NCLEX PN Test
Question 1 of 5.
A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply.
A. Ensuring the client wears an N95 respirator at all times
B. Keeping the door of the client's room closed at all times
C. Maintaining a log of everyone in and out of the client's room
D. Removing both pairs of gloves before removing gown and mask
E. Restricting visitors from entering the client's room
Explanation: Keeping the door closed, maintaining a log, and restricting visitors minimize Ebola transmission risk. The client does not need an N95 respirator, and gloves should be removed after gown and mask to prevent contamination.
Question 2 of 5.
The nurse is caring for a woman who is HIV positive. The woman starts her period. There is menstrual blood on the floor. What substance should the nurse use to clean up the floor?
A. Chlorine bleach
B. Hydrogen peroxide
C. Betadine
D. Ammonia
Explanation: Chlorine bleach is the best product for cleaning blood spills, as HIV can be present in menstrual blood, requiring a disinfectant effective against bloodborne pathogens.
Question 3 of 5.
A client is admitted with right lower quadrant pain, nausea, and a temperature of 100°F. What does the nurse expect will be done initially?
A. X-ray of the abdomen
B. Deep palpation of the abdomen
C. Blood drawn for complete blood count (CBC)
D. Administration of a tap water enema
Explanation: Symptoms suggest appendicitis; a CBC is initial to assess for infection (elevated WBC), guiding further diagnostic steps.
Question 4 of 5.
The nurse is caring for an adult who was admitted for observation following an automobile accident. The client has several lacerations that were sutured in the emergency room and a fractured leg that has been casted. The baseline vital signs are BP=120/72, P=76, and R=16. One hour after arriving on the unit, the client's vital signs are BP=108/68, P=90, and R=22. The nurse most correctly interprets these results to mean that the client may be developing which condition?
A. Shock
B. Increased intracranial pressure
C. Panic attack
D. Autonomic hyperreflexia
Explanation: Decreased BP, increased pulse, and respirations suggest shock, possibly from occult bleeding or trauma response, requiring urgent evaluation.
Question 5 of 5.
The nurse is caring for a client who is scheduled for a cardiac stress test tomorrow. Prior to the stress test, the nurse should:
A. encourage the client to eat a hearty meal just before the test.
B. not give the client caffeine to drink.
C. have the client practice by walking vigorously around the unit.
D. not let the client watch stressful programs on television.
Explanation: Caffeine can affect heart rate and test results, so it should be avoided before a stress test.
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