Nclexpn
Practice Test 8 for Nclexpn: real questions and explanations from the Varsity Tutors practice-test pool.
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A 64-year-old client has a new colostomy 3 days after abdominal surgery. The client’s stoma was red and moist yesterday; today it appears dark purple and cool to touch, with minimal output and increasing abdominal pain. The client is anxious and asks if this is normal. Which action should the nurse take FIRST regarding the ostomy care?
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A 64-year-old client has a new colostomy 3 days after abdominal surgery. The client’s stoma was red and moist yesterday; today it appears dark purple and cool to touch, with minimal output and increasing abdominal pain. The client is anxious and asks if this is normal. Which action should the nurse take FIRST regarding the ostomy care?
Explanation: This question tests clinical judgment in ostomy care, specifically recognizing stoma ischemia as a surgical emergency. Priority concerns in ostomy management include assessing stoma viability, recognizing signs of compromised blood flow, and preventing tissue necrosis. Notifying the registered nurse or provider immediately (A) addresses the highest priority need because a dark purple, cool stoma indicates ischemia that requires urgent surgical evaluation to prevent necrosis and life-threatening complications. Option B could worsen the situation through inappropriate intervention, option C is contraindicated with suspected ischemia, and option D dangerously normalizes a critical finding. The decision-making principle used is recognizing surgical emergencies - stoma color changes from red to purple/black indicate vascular compromise requiring immediate medical intervention. A transferable strategy for prioritizing ostomy care interventions is to know that healthy stomas are always pink/red and moist; any color change to purple, blue, or black requires immediate notification as it indicates compromised blood flow.
Before initiating a blood product transfusion, which pre-administration step must the LPN/VN perform to ensure client safety?
Explanation: Pre-transfusion safety requires two licensed nurses to confirm the client's identity using two unique identifiers and to match the blood product label against the order and compatibility report before the transfusion is started. This two-nurse verification is a non-negotiable safety step. Initiating at full rate is incorrect; the standard practice is to run the transfusion slowly for the first 15 minutes to monitor for reactions. Independent assessment of reaction history is outside the LPN/VN scope; the LPN/VN collects data and reports rather than independently assesses. IV solution selection for concurrent infusion is an RN decision, not an LPN/VN determination.
A client with a gastrostomy tube (G-tube) begins to vomit shortly after the practical nurse (PN) starts a bolus feeding. What is the nurse's immediate action?
Explanation: The immediate priorities are to prevent further vomiting and to protect the client's airway from aspiration. The nurse must first stop the feeding and then position the client on their side to allow the vomitus to drain out of their mouth. Continuing the feeding or lowering the head of the bed would increase the risk of aspiration. Administering medication is not the first priority.
A hospital has declared an 'Internal Disaster' due to a massive power outage affecting the entire facility. The nurse is assigned to a unit where all the clients are on electronic monitoring.
What is the priority nursing action during this internal disaster response?
Explanation: When electronic monitoring fails due to a power outage, the nurse's immediate priority is to perform manual vital sign assessments on all clients who were being electronically monitored. Electronic monitors serve as continuous safety surveillance — when they fail, the nurse must re-establish that surveillance using manual techniques (blood pressure cuff, pulse palpation, direct respiratory observation) until power is restored or battery backup activates. Critically ill or unstable clients require the most immediate assessment. Contacting the news media (A) is not a nursing responsibility and diverts attention from client care. Moving clients to the hallway (C) is not indicated for a power outage and disrupts care unnecessarily. Delegating monitoring to family members (D) asks untrained individuals to perform clinical assessments that require professional nursing judgment.
A client signed a general consent for treatment upon admission to the hospital. A surgeon now informs the client that they need an invasive surgical procedure. Which statement is true regarding consent for this surgery?
Explanation: A general consent for treatment, signed on admission, covers routine nursing care and minor procedures. It does not cover invasive, high-risk procedures like surgery. For these, a separate, specific informed consent is required, detailing the procedure, risks, benefits, and alternatives. Verbal agreement (C) is not sufficient for major procedures; a signed form is the legal standard. Amending the general consent (D) is not appropriate.
An 80-year-old client with advanced dementia needs to have a gastrostomy tube placed. The client is unable to provide consent. The practical nurse should check the client's medical record for which document to identify the legal decision-maker?
Explanation: A durable power of attorney for health care (also known as a healthcare proxy or surrogate) is a legal document that designates a specific person to make medical decisions on the client's behalf when they are incapacitated. A living will (A) typically outlines wishes for end-of-life care. A DNR (B) is specific to resuscitation efforts. An admission agreement (D) is an administrative document.
A 26-year-old client is 1 hour postpartum after a vaginal birth at 39 weeks. Vital signs: blood pressure 114/72 mm Hg, heart rate 100/min, temperature 98.4°F (36.9°C); fundus firm and midline; lochia is heavy with multiple clots larger than a plum. What is the nurse's PRIORITY intervention (under RN supervision)?
Explanation: This question tests clinical judgment in monitoring labor/postpartum clients. The priority framework is safety, monitoring for postpartum hemorrhage, and identifying causes like retained products. Notifying the RN and continuing assessment for retained products or lacerations while monitoring vital signs closely is the highest priority because heavy lochia with large clots despite firm fundus suggests retained tissue or trauma. Massaging is unnecessary if firm; encouraging activity or teaching about clots minimizes the issue. The decision-making principle is to suspect non-atony causes when fundus is firm but bleeding persists. For example, large clots may require ultrasound or exploration. A transferable monitoring strategy is to note clot size and notify for anything larger than a lemon in postpartum assessments.
The LPN/VN is administering a blood transfusion to a client. After the first 15 minutes pass without signs of a reaction, how frequently should the nurse obtain vital signs for the remainder of the transfusion?
Explanation: Transfusion monitoring requires vital signs before starting, at 15 minutes after initiation, and upon completion. The frequency for the remainder of the infusion is generally defined by institutional policy rather than a single fixed universal standard, though every 30 minutes is a commonly cited interval that supports timely detection of delayed reactions. Checking every 5 minutes for the full transfusion is excessive and not standard practice for a stable client. Checking only at the midpoint and completion creates gaps that may allow reactions to go undetected. Vital signs must be obtained on a scheduled, policy-directed basis and not only in response to client-reported symptoms.
An LPN/VN is caring for a 47-year-old client with pancreatitis who reports severe abdominal pain and nausea. Current findings: pain 9/10, heart rate 118/min, blood pressure 88/56 mm Hg, cool clammy skin; history includes heavy alcohol use. What is the PRIORITY action under RN supervision?
Explanation: This question tests organizing and prioritizing client care. The framework used for prioritization is the ABCs and urgency, addressing circulatory shock. The correct answer, notifying RN of hypotension and shock signs, represents the highest priority to manage hypovolemia in pancreatitis. The distractors are lower priority: administering analgesics addresses pain, teaching diet is preventive, and offering fluids risks aspiration. A key principle is recognizing third-spacing as a shock trigger. Another principle is staying with unstable clients during escalation. A transferable strategy is to assess for clammy skin and tachycardia, prioritizing hemodynamic support in abdominal pain scenarios.
The practical nurse (PN) is reinforcing instructions for a female client on how to collect a clean-catch midstream urine specimen. Which statement by the client indicates that the teaching has been effective?
Explanation: The correct procedure for a female client collecting a clean-catch midstream urine specimen is to separate the labia to prevent contamination from the surrounding skin and then urinating. Wiping from back to front can introduce bacteria into the meatus. The client should urinate a small amount into the toilet first (midstream) to clear the urethra. The container only needs to be filled to the level indicated, not to the top.
A 6-month-old infant is seen in clinic for poor weight gain. Birth weight was 3.2 kg; current weight is 5.6 kg (below expected), and the caregiver reports the infant takes 2–3 oz of formula every 4–5 hours and often falls asleep during feeds. The infant has sparse subcutaneous fat and fewer than 4 wet diapers/day. Which dietary modification is MOST appropriate for this client?
Explanation: This question tests understanding of nutrition and oral hydration. The primary concern is poor weight gain and dehydration in an infant, indicated by low intake, sparse fat, and few wet diapers. Increasing feeding frequency and ensuring correct formula mixing per instructions is the most appropriate because it promotes adequate calorie and fluid intake without risking imbalances. Diluting formula can cause hyponatremia; switching to low-fat milk is unsuitable for infants; adding honey risks botulism. A key decision-making principle is to verify caregiver education on formula preparation to prevent errors. Another principle is to assess growth parameters regularly in infants. A transferable strategy is to teach caregivers about signs of dehydration and proper feeding techniques for optimal nutrition.
A 66-year-old client is taking warfarin for atrial fibrillation. The client reports dark, tarry stools and bleeding gums when brushing teeth. Vital signs: T 98.7°F (37.1°C), HR 106/min, BP 102/64 mm Hg, RR 18/min, SpO2 98% on room air; international normalized ratio (INR) 5.2 (therapeutic 2.0–3.0). Which finding indicates a potential complication?
Explanation: This question tests recognition of potential complications related to anticoagulation therapy. The key symptoms indicating risk are INR 5.2 (therapeutic range 2.0-3.0), melena (dark tarry stools indicating GI bleeding), and gum bleeding, which together indicate warfarin toxicity with active bleeding. Option A correctly identifies the supratherapeutic INR with bleeding manifestations as the complication requiring immediate vitamin K administration and possible blood products. Option B (normal oxygen saturation), option C (normal temperature), and option D (history of atrial fibrillation) are expected findings that don't indicate complications. The principle for early recognition is that INR above therapeutic range with any bleeding symptoms indicates anticoagulation-related hemorrhage requiring reversal. A transferable monitoring strategy is to correlate INR values with clinical bleeding signs, as even minor bleeding with elevated INR can progress to major hemorrhage.
When reporting a fire to the emergency dispatcher or operator, what is the most critical piece of information the nurse must provide?
Explanation: The most critical piece of information for a rapid and effective response is the exact location of the fire (e.g., unit, floor, room number). This allows firefighters to proceed directly to the scene without delay. While other information may be helpful, the location is the absolute priority.
An 18-year-old client is preparing to live in a college dormitory. The PN is reviewing the client's immunization record. The record shows a primary dose of meningococcal conjugate (MenACWY) vaccine was given at age 12. Which action should the PN anticipate?
Explanation: A booster dose of the MenACWY vaccine is recommended for adolescents at age 16. This is especially important for those entering settings like college dormitories where the risk of meningitis outbreaks is higher.
An LPN in the emergency department is cleaning a treatment room and is accidentally stuck by an uncapped needle left on the bedside table after a procedure; the source client is not immediately identifiable. What is the nurse’s PRIORITY action following the exposure?
Explanation: This question tests the immediate response to biohazard and needle-stick exposure from an unknown source. The priority concern is infection prevention through immediate wound care, regardless of source identification. Immediately washing the puncture site with soap and water (A) is the best choice because decontamination should never be delayed while trying to identify the source patient. Searching records before wound care (B) dangerously delays immediate decontamination, recapping the needle (C) violates safety protocols and could cause additional injury, and waiting to report until source identification (D) delays critical post-exposure interventions. The clinical judgment model emphasizes prioritizing immediate safety actions over information gathering. The transferable strategy is: treat all needle-stick injuries as potentially infectious and perform immediate wound care first, then work on source identification and reporting.
A client received an intramuscular antibiotic 15 minutes ago and now reports feeling anxious, having difficulty breathing, and itching all over. The nurse observes facial swelling.
What is the nurse's immediate priority?
Explanation: The client is exhibiting signs of anaphylaxis, a life-threatening allergic reaction. The LPN's immediate priority is to recognize this emergency and activate the facility's emergency response system or call for the RN and other help. This ensures the client receives rapid, advanced medical intervention. While documentation and medication administration are important, securing immediate help is the first and most critical action.
A client receiving palliative care reports persistent nausea. After administering a prescribed antiemetic, which additional action should the practical nurse (PN) take to promote comfort?
Explanation: Offering small, frequent amounts of clear liquids (like ginger ale) or bland foods (like crackers) is a standard non-pharmacological intervention for nausea. These items are typically well-tolerated and can help settle the stomach without overwhelming it.
A 31-year-old client who delivered vaginally 2 hours ago at 40 weeks is in a postpartum recovery room. Vital signs: blood pressure 104/66 mm Hg, heart rate 112/min, temperature 99.1°F (37.3°C); fundus is boggy and 2 cm above the umbilicus; lochia is heavy with clots and saturating a pad in 10 minutes. What is the nurse's PRIORITY intervention (under RN supervision)?
Explanation: This question tests clinical judgment in monitoring labor/postpartum clients. The priority framework is safety, monitoring for postpartum hemorrhage, and addressing potential complications like uterine atony. Massaging the uterine fundus and assessing for firmness while calling the RN for assistance is the highest priority because a boggy fundus and heavy lochia indicate uterine atony, requiring immediate intervention to prevent excessive blood loss. Encouraging rest and rechecking lochia delays action; applying an ice pack addresses perineal issues, not uterine bleeding; and administering methylergonovine requires an order and is not the first step. The decision-making principle is to prioritize fundal assessment and massage in postpartum bleeding to promote contraction and hemostasis. For instance, in similar cases of atony, early massage can reduce the need for medications or further interventions. A transferable monitoring strategy is to routinely check fundus position, tone, and lochia every 15 minutes in the first postpartum hour to detect hemorrhage early.
A 31-year-old client with type 1 diabetes took rapid-acting insulin but vomited and did not eat. The client is diaphoretic, shaky, and has slurred speech; capillary blood glucose is 40 mg/dL. What is the nurse's PRIORITY action after obtaining this blood glucose reading?
Explanation: This question tests blood glucose monitoring and client safety in severe hypoglycemia with neurological symptoms. The key assessment finding is a capillary blood glucose of 40 mg/dL with diaphoresis, shakiness, and slurred speech after vomiting. The correct answer, offering 15 g of fast-acting carbohydrate if safe to swallow and rechecking in 15 minutes, is the best choice to restore glucose levels quickly. Encouraging diet soda provides no glucose, administering insulin exacerbates the issue, and waiting for resolution is dangerous. A decision-making principle in glucose monitoring is to assess swallowing ability before oral treatment in symptomatic hypoglycemia. A transferable nursing strategy for monitoring blood glucose levels is to anticipate glucose drops in illness and adjust insulin proactively.
A client is to receive 1.5 L of Lactated Ringer's solution over 12 hours.
The nurse should program the infusion pump to deliver the fluid at what rate in mL/hr?
Explanation: First, convert the volume from liters (L) to milliliters (mL). Since 1 L = 1,000 mL, 1.5 L = 1,500 mL. Next, calculate the rate in mL/hr by dividing the total volume by the total time: (\frac{1500 \text{ mL}}{12 \text{ hr}} = 125 \text{ mL/hr}).
A 16-year-old client is recovering from an appendectomy. To support the client's psychosocial needs, what is the nurse's most appropriate action?
Explanation: Adolescents are in Erikson's stage of Identity vs. Role Confusion. Peer relationships are critically important for developing identity. Allowing friends to visit provides social support and normalcy. Parents should be involved, but the adolescent should be encouraged to participate in decisions. Restricting peer contact can lead to feelings of isolation. While rest is important, dismissing concerns about school ignores a central part of the adolescent's life.
A client asks the practical nurse (PN) to explain the potential complications of an upcoming cardiac catheterization. Which response by the nurse is most appropriate?
Explanation: Explaining the risks, benefits, and alternatives of a procedure is the legal responsibility of the healthcare provider obtaining the consent. It is outside the PN's scope of practice. The most appropriate action is to recognize the client's need for more information and to notify the provider. Providing a partial answer (A) is inappropriate. A brochure (B) is a supplement, not a replacement for discussion with the provider. Offering false reassurance (D) dismisses the client's valid concerns.
A 74-year-old client with type 2 diabetes is admitted with generalized weakness and stays in bed most of the day. The nurse notes dry, cracked skin on the heels and elbows; no open areas are present. Braden Scale score is 14. Current interventions include turning every 2 hours and a standard mattress. Which assessment finding indicates a risk for pressure injury?
Explanation: This question tests understanding of skin integrity and pressure injury prevention by recognizing skin condition risks. The priority framework for preventing pressure injuries involves assessing for dryness that compromises barrier function. Dry, cracked skin on areas exposed to pressure and friction indicates the best choice as it increases vulnerability to breakdown. Clear lungs, quick capillary refill, and normal temperature are unrelated to skin risk. The evidence-based principle of pressure injury prevention addresses hydration to maintain skin resilience. A transferable strategy for maintaining skin integrity is to apply moisturizers routinely to extremities. Proactive assessment and intervention are essential in diabetic clients with weakness.
A client is scheduled to receive several units of packed red blood cells following significant blood loss from trauma. Which complications associated specifically with receiving large volumes of stored blood should the LPN/VN monitor for and report?
Explanation: Large-volume transfusion carries specific metabolic and thermal risks. Stored blood contains citrate preservative, which binds calcium in the recipient's bloodstream and can cause hypocalcemia manifesting as paresthesias, muscle cramps, and tetany. Large volumes of refrigerated blood can also lower the recipient's core body temperature, causing hypothermia. A blood warmer may be used to address this risk. Hyperkalemia can occur with massive transfusion due to potassium leaking from stored red cells, but fluid volume excess rather than deficit is the typical circulatory consequence. Metabolic alkalosis, hypomagnesemia, and hypernatremia are not primary complications of large-volume blood product transfusion.
The practical nurse (PN) is reviewing pre-procedure orders for a client undergoing an endoscopy. The orders include an IV sedative to be given on call to the procedure room. The nurse notes the consent form has not yet been signed. What is the priority action?
Explanation: Informed consent must be obtained before any mind-altering medications, such as sedatives, are administered. Giving the sedative (A) would render the client unable to provide valid consent. The priority action is to hold the medication and immediately report the situation to the RN, who will coordinate with the provider to get the consent signed. Asking the client to sign quickly (C) is outside the PN's scope and is coercive. Notifying the endoscopy department (D) is secondary to ensuring the medication is not given and the direct chain of command (the RN) is notified.