NCLEX-PN EXAM LATEST 2024 -2025 TEST BANK
COMPLETE 360 ACTUAL EXAM QUESTIONS
WITH CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) AGRADE ASSURED!!
A client has just undergone lumbar puncture (LP). The nurse assists the
client into which most optimal position if tolerated by the client? - Correct
Answer - Prone, with a pillow under the abdomen
Rationale:
If it can be tolerated by the client, the optimal position following LP is prone
with a small pillow under the abdomen. This position helps minimize or
prevent continued leakage of cerebrospinal fluid (CSF) from the site by
enlisting the aid of gravity. If the client cannot tolerate this position, the
client should be positioned flat in bed and turned from side to side as
necessary. It is important that the head of the bed remain flat to prevent
CSF leakage and to prevent postprocedure headache.
A nurse is collecting data on a client with chronic sinusitis. The nurse
interprets that which of the following client manifestations is unrelated to
this problem? - Correct Answer - Severe evening headache
Rationale:
Chronic sinusitis is characterized by persistent purulent nasal discharge, a
chronic cough caused by nasal discharge, anosmia (loss of smell), nasal
stuffiness, and headache that is worse on arising after sleep.
pg. 1
,A nurse is caring for a client who has been admitted to the hospital with a
diagnosis of angina pectoris. The client is receiving oxygen via nasal
cannula at 2 L. The client asks the nurse why the oxygen is necessary. The
nurse bases the response on which of the following? - Correct Answer -
Oxygen supply to the heart cells that is deficient results in angina pectoris
pain.
Rationale:
The pain associated with angina is derived from ischemic myocardial cells.
The pain is often associated with activity that places more oxygen demand
on heart muscle. Supplemental oxygen helps meet the added demands on
the heart muscle. Oxygen does not dilate blood vessels, prevent thrombus
formation, or directly calm the client.
A client is admitted to the hospital with a diagnosis of pleurisy. The nurse
checks the client for which characteristic symptom of this disorder?
✓ Knifelike pain that worsens on inspiration
Rationale:
A typical symptom with pleurisy is a knifelike pain that worsens on
inspiration. This is a result of the friction caused by the rubbing together of
inflamed pleural surfaces. This pain usually disappears when the breath is
held because these surfaces stop moving. The client does not experience
early morning fatigue or dyspnea relieved by lying flat.
A nurse is planning to instruct a client with diabetes mellitus who has
hypertension about "sick day management." Which of the following does
the nurse avoid putting on a list of easily consumed carbohydrate-
containing beverages for use when the client cannot tolerate food orally?
✓ Mineral water
Rationale:
pg. 2
,Diabetic clients should take in approximately 15 g of carbohydrate every 1
to 2 hours when unable to tolerate food because of illness. Each of the
beverages listed in options 1, 2, and 3 provides approximately 13 to 15 g of
carbohydrate in a half-cup serving. Mineral water is incorrect for two
reasons. First, it contains sodium and should not be used by the client with
hypertension. Second, it is not a source of carbohydrates.
A client is admitted to the hospital with a diagnosis of pericarditis. The
nurse reviews the client's record for which manifestation that differentiates
pericarditis from other cardiopulmonary problems?
✓ Pericardial friction rub
Rationale:
A pericardial friction rub is heard when there is inflammation of the
pericardial sac during the inflammatory phase of pericarditis. Chest pain
that worsens on inspiration is characteristic of both pericarditis and pleurisy.
Anterior chest pain may be experienced with angina pectoris and
myocardial infarction. Weakness and irritability are nonspecific complaints
that could accompany a wide variety of disorders.
A client with a T4 spinal cord injury is to be monitored for autonomic
dysreflexia (hyperreflexia). Which finding is indicative of this complication? -
Correct Answer - The client complains of a headache and the blood
pressure is elevated.
Rationale:
Autonomic dysreflexia, also known as autonomic hyperreflexia, is a life-
threatening syndrome. It is a cluster of clinical manifestations that results
when multiple spinal cord autonomic responses discharge simultaneously.
Exaggerated autonomic nervous system reactions to stimuli result in
sudden hypertensive episodes with severe headache. The client may
sweat profusely above the level of the cord lesion and complain of a stuffy
pg. 3
, nose. The knee-jerk response is not affected. Pupils may be dilated.
Although a distended bladder is often the precipitating event, it is not
indicative of dysreflexia, and not all clients with bladder distention exhibit
dysreflexia.
A nurse is reviewing the record of a client with acute respiratory distress
syndrome (ARDS). The nurse determines that which finding documented in
the client's record is consistent with the most expected characteristic of this
disorder? - Correct Answer - Arterial PaO2 of 48
Rationale:
The most characteristic sign of ARDS is increasing hypoxemia with a PaO2
of less than 60 mm Hg. This occurs despite increasing levels of oxygen that
are administered to the client. The client's earliest sign is an increased
respiratory rate. Breathing then becomes labored, and the client may
exhibit air hunger, retractions, and peripheral cyanosis.
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in
the emergency department. Which of the following findings would the nurse
expect to note as confirming this diagnosis? - Correct Answer - Elevated
blood glucose and low plasma bicarbonate
Rationale:
In DKA, the arterial pH is less than 7.35, plasma bicarbonate is less than
15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones
are present in the blood and urine. The client would be experiencing
polyuria and Kussmaul's respirations. Coma may occur if DKA is not
treated, but coma would not confirm the diagnosis.
A nurse assisting in caring for a client hospitalized with acute pericarditis is
monitoring the client for signs of cardiac tamponade. The nurse determines
pg. 4
COMPLETE 360 ACTUAL EXAM QUESTIONS
WITH CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) AGRADE ASSURED!!
A client has just undergone lumbar puncture (LP). The nurse assists the
client into which most optimal position if tolerated by the client? - Correct
Answer - Prone, with a pillow under the abdomen
Rationale:
If it can be tolerated by the client, the optimal position following LP is prone
with a small pillow under the abdomen. This position helps minimize or
prevent continued leakage of cerebrospinal fluid (CSF) from the site by
enlisting the aid of gravity. If the client cannot tolerate this position, the
client should be positioned flat in bed and turned from side to side as
necessary. It is important that the head of the bed remain flat to prevent
CSF leakage and to prevent postprocedure headache.
A nurse is collecting data on a client with chronic sinusitis. The nurse
interprets that which of the following client manifestations is unrelated to
this problem? - Correct Answer - Severe evening headache
Rationale:
Chronic sinusitis is characterized by persistent purulent nasal discharge, a
chronic cough caused by nasal discharge, anosmia (loss of smell), nasal
stuffiness, and headache that is worse on arising after sleep.
pg. 1
,A nurse is caring for a client who has been admitted to the hospital with a
diagnosis of angina pectoris. The client is receiving oxygen via nasal
cannula at 2 L. The client asks the nurse why the oxygen is necessary. The
nurse bases the response on which of the following? - Correct Answer -
Oxygen supply to the heart cells that is deficient results in angina pectoris
pain.
Rationale:
The pain associated with angina is derived from ischemic myocardial cells.
The pain is often associated with activity that places more oxygen demand
on heart muscle. Supplemental oxygen helps meet the added demands on
the heart muscle. Oxygen does not dilate blood vessels, prevent thrombus
formation, or directly calm the client.
A client is admitted to the hospital with a diagnosis of pleurisy. The nurse
checks the client for which characteristic symptom of this disorder?
✓ Knifelike pain that worsens on inspiration
Rationale:
A typical symptom with pleurisy is a knifelike pain that worsens on
inspiration. This is a result of the friction caused by the rubbing together of
inflamed pleural surfaces. This pain usually disappears when the breath is
held because these surfaces stop moving. The client does not experience
early morning fatigue or dyspnea relieved by lying flat.
A nurse is planning to instruct a client with diabetes mellitus who has
hypertension about "sick day management." Which of the following does
the nurse avoid putting on a list of easily consumed carbohydrate-
containing beverages for use when the client cannot tolerate food orally?
✓ Mineral water
Rationale:
pg. 2
,Diabetic clients should take in approximately 15 g of carbohydrate every 1
to 2 hours when unable to tolerate food because of illness. Each of the
beverages listed in options 1, 2, and 3 provides approximately 13 to 15 g of
carbohydrate in a half-cup serving. Mineral water is incorrect for two
reasons. First, it contains sodium and should not be used by the client with
hypertension. Second, it is not a source of carbohydrates.
A client is admitted to the hospital with a diagnosis of pericarditis. The
nurse reviews the client's record for which manifestation that differentiates
pericarditis from other cardiopulmonary problems?
✓ Pericardial friction rub
Rationale:
A pericardial friction rub is heard when there is inflammation of the
pericardial sac during the inflammatory phase of pericarditis. Chest pain
that worsens on inspiration is characteristic of both pericarditis and pleurisy.
Anterior chest pain may be experienced with angina pectoris and
myocardial infarction. Weakness and irritability are nonspecific complaints
that could accompany a wide variety of disorders.
A client with a T4 spinal cord injury is to be monitored for autonomic
dysreflexia (hyperreflexia). Which finding is indicative of this complication? -
Correct Answer - The client complains of a headache and the blood
pressure is elevated.
Rationale:
Autonomic dysreflexia, also known as autonomic hyperreflexia, is a life-
threatening syndrome. It is a cluster of clinical manifestations that results
when multiple spinal cord autonomic responses discharge simultaneously.
Exaggerated autonomic nervous system reactions to stimuli result in
sudden hypertensive episodes with severe headache. The client may
sweat profusely above the level of the cord lesion and complain of a stuffy
pg. 3
, nose. The knee-jerk response is not affected. Pupils may be dilated.
Although a distended bladder is often the precipitating event, it is not
indicative of dysreflexia, and not all clients with bladder distention exhibit
dysreflexia.
A nurse is reviewing the record of a client with acute respiratory distress
syndrome (ARDS). The nurse determines that which finding documented in
the client's record is consistent with the most expected characteristic of this
disorder? - Correct Answer - Arterial PaO2 of 48
Rationale:
The most characteristic sign of ARDS is increasing hypoxemia with a PaO2
of less than 60 mm Hg. This occurs despite increasing levels of oxygen that
are administered to the client. The client's earliest sign is an increased
respiratory rate. Breathing then becomes labored, and the client may
exhibit air hunger, retractions, and peripheral cyanosis.
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in
the emergency department. Which of the following findings would the nurse
expect to note as confirming this diagnosis? - Correct Answer - Elevated
blood glucose and low plasma bicarbonate
Rationale:
In DKA, the arterial pH is less than 7.35, plasma bicarbonate is less than
15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones
are present in the blood and urine. The client would be experiencing
polyuria and Kussmaul's respirations. Coma may occur if DKA is not
treated, but coma would not confirm the diagnosis.
A nurse assisting in caring for a client hospitalized with acute pericarditis is
monitoring the client for signs of cardiac tamponade. The nurse determines
pg. 4
