NCLEX PN 2024 / PN NCLEX EXAM NEWEST ACTUAL
EXAM 120 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
The nurse is caring for a 3-year-old client with impetigo.
Which of the following infection control precautions should the nurse implement? Select all that apply.
1. Wear a surgical mask when bathing the client.
2. Wear a protective gown when changing the client's bed linens.
3. Keep the door to the client's room closed.
4. Place a box of clean gloves outside the client's door.
5. Place a surgical mask on the client during transport to other departments. - answer-2. Wear a
protective gown when changing the client's bed linens.
4. Place a box of clean gloves outside the client's door.
Rationale: Impetigo is a highly infectious skin disease spread by direct contact. Contact precautions
include gown and gloves. Private closed door and surgical masks are appropriate for airborne and not
necessary for contact
The nurse is evaluating a staff member's care of a client with active pulmonary tuberculosis (TB). Which
of the following actions by the staff member would indicate to the nurse an understanding of the
principles of infection control for tuberculosis isolation?
1. instructing visitors to wash their hands before entering the client's room
2. putting on a mask, gown, and gloves before entering the client's room
3. placing tissues and a trash receptacle within the client's reach
4. asking the client to put on a clean mask each time someone enters the room - answer-3. placing
tissues and a trash receptacle within the client's reach
Important to not leave tissues laying around and to put them in a leak proof bag in the trash.
The nurse in the pediatric unit is preparing to admit a client with rubeola (measles). The nurse should
assign the client to a
1. private room at the end of the hallway
2. private room with monitored negative air pressure
,3. room with a client who has chickenpox
4. room with a client who has atopic dermatitis (eczema) - answer-2. private room with monitored
negative air pressure
Measles is airborne (MTV) and requires a private room with negative air pressure
The charge nurse is observing the following client situations. It would require intervention if a
1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
2. visitor is sitting on the side of the bed of a client with acute pancreatitis
3. staff member is entering the room of a client with Haemophilus influenzae meningitis wearing a
protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the client's room open -
answer-1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
HBV is spread through contact with body fluids including saliva, so it is important to intervene if the
patient is eating and possibly sharing food with another person.
The nurse is reviewing the orders of a client who has acute kidney injury. Which of the following orders
should the nurse clarify?
1. computed tomography (CT) scan of the abdomen with intravenous contrast media
2. urine specimen for urinalysis
3. blood specimen for arterial blood gas (ABG)
4. referral to registered dietitian for parenteral nutrition evaluation - answer-1. computed tomography
(CT) scan of the abdomen with intravenous contrast media
CTs use iodinated contrast which is harmful to the kidneys and therefore contraindicated in a client with
AKI
The nurse is planning a staff education program about caring for clients with restraints. Which of the
following information should the nurse include?
1. "Restraints should be removed once during a shift to perform passive range-of-motion (ROM)
exercises for the client."
2. "Restraints should be secured to the side rails of the client's bed for quick release."
3. "Restraints require an order from the primary health care provider."
,4. "Restraints may be used p.r.n. for clients who are confused." - answer-3. "Restraints require an order
from the primary health care provider."
Rationale:
1. Restraints are removed every 2 HOURS for ROM exercises, toileting, and fluids. Assess every 15 mins
for the first hour and then every 30 minutes
2. Restraints should be secured to the bed, not side rails
4. Restraints are never PRN
The nurse is caring for a client with active pulmonary tuberculosis (TB). Which of the following should
the nurse include in the client's plan of care?
1. placing the client in a private room with the door open
2. putting a surgical mask on the client during transport to the radiology department
3. instructing the primary caregivers to wear surgical masks when caring for the client
4. instituting the standards for droplet precautions while caring for the client - answer-2. putting a
surgical mask on the client during transport to the radiology department
X-Ray to confirm active TB d(x)
Rationale:
1. Door should be closed
3.
4. Airborne precautions
The home-health nurse is teaching the parents of a 4-year-old client with impetigo. Which of the
following information should the nurse include?
1. "Put a surgical mask on your child when around siblings."
2. "Cleanse the lesions with a povidone-iodine solution daily."
3. "Apply petroleum jelly to the lesions daily."
4. "Instruct your child not to use the same towels as siblings." - answer-4. "Instruct your child not to use
the same towels as siblings."
Impetigo is highly contagious through contact. Towels can easily spread the infection
Rationale:
1. It is contact precautions; surgical mask would be for airborne
, The nurse has attended a staff education program about bioterrorism. Which of the following
statements by the nurse would require follow-up?
1. "Botulism is transmitted by ingestion of contaminated canned foods."
2. "Hemorrhagic fever is spread by direct contact with blood or body fluids."
3. "Anthrax is spread through direct contact with the bacteria and its spores."
4. "Bubonic plague is transmitted from person to person via airborne droplets." - answer-4. "Bubonic
plague is transmitted from person to person via airborne droplets."
It is spread through flea bites and contact with infected skin
Rationale:
1. Botulism is transmitted by foods. ex: babies getting Botulism from honey
2. Infectious diseases that affect clotting and is spread by blood or body fluids
3. Anthrax: Contact
The nurse observes a coworker who is assessing a client's thoracic expansion.
Which of the following would indicate that the coworker is using the correct assessment technique?
1. percussion from the apex of the scapula downward on each side
2. placement of the hands flat on the back with the thumbs at the level of the tenth ribs pointing to the
spine, then asking the client to inhale
3. measurement of the anteroposterior diameter of the chest
4. placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid process,
then asking the client to inhale - answer-4. placement of the palms at the level of the tenth ribs with
thumbs pointing to the xiphoid process, then asking the client to inhale
This is how to measure anterior thoracic expansion.
2. Posterior thoracic expansion
The nurse at a health fair is talking with a client who is in perimenopause and is experiencing hot flashes.
Which of the following lifestyle modifications would be appropriate for the nurse to recommend?
1. increasing fluid intake
2. exercising daily
3. decreasing sodium intake
EXAM 120 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+
The nurse is caring for a 3-year-old client with impetigo.
Which of the following infection control precautions should the nurse implement? Select all that apply.
1. Wear a surgical mask when bathing the client.
2. Wear a protective gown when changing the client's bed linens.
3. Keep the door to the client's room closed.
4. Place a box of clean gloves outside the client's door.
5. Place a surgical mask on the client during transport to other departments. - answer-2. Wear a
protective gown when changing the client's bed linens.
4. Place a box of clean gloves outside the client's door.
Rationale: Impetigo is a highly infectious skin disease spread by direct contact. Contact precautions
include gown and gloves. Private closed door and surgical masks are appropriate for airborne and not
necessary for contact
The nurse is evaluating a staff member's care of a client with active pulmonary tuberculosis (TB). Which
of the following actions by the staff member would indicate to the nurse an understanding of the
principles of infection control for tuberculosis isolation?
1. instructing visitors to wash their hands before entering the client's room
2. putting on a mask, gown, and gloves before entering the client's room
3. placing tissues and a trash receptacle within the client's reach
4. asking the client to put on a clean mask each time someone enters the room - answer-3. placing
tissues and a trash receptacle within the client's reach
Important to not leave tissues laying around and to put them in a leak proof bag in the trash.
The nurse in the pediatric unit is preparing to admit a client with rubeola (measles). The nurse should
assign the client to a
1. private room at the end of the hallway
2. private room with monitored negative air pressure
,3. room with a client who has chickenpox
4. room with a client who has atopic dermatitis (eczema) - answer-2. private room with monitored
negative air pressure
Measles is airborne (MTV) and requires a private room with negative air pressure
The charge nurse is observing the following client situations. It would require intervention if a
1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
2. visitor is sitting on the side of the bed of a client with acute pancreatitis
3. staff member is entering the room of a client with Haemophilus influenzae meningitis wearing a
protective gown and gloves
4. family member of a client with mycoplasma pneumonia leaves the door to the client's room open -
answer-1. client with hepatitis B (HBV) is eating food brought into the facility by a visitor
HBV is spread through contact with body fluids including saliva, so it is important to intervene if the
patient is eating and possibly sharing food with another person.
The nurse is reviewing the orders of a client who has acute kidney injury. Which of the following orders
should the nurse clarify?
1. computed tomography (CT) scan of the abdomen with intravenous contrast media
2. urine specimen for urinalysis
3. blood specimen for arterial blood gas (ABG)
4. referral to registered dietitian for parenteral nutrition evaluation - answer-1. computed tomography
(CT) scan of the abdomen with intravenous contrast media
CTs use iodinated contrast which is harmful to the kidneys and therefore contraindicated in a client with
AKI
The nurse is planning a staff education program about caring for clients with restraints. Which of the
following information should the nurse include?
1. "Restraints should be removed once during a shift to perform passive range-of-motion (ROM)
exercises for the client."
2. "Restraints should be secured to the side rails of the client's bed for quick release."
3. "Restraints require an order from the primary health care provider."
,4. "Restraints may be used p.r.n. for clients who are confused." - answer-3. "Restraints require an order
from the primary health care provider."
Rationale:
1. Restraints are removed every 2 HOURS for ROM exercises, toileting, and fluids. Assess every 15 mins
for the first hour and then every 30 minutes
2. Restraints should be secured to the bed, not side rails
4. Restraints are never PRN
The nurse is caring for a client with active pulmonary tuberculosis (TB). Which of the following should
the nurse include in the client's plan of care?
1. placing the client in a private room with the door open
2. putting a surgical mask on the client during transport to the radiology department
3. instructing the primary caregivers to wear surgical masks when caring for the client
4. instituting the standards for droplet precautions while caring for the client - answer-2. putting a
surgical mask on the client during transport to the radiology department
X-Ray to confirm active TB d(x)
Rationale:
1. Door should be closed
3.
4. Airborne precautions
The home-health nurse is teaching the parents of a 4-year-old client with impetigo. Which of the
following information should the nurse include?
1. "Put a surgical mask on your child when around siblings."
2. "Cleanse the lesions with a povidone-iodine solution daily."
3. "Apply petroleum jelly to the lesions daily."
4. "Instruct your child not to use the same towels as siblings." - answer-4. "Instruct your child not to use
the same towels as siblings."
Impetigo is highly contagious through contact. Towels can easily spread the infection
Rationale:
1. It is contact precautions; surgical mask would be for airborne
, The nurse has attended a staff education program about bioterrorism. Which of the following
statements by the nurse would require follow-up?
1. "Botulism is transmitted by ingestion of contaminated canned foods."
2. "Hemorrhagic fever is spread by direct contact with blood or body fluids."
3. "Anthrax is spread through direct contact with the bacteria and its spores."
4. "Bubonic plague is transmitted from person to person via airborne droplets." - answer-4. "Bubonic
plague is transmitted from person to person via airborne droplets."
It is spread through flea bites and contact with infected skin
Rationale:
1. Botulism is transmitted by foods. ex: babies getting Botulism from honey
2. Infectious diseases that affect clotting and is spread by blood or body fluids
3. Anthrax: Contact
The nurse observes a coworker who is assessing a client's thoracic expansion.
Which of the following would indicate that the coworker is using the correct assessment technique?
1. percussion from the apex of the scapula downward on each side
2. placement of the hands flat on the back with the thumbs at the level of the tenth ribs pointing to the
spine, then asking the client to inhale
3. measurement of the anteroposterior diameter of the chest
4. placement of the palms at the level of the tenth ribs with thumbs pointing to the xiphoid process,
then asking the client to inhale - answer-4. placement of the palms at the level of the tenth ribs with
thumbs pointing to the xiphoid process, then asking the client to inhale
This is how to measure anterior thoracic expansion.
2. Posterior thoracic expansion
The nurse at a health fair is talking with a client who is in perimenopause and is experiencing hot flashes.
Which of the following lifestyle modifications would be appropriate for the nurse to recommend?
1. increasing fluid intake
2. exercising daily
3. decreasing sodium intake
