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PN NCLEX Exam 2025 | Updated Questions
and Correct Answers with Explanations |
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The nurse is talking with a client with unilateral facial paralysis, which of the following statements by the client would require follow up? SATA A) I may chew food on either side of my mouth because it does not hurt B) I need to use my fingers to close my eyelid after instilling eyedrops C) I should prepare meals that include soft, high calorie foods D) I will place tape on my affected eyelid before I go to sleep E) I will put ice on the affected side of my face when it hurts ---------CORRECT ANSWER-----------------A and E Clients with unilateral facial paralysis should manually close the eyelid, tape the eyelid shut (prevent drying) eat soft, high calorie foods to prevent choking and use a warm compress for pain For a Staff education program about ethical practices and Nursing, which of the following statements by the nurse would indicate a correct understanding of the program? SATA A) accountability is notifying the HCP after making a med error B) autonomy is informing the client of the care decisions the family has made C) confidentiality is respecting a clients request to keep suicidal ideation a secret from the HCT D) fidelity is returning to room with pain meds at the time they were promised
E) Nonmaleficence is reporting suspected elder abuse of a client with Alzheimer disease ---------CORRECT ANSWER-----------------A, D, E The nurse is caring for a postop client who is unresponsive to painful stimuli and is given naloxone. Within five minutes the client can be aroused and respond. One hour later the client is difficult to arouse with no response to physical stimuli. What action does the nurse take? A) administer oxygen B) administer second dose of naloxone C) discontinue pain, med D) initiate rapid response, or code E) monitor respiratory rate ---------CORRECT ANSWER-----------------A, B, E A nurse is collecting data on a 58 year old client with blurred vision and reduced visual fields. The nurse finds which clinical manifestation MOST concerning? A) Difficulty adjusting to dimmed lights B) Extreme eye pain C) Gradual loss of peripheral vision D) Opaque appearance of lens ---------CORRECT ANSWER-----------------B, glaucoma is characterized by increased intraocular pressure (IOP) resulting in compression of the optic nerve. When IOP increases rapidly sudden onset of severe eye pain can occur.
E) "I tested positive for human papillomavirus a few years ago." ---------CORRECT ANSWER-----------------A, B, D, E, the most important risk factor for cervical cancer is persistent human papillomavirus (HPV) infection. Other risks factors for cervical cancer include multiple sex partners (>1), smoking tobacco, being infected with other STIs (chlamydia). As these all increase the likelihood of HPV infection. Condoms help prevent HPV, and not taking oral birth control is associated with a decreased risk of cervical cancer. A client with methicillin resistant staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last three days. Which blood test is most important to review when preparing administration of the med? A) blood cultures B) creatinine levels C) magnesium levels D) white blood cell count ---------CORRECT ANSWER-----------------B Creatinine levels should be closely monitored for signs of nephrotoxicity in the client. If increasing creatinine is identified, the nurse should hold the dose and contact the HCP. General: Client is a G 2 P 1 at 36 weeks. reports a throbbing headache 7/10, blurred vision, and epigastric pain; client states she took 1000 mg tylenol with no relief. VS: prenatal visit 33 weeks: T 98.4, P 79, RR 17, BP, 122/75, 99% RA Admission: T 98.8, P 84, RR 18, BP 176/111, 97% RA What is priority for the nurse? A) Blood pressure
B) Cervical exam C) Deep tendon reflexes D) Gestational age of fetus ---------CORRECT ANSWER-----------------A The nurse suspects of the client has preeclampsia, which of the following findings are clinical manifestations of preeclampsia A) epigastric pain B) facial edema C) high blood pressure D) proteinuria E) throbbing headache F) visual disturbances ---------CORRECT ANSWER-----------------A, B, C, D, E, F The following abnormal laboratory results support the clients preeclampsia diagnosis _________ & ________ WBC count Hemoglobin 24 hour urine protein Serum creatinine ---------CORRECT ANSWER-----------------24 hour urine protein and serum creatinine
over 500 mL over the past four hours. Client states she cannot properly latch the newborn during breast-feeding. Tolerating oral labetalol. Systolic blood pressure has been 110-130 and diastolic 70-80 past 12 hrs. Client reports no headaches and remains free of seizures ---------CORRECT ANSWER-----------------When is clean dry and intact no bleeding or foul smelling drainage, your an output was 500 mL over the past four hours, systolic blood pressure 110-130 and diastolic 70-80 past 12 hrs. Client reports no headaches and remains free of seizures. The nurse is caring for a 75-year-old client who was admitted to the hospital with pneumonia. Which assessment findings most consistent with a diagnosis of delirium A) client is experiencing muscle stiffness and resting hand tremors B) client is inattentive and disoriented C) client reports decreased enjoyment in hobbies D) family reports a gradual inability to remember recent events ---------CORRECT ANSWER-----------------B The nurse is caring for a client with hearing aids. Which actions by the client indicates proper use, and care of hearing aids? SATA A) keeps hearing aids clean by rinsing them with water B) lowers television, volume when talking with nurse C) places hearing aids on food tray, when not in use D) turn the volume completely down prior to insertion of aid into ear E) verifies the battery compartment is closed before insertion ---------CORRECT ANSWER-----------------B, D, E
Should be cleaned with a soft cloth, not by immersing them in water. Also keeping them in a safe dry place. A client diagnosed with endometrial cancer is receiving brachytherapy. Which intervention should the nurse anticipate for the client? SATA A) customer care to limit staff members time in room B) instruct the client to be up and around in the room, but not leave the room C) remind family members and visitors to limit close contact with the client D) use protective shielding if available when providing direct client care E) where radiation badge in room to measure exposure ---------CORRECT ANSWER- ----------------A, C, D, E The client should remain on bedrest and use caution when repositioning to avoid device dislodgment The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk? A) choose an infant carrier with a narrow seat B) place two diapers on the infant at all times C) swaddle the infant with hips, flexed and abducted D) use an infant swing that keeps both legs straight ---------CORRECT ANSWER------ -----------C Dysplasia of the hip can result from poor swaddling, narrow infant carriers, multiple diapers. You do not want the legs and knees straightened together.
smoking 1 pack of cigarettes per day for 35 years; the client was hospitalized with pneumonia 6 months ago. CARDIOVASCULAR: VS: T 99 F (37.2 C), P 90, BP 170/100; continuous cardiac monitor shows sinus rhythm with occasional premature ventricular contractions; S1, S2, and S3 are heard on auscultation; bilateral lower extremity pitting edema is noted. Highlight below the 5 findings that are MOST concerning. ---------CORRECT ANSWER-----------------SpO2 88% on RA (hypoxia), lung auscultation reveals bilateral crackles (pulmonary edema), BP 170/100 (HTN), S3 are heard on auscultation (abnormal heart sounds), bilateral lower extremity pitting edema (peripheral edema). Smoking and homelessness require follow-up to ensure the client receives appropriate resources and support, but they do not require immediate intervention. Decreased O2, crackles, extra heart tones, HTN, peripheral edema require further intervention due to concern of fluid overload and impaired gas exchange characteristics of HF. The nurse has reviewed the information from the Laboratory Results and Diagnostic Results, the nurse suspects the client is experiencing acute decompensated HF. Which of the following findings are consistent with this condition? SATA A) Crackles with auscultation B) Decreased capillary oxygen saturation
C) Elevated b-type natriuretic peptide D) left ventricular ejection fraction 30% E) Lower extremity pitting edema ---------CORRECT ANSWER-----------------A, B, C, D, E, Decompensated HF is characterized by pulmonary congestion (crackles, decreased O2, fluid overload [peripheral edema]). In addition clients will have an elevated b-type natriuretic peptide and low ejection fraction (<50%). The nurse should prioritize interventions for acute decompensated heart failure to reduce the risk of the client developing ____________ and ____________. Disseminated intravascular coagulation Bacterial endocarditis Empyema Dysrhythmias Acute kidney injury (AKI) ---------CORRECT ANSWER-----------------Dysrhythmias and Acute kidney injury (AKI). Dysrhythmias are due to structural changes altering the electrical activity of the heart. AKI is due to hypo-perfusion (decreased perfusion) of vital organs secondary to decreased cardiac output. Both complications of decompensated HF. Empyema is pus in the pleural cavity due to bacteria in the lungs, HF can cause pleural effusions, but empyema is not an expected finding. Bacterial endocarditis can precipitate HF, but this client shows no signs of infection. DIC is a life threatening condition from abnormal blood clotting. Caused by sepsis and trauma, HF is not a common cause.
Increases O2 saturation ---------CORRECT ANSWER-----------------Carvedilol: Decreases HR and Decreases BP Enalapril: Decreases BP Furosemide: Increased urinary output, Decreases BP and Increases O saturation Beta blockers (carvedilol) reduce cardiac workload and decrease myocardial oxygen demand by DECREASING BP and DECREASING HR Angiotensin-converting enzyme (ACE) inhibitors (enalapril) reduces circulating aldosterone, promoting vasodilation resulting in DECREASED BP. Aldosterone retains Na and water promoting vasoconstriction, we want to use ACE inhibitors to prevent the release of aldosterone. Loop diuretics (furosemide) prevent the reabsorption of Na and Cl in the kidneys, INCREASING URINE OUTPUT and fluid excretion. Decreases in fluid volume will DECREASE BP and reduce pulmonary edema (INCREASE O SATURATION) Management of HF focuses on reducing cardiac workload and improving cardiac output. Which of the following findings indicate that the client is improving as expected? SATA A) BP 138/70 mm Hg B) Clear lung sounds
C) Increased urinary output D) SpO2 95% on RA E) Unilateral lower extremity edema - --------CORRECT ANSWER-----------------A, B, C, D Improvement in a client with HF includes improvement of fluid volume status and gas exchange. Unilateral lower extremity edema is concerning for DVT and requires immediate follow-up, as it could lead to a life threatening PE. The nurse is reinforcing information for a client with COPD. Which statements by the client indicate the understanding of the pursed lip breathing technique? SATA A) "I exhale for 2 seconds through pursed lips." B) "I exhale for 4 seconds through pursed lips." C) "I inhale for 2 seconds through my mouth." D) "I inhale for 2 second through my nose, keeping my mouth closed." E) "I inhale for 4 seconds through my nose, keeping my mouth closed." --------- CORRECT ANSWER-----------------B and D Pursed lip-breathing helps decrease SOB by preventing airway collapse, promoting CO2 elimination. COPD patients should use this for 5-10 minutes 4 times daily. Step 1) Relax the neck and shoulders Step 2) Inhale deeply for 2 seconds through the nose with the mouth closed.
The graduate nurse (GN) is caring for a client with a fractured femur in balanced suspension skeletal traction. Which action by the GN will require precepting nurse to intervene? A) Encourages the client to drink plenty of water and choose high-fiber foods from the diet menu. B) Lifts the traction weights while the UAP provide a bed bath and linen change. C) Monitors the incision and pin insertion sites for erythema, drainage, and malodor. D) Performs doppler ultrasound pulse checks in the affected leg every hour for the first 24 hours after surgery. ---------CORRECT ANSWER-----------------B, to work effectively skeletal traction must be continuous, therefore weights should not be lifted or removed, even briefly unless prescribed by the HCP. The nurse is talking with the client who is entering the second trimester of pregnancy. Which of the following information should the nurse include? SATA A) "Anticipate experiencing light fetal movements around 16 to 20 weeks gestation." B) "Increase your consumption of iron-rich foods like meat and dried fruit." C) "Try to gain 3 lb (1.4 kg) each week if your pre pregnancy BMI was normal." D) "Expect to have an abdominal ultrasound scheduled to check fetal anatomy." E) "Plan to be screened for gestational diabetes around 24 to 28 weeks gestation." ---------CORRECT ANSWER-----------------A, B, D, E The second trimester occurs at 14 weeks to 27 weeks and 6 days.Nurse should reinforce physical changes, potential complications, and routine screening/diagnostic test during this time period.
Clients should expect quickening (Clients first perception of fetal movement) at 16 - 20 weeks, gain approximately 1 lb (0.5 kg) per week if prepregnancy BMI was normal, consume iron-rich foods, and anticipate screening/diagnostic tests (1- hour glucose challenge test, fetal anatomy ultrasounds. The nurse is caring for a 28-year old client in the maternal health clinic. The client has had right breast pain, fever, chills, fatigue, and increased pain while breastfeeding her newborn for the past two days. Physical assessment shows erythema, induration, and tenderness of the right breast. the left breast has no abnormalities. For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client. Administer antibiotics Increase daily fluid intake Encourage the client to take NSAIDs for pain Apply a warm compress to the affected breast Discontinue breastfeeding until symptoms resolve ---------CORRECT ANSWER-------- ---------Indicated: Administer antibiotics, Increase daily fluid intake, Encourage the client to take NSAIDs for pain , Apply a warm compress to the affected breast Not indicated: Discontinue breastfeeding until symptoms resolve Lactation mastitis is infection and inflammation of breast tissue that may result from inadequate milk duct drainage or poor breastfeeding technique.
RESTING TONE: Tension in uterine muscle between contractions, allows fetal oxygenation between contractions, average 10 mm Hg, should not exceed 20 mm Hg The nurse is caring for a client who has been hospitalized for major depressive disorder. When the nurse reminds the client that breakfast will be served in the dining room in 20 minutes, the client says, "I'm not hungry and don't feel like doing anything." Which is the best response by the nurse? A) "I will help you get ready, then we can walk to the dining room together." B) "I will have breakfast brought to your room. I know you don't have much energy right now." C) "It is okay. You can join us when you are ready. Take your time." D) You will feel better when you get up and get dressed. You need to eat something." ---------CORRECT ANSWER-----------------A reduced appetite and low energy level are common in major depressive disorder. Hard to get out of bed and perform ADLs. Client needs direction and structure with their ADLs also assistance. The nurse should assist the client with completing ADLs and with initiating social interaction with others. A client with borderline personality disorder says to the nurse, "Your the only one I trust around here. the others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority nursing action?
A) Assign different staff members to care for the client each day B) Assign the client's stated preferred nurse to care for the client C) Reassure the client that all staff members are competent in their jobs D) Reinforce unit guidelines and appropriate boundaries with the client --------- CORRECT ANSWER-----------------D BPD is characterized by intense impulsivity and emotional dysregulation combined with unstable relationships and self image. They fear abandonment and rejection. Use manipulative behavior for control (flattery or distancing) Splitting is a defense mechanism where BPD patients hold opposing thoughts and perceive people or events as "all good" or "all bad." Staff should prevent this by calmly reinforcing unit guidelines and appropriate boundaries. The nurse is caring for a 3 year old child. The child recently started attending a new preschool and hit a teacher during lunch. The parent says, "My child has never been aggressive before but he has always been particular about food." The client was born at full term without complication and has no significant medical history. The child started babbling at age 6 months,and the parent reports that the first words were spoken around age 12 months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color. The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vital signs are normal, and the client's tracking adequately on growth curves. During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow the parent's gaze when the parent points to toys in the office. The child begins screaming and rocking ---------CORRECT ANSWER------------- ----Quiet and "obsessed" with stacking blocks and organizing toys by color. Now says two-word phrases. Client does not follow the parent's gaze when pointing to
