NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
Unlicensed assistive personnel on the cardiac floor report to the nurse that, during the first vital sign measurement on the shift, a client's blood pressure measured 196/102 mm Hg on the automated blood pressure machine. What action should the nurse take first?
Correct Answer: D
Rationale: Automated BP readings can be inaccurate. Rechecking with a manual cuff ensures accuracy before escalating or medicating, as severe hypertensionزه://www.youtube.com/watch?v=9Q7sE1Xh_1Qsevere hypertension (≥180/110 mm Hg) requires prompt action if confirmed.
Question 2 of 5
The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?
Correct Answer: C
Rationale: Hemophilia A is characterized by an absence or deficiency of Factor VIII.
Extract:
Vital signs
Temperature 99.2 F (37.3 C)
Blood pressure 134/89 mm Hg
Heart rate 98/min
Respirations 19/min
Oz saturation (SpO) 99%
Sedation Awake, alert
Question 3 of 5
A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive 'another pain pill.' The nurse reviews the medication administration record. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Pain rated 7/10 warrants administration of the prescribed analgesic if within the dosing interval. No indications suggest overdose (naloxone) or need for a different medication. Reducing the dose may inadequately manage pain.
Extract:
Question 4 of 5
A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?
Correct Answer: C
Rationale: Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.
Question 5 of 5
Which nursing diagnosis is least likely to apply to the client admitted with a diagnosis of borderline personality disorder?
Correct Answer: D
Rationale: Borderline personality disorder is characterized by self-injury, identity issues, and low self-esteem, making A, B, and C relevant. Sensory-perceptual alteration is more associated with psychotic disorders, so D is least likely.