NCLEX-PN (VERSION B) ACTUAL EXAM NEWEST
VERSION QUESTION AND CORRECT DETAILED
VERIFIED ANSWERS FROM VERIFIED SOURCES
RATED A GRADE.
The nurse is caring for a 6-year-old client who is receiving skeletal traction.
Which of the following would be a priority for the nurse to monitor?
1. the distance between the client's knees
2. the pull of the traction on the client's pins
3. the degree of flexion of the client's ankles
4. the position of the client's cervical spine on the bed✔✔Correct
Answer✔✔2. the pull of the traction on the client's pins
The nurse is collecting data from a client with an acute myocardial infarction
(MI). Which of the following findings would be consistent with an acute MI?
Select all that apply.
1. nailbed splinter hemorrhages
2. nausea and vomiting
3. diaphoresis
4. dyspnea
5. petechiae✔✔Correct Answer✔✔2. nausea and vomiting
3. diaphoresis
4. dyspnea
,The nurse is caring for a client who sustained a closed head injury. Which of
the following findings would require immediate intervention?
1. blood pressure of 136/76 mm Hg
2. ecchymotic area over the left temple
3. headache that worsens with coughing
4. Glasgow Coma Scale (GCS) score of 13✔✔Correct Answer✔✔2.
ecchymotic area over the left temple
The nurse has attended a staff education program about elder abuse. Which
of the following statements by the nurse would indicate a correct
understanding of the teaching?
1. "A health care worker or family member who threatens to withhold food,
water, or medical care is committing a form of abuse."
2. "The nurse should explain to the victim of elder abuse that data collected
about the abuse will be kept confidential."
3. "Clients who are physically disabled and living in a long-term care facility
are the typical victims of elder abuse."
4. "Older adults who are abused will readily explain their situation to a
health care provider if asked directly."✔✔Correct Answer✔✔1. "A health
care worker or family member who threatens to withhold food, water, or
medical care is committing a form of abuse."
The nurse is caring for a client born 6 hours ago and observes the finding
depicted below.Which of the following actions should the nurse take?
1. Notify the primary health care provider of the finding.
, 2. Administer oxygen therapy prescribed p.r.n.
3. Continue to perform routine newborn care.
4. Prepare the client for phototherapy.✔✔Correct Answer✔✔2. Administer
oxygen therapy prescribed p.r.n.
The nurse is contributing to a staff education program about confidentiality.
Which of the following information should the nurse suggest including?
1. "Clients must wait until after discharge to view their medical records."
2. "Clients must disclose all personal information in order to receive care."
3. "Nurses in a hospital unit may review the medical records for all clients in
that unit."
4. "Certain information in the client's medical record may not be considered
confidential."✔✔Correct Answer✔✔1. "Clients must wait until after
discharge to view their medical records."
The nurse and unlicensed assistive personnel (UAP) are caring for assigned
clients. Which of the following activities would be appropriate for the nurse
to assign to UAP?
1. applying a condom catheter to the male client with a hip fracture who is
incontinent
2. applying a pressure dressing to the right hand of the client who has a stab
wound
3. obtaining vital signs from the client who is experiencing delirium tremens
(DTs)
VERSION QUESTION AND CORRECT DETAILED
VERIFIED ANSWERS FROM VERIFIED SOURCES
RATED A GRADE.
The nurse is caring for a 6-year-old client who is receiving skeletal traction.
Which of the following would be a priority for the nurse to monitor?
1. the distance between the client's knees
2. the pull of the traction on the client's pins
3. the degree of flexion of the client's ankles
4. the position of the client's cervical spine on the bed✔✔Correct
Answer✔✔2. the pull of the traction on the client's pins
The nurse is collecting data from a client with an acute myocardial infarction
(MI). Which of the following findings would be consistent with an acute MI?
Select all that apply.
1. nailbed splinter hemorrhages
2. nausea and vomiting
3. diaphoresis
4. dyspnea
5. petechiae✔✔Correct Answer✔✔2. nausea and vomiting
3. diaphoresis
4. dyspnea
,The nurse is caring for a client who sustained a closed head injury. Which of
the following findings would require immediate intervention?
1. blood pressure of 136/76 mm Hg
2. ecchymotic area over the left temple
3. headache that worsens with coughing
4. Glasgow Coma Scale (GCS) score of 13✔✔Correct Answer✔✔2.
ecchymotic area over the left temple
The nurse has attended a staff education program about elder abuse. Which
of the following statements by the nurse would indicate a correct
understanding of the teaching?
1. "A health care worker or family member who threatens to withhold food,
water, or medical care is committing a form of abuse."
2. "The nurse should explain to the victim of elder abuse that data collected
about the abuse will be kept confidential."
3. "Clients who are physically disabled and living in a long-term care facility
are the typical victims of elder abuse."
4. "Older adults who are abused will readily explain their situation to a
health care provider if asked directly."✔✔Correct Answer✔✔1. "A health
care worker or family member who threatens to withhold food, water, or
medical care is committing a form of abuse."
The nurse is caring for a client born 6 hours ago and observes the finding
depicted below.Which of the following actions should the nurse take?
1. Notify the primary health care provider of the finding.
, 2. Administer oxygen therapy prescribed p.r.n.
3. Continue to perform routine newborn care.
4. Prepare the client for phototherapy.✔✔Correct Answer✔✔2. Administer
oxygen therapy prescribed p.r.n.
The nurse is contributing to a staff education program about confidentiality.
Which of the following information should the nurse suggest including?
1. "Clients must wait until after discharge to view their medical records."
2. "Clients must disclose all personal information in order to receive care."
3. "Nurses in a hospital unit may review the medical records for all clients in
that unit."
4. "Certain information in the client's medical record may not be considered
confidential."✔✔Correct Answer✔✔1. "Clients must wait until after
discharge to view their medical records."
The nurse and unlicensed assistive personnel (UAP) are caring for assigned
clients. Which of the following activities would be appropriate for the nurse
to assign to UAP?
1. applying a condom catheter to the male client with a hip fracture who is
incontinent
2. applying a pressure dressing to the right hand of the client who has a stab
wound
3. obtaining vital signs from the client who is experiencing delirium tremens
(DTs)
