NCLEX PN Exam Practice Test
Question 1 of 5.
The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate? Click the exhibit button for additional information.
A. Check the newborn's hemoglobin, hematocrit, and platelet levels
B. Measure and document the size and location of the markings
C. Notify the registered nurse of the markings immediately
D. Review the delivery record for evidence of a traumatic birth
Explanation: Skin discoloration in the buttock and lumbar area of a newborn is often due to Mongolian spots (also called congenital dermal melanocytosis). These are benign, flat, bluish-gray patches typically found on the lower back or buttocks. They are more common in infants with darker skin tones and are not harmful, but they can be mistaken for bruises, which raises concern for abuse later on. The appropriate nursing action is to measure and document the size, shape, and location of the spots in the medical record. This ensures that there is a clear, dated record of the findings to avoid confusion in the future.
Question 2 of 5.
There is a train wreck causing 46 casualties. The nurse is asking personnel on the floor to suggest clients who could be discharged to make room for casualties. Which client would be best for the LPN to suggest?
A. A 77-year-old who had a fractured femur with hip replacement yesterday
B. A 58-year-old who had an open cholecystectomy two days ago
C. A 52-year-old who had a bowel resection with colostomy yesterday
D. A 44-year-old who is undergoing internal radiation for cancer of the cervix
Explanation: The client who had an open cholecystectomy two days ago is likely stable and closer to discharge compared to those with recent major surgeries or ongoing radiation, which require specialized care.
Question 3 of 5.
The LPN on a medical unit observes a coworker taking diazepam ordered for a client. What should the nurse do initially?
A. Immediately call the supervisor
B. Confront the nurse
C. Observe the nurse for unsafe behavior
D. Administer that nurse's medications for the rest of the shift
Explanation: Observing for unsafe behavior assesses immediate risk to patients, allowing appropriate reporting if impairment is confirmed.
Question 4 of 5.
The nurse is caring for an adult who is admitted with severe nausea, vomiting, and diarrhea. During the last eight hours, the client has had 1000 mL of IV fluids and 100 mL of fluid from ice chips. The client has vomited a total of 600 mL and had four large diarrheal stools. The urine output for the last eight hours is 350 mL. The best interpretation of these data is that the client:
A. is maintaining an appropriate fluid balance.
B. has a normal urine output.
C. is at risk for dehydration.
D. is at risk for fluid overload.
Explanation: Significant fluid losses from vomiting and diarrhea exceed intake, and low urine output indicates dehydration risk.
Question 5 of 5.
An adult is to have a cardiac catheterization performed tomorrow. When preparing the client for the cardiac catheterization, it is essential for the nurse to do which of the following?
A. Administer an enema two hours before the procedure
B. Limit caffeine the day before the procedure
C. Ask the client about allergies to shellfish
D. Restrict fat intake the day before the procedure
Explanation: Shellfish allergies may indicate iodine sensitivity, critical for contrast dye used in cardiac catheterization.
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