NCLEX-PN Test Questions with 100% Verified Answers Graded A+
1. When preparing Supine with the head of bed elevated at a 45- to 60-degree
a client for angle
a pericardiocen-
tesis, how does Rationale:
the nurse posi- The client undergoing pericardiocentesis is positioned
tion the client? supine with the head of bed elevated to a 45- to 60-de-
gree angle. This places the heart in proximity to the chest
wall for easier insertion of the needle into the pericardial
sac. The remaining options are incorrect positions for this
procedure.
2. A client with Variant angina
angina com-
plains that the Rationale:
anginal pain is Variant angina, or Prinzmetal's angina, is prolonged and
prolonged and severe and occurs at the same time each day, most often
severe and oc- in the morning. Stable angina is induced by exercise and
curs at the same relieved by rest or nitroglycerin tablets. Unstable angina
time each day, occurs at lower and lower levels of activity or at rest, is
most often in the less predictable, and is often a precursor of myocardial
morning. On fur- infarction.
ther data collec-
tion, the nurse
notes that the
pain occurs in
the absence of
precipitating fac-
tors. This type
of anginal pain
is best described
as:
3. A nurse is car- Hypotension
ing for a client
after thyroidecto- Rationale:
my and moni- Clinical manifestations associated with thyroid storm in-
toring for signs clude a fever as high as 106° F (41.1° C), severe tachycar-
of thyroid storm. dia, profuse diarrhea, extreme vasodilation, hypotension,
The nurse un- atrial fibrillation, hyperreflexia, abdominal pain, diarrhea,
,NCLEX-PN Test Questions with 100% Verified Answers Graded A+
derstands that and dehydration. With this disorder, the client's condition
which of the fol- can rapidly progress to coma and cardiovascular collapse.
lowing is a man-
ifestation associ-
ated with this dis-
order?
4. A client is admit- Has a brownish or "brawny" appearance
ted to the hos-
pital with a ve- Rationale:
nous stasis leg Venous leg ulcers, also called stasis ulcers, are typically
ulcer. The nurse partial-thick wounds that extend through the epidermis
inspects the ul- and portions of the dermis. The skin of the lower leg is
cer, expecting to leathery, with a characteristic brownish or "brawny" ap-
note that the ul- pearance from the hemosiderin deposition. The edges of
cer: the ulcer are irregular and the tissue is a ruddy color. The
client also may exhibit peripheral edema.
5. A client who has Applying manual pressure over the site
had a radical
neck dissection Rationale:
begins to hemor- If the client begins to hemorrhage from the surgical site
rhage at the in- following radical neck dissection, the nurse elevates the
cision site. Which head of the bed to maintain airway patency and prevent
action by the aspiration. The nurse applies pressure over the bleeding
nurse would be site and calls the health care provider immediately.
contraindicated?
6. A nurse checks The system is functioning as expected.
the water seal
chamber of a Rationale:
closed chest Fluctuations in the water seal chamber are normal during
drainage system inhalation and exhalation until the lung re-expands and the
and notes fluc- client no longer requires chest drainage. If fluctuations are
tuations in the absent, it could indicate an air leak, kinking, or that the
chamber. Based lung has re-expanded.
on this finding,
the nurse deter-
mines that:
, NCLEX-PN Test Questions with 100% Verified Answers Graded A+
7. An ambulato- "Does the pain get worse when you breathe in?"
ry clinic nurse
is interviewing Rationale:
a client who Chest pain is assessed using the standard pain assess-
is complaining ment parameters, (characteristics, location, intensity, du-
of flu-like symp- ration, precipitating and alleviating factors, and associated
toms. The client symptoms). Options 1, 2, and 4 may or may not help de-
suddenly devel- termine the origin of pain. Pain of pleuropulmonary origin
ops chest pain. usually worsens on inspiration.
Which question
would best help
the nurse to
discriminate pain
caused by a
noncardiac prob-
lem?
8. A nurse is assist- Percuss the medial nerve at the wrist as it enters the
ing in checking carpal tunnel, and monitor for tingling sensations.
for Tinel's sign
in a client sus- Rationale:
pected of hav- The presence of Tinel's sign is determined by percussing
ing carpal tunnel the medial nerve at the wrist as it enters the carpal tunnel.
syndrome (CTS). A tingling sensation over the distribution of the nerve oc-
Which technique curs in CTS. The presence of Phalen's sign is determined
would the nurse by asking the client to flex the wrist at a 90-degree angle
expect to be for 1 minute. Numbness and tingling over the distribution
used to elicit this of the median nerve, the palmar surface of the thumb, and
sign? the index and middle fingers suggest CTS. Phalen's sign
is also an indication of CTS.
9. The nurse is col- Emphysema
lecting data on a
client with chron- Rationale:
ic airflow limita- The client with emphysema has hyperinflation of the alve-
tion (CAL) and oli and has flattening of the diaphragm. These lead to
notes that the increased anteroposterior diameter, which is referred to as
client has a "bar- "barrel chest." The client also has dyspnea with prolonged
rel chest." The expiration and has hyperresonant lungs to percussion.
1. When preparing Supine with the head of bed elevated at a 45- to 60-degree
a client for angle
a pericardiocen-
tesis, how does Rationale:
the nurse posi- The client undergoing pericardiocentesis is positioned
tion the client? supine with the head of bed elevated to a 45- to 60-de-
gree angle. This places the heart in proximity to the chest
wall for easier insertion of the needle into the pericardial
sac. The remaining options are incorrect positions for this
procedure.
2. A client with Variant angina
angina com-
plains that the Rationale:
anginal pain is Variant angina, or Prinzmetal's angina, is prolonged and
prolonged and severe and occurs at the same time each day, most often
severe and oc- in the morning. Stable angina is induced by exercise and
curs at the same relieved by rest or nitroglycerin tablets. Unstable angina
time each day, occurs at lower and lower levels of activity or at rest, is
most often in the less predictable, and is often a precursor of myocardial
morning. On fur- infarction.
ther data collec-
tion, the nurse
notes that the
pain occurs in
the absence of
precipitating fac-
tors. This type
of anginal pain
is best described
as:
3. A nurse is car- Hypotension
ing for a client
after thyroidecto- Rationale:
my and moni- Clinical manifestations associated with thyroid storm in-
toring for signs clude a fever as high as 106° F (41.1° C), severe tachycar-
of thyroid storm. dia, profuse diarrhea, extreme vasodilation, hypotension,
The nurse un- atrial fibrillation, hyperreflexia, abdominal pain, diarrhea,
,NCLEX-PN Test Questions with 100% Verified Answers Graded A+
derstands that and dehydration. With this disorder, the client's condition
which of the fol- can rapidly progress to coma and cardiovascular collapse.
lowing is a man-
ifestation associ-
ated with this dis-
order?
4. A client is admit- Has a brownish or "brawny" appearance
ted to the hos-
pital with a ve- Rationale:
nous stasis leg Venous leg ulcers, also called stasis ulcers, are typically
ulcer. The nurse partial-thick wounds that extend through the epidermis
inspects the ul- and portions of the dermis. The skin of the lower leg is
cer, expecting to leathery, with a characteristic brownish or "brawny" ap-
note that the ul- pearance from the hemosiderin deposition. The edges of
cer: the ulcer are irregular and the tissue is a ruddy color. The
client also may exhibit peripheral edema.
5. A client who has Applying manual pressure over the site
had a radical
neck dissection Rationale:
begins to hemor- If the client begins to hemorrhage from the surgical site
rhage at the in- following radical neck dissection, the nurse elevates the
cision site. Which head of the bed to maintain airway patency and prevent
action by the aspiration. The nurse applies pressure over the bleeding
nurse would be site and calls the health care provider immediately.
contraindicated?
6. A nurse checks The system is functioning as expected.
the water seal
chamber of a Rationale:
closed chest Fluctuations in the water seal chamber are normal during
drainage system inhalation and exhalation until the lung re-expands and the
and notes fluc- client no longer requires chest drainage. If fluctuations are
tuations in the absent, it could indicate an air leak, kinking, or that the
chamber. Based lung has re-expanded.
on this finding,
the nurse deter-
mines that:
, NCLEX-PN Test Questions with 100% Verified Answers Graded A+
7. An ambulato- "Does the pain get worse when you breathe in?"
ry clinic nurse
is interviewing Rationale:
a client who Chest pain is assessed using the standard pain assess-
is complaining ment parameters, (characteristics, location, intensity, du-
of flu-like symp- ration, precipitating and alleviating factors, and associated
toms. The client symptoms). Options 1, 2, and 4 may or may not help de-
suddenly devel- termine the origin of pain. Pain of pleuropulmonary origin
ops chest pain. usually worsens on inspiration.
Which question
would best help
the nurse to
discriminate pain
caused by a
noncardiac prob-
lem?
8. A nurse is assist- Percuss the medial nerve at the wrist as it enters the
ing in checking carpal tunnel, and monitor for tingling sensations.
for Tinel's sign
in a client sus- Rationale:
pected of hav- The presence of Tinel's sign is determined by percussing
ing carpal tunnel the medial nerve at the wrist as it enters the carpal tunnel.
syndrome (CTS). A tingling sensation over the distribution of the nerve oc-
Which technique curs in CTS. The presence of Phalen's sign is determined
would the nurse by asking the client to flex the wrist at a 90-degree angle
expect to be for 1 minute. Numbness and tingling over the distribution
used to elicit this of the median nerve, the palmar surface of the thumb, and
sign? the index and middle fingers suggest CTS. Phalen's sign
is also an indication of CTS.
9. The nurse is col- Emphysema
lecting data on a
client with chron- Rationale:
ic airflow limita- The client with emphysema has hyperinflation of the alve-
tion (CAL) and oli and has flattening of the diaphragm. These lead to
notes that the increased anteroposterior diameter, which is referred to as
client has a "bar- "barrel chest." The client also has dyspnea with prolonged
rel chest." The expiration and has hyperresonant lungs to percussion.
