PN NCLEX Practice Test
Question 1 of 5.
Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care? Select all that apply.
A. Client diagnosed with lumbar spinal cord compression has paraplegia
B. Client's Glasgow Coma Scale (GCS) score is 3
C. Client is refusing a life-saving treatment due to religious beliefs
D. Client with intracerebral hemorrhage has aphasia
E. Oriented client has cancer and is on a ventilator
Explanation: Advance directives guide care when clients cannot communicate decisions, as with a GCS of 3 (unconscious) or aphasia from hemorrhage. Paraplegia, religious refusal, and ventilator use in an oriented client do not impair decision-making capacity.
Question 2 of 5.
The nurse approaches a 4-year-old boy to administer a medication. The child has no identification armband. Which action is most appropriate?
A. Check the room and bed number the child is in with the room and bed number on the medication order and administer the medication if they agree
B. Ask the child what his name is before administering the medication
C. Ask the child if his name is George (the name on the medication order) and administer the medication if the child says that is his name
D. Ask the adults at the bedside what the child's name is and administer the medication if the adults verify the name of the child
Explanation: Verifying the child's identity with adults at the bedside ensures safety, as children may not reliably confirm their own identity, and room/bed numbers are not sufficient for identification.
Question 3 of 5.
The nurse is caring for an adult who has atrial fibrillation and osteoporosis. Atenolol is prescribed. The nurse should expect that this medication was prescribed to:
A. decrease elevated blood pressure.
B. decrease inflammation.
C. relieve pain.
D. slow the heart rate.
Explanation: Atenolol, a beta-blocker, is used in atrial fibrillation to control heart rate, reducing rapid ventricular response.
Question 4 of 5.
A father brings his 17-year-old son to a walk-in clinic. The client reports a sudden severe headache. He has a temperature of 104°F and a purple rash. What is the best action for the nurse at this time?
A. Prepare for a throat culture
B. Schedule him for an appointment later in the day
C. Isolate and alert the physician immediately
D. Obtain a urine specimen
Explanation: Symptoms suggest meningococcal meningitis, a medical emergency requiring isolation and immediate physician notification.
Question 5 of 5.
Which nursing action is essential in the care of an adult following a left side cardiac catheterization?
A. Keep the client NPO for two hours.
B. Ask the client about a shellfish allergy.
C. Check pulses proximal to the insertion site.
D. Check the insertion site for bleeding.
Explanation: Checking the insertion site for bleeding is critical post-catheterization to detect hematoma or hemorrhage, ensuring patient safety.