NCLEX-PN
2023 NCLEX-PN Practice Questions Questions
Question 1 of 5
A nurse is caring for a client with a ventricular shunt for hydrocephalus. Which assessment finding requires immediate intervention?
Correct Answer: B
Rationale: Headache and irritability may indicate shunt malfunction or infection, which can lead to increased intracranial pressure and requires urgent evaluation.
Question 2 of 5
A nurse is caring for a client with a Sengstaken-Blakemore tube for esophageal varices. Which complication should the nurse monitor for?
Correct Answer: B
Rationale: The Sengstaken-Blakemore tube can obstruct the airway if it migrates or the balloon inflates improperly, requiring close monitoring.
Question 3 of 5
A client with a history of chronic lymphocytic leukemia is receiving chemotherapy. Which assessment finding indicates a need for immediate intervention?
Correct Answer: B
Rationale: A fever of 102°F in a chemotherapy client suggests possible neutropenic sepsis, a life-threatening infection requiring immediate intervention.
Question 4 of 5
Which nursing assessment finding provides the best evidence that a client with acute angle-closure glaucoma is responding to drug therapy?
Correct Answer: C
Rationale: Acute angle-closure glaucoma causes severe eye pain due to increased intraocular pressure; reduced or eliminated pain indicates that drug therapy is effectively lowering pressure.
Question 5 of 5
Immediately after a pregnant client's membranes rupture, which nursing action is a priority?
Correct Answer: A
Rationale: Monitoring the fetal heart rate is critical after membrane rupture to detect signs of fetal distress, such as cord compression, which can occur.