NCLEX-PN
NCLEX PN Test Questions Questions
Question 1 of 5
In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?
Correct Answer: C
Rationale: Check the client for bladder distention and the client's urinary catheter for kinks. These are findings of autonomic dysreflexia, typically initiated by a noxious stimulus below the level of injury such as a full bladder.
Question 2 of 5
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
Correct Answer: B
Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm, as uterine atony is the primary cause of bleeding in the first hour after delivery.
Question 3 of 5
A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the child's mother?
Correct Answer: C
Rationale: Promoting the child's optimal development. The primary goal is to promote the child's optimum development.
Question 4 of 5
The nurse is preparing to administer IV furosemide to a client with chronic kidney disease. The nurse should administer the medication slowly to prevent
Correct Answer: B
Rationale: Rapid IV furosemide can cause ototoxicity (
B) in CKD patients due to drug accumulation. Oliguria (
A) is already present, and furosemide does not typically cause bradycardia (
C) or hypertension (
D).
Question 5 of 5
The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, 'I already have a power of attorney.' What is the best response by the nurse?
Correct Answer: D
Rationale: Clarifying if the POA includes healthcare decisions (
D) ensures proper advance directive planning. Vague affirmations (A,
B) or suggesting a lawyer (
C) do not address the need for a healthcare-specific POA.