NCLEX PN Practice Test
Question 1 of 5.
Extract:Laboratory results Hematocrit Male: 42% - 52% (0.42-0.52) Female: 37% - 47% (0.37 - 0.47) 30% (0.30) Activated PTT Baseline: 30 - 40 sec 110 sec Platelets 150,000 - 400,000/mm3 (150 - 400 x 109/L) 80,000/mm3 (80 x 109/L) PT 11 - 12.5 sec 11 sec
The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
A. Activated PTT(62%)
B. Hemotocrit(5%)
C. Platelets(23%)
D. PT(8%)
Explanation: Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on activated partial thromboplastin time (aPTT). The therapeutic aPTT target is 1.5-2.0 times the normal reference range of 30-40 seconds. A aPTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestina bleeds (Option 1). (Option 2) A normal hematocrit for a female is 37%-47% (0.37-0.47). In a client with a history of chronic anemia, a hematocrit of 30% (0.30) may be an expected finding. (Option 3) A normal platelet count is 150,000-400,000/mm* (150-400 x 10%L). In a client with a history of liver cirrhosis, a platelet count of 80,000/mmª (80 x 10%/L) would be anticipated. An episode of bleeding rarely occurs with a platelet count >50,000 mm* (50 x 10%/L). (Option 4) A normal prothrombin time is 11-12.5 seconds, and so a level of 11 seconds would not be concerning.
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A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes.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.