NCLEX-PN
NCLEX PN Practice Test Questions
Extract:
Question 1 of 5
While caring for a woman who delivered a healthy term infant six hours ago, the nurse notes that the fundus is soft, 2 cm above the umbilicus, and off to the left. The lochia is red. The nurse suspects that the client has which problem?
Correct Answer: C
Rationale: A soft, displaced fundus suggests urinary retention, causing bladder pressure on the uterus. Normal involution shows a firm, midline fundus; fragments or lacerations present differently.
Question 2 of 5
An adult who has cholecystitis reports clay-colored stools and moderate jaundice. The nurse knows that which is the best explanation for the presence of clay-colored stools and jaundice?
Correct Answer: D
Rationale: Clay-colored stools and jaundice result from a common bile duct obstruction, preventing bile flow to the intestines and causing bilirubin buildup in the blood. The gallbladder stores, not produces, bile, and pancreatic or gallbladder issues are less directly related.
Question 3 of 5
The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?
Correct Answer: C
Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (
C). Auditory hallucinations (
A) involve hearing voices, not reference. Tactile hallucinations (
B) involve false sensations, and persecutory delusions (
D) involve belief in harm without reference to neutral stimuli.
Question 4 of 5
The nurse is caring for a client who is experiencing hypotension and respiratory depression after administration of IV midazolam. The nurse should anticipate that the client will receive
Correct Answer: D
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression and hypotension in overdose. Flumazenil (
D) is the specific antidote, reversing benzodiazepine effects. Acetylcysteine (
A) treats acetaminophen overdose, benztropine (
B) manages extrapyramidal symptoms, and phentolamine (
C) treats hypertensive crises, none of which apply here.
Question 5 of 5
A client is receiving lithium carbonate 600 mg T.I.D. to treat bipolar disorder. Which of these indicate early signs of toxicity?
Correct Answer: B
Rationale: Vomiting, diarrhea, and lethargy are early signs of lithium toxicity.