NCLEX PN Test
Question 1 of 5.
The nurse is contributing to the plan of care for a client with diabetes who reports breast tenderness, vaginal discharge, and urinary frequency. Which action is most important to include in the plan of care?
A. Ask if the client performs breast self-exams
B. Ask the client about characteristics of vaginal discharge
C. Determine the date of the client's last menstrual period
D. Review the client's home blood sugar logs
Explanation: Determining the date of the client's last menstrual period is critical to assess for pregnancy or menopausal changes, which could explain the symptoms and impact diabetes management. Breast self-exams and vaginal discharge characteristics are less urgent, and blood sugar logs, while important, are not directly related to the reported symptoms.
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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