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
A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?
Correct Answer: B
Rationale: Disseminated shingles in immunocompromised clients requires contact and airborne precautions due to varicella-zoster virus transmission risk. A private room with negative airflow prevents spread. Droplet or standard precautions are insufficient, and positive airflow is inappropriate.
Question 3 of 5
A mother has brought her 9-month-old baby to the physician's office for a well baby visit. Based on knowledge of normal growth and development, the nurse would expect that the ability the child has acquired most recently is which of the following?
Correct Answer: A
Rationale: By 9 months, sitting unsupported is a recently acquired milestone, typically achieved around 6-8 months, following earlier skills like rolling over and head control.
Question 4 of 5
A client is admitted for COPD. Which findings would require the nurse's immediate attention?
Correct Answer: B
Rationale: Restlessness and confusion. Respiratory failure may be signaled by excessive somnolence, restlessness, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.
Extract:
Medication administration record
Allergies: No Known Allergies
Sliding scale blood glucose levels, regular insulin dose
<150 mg/dL (<8.3 mmol/L), O units
150-199 mg/dL (8.3-11.0 mmol/L), 2 units
200-249 mg/dL (11.1-13.8 mmoV/L), 4 units
250-299 mg/dL (13.9-16.6 mmol/L), 6 units
≥300 mg/dL (≥16.7 mmol/L), 8 units and notify health care provider
Question 5 of 5
A client with type 1 diabetes has a prescription for 30 units of insulin glargine at bedtime. Fingerstick blood glucose measurements are prescribed before meals and at bedtime with regular insulin based on a sliding scale. At 9 PM, the client's blood glucose measurement is 180 mg/dL (10.0 mmol/L). What action should the nurse take?
Correct Answer: B
Rationale: The sliding scale indicates 2 units of regular insulin for a glucose of 180 mg/dL. Glargine, a long-acting insulin, should be given as prescribed (30 units). Glargine cannot be mixed with regular insulin in the same syringe due to differing pH levels, so separate injections are required.