Grade A+
Page |1
NCLEX-PN (Solved Questions & Answers | 100% Guaranteed Pass
|Grade A+
A nurse cares for a postoperative patient with abdominal incision. Which intervention should
the nurse prioritize to prevent respiratory complications, considering patient’s immobility, pain,
and shallow breathing caused by abdominal discomfort?
A. Encourage coughing and deep breathing
B. Restrict fluid intake to reduce edema
C. Administer sedatives to promote rest
D. Apply warm compresses to abdomen
Answer: A
A patient with heart failure reports shortness of breath, orthopnea, and productive cough with
frothy sputum. Which nursing action takes priority to reduce pulmonary congestion and
improve oxygenation during acute episode?
A. Elevate head of bed
B. Provide fluid restriction
C. Administer antipyretics as prescribed
D. Encourage increased oral intake
Answer: A
When caring for a diabetic patient experiencing hypoglycemia with sweating, tremors, and
confusion, which nursing intervention should be implemented first to restore normal glucose
levels and prevent worsening symptoms?
A. Administer glucagon injection
B. Provide orange juice orally
C. Check blood pressure immediately
D. Initiate oxygen via nasal cannula
Answer: B
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, Page |2
The nurse observes an elderly patient with dementia attempting to leave bed unsafely at night.
Which nursing intervention is most appropriate to ensure safety while maintaining dignity and
preventing patient harm?
A. Apply four-point restraints
B. Use a bed alarm
C. Administer sedative medication
D. Place side rails up
Answer: B
A patient with pneumonia develops high fever, productive cough, pleuritic chest pain, and
dyspnea. Which nursing assessment finding requires immediate intervention because it
indicates worsening respiratory distress needing urgent provider notification?
A. Oxygen saturation 82%
B. Temperature 101.8°F
C. Respiratory rate 22/min
D. Pulse 96 beats/min
Answer: A
A nurse cares for a patient prescribed furosemide for heart failure. Which laboratory result
requires immediate intervention due to potential adverse drug effect, warranting provider
notification and appropriate treatment modification?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Chloride 100 mEq/L
D. Bicarbonate 25 mEq/L
Answer: B
During assessment of a postoperative patient receiving morphine, which finding requires
immediate nursing intervention because it indicates a potential adverse effect of opioid therapy
requiring prompt action to ensure patient safety?
A. Respiratory rate 8/min
w
is
et
uto
r
Page |1
NCLEX-PN (Solved Questions & Answers | 100% Guaranteed Pass
|Grade A+
A nurse cares for a postoperative patient with abdominal incision. Which intervention should
the nurse prioritize to prevent respiratory complications, considering patient’s immobility, pain,
and shallow breathing caused by abdominal discomfort?
A. Encourage coughing and deep breathing
B. Restrict fluid intake to reduce edema
C. Administer sedatives to promote rest
D. Apply warm compresses to abdomen
Answer: A
A patient with heart failure reports shortness of breath, orthopnea, and productive cough with
frothy sputum. Which nursing action takes priority to reduce pulmonary congestion and
improve oxygenation during acute episode?
A. Elevate head of bed
B. Provide fluid restriction
C. Administer antipyretics as prescribed
D. Encourage increased oral intake
Answer: A
When caring for a diabetic patient experiencing hypoglycemia with sweating, tremors, and
confusion, which nursing intervention should be implemented first to restore normal glucose
levels and prevent worsening symptoms?
A. Administer glucagon injection
B. Provide orange juice orally
C. Check blood pressure immediately
D. Initiate oxygen via nasal cannula
Answer: B
w
is
et
u
to
r
, Page |2
The nurse observes an elderly patient with dementia attempting to leave bed unsafely at night.
Which nursing intervention is most appropriate to ensure safety while maintaining dignity and
preventing patient harm?
A. Apply four-point restraints
B. Use a bed alarm
C. Administer sedative medication
D. Place side rails up
Answer: B
A patient with pneumonia develops high fever, productive cough, pleuritic chest pain, and
dyspnea. Which nursing assessment finding requires immediate intervention because it
indicates worsening respiratory distress needing urgent provider notification?
A. Oxygen saturation 82%
B. Temperature 101.8°F
C. Respiratory rate 22/min
D. Pulse 96 beats/min
Answer: A
A nurse cares for a patient prescribed furosemide for heart failure. Which laboratory result
requires immediate intervention due to potential adverse drug effect, warranting provider
notification and appropriate treatment modification?
A. Sodium 138 mEq/L
B. Potassium 2.9 mEq/L
C. Chloride 100 mEq/L
D. Bicarbonate 25 mEq/L
Answer: B
During assessment of a postoperative patient receiving morphine, which finding requires
immediate nursing intervention because it indicates a potential adverse effect of opioid therapy
requiring prompt action to ensure patient safety?
A. Respiratory rate 8/min
w
is
et
uto
r
