NCLEX-PN
2024 PN NCLEX Questions
1. When reviewing a client's medical notes to confirm pregnancy, a nurse should look for which finding to determine that pregnancy is confirmed?
- A. Amenorrhea
- B. Thinning of the cervix
- C. Palpable fetal movement
- D. Positive result on a home urine test for pregnancy
Correct answer: C
Rationale: To confirm pregnancy, the presence of palpable fetal movement is a positive indicator. Palpable fetal movement is a certain sign of pregnancy, known as a fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy as it is reported by the woman but is not confirmatory. Thinning of the cervix (Hegar sign) is a probable sign of pregnancy, which is not confirmatory. A positive result on a home urine test for pregnancy is also a probable indicator. However, a positive pregnancy test result can sometimes yield false-positive results due to various factors like medication, recent pregnancy, or errors in reading.
2. An older client reports that she has been awakening during the night, awakes early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on these reported data, what should the nurse do?
- A. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours.
- B. Ask the registered nurse to obtain a prescription for a nighttime sedative.
- C. Report the findings to the registered nurse.
- D. Document the findings in the medical record.
Correct answer: D
Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Since the reported data are normal age-related changes, the appropriate action for the nurse would be to document the findings in the medical record. Reporting the findings to the registered nurse is unnecessary as these changes are expected with aging and do not indicate a need for immediate intervention. Prescribing sedatives should be avoided as a first-line approach due to potential side effects and risks, especially in older adults. Encouraging the consumption of stimulants like caffeinated beverages during the daytime may further disrupt sleep patterns, which is counterproductive in addressing the client's reported sleep issues.
3. When should rehabilitation services begin?
- A. when the client enters the health care system.
- B. after the client requests rehabilitation services
- C. after the client's physical condition stabilizes.
- D. when the client is discharged from the hospital.
Correct answer: A
Rationale: Rehabilitation services should begin when the client enters the health care system to ensure early intervention and optimal outcomes. Initiating rehabilitation early can help prevent complications, improve recovery, and enhance overall well-being. Option B is incorrect because waiting for the client to request services may lead to delays in starting treatment, potentially affecting the recovery process. Option C is incorrect as rehabilitation can often commence even when the client's physical condition is not fully stabilized, as early intervention is crucial for progress. Option D is incorrect as beginning rehabilitation only after hospital discharge may not be ideal, as early intervention within the healthcare system is preferred for a more effective recovery journey.
4. When preparing a client for surgery, the graduate nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure but received his preoperative medication approximately 10 minutes prior. The appropriate action would be:
- A. Have the client sign the permit, as he verbalizes understanding.
- B. Witness the form after having the client sign it.
- C. Have his wife sign the form as she witnessed him saying he wants the surgery.
- D. Call the surgical area and explain the surgery will have to be cancelled.
Correct answer: D
Rationale: The correct action in this scenario is to call the surgical area and explain that the surgery will have to be cancelled. The client must sign the operative permit or any other legal document before receiving preoperative medication. Without the signed permit, the surgery cannot proceed to ensure the client's safety and legal compliance. Having the client sign the permit, witnessing the form after the client signs it, or having someone else sign the form are all inappropriate actions and do not address the legal requirement of the client's signature before receiving preoperative medication.
5. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously
- B. give the medications sequentially, and flush well between them
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug
- D. start one medication now and begin the other medication in 2-4 hours
Correct answer: B
Rationale: The correct answer is to give the medications sequentially and flush well between them. Ampicillin has a pH of 8-10, while gentamicin has a pH of 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent any potential interactions. Option A is incorrect because administering both medications simultaneously can lead to incompatibility issues. Option C is incorrect because the nurse should already be aware of the correct administration sequence and not need to consult the physician or pharmacy each time. Option D is incorrect because delaying the second medication by several hours can slow down the treatment of the client's infection, which is not ideal in this scenario.
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