NCLEX PN Practice Test
Question 1 of 5.
Extract:Laboratory reference ranges Glucose (random) 71-200 mg/dL (3.9-11.1 mmol/L)
A category 4 hurricane has affected a rural, local health care system, creating a significant increase in emergency department admissions. Which of the following clients should the nurse anticipate as the priority for intervention?
A. Client with status asthmaticus and a pulse oximetry reading of 89%
B. Client with diabetes mellitus reporting a headache after being involved in a minor motor vehicle collision
C. Client who is 11 weeks pregnant, has gestational diabetes, and nausea and vomiting over the past 2 days
D. Client with diabites mellitus with a serum glucose level of 690 mg/dl (38.3 mmol/L ,abdominal pain, and fatigue)
Explanation: Status asthmaticus with 80% pulse oximetry (A) indicates severe hypoxia, requiring immediate intervention to prevent respiratory failure. Headache post-collision (B) and nausea in pregnancy (C) are less acute, as they do not indicate immediate life-threatening conditions.
Question 2 of 5.
The nurse is to change a dressing. Which is essential to do when opening the dressing set?
A. Open the first flap away from the nurse.
B. Open the first flap toward the nurse.
C. Place the dressing set on a chair beside the bed.
D. Place the dressing set on the client's bed.
Explanation: The first flap should be opened away from the nurse to allow the last flap to be opened toward the nurse, preventing contamination. The dressing set should be placed at waist height on a clean surface like an overbed table, not on the bed or a chair.
Question 3 of 5.
A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?
A. Explain the unit routines to her in detail
B. Ask her if she has any question about the unit or what she is supposed to do
C. Briefly explain the most essential information and then sit with her
D. Take her by the hand and orient her to the unit
Explanation: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.
Question 4 of 5.
A 1-year-old boy is hospitalized for a fractured femur. There is a PRN order for pain medication. What is the best way to assess the child for pain?
A. Ask the parent who is present if the child appears to be in pain.
B. Observe the child's behavior carefully.
C. Ask the child where it hurts and how badly it hurts.
D. Have the child look at pictures of faces and select the one that best describes how he feels right now.
Explanation: A 1-year-old cannot verbalize pain; observing behavior (e.g., crying, guarding) is the most reliable pain assessment method.
Question 5 of 5.
A client is to be discharged on enoxaparin (Lovenox) for the next two days. Which comment by the client indicates a need for further instruction?
A. I will wash my hands before I prepare the injection.
B. I will give the injection in my thigh.
C. I will pinch the skin before I inject the medicine.
D. I will not massage the area after the shot.
Explanation: Enoxaparin is injected subcutaneously in the abdomen, not the thigh, indicating a need for further teaching.
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