Free PN NCLEX Practice Questions

Free PN NCLEX Practice Questions Related

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B.C. is a 14-yr-old boy who was brought to the ER after he had sustained flame burns. He had been wearing masquerade costume during Halloween celebration when his costume was set ablaze by the lighted candles in the party room. He extinguished the fire by rolling on the floor. On admission, resuscitation was commenced with intravenous fluids, antibiotics, and wound dressing. On examination he was found to be a young man, not pale, but febrile (body temperature, 37.8°C). He was tachypneic, RR 26 per min, with audible breath sounds bilaterally. Burn assessment revealed a total body surface area involved of 30%, with mixed-thickness burns sparing some patchy areas of the back and the right upper limb. B.C. anterior chest was affected.

For the first 24 hours after hospitalization, the nurse should primarily observe him for

  • A. wound sepsis.
  • B. complain of pain.
  • C. dyspnea or stridor.
  • D. initiate IV therapy.
Correct Answer: C

Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia from irritation and edema of the respiratory passages and lungs.

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The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?

  • A. Deficient fluid volume
  • B. Disturbed body image
  • C. Risk for impaired skin integrity
  • D. Risk for ineffective health maintenance
Correct Answer: A

Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.

Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?

  • A. open leg fracture
  • B. open head injury
  • C. stab wound to the chest
  • D. traumatic amputation of a thumb
Correct Answer: C

Rationale: A stab wound to the chest is the highest priority due to potential for pneumothorax or mediastinal shift, which can be life-threatening. The ABC (airway, breathing, circulation) principle prioritizes this injury. Physiological Adaptation

The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique?

  • A. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
  • B. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
  • C. The nurse packs wet gauze into the incision without overlapping it onto the skin.
  • D. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C

Rationale: Wet-to-dry dressings should have wet gauze packed into the incision without overlapping onto the skin to prevent skin breakdown. Cleansing (A) should be from the center outward, dressings (B) are soaked before packing, and old dressings (D) are removed dry to debride the wound.

A client's vision is to be evaluated using the Ishihara exam. The nurse recognizes that the client will be checked for:

  • A. Macular degeneration
  • B. Astigmatism
  • C. Color blindness
  • D. Glaucoma
Correct Answer: C

Rationale: The Ishihara exam tests for color blindness by assessing color perception. It does not evaluate macular degeneration, astigmatism, or glaucoma.

For a client with Graves' disease, which nursing intervention promotes comfort?

  • A. Restricting intake of oral fluids
  • B. Placing extra blankets on the client's bed
  • C. Limiting intake of high-carbohydrate foods
  • D. Maintaining room temperature in the low-normal range
Correct Answer: D

Rationale: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.

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