NCLEX-PN Test #5 3

Question 1

The PN is caring for a client post-craniotomy. Which finding requires the most immediate nursing action?

Accepted Answer

Blood pressure of 160/90 mmHg with heart rate of 54 bpm

Answer

Hypertension combined with bradycardia (Cushing's triad — hypertension, bradycardia, and irregular respirations) signals increased intracranial pressure (ICP), which is a life-threatening emergency requiring immediate notification of the provider. This triad indicates impending brainstem herniation.

Question 2

A client has a cast applied to the right forearm after a fracture. Two hours later, the client reports severe pain that increases with passive extension of the fingers. What complication does the nurse suspect?

Accepted Answer

Compartment syndrome

Answer

Pain with passive stretch of muscles within the compartment is the hallmark early sign of compartment syndrome. This is a surgical emergency (fasciotomy) as increased compartment pressure causes ischemia and irreversible muscle and nerve damage within 4–6 hours.

Question 3

A client is admitted with a new stroke affecting the left hemisphere. Which deficit is most likely?

Accepted Answer

Right-sided hemiplegia and aphasia

Answer

The left hemisphere controls the right side of the body (motor/sensory) and language. A left hemisphere stroke typically causes right-sided hemiplegia and aphasia (expressive, receptive, or mixed). Left-sided hemiplegia and spatial deficits indicate right hemisphere involvement.

Question 4

A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). The nurse knows this drug works by:

Accepted Answer

Inhibiting acetylcholinesterase to increase available acetylcholine

Answer

Pyridostigmine is an acetylcholinesterase inhibitor. Myasthenia gravis is caused by autoimmune destruction of acetylcholine receptors. By inhibiting the enzyme that breaks down acetylcholine, pyridostigmine increases its availability at the neuromuscular junction, improving muscle strength.

Question 5

A client with a hip replacement is being prepared for discharge. Which instruction is most important to prevent dislocation?

Accepted Answer

Avoid crossing the legs and bending the hip beyond 90 degrees

Answer

After total hip replacement, the most common cause of early dislocation is violating hip precautions: no hip flexion beyond 90 degrees, no adduction (crossing legs), and no internal rotation. A raised toilet seat and chair seat raisers help maintain safe positioning.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #5 3