NCLEX PN Practice Test
Question 1 of 5.
The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.
A. Do not leave a tourniquet on more than 1 minute while looking for a vein
B. Draw the specimen while the skin is still wet with the alcohol prep
C. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes
D. Use a highly visible vein on the ventral side of the client's wrist
E. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution
Explanation: A tourniquet left on too long (A) can cause hemoconcentration, so it should be removed after 1 minute. Pulsating blood (C) indicates arterial puncture, requiring immediate needle withdrawal and pressure to prevent hematoma. Wet alcohol (B) can cause hemolysis, and the ventral wrist (D) is a risky site due to nerves and arteries. Vigorous shaking (E) damages blood cells, so gentle inversion is preferred.
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A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes.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Explanation: A withdrawn client may be overwhelmed by detailed explanations.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.
Related Questions