Simple Nclex PN questions
34 Questions • 15 Minutes
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A nurse is delegating tasks. Which task is appropriate for a UAP?
Rationale
UAPs can perform basic tasks like vital signs on stable patients. Teaching, assessment, and care planning require RN licensure.
A patient on warfarin has an INR of 5.2. What is the priority action?
Rationale
INR of 5.2 is above therapeutic range (2-3). Hold the dose and notify provider to prevent bleeding complications.
Which action promotes comfort for a patient with arthritis?
Rationale
Warm compresses help reduce stiffness and pain in arthritic joints. Cold is used for acute inflammation.
A patient is on contact precautions. What PPE is required?
Rationale
Contact precautions require gown and gloves to prevent transmission through direct contact.
A client with severe anemia received a transfusion of packed RBCs. Which data indicates the goal of therapy has been met?
Rationale
Hemoglobin of 12 g/dL indicates therapeutic response. Packed RBCs increase red blood cells and improve hemoglobin levels in clients with severe anemia.
A nurse provides discharge teaching for a client who had a below-knee amputation. Which instruction should be included?
Rationale
The socket should be thoroughly cleaned and dried to prevent skin breakdown. Daily inspection of the limb for signs of infection or inflammation is essential.
A nurse cares for a toddler with decreased appetite, erratic eating pattern, and fussiness at mealtime. Which recommendation should be made to parents?
Rationale
Toddlers prefer routine and consistent mealtimes. Frequent nutritious snacks ensure proper nutrition when appropriate foods like crackers, carrots, and raisins are offered.
A nurse plans teaching for a client with coronary artery disease. Which dietary recommendation is most important?
Rationale
Atherosclerosis is the primary risk factor in CAD. Health promotion focuses on eliminating saturated and trans fats by preparing foods that are broiled instead of fried.
A client at 30 weeks gestation states, 'I may be in labor.' Which findings should the nurse anticipate?
Rationale
Pelvic pressure and menstrual-like cramps are symptoms of preterm labor. Contractions in preterm labor increase in frequency and do not decrease with rest.
A newborn is being assessed immediately after birth. Which action prevents hypothermia via evaporation?
Rationale
Drying the wet newborn at birth prevents hypothermia via evaporation. Keeping the newborn dry is the most effective way to prevent heat loss through evaporation.
A toddler with varicella-zoster virus has fluid-filled vesicles on face and chest. Which action should the nurse implement?
Rationale
Varicella requires airborne and contact precautions. A negative air-flow room is required, and assigned staff must have confirmed immunity due to high contagion.
A nurse is caring for a client with tuberculosis. Which type of isolation precaution is required?
Rationale
Tuberculosis requires airborne precautions with negative pressure room and N95 respirator due to transmission via airborne particles smaller than 5 microns.
A client with renal failure is prescribed a low potassium diet. Which food choice would be best?
Rationale
Rice is considered a low-potassium food. Potatoes, raisins, and broth contain higher amounts of potassium and should be avoided in renal failure.
A client with diverticular disease is being discharged after acute diverticulitis. Which instruction reduces risk of future episodes?
Rationale
After acute diverticulitis resolves, gradually increasing fiber intake and maintaining adequate hydration helps prevent future episodes by promoting regular bowel movements.
A nurse is teaching about fire safety using the RACE acronym. What does RACE stand for?
Rationale
RACE stands for Rescue (remove patients from danger), Alarm (activate fire alarm), Confine (close doors to contain fire), Extinguish (use extinguisher if safe).
A nurse is preparing to measure head circumference of a newborn. Which measurement technique is correct?
Rationale
Head circumference is measured around the most prominent part of the occiput and across the eyebrows to obtain the largest measurement of the head.
A nurse is assessing a newborn immediately after birth. Which finding requires immediate intervention?
Rationale
Central cyanosis (bluish discoloration of trunk and mucous membranes) indicates inadequate oxygenation and requires immediate intervention. Acrocyanosis is normal in newborns.
A nurse is caring for a client with acute pancreatitis. Which position should the nurse encourage?
Rationale
Side-lying with knees flexed toward chest (fetal position) reduces tension on the abdomen and decreases pain in clients with acute pancreatitis.
A nurse is teaching a client with hypertension about lifestyle modifications. Which statement by the client indicates understanding?
Rationale
Limiting sodium intake to less than 2,300 mg daily is a key lifestyle modification for managing hypertension. Exercise, smoking cessation, and limiting alcohol are also important.
A client is receiving chemotherapy and has a white blood cell count of 2,000/mm³. Which precaution should the nurse implement?
Rationale
WBC count below 4,000/mm³ indicates neutropenia. Protective isolation protects the immunocompromised client from potential infections from visitors and staff.
A client with pneumonia has thick, tenacious secretions. Which intervention should the nurse implement?
Rationale
Adequate hydration (2-3 liters daily) helps thin secretions, making them easier to expectorate and improving airway clearance in clients with pneumonia.
A nurse is teaching a client with GERD. Which instruction should be included?
Rationale
Elevating the head of the bed 6-8 inches uses gravity to reduce reflux of gastric contents into the esophagus, especially during sleep.
A client with cirrhosis has ascites. Which intervention should the nurse implement?
Rationale
Daily measurement of abdominal girth at the same location monitors progression or resolution of ascites. Sodium restriction and diuretics are also used.
A nurse is teaching a client with osteoporosis. Which instruction should be included?
Rationale
Weight-bearing exercises like walking stimulate bone formation and slow bone loss. Calcium should not be taken with iron as they compete for absorption.
A nurse is caring for a client with acute glomerulonephritis. Which dietary modification should be implemented?
Rationale
Acute glomerulonephritis requires protein and sodium restriction to reduce kidney workload and manage hypertension and edema.
A client with heart failure is prescribed a low-sodium diet. Which food choice indicates understanding?
Rationale
Fresh grilled chicken with vegetables is low in sodium. Canned, processed, and frozen foods typically contain high sodium levels and should be avoided.
A nurse is caring for a client receiving chemotherapy who develops stomatitis. Which intervention should be implemented?
Rationale
Stomatitis causes painful mouth sores. Soft, bland foods and gentle oral rinses with saline or baking soda solution provide comfort and promote healing.
A client with Parkinson's disease has difficulty swallowing. Which intervention reduces aspiration risk?
Rationale
Thickened liquids are easier to control and reduce aspiration risk. Upright positioning uses gravity to assist swallowing and prevent aspiration.
A nurse is caring for a client with acute kidney injury. Which dietary modification should be implemented?
Rationale
Acute kidney injury requires protein and potassium restriction to reduce kidney workload and prevent hyperkalemia. Phosphorus and sodium are also restricted.
A nurse is assessing a newborn and notes a positive Babinski reflex. What action should the nurse take?
Rationale
Positive Babinski reflex (toes fan out when sole is stroked) is normal in newborns and infants up to 12-24 months. It becomes abnormal in older children and adults.
A nurse is teaching a client with gout about dietary modifications. Which food should be avoided?
Rationale
Organ meats, shellfish, and red meat are high in purines, which increase uric acid levels and trigger gout attacks. These should be limited or avoided.
A nurse is caring for a client with acute pancreatitis. Which position provides the most comfort?
Rationale
Side-lying with knees flexed toward chest (fetal position) reduces abdominal tension and decreases pain in acute pancreatitis.
A nurse is teaching a client with heart failure about daily weights. Which instruction should be included?
Rationale
Daily weights at the same time, wearing same clothing, detect fluid retention early. Weight gain of 2-3 pounds in 1-2 days indicates fluid retention requiring intervention.
A client with cirrhosis has ascites. Which intervention should the nurse implement?
Rationale
Daily measurement of abdominal girth at the same location (mark with pen) monitors progression or resolution of ascites. Sodium restriction and diuretics are also used.