NCLEX-PN Exam Review– Questions And Answers |
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1. A licensed practical nurse (LPN) is caring for a client newly diagnosed with type 1
diabetes mellitus who is learning self-administration of insulin. Which client statement
indicates a need for further instruction regarding the injection technique?
A. "I will rotate my injection sites within the same anatomical area from week to week."
B. "I should pinch a fold of skin and insert the needle at a 45-to-90-degree angle."
C. "I will massage the injection site vigorously immediately after administering the insulin."
D. "I need to store my unopen insulin vials in the refrigerator until ready for use."
Answer: C. "I will massage the injection site vigorously immediately after administering the
insulin."
Rationale: Massaging the injection site after administering insulin is incorrect because it
accelerates the absorption rate, which can lead to unpredictable blood glucose fluctuations
and hypoglycemia. Sites should be rotated, skin pinched for sub-q administration, and unopen
vials refrigerated.
2. The LPN is monitoring a client receiving an intravenous infusion of 0.9% sodium
chloride at 125 mL/hr. The client reports pain, swelling, and coolness at the insertion site,
and the infusion has stopped flowing. What is the priority nursing action?
A. Slow the infusion rate by half and apply a warm compress over the site.
B. Stop the infusion immediately, remove the catheter, and elevate the affected extremity.
C. Flush the intravenous line with normal saline to check for patency.
D. Document the findings and notify the primary healthcare provider before altering the site.
Answer: B. Stop the infusion immediately, remove the catheter, and elevate the affected
extremity.
Rationale: The client is experiencing infiltration, where intravenous fluid enters the
surrounding subcutaneous tissue. The immediate action is to stop the infusion, remove the
device to prevent further tissue damage, and elevate the limb to promote reabsorption.
Flushing or slowing the infusion would worsen the injury.
,3. An LPN is reviewing the morning laboratory results for several assigned clients. Which
value requires immediate notification of the registered nurse (RN) or healthcare provider?
A. Serum potassium level of 3.1 mEq/L in a client taking furosemide
B. Fasting blood glucose level of 118 mg/dL in a client with type 2 diabetes
C. International Normalized Ratio (INR) of 1.2 in a client receiving warfarin therapy
D. Serum sodium level of 138 mEq/L in a client with a history of hypertension
Answer: A. Serum potassium level of 3.1 mEq/L in a client taking furosemide
Rationale: A serum potassium level of 3.1 mEq/L indicates hypokalemia, which is a critical
electrolyte imbalance often caused by loop diuretics like furosemide. This places the client at
high risk for fatal cardiac arrhythmias and requires prompt intervention. The other values are
either within acceptable therapeutic ranges or represent minor, non-urgent elevations.
4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen via
nasal cannula at 2 L/min. The client reports increased shortness of breath and restlessness.
What is the most appropriate initial nursing action?
A. Increase the oxygen flow rate to 6 L/min to relieve the hypoxia immediately.
B. Assess the client's current respiratory rate, depth, and oxygen saturation level.
C. Place the client in a high Fowler's position and administer prescribed sublingual nitroglycerin.
D. Coach the client on diaphragmatic breathing and pursed-lip breathing techniques.
Answer: B. Assess the client's current respiratory rate, depth, and oxygen saturation level.
Rationale: Assessment must precede intervention. Before altering the oxygen flow rate or
initiating specific breathing exercises, the nurse must evaluate the client's clinical status to
determine the cause of the distress. Indiscriminately increasing oxygen in a COPD client can
suppress the hypoxic respiratory drive.
5. The LPN is reinforcing discharge instructions for a client prescribed digoxin 0.25 mg
orally daily. Which instruction is most critical for the LPN to emphasize?
A. "Take the medication with a full glass of grapefruit juice to enhance absorption."
B. "Check your radial pulse before taking the medication and hold it if it is below 60 beats per minute."
C. "Double your next dose if you happen to miss a daily scheduled dose."
D. "Stop taking the medication immediately if you experience mild fatigue or weakness."
, Answer: B. Check your radial pulse before taking the medication and hold it if it is below
60 beats per minute.
Rationale: Digoxin is a cardiac glycoside that slows the heart rate and increases myocardial
contractility. Clients must monitor their pulse and withhold the drug if bradycardia occurs to
prevent toxicity. Grapefruit juice does not interact with digoxin, doses should never be
doubled, and clients should consult their provider before stopping medications.
6. An older adult client is admitted to the medical-surgical unit with a diagnosis of
dehydration and acute confusion. Which nursing intervention is essential to include in the
client's plan of care?
A. Apply bilateral wrist restraints to prevent accidental dislodgement of lines.
B. Keep the room lights completely turned off at night to promote deep sleep.
C. Maintain a low-stimulus environment and provide frequent reality orientation.
D. Restrict oral fluid intake to prevent overnight episodes of urinary incontinence.
Answer: C. Maintain a low-stimulus environment and provide frequent reality orientation.
Rationale: Dehydration-induced acute confusion (delirium) is best managed by creating a
calm, safe environment, utilizing reorientation strategies, and ensuring adequate hydration.
Restraints increase agitation and injury risk, darkness can worsen disorientation, and fluids
should not be restricted.
7. A client with a nasogastric tube connected to low intermittent suction complains of
nausea and upper abdominal fullness. The LPN notes that the tube has not drained any
gastric contents in the past two hours. What is the initial action the LPN should take?
A. Irrigate the nasogastric tube with sterile water as prescribed.
B. Check the patency and alignment of the tubing system for kinks or pressure.
C. Advance the nasogastric tube an additional 5 centimeters into the stomach.
D. Disconnect the suction source and clamp the tube for 30 minutes.
Answer: B. Check the patency and alignment of the tubing system for kinks or pressure.
Rationale: The first step in troubleshooting a non-functioning nasogastric tube is to assess
external factors, such as kinks, client positioning, or blockages in the collection tubing.
Irrigation or manipulation should only be performed if external inspection confirms the tube
is unobstructed externally and per protocol.
Verified And Well Detailed Answers Plus Rationales |
Guaranteed Pass | Latest Exam Update | Exam Prep | Study
Guide | Practice Test| Download Instant Pdf
1. A licensed practical nurse (LPN) is caring for a client newly diagnosed with type 1
diabetes mellitus who is learning self-administration of insulin. Which client statement
indicates a need for further instruction regarding the injection technique?
A. "I will rotate my injection sites within the same anatomical area from week to week."
B. "I should pinch a fold of skin and insert the needle at a 45-to-90-degree angle."
C. "I will massage the injection site vigorously immediately after administering the insulin."
D. "I need to store my unopen insulin vials in the refrigerator until ready for use."
Answer: C. "I will massage the injection site vigorously immediately after administering the
insulin."
Rationale: Massaging the injection site after administering insulin is incorrect because it
accelerates the absorption rate, which can lead to unpredictable blood glucose fluctuations
and hypoglycemia. Sites should be rotated, skin pinched for sub-q administration, and unopen
vials refrigerated.
2. The LPN is monitoring a client receiving an intravenous infusion of 0.9% sodium
chloride at 125 mL/hr. The client reports pain, swelling, and coolness at the insertion site,
and the infusion has stopped flowing. What is the priority nursing action?
A. Slow the infusion rate by half and apply a warm compress over the site.
B. Stop the infusion immediately, remove the catheter, and elevate the affected extremity.
C. Flush the intravenous line with normal saline to check for patency.
D. Document the findings and notify the primary healthcare provider before altering the site.
Answer: B. Stop the infusion immediately, remove the catheter, and elevate the affected
extremity.
Rationale: The client is experiencing infiltration, where intravenous fluid enters the
surrounding subcutaneous tissue. The immediate action is to stop the infusion, remove the
device to prevent further tissue damage, and elevate the limb to promote reabsorption.
Flushing or slowing the infusion would worsen the injury.
,3. An LPN is reviewing the morning laboratory results for several assigned clients. Which
value requires immediate notification of the registered nurse (RN) or healthcare provider?
A. Serum potassium level of 3.1 mEq/L in a client taking furosemide
B. Fasting blood glucose level of 118 mg/dL in a client with type 2 diabetes
C. International Normalized Ratio (INR) of 1.2 in a client receiving warfarin therapy
D. Serum sodium level of 138 mEq/L in a client with a history of hypertension
Answer: A. Serum potassium level of 3.1 mEq/L in a client taking furosemide
Rationale: A serum potassium level of 3.1 mEq/L indicates hypokalemia, which is a critical
electrolyte imbalance often caused by loop diuretics like furosemide. This places the client at
high risk for fatal cardiac arrhythmias and requires prompt intervention. The other values are
either within acceptable therapeutic ranges or represent minor, non-urgent elevations.
4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen via
nasal cannula at 2 L/min. The client reports increased shortness of breath and restlessness.
What is the most appropriate initial nursing action?
A. Increase the oxygen flow rate to 6 L/min to relieve the hypoxia immediately.
B. Assess the client's current respiratory rate, depth, and oxygen saturation level.
C. Place the client in a high Fowler's position and administer prescribed sublingual nitroglycerin.
D. Coach the client on diaphragmatic breathing and pursed-lip breathing techniques.
Answer: B. Assess the client's current respiratory rate, depth, and oxygen saturation level.
Rationale: Assessment must precede intervention. Before altering the oxygen flow rate or
initiating specific breathing exercises, the nurse must evaluate the client's clinical status to
determine the cause of the distress. Indiscriminately increasing oxygen in a COPD client can
suppress the hypoxic respiratory drive.
5. The LPN is reinforcing discharge instructions for a client prescribed digoxin 0.25 mg
orally daily. Which instruction is most critical for the LPN to emphasize?
A. "Take the medication with a full glass of grapefruit juice to enhance absorption."
B. "Check your radial pulse before taking the medication and hold it if it is below 60 beats per minute."
C. "Double your next dose if you happen to miss a daily scheduled dose."
D. "Stop taking the medication immediately if you experience mild fatigue or weakness."
, Answer: B. Check your radial pulse before taking the medication and hold it if it is below
60 beats per minute.
Rationale: Digoxin is a cardiac glycoside that slows the heart rate and increases myocardial
contractility. Clients must monitor their pulse and withhold the drug if bradycardia occurs to
prevent toxicity. Grapefruit juice does not interact with digoxin, doses should never be
doubled, and clients should consult their provider before stopping medications.
6. An older adult client is admitted to the medical-surgical unit with a diagnosis of
dehydration and acute confusion. Which nursing intervention is essential to include in the
client's plan of care?
A. Apply bilateral wrist restraints to prevent accidental dislodgement of lines.
B. Keep the room lights completely turned off at night to promote deep sleep.
C. Maintain a low-stimulus environment and provide frequent reality orientation.
D. Restrict oral fluid intake to prevent overnight episodes of urinary incontinence.
Answer: C. Maintain a low-stimulus environment and provide frequent reality orientation.
Rationale: Dehydration-induced acute confusion (delirium) is best managed by creating a
calm, safe environment, utilizing reorientation strategies, and ensuring adequate hydration.
Restraints increase agitation and injury risk, darkness can worsen disorientation, and fluids
should not be restricted.
7. A client with a nasogastric tube connected to low intermittent suction complains of
nausea and upper abdominal fullness. The LPN notes that the tube has not drained any
gastric contents in the past two hours. What is the initial action the LPN should take?
A. Irrigate the nasogastric tube with sterile water as prescribed.
B. Check the patency and alignment of the tubing system for kinks or pressure.
C. Advance the nasogastric tube an additional 5 centimeters into the stomach.
D. Disconnect the suction source and clamp the tube for 30 minutes.
Answer: B. Check the patency and alignment of the tubing system for kinks or pressure.
Rationale: The first step in troubleshooting a non-functioning nasogastric tube is to assess
external factors, such as kinks, client positioning, or blockages in the collection tubing.
Irrigation or manipulation should only be performed if external inspection confirms the tube
is unobstructed externally and per protocol.
