NCLEX PN Test
Question 1 of 5.
The nurse is caring for a newborn 12 hours after an uncomplicated vaginal birth at 39 weeks gestation. Which of the following findings would require follow up? Select all that apply.
A. Plantar creases are present over the entire soles of the feet
B. Skin on the forehead blanches to a yellowish hue
C. Toes fan outward as the sole of the foot is stroked upward
D. Umbilical cord has one artery and one vein
E. White, pearl-like cysts are present on the gum margins
Explanation: Yellowish skin suggests jaundice, which requires monitoring for bilirubin levels. An umbilical cord with one artery (instead of two) and one vein may indicate congenital anomalies, needing further evaluation. Plantar creases are normal at 39 weeks, the Babinski reflex (toes fanning) is expected, and gum cysts (Epstein pearls) are benign.
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.