NCLEX PN Practice Test
Question 1 of 5.
The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
A. Your child may develop a low-grade fever after receiving the vaccine
B. Your child can have aspirin to decrease discomfort caused by the vaccine.
C. Your child may develop a rash at the injection site after receiving the vaccine.
D. Your child will require a second dose of the vaccine at a subsequent visit.
E. Your child should not receive any other vaccines at the same visit.
Explanation: The varicella vaccine may cause a low-grade fever (A) or a rash at the injection site (C) as common side effects. A second dose (D) is required at 4-6 years for full immunity. Aspirin (B) is contraindicated in children due to Reye's syndrome risk. Other vaccines (E) can be given concurrently, per CDC guidelines, unless contraindicated.
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A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes.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Explanation: A withdrawn client may be overwhelmed by detailed explanations.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.
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