NCLEX-PN Test #2 2

Question 1

A PN is caring for a client receiving IV heparin. Which laboratory value requires immediate notification of the charge nurse?

Accepted Answer

Platelet count of 40,000/mm³

Answer

Heparin-induced thrombocytopenia (HIT) is a life-threatening complication. A platelet count of 40,000/mm³ is critically low and must be reported immediately. The aPTT value shown is within therapeutic range and does not require urgent notification.

Question 2

A postpartum client is 12 hours after vaginal delivery. The nurse assesses the fundus to be firm, two finger-breadths above the umbilicus, and deviated to the right. What is the priority nursing action?

Accepted Answer

Ask the client to void

Answer

A deviated uterine fundus is most commonly caused by a full bladder displacing the uterus. The priority action is to have the client void; if the bladder is emptied and the fundus repositions at or below the umbilicus midline, no further intervention is needed.

Question 3

The PN is preparing to administer a subcutaneous insulin injection to a diabetic client. Which site provides the most consistent insulin absorption?

Accepted Answer

Abdomen (at least 2 inches from the navel)

Answer

The abdomen provides the fastest and most consistent absorption rate for subcutaneous insulin. Rotation within the abdominal site is recommended. The outer arm and thigh have slower, more variable absorption rates.

Question 4

A client at 36 weeks gestation reports decreased fetal movement. The nurse performs a non-stress test (NST). Which result indicates a reactive (normal) NST?

Accepted Answer

Two accelerations of ≥15 bpm lasting ≥15 seconds within 20 minutes

Answer

A reactive NST requires at least two fetal heart rate accelerations of ≥15 bpm above baseline, each lasting at least 15 seconds, within a 20-minute window. This indicates fetal well-being and an intact autonomic nervous system.

Question 5

The PN is caring for a newborn at 2 hours of life. Which finding requires immediate intervention?

Accepted Answer

Nasal flaring with intercostal retractions

Answer

Nasal flaring with intercostal retractions are signs of respiratory distress in a newborn and require immediate intervention. Acrocyanosis (blue hands/feet) in the first hours is normal. A respiratory rate of 48/min is within the normal newborn range (30–60/min).

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #2 2