NCLEX PN Test Questions
Question 1 of 5.
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?
A. Assist maternal pushing efforts by applying fundal pressure during each contraction
B. Document the time the fetal head was born
C. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis
D. Prepare for a forceps-assisted birth
E. Request additional assistance from other nurses immediately
Explanation: Shoulder dystocia requires urgent interventions like the McRoberts maneuver (flexing legs back, C) and suprapubic pressure (C) to dislodge the fetal shoulder. Additional assistance (E) is critical. Fundal pressure (A) can worsen impaction. Documentation (B) is secondary to immediate action. Forceps (D) are not typically used for shoulder dystocia.
Question 2 of 5.
An alert adult is being admitted for elective surgery. Which comment made by the client indicates a need for more instruction regarding advance directives?
A. I brought a copy of the completed form with me.
B. I am glad I don't have to make decisions about my care anymore.
C. My husband is the one who gets to make decisions for me.
D. My children all have copies of the living will.
Explanation: Advance directives allow clients to specify care preferences, not relinquish decision-making entirely. This comment suggests a misunderstanding that requires further education.
Question 3 of 5.
A mother calls the pediatrician's office stating that her 15-month-old son received an MMR vaccination yesterday. Today, the site of the injection is red, warm, and puffy. What is the best action for the nurse to take?
A. Report the symptoms to the physician as an adverse reaction
B. Suggest the mother apply a warm compress every two hours
C. Advise the mother to give her son baby aspirin
D. Explain to the mother that this is an expected response
Explanation: Mild redness, warmth, and swelling at the MMR injection site are expected reactions, resolving without intervention.
Question 4 of 5.
A 56-year-old client who had a complete hysterectomy 8 months ago is admitted for opiate detoxification. The second day after admission, the client complains of abdominal cramping and sweating. What is the nurse's best response?
A. Contact the gynecologist for details of the operation
B. Suspect drug seeking and suggest the client take a walk around the unit
C. Tell the client she is probably constipated and ask for an order for Milk of Magnesia
D. Explain to the client that her symptoms are an expected physical response to detoxification and offer comfort medications as ordered
Explanation: Abdominal cramping and sweating are withdrawal symptoms during opiate detoxification, requiring comfort measures and reassurance.
Question 5 of 5.
Immediately following a cardiac catheterization, the client asks to go to the toilet. What is the best response by the nurse?
A. Assist the client to the toilet
B. Show the client where the toilet is and allow him/her to walk there if stable
C. Assist the client to a bedside commode
D. Assist the client onto a bedpan
Explanation: Post-catheterization, bed rest is required to prevent bleeding at the insertion site; a bedpan maintains immobility.
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