Test Bank for NCLEX PN Exam | Updated Questions
and Correct Answers with Rationales | Graded A+
| Latest Version 2025
A client with methicillin resistant staphylococcus aureus (MRSA) bacteremia has
been receiving IV vancomycin for the last three days. Which blood test is most
important to review when preparing administration of the med?
A) blood cultures
B) creatinine levels
C) magnesium levels
D) white blood cell count ---------CORRECT ANSWER-----------------B
Creatinine levels should be closely monitored for signs of nephrotoxicity in the
client. If increasing creatinine is identified, the nurse should hold the dose and
contact the HCP.
General: Client is a G 2 P 1 at 36 weeks. reports a throbbing headache 7/10,
blurred vision, and epigastric pain; client states she took 1000 mg tylenol with no
relief. VS: prenatal visit 33 weeks: T 98.4, P 79, RR 17, BP, 122/75, 99% RA
Admission: T 98.8, P 84, RR 18, BP 176/111, 97% RA
What is priority for the nurse?
A) Blood pressure
B) Cervical exam
C) Deep tendon reflexes
D) Gestational age of fetus ---------CORRECT ANSWER-----------------A
,The nurse suspects of the client has preeclampsia, which of the following findings
are clinical manifestations of preeclampsia
A) epigastric pain
B) facial edema
C) high blood pressure
D) proteinuria
E) throbbing headache
F) visual disturbances ---------CORRECT ANSWER-----------------A, B, C, D, E, F
The following abnormal laboratory results support the clients preeclampsia
diagnosis _________ & ________
WBC count
Hemoglobin
24 hour urine protein
Serum creatinine ---------CORRECT ANSWER-----------------24 hour urine protein and
serum creatinine
For each potential intervention, click to specify of the intervention is indicated or
not indicated for the care of the client with preeclampsia.
Initiate seizure precautions
Encourage frequent ambulation
Start a magnesium sulfate infusion
,Prepare to administer antihypertensives ---------CORRECT ANSWER-----------------
Indicated: initiate seizure precautions, start a magnesium sulfate infusion,
prepared to administer antihypertensives
Not indicated: encourage frequent ambulation
The client is two hours, postpartum, and the nurse is called to the clients bedside.
Which action should the nurse perform immediately?
The client is sleeping and not easily aroused, VS T 98 F, P 65, RR 11, BP 121/75,
SpO2 93% ra
A) alert the registered nurse
B) collect a blood specimen for serum magnesium level
C) perform fundal massage
D) request a prescription for IV fluids ---------CORRECT ANSWER-----------------A
If symptoms of magnesium toxicity occur (somnolence, respiratory depression,
diminished deep tendon reflexes) the nurse should stop the infusion, notify the
RN, and anticipate giving the antidote calcium gluconate
Highlight the findings that indicate the client is improving.
Abdominal dressing removed. Wound is clean dry and intact. No bleeding or foul
smelling drainage. On this is for midline and at the umbilicus. Your an output was
over 500 mL over the past four hours. Client states she cannot properly latch the
newborn during breast-feeding. Tolerating oral labetalol. Systolic blood pressure
has been 110-130 and diastolic 70-80 past 12 hrs. Client reports no headaches
and remains free of seizures ---------CORRECT ANSWER-----------------When is clean
dry and intact no bleeding or foul smelling drainage, your an output was 500 mL
over the past four hours, systolic blood pressure 110-130 and diastolic 70-80 past
12 hrs. Client reports no headaches and remains free of seizures.
, The nurse is caring for a 75-year-old client who was admitted to the hospital with
pneumonia. Which assessment findings most consistent with a diagnosis of
delirium
A) client is experiencing muscle stiffness and resting hand tremors
B) client is inattentive and disoriented
C) client reports decreased enjoyment in hobbies
D) family reports a gradual inability to remember recent events ---------CORRECT
ANSWER-----------------B
The nurse is caring for a client with hearing aids. Which actions by the client
indicates proper use, and care of hearing aids? SATA
A) keeps hearing aids clean by rinsing them with water
B) lowers television, volume when talking with nurse
C) places hearing aids on food tray, when not in use
D) turn the volume completely down prior to insertion of aid into ear
E) verifies the battery compartment is closed before insertion ---------CORRECT
ANSWER-----------------B, D, E
Should be cleaned with a soft cloth, not by immersing them in water. Also
keeping them in a safe dry place.
A client diagnosed with endometrial cancer is receiving brachytherapy. Which
intervention should the nurse anticipate for the client? SATA
and Correct Answers with Rationales | Graded A+
| Latest Version 2025
A client with methicillin resistant staphylococcus aureus (MRSA) bacteremia has
been receiving IV vancomycin for the last three days. Which blood test is most
important to review when preparing administration of the med?
A) blood cultures
B) creatinine levels
C) magnesium levels
D) white blood cell count ---------CORRECT ANSWER-----------------B
Creatinine levels should be closely monitored for signs of nephrotoxicity in the
client. If increasing creatinine is identified, the nurse should hold the dose and
contact the HCP.
General: Client is a G 2 P 1 at 36 weeks. reports a throbbing headache 7/10,
blurred vision, and epigastric pain; client states she took 1000 mg tylenol with no
relief. VS: prenatal visit 33 weeks: T 98.4, P 79, RR 17, BP, 122/75, 99% RA
Admission: T 98.8, P 84, RR 18, BP 176/111, 97% RA
What is priority for the nurse?
A) Blood pressure
B) Cervical exam
C) Deep tendon reflexes
D) Gestational age of fetus ---------CORRECT ANSWER-----------------A
,The nurse suspects of the client has preeclampsia, which of the following findings
are clinical manifestations of preeclampsia
A) epigastric pain
B) facial edema
C) high blood pressure
D) proteinuria
E) throbbing headache
F) visual disturbances ---------CORRECT ANSWER-----------------A, B, C, D, E, F
The following abnormal laboratory results support the clients preeclampsia
diagnosis _________ & ________
WBC count
Hemoglobin
24 hour urine protein
Serum creatinine ---------CORRECT ANSWER-----------------24 hour urine protein and
serum creatinine
For each potential intervention, click to specify of the intervention is indicated or
not indicated for the care of the client with preeclampsia.
Initiate seizure precautions
Encourage frequent ambulation
Start a magnesium sulfate infusion
,Prepare to administer antihypertensives ---------CORRECT ANSWER-----------------
Indicated: initiate seizure precautions, start a magnesium sulfate infusion,
prepared to administer antihypertensives
Not indicated: encourage frequent ambulation
The client is two hours, postpartum, and the nurse is called to the clients bedside.
Which action should the nurse perform immediately?
The client is sleeping and not easily aroused, VS T 98 F, P 65, RR 11, BP 121/75,
SpO2 93% ra
A) alert the registered nurse
B) collect a blood specimen for serum magnesium level
C) perform fundal massage
D) request a prescription for IV fluids ---------CORRECT ANSWER-----------------A
If symptoms of magnesium toxicity occur (somnolence, respiratory depression,
diminished deep tendon reflexes) the nurse should stop the infusion, notify the
RN, and anticipate giving the antidote calcium gluconate
Highlight the findings that indicate the client is improving.
Abdominal dressing removed. Wound is clean dry and intact. No bleeding or foul
smelling drainage. On this is for midline and at the umbilicus. Your an output was
over 500 mL over the past four hours. Client states she cannot properly latch the
newborn during breast-feeding. Tolerating oral labetalol. Systolic blood pressure
has been 110-130 and diastolic 70-80 past 12 hrs. Client reports no headaches
and remains free of seizures ---------CORRECT ANSWER-----------------When is clean
dry and intact no bleeding or foul smelling drainage, your an output was 500 mL
over the past four hours, systolic blood pressure 110-130 and diastolic 70-80 past
12 hrs. Client reports no headaches and remains free of seizures.
, The nurse is caring for a 75-year-old client who was admitted to the hospital with
pneumonia. Which assessment findings most consistent with a diagnosis of
delirium
A) client is experiencing muscle stiffness and resting hand tremors
B) client is inattentive and disoriented
C) client reports decreased enjoyment in hobbies
D) family reports a gradual inability to remember recent events ---------CORRECT
ANSWER-----------------B
The nurse is caring for a client with hearing aids. Which actions by the client
indicates proper use, and care of hearing aids? SATA
A) keeps hearing aids clean by rinsing them with water
B) lowers television, volume when talking with nurse
C) places hearing aids on food tray, when not in use
D) turn the volume completely down prior to insertion of aid into ear
E) verifies the battery compartment is closed before insertion ---------CORRECT
ANSWER-----------------B, D, E
Should be cleaned with a soft cloth, not by immersing them in water. Also
keeping them in a safe dry place.
A client diagnosed with endometrial cancer is receiving brachytherapy. Which
intervention should the nurse anticipate for the client? SATA
