. What is the most likely cause of the temperature elevation?
Correct Answer: B
Rationale: Atelectasis, due to reduced lung expansion post-surgery, is a common cause of low-grade fever within 24–48 hours. Dehydration, wound infection (typically later), or bladder infection are less likely without specific symptoms.
Question 2 of 5
The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?
Correct Answer: B
Rationale: Maintaining a sterile field (
B) is critical to prevent infection, especially in a disoriented client. Explaining the procedure (
A) is ideal but not feasible, kit placement (
C) is secondary, and swab disposal (
D) follows insertion.
Question 3 of 5
The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?
Correct Answer: A
Rationale: Asking the interpreter to explain the discussion (
A) ensures the nurse understands any concerns or clarifications, verifying informed consent. Gestures (
B) are unreliable, the interpreter witnessing (
C) is inappropriate, and noting interpreter use (
D) is insufficient without understanding the discussion.
Question 4 of 5
A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first?
Correct Answer: A
Rationale: Auscultating breath sounds (
A) assesses the cause of breathlessness (e.g., pulmonary edema) in heart failure, guiding immediate interventions. Edema (
B), vitals (
C), and weight (
D) are secondary.
Question 5 of 5
The nurse is caring for a 10-year-old client with sickle cell disease who is experiencing an episode of acute pain. Which of the following diversional activities would be appropriate for the nurse to offer the client?
Correct Answer: B
Rationale: Reading a book (
B) is a calm, stationary activity suitable for pain management. Puzzles (
A) may require movement, walking (
C) could worsen pain, and puppets (
D) may be too childish for a 10-year-old.