NCLEX NCLEX-PN
2024 PN NCLEX Questions
1. To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask a client providing subjective data?
- A. Do you normally experience menstrual cramps with your periods?
- B. Do you smoke cigarettes?
- C. Are you currently dieting?
- D. Do you engage in strenuous exercise, such as jogging?
Correct answer: B: 'Do you smoke cigarettes?'
Rationale: The correct question the nurse should ask to identify risk factors associated with the use of an oral contraceptive is whether the client smokes cigarettes. Oral contraceptives are associated with an increased risk of thromboembolic phenomena, particularly when combined with other risk factors like smoking and a history of thrombosis. Other risk factors include hypertension, cerebrovascular disease, coronary artery disease, and postoperative thrombosis risk. Choices A, C, and D are not directly related to the increased risks associated with oral contraceptive use. Menstrual cramps, dieting, and strenuous exercise are not significant risk factors for thromboembolic events.
2. A nurse working in a pediatric clinic observes bruises on the body of a four-year-old boy. The parents report the boy fell while riding his bike. The bruises are located on his posterior chest wall and gluteal region. What should the nurse do?
- A. Suggest a script for counseling the family to the doctor on duty.
- B. Recommend a warm bath for the boy to decrease healing time.
- C. Notify the case manager in the clinic about possible child abuse concerns.
- D. Recommend ROM exercises to the patient’s spine to decrease healing time.
Correct answer: Notify the case manager in the clinic about possible child abuse concerns.
Rationale: In this scenario, the nurse is observing bruises on a child's body that are located in areas not commonly associated with accidental injuries. Given the concerning nature of the bruising pattern and the inconsistent history provided by the parents, the nurse should suspect possible child abuse and take appropriate action by notifying the case manager in the clinic. The safety and well-being of the child should always be the top priority. Counseling for the family, warm baths, or recommending range of motion (ROM) exercises are not appropriate actions in this situation and may not address the underlying issue of potential child abuse.
3. A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
- A. A client with brain attack (stroke) receiving tube feedings
- B. A client with congestive heart failure complaining of nighttime dyspnea
- C. A client who had a thoracotomy 6 months ago
- D. A client with Parkinson’s disease
Correct answer: B
Rationale: The correct answer is B. The client with congestive heart failure complaining of nighttime dyspnea should be seen first as airway management is a priority in nursing care. This client's symptoms indicate potential respiratory distress, requiring immediate attention. Choices A, C, and D involve clients who are more stable and do not present with urgent or acute conditions that require immediate intervention. Choice A with a client receiving tube feedings for a stroke may require attention, but the urgency of addressing potential respiratory distress in choice B takes precedence. Choice C, a client who had a thoracotomy 6 months ago, unless presenting with acute distress, does not necessitate immediate attention. Choice D, a client with Parkinson's disease, is usually a chronic condition that does not typically require immediate intervention for the described scenario.
4. While reviewing a client’s health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client’s bowel sounds?
- A. Hypoactive bowel sounds
- B. Low-pitched bowel sounds
- C. Hyperactive bowel sounds
- D. An absence of bowel sounds
Correct answer: Hyperactive bowel sounds
Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.
5. A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first?
- A. Left upper quadrant
- B. Left lower quadrant
- C. Right upper quadrant
- D. Right lower quadrant
Correct answer: Right lower quadrant
Rationale: The correct answer is the right lower quadrant. The nurse starts auscultating in this quadrant at the ileocecal valve as bowel sounds are normally always present there. Then, the nurse proceeds to listen for bowel sounds in the other quadrants. Choices A, B, and C are incorrect as the initial placement of the stethoscope should be in the right lower quadrant to assess bowel sounds post-surgery.
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