NCLEX PN ACTUAL EXAM
2024 QUESTIONS AND
ANSWERS WITH
RATIONALE.
Question 1:
A nurse is caring for a patient with pneumonia who is experiencing shortness of breath. Which
position is most appropriate to improve oxygenation?
A. Supine
B. Semi-Fowler’s
C. High Fowler’s
D. Lying on the left side
Answer:
C. High Fowler’s
Rationale:
The High Fowler’s position (sitting upright at a 90-degree angle) allows for maximum lung
expansion, which helps ease breathing and improve oxygenation in patients with respiratory
issues like pneumonia. Semi-Fowler’s is less effective in severe respiratory distress, while lying
flat or on the side may further impair lung expansion.
Question 2:
A 10-year-old child with diabetes mellitus type 1 is admitted to the hospital with diabetic
ketoacidosis (DKA). Which laboratory finding would the nurse expect to observe?
A. Decreased blood glucose
B. Increased pH
C. Increased blood glucose
D. Decreased ketones
Answer:
C. Increased blood glucose
,Rationale:
DKA occurs due to a lack of insulin, leading to high blood glucose levels and ketone production.
Patients typically present with hyperglycemia (increased blood glucose), a decreased pH
(indicating acidosis), and increased ketones in the blood and urine.
Question 3:
A patient who is post-op from an appendectomy is requesting pain medication. The nurse
notices the patient’s abdomen is distended and firm. What is the priority nursing action?
A. Administer the prescribed analgesic
B. Encourage the patient to walk
C. Assess for bowel sounds
D. Give the patient ice chips
Answer:
C. Assess for bowel sounds
Rationale:
Abdominal distension and a firm abdomen may indicate paralytic ileus or other post-operative
complications such as peritonitis. Assessing bowel sounds is critical to determine the cause and
severity of the issue before administering pain medication or encouraging ambulation.
Question 4:
A nurse is caring for a client who has a history of deep vein thrombosis (DVT). Which statement
made by the client indicates a need for further teaching?
A. “I will wear compression stockings as prescribed.”
B. “I should remain seated for long periods.”
C. “I will elevate my legs when I rest.”
D. “I will avoid crossing my legs when sitting.”
Answer:
B. “I should remain seated for long periods.”
Rationale:
Clients with a history of DVT should avoid prolonged sitting or immobility, as it can increase the
risk of clot formation. Wearing compression stockings, elevating the legs, and avoiding leg
crossing are all appropriate interventions to prevent DVT recurrence.
Question 5:
A nurse is reviewing laboratory results for a client taking warfarin (Coumadin). Which finding
would require immediate intervention?
A. INR of 1.5
B. Hemoglobin of 13.0 g/dL
, C. INR of 4.5
D. Platelet count of 150,000/mm³
Answer:
C. INR of 4.5
Rationale:
An International Normalized Ratio (INR) of 4.5 indicates an elevated risk of bleeding, as the
therapeutic range for warfarin is usually 2.0–3.0 for most indications. Immediate intervention is
required to prevent serious complications. An INR of 1.5 suggests the need for a dose
adjustment, but it is not as critical as a high INR. Hemoglobin and platelet levels are within
normal ranges.
Question 6:
A nurse is preparing to administer an intramuscular injection to a client. Which of the following is
the preferred site for an IM injection for an adult?
A. Deltoid muscle
B. Ventrogluteal muscle
C. Dorsogluteal muscle
D. Vastus lateralis muscle
Answer:
B. Ventrogluteal muscle
Rationale:
The ventrogluteal site is preferred for IM injections in adults because it is located away from
major nerves and blood vessels, reducing the risk of injury. The deltoid is used for smaller
volumes, and the dorsogluteal muscle has a higher risk of injury to the sciatic nerve.
Question 7:
The nurse is caring for a patient with chronic renal failure. Which dietary restriction is most
important to prevent complications?
A. Protein
B. Fats
C. Carbohydrates
D. Calcium
Answer:
A. Protein
Rationale:
In chronic renal failure, the kidneys cannot effectively filter waste products from protein
metabolism, leading to a buildup of urea. Reducing protein intake minimizes the accumulation of
toxic waste products in the blood.
2024 QUESTIONS AND
ANSWERS WITH
RATIONALE.
Question 1:
A nurse is caring for a patient with pneumonia who is experiencing shortness of breath. Which
position is most appropriate to improve oxygenation?
A. Supine
B. Semi-Fowler’s
C. High Fowler’s
D. Lying on the left side
Answer:
C. High Fowler’s
Rationale:
The High Fowler’s position (sitting upright at a 90-degree angle) allows for maximum lung
expansion, which helps ease breathing and improve oxygenation in patients with respiratory
issues like pneumonia. Semi-Fowler’s is less effective in severe respiratory distress, while lying
flat or on the side may further impair lung expansion.
Question 2:
A 10-year-old child with diabetes mellitus type 1 is admitted to the hospital with diabetic
ketoacidosis (DKA). Which laboratory finding would the nurse expect to observe?
A. Decreased blood glucose
B. Increased pH
C. Increased blood glucose
D. Decreased ketones
Answer:
C. Increased blood glucose
,Rationale:
DKA occurs due to a lack of insulin, leading to high blood glucose levels and ketone production.
Patients typically present with hyperglycemia (increased blood glucose), a decreased pH
(indicating acidosis), and increased ketones in the blood and urine.
Question 3:
A patient who is post-op from an appendectomy is requesting pain medication. The nurse
notices the patient’s abdomen is distended and firm. What is the priority nursing action?
A. Administer the prescribed analgesic
B. Encourage the patient to walk
C. Assess for bowel sounds
D. Give the patient ice chips
Answer:
C. Assess for bowel sounds
Rationale:
Abdominal distension and a firm abdomen may indicate paralytic ileus or other post-operative
complications such as peritonitis. Assessing bowel sounds is critical to determine the cause and
severity of the issue before administering pain medication or encouraging ambulation.
Question 4:
A nurse is caring for a client who has a history of deep vein thrombosis (DVT). Which statement
made by the client indicates a need for further teaching?
A. “I will wear compression stockings as prescribed.”
B. “I should remain seated for long periods.”
C. “I will elevate my legs when I rest.”
D. “I will avoid crossing my legs when sitting.”
Answer:
B. “I should remain seated for long periods.”
Rationale:
Clients with a history of DVT should avoid prolonged sitting or immobility, as it can increase the
risk of clot formation. Wearing compression stockings, elevating the legs, and avoiding leg
crossing are all appropriate interventions to prevent DVT recurrence.
Question 5:
A nurse is reviewing laboratory results for a client taking warfarin (Coumadin). Which finding
would require immediate intervention?
A. INR of 1.5
B. Hemoglobin of 13.0 g/dL
, C. INR of 4.5
D. Platelet count of 150,000/mm³
Answer:
C. INR of 4.5
Rationale:
An International Normalized Ratio (INR) of 4.5 indicates an elevated risk of bleeding, as the
therapeutic range for warfarin is usually 2.0–3.0 for most indications. Immediate intervention is
required to prevent serious complications. An INR of 1.5 suggests the need for a dose
adjustment, but it is not as critical as a high INR. Hemoglobin and platelet levels are within
normal ranges.
Question 6:
A nurse is preparing to administer an intramuscular injection to a client. Which of the following is
the preferred site for an IM injection for an adult?
A. Deltoid muscle
B. Ventrogluteal muscle
C. Dorsogluteal muscle
D. Vastus lateralis muscle
Answer:
B. Ventrogluteal muscle
Rationale:
The ventrogluteal site is preferred for IM injections in adults because it is located away from
major nerves and blood vessels, reducing the risk of injury. The deltoid is used for smaller
volumes, and the dorsogluteal muscle has a higher risk of injury to the sciatic nerve.
Question 7:
The nurse is caring for a patient with chronic renal failure. Which dietary restriction is most
important to prevent complications?
A. Protein
B. Fats
C. Carbohydrates
D. Calcium
Answer:
A. Protein
Rationale:
In chronic renal failure, the kidneys cannot effectively filter waste products from protein
metabolism, leading to a buildup of urea. Reducing protein intake minimizes the accumulation of
toxic waste products in the blood.
