NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
Which findings reflect vital signs that are concerning and require further nursing monitoring and intervention? Select all that apply.
Correct Answer: C,D,E
Rationale: Hypotension (90/60 mm Hg) with nifedipine risks severe hypotension. Transfusion-related hypotension and tachycardia suggest a reaction. Fetal heart rate deceleration post-contraction indicates potential distress. Albuterol's tachycardia/tremor and hydromorphone's mild BP drop are expected.
Question 2 of 5
An adult is taking phenazopyridine hydrochloride (Pyridium) 200 mg PO tid after meals. Which comment by the client indicates a lack of understanding about the medication?
Correct Answer: B
Rationale: Bright orange urine is a normal effect of Pyridium, so concern about it indicates a lack of understanding of the medication's side effects.
Question 3 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 4 of 5
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
Question 5 of 5
During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the well in the wheelchair. What is the priority nursing action?
Correct Answer: C
Rationale: Multiple bruises in various stages raise suspicion for elder abuse, requiring reporting to the HCP for investigation. Further questioning may cause distress, and hygiene/nutrition assessments are secondary. Discussing with family risks alerting potential abusers.