NCLEX PN Practice Test
Question 1 of 5.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
A. Encourage the visitor to lie down to see if symptoms change
B. Initiate protocol to assist the visitor to the emergency department
C. Proceed to take the visitor's blood pressure
D. Suggest that the visitor call the health care provider
Explanation: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
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A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes.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Explanation: A withdrawn client may be overwhelmed by detailed explanations.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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