NCLEX PN 3/2023 (Before Spring Break) Exam Challenge Questions &
Answers Best Rated A+ 2023-2024.
1. The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is
being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse finds the
client to be unresponsive and pulseless, and there is no other caregivers present. Which action
should the nurse take FIRST?
Answer: Begin chest compressions
2. The student nurse observes the respiratory therapist preparing to draw an arterial blood gas
from the radial artery. The RT performs the Allen's test and the student asks why this test
performed before the blood sample is drawn. Which statement made by the RT is the most
accurate?
Answer: The Allen's test is done to determine the patency of the ulnar artery
3. The nurse observes a student performing chest compressions on an adult client. Which
technique indicates that the student understands how to provide high-quality chest compressions
during cardiopulmonary resuscitation?
Answer: Compressing the chest to a depth of at least 2 in. (5 cm)
4. A 2-year-old at an outpatient clinic stops breathing and doesn't have a pulse. CPR is initiated.
When the automated external defibrillator (AED) arrives, the nurse notes that is has only adult
AED pads. What is the appropriate action at this time?
Answer: Place one AED pad on the chest and the other pad on the back
5. A practical nurse is evaluating the external fetal monitoring strip of a laboring primigravida
who is at 36 weeks gestation. Which nursing interventions should the practical nurse anticipate
when there is found to be LATE DECELERATIONS?
Answer: • administer supplemental O2 by mask
• increase the IV fluid rate
• stop the client's oxytocin infusion
6. A client who is pregnant at 30 weeks gestation comes to the prenatal clinic. Which vaccines
may be administered safely at this prenatal visit?
Answer: • influenze injection
• tetanus, diphtheria & pertussis
7. The nurse is reinforcing education to a pregnant client who is HIV-positive. Which
information is appropriate for the nurse to include?
Answer: Prescribed antiretroviral therapy should be continued during pregnancy
8. A nurse is reinforcing information on formula preparation for a client with a newborn. Which
statements by the client indicate proper understanding?
Answer: • I must wash the top of the concentrated formula can before opening it
• Prepared formula should be kept in the refrigerator and discarded after 48 hours
9. A PN is assisting the RN to care for a 6-hour-old term newborn of a mother with gestational
diabetes. A bedside capillary blood glucose reveals the newborn's blood glucose is 45mg/dl. The
new born is asymptomatic. Which intervention should the PN anticipate implementing FIRST?
Answer: Feed the newborn
10. The nurse is reinforcing instructions to a client at 34 weeks gestation who is preparing to
travel by airplane. Which of the following instructions are appropriate?
Answer: • carry a copy of your most up-to date prenatal record
• increase fluid intake before and during flight
• secure the lap belt below the abdomen and across your hips when seated
• wear compression stockings and loose fitting clothing
11. A client indicates to the nurse a desire to become pregnant. The client drinks 1-2 glasses of
wine on weekends. BMI is 32 kg. Which teachings should the nurse reinforce as part of proper
preconception health care for this client?
Answer: • avoid eating undercooked hamburgers
• receive a rubella vaccine at least 3 months before attempting pregnancy
• take 0.4mg folic acid supplementation daily
12. Which of the following clinical findings should the nurse recognize as expected during
monitoring a newborn?
Answer: • cyanosis of the hands and feet
• heart rate 150/min
13. The PN assists the RN while recognizing that an oxytocin infusion can lead to which of the
following conditions?
Answer: Fetal distress & cesarean birth
14. The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which
finding requires intervention by the nurses?
Answer: Contraction duration of 95 seconds
15. The nurse is reinforcing instructions to a postpartum client about cord care for the newborn.
Which client statement indicates a need for further teaching?
Answer: "I will secure the diaper over the cord to protect it"
16. The nurse preceptor should intervene if the graduate PN performs which action when caring
for a jaundiced newborn being treated with phototherapy?
Answer: Applying a shirt while the newborn is exposed to phototherapy
17. A nurse is reinforcing teaching to a client that breastfeeds who has been diagnosed with
mastitis of the right breast. Which of the following instructions should be included?
Answer: • increase oral fluid intake
• take ibuprofen PRN for apin
18. On postpartum day 3 the nurse is reinforcing education on diaper changes & discharge. The
client states, "I think my baby has a dirty diaper. I can't change it as well as you can. Will you
change my baby's diaper for me?" What is the nurse's best response?
Answer: "I will stay at the bedside and watch while you change the diaper"
19. A newborn client is seen in the ER for vomiting. Which assessment finding indicates a
possible emergency?
Answer: Vomit that is green (most likely caused by obstruction in the intestines and stool cannot
pass, coming back up as green vomit)
20. A nurse is caring for a client following the delivery of a stillborn infant. Which of the
following actions should the nurse take?
Answer: • Ask the parents if they would like to help bathe the infant
• Encourage the parents and family members to hold the infant
• Offer to obtain handprints, footprints & photographs of the infant
21. The nurse is performing an assessment on an 39-week neonate an hour after a spontaneous
vaginal delivery. What are common expected newborn findings?
Answer: • plantar creases up the entire sole
• toes fan outward when the lateral sole surface is stroked
• white pearl like cysts on gum margins
22. A nurse is participating in an obstetrical emergency simulation in which the health care
provider announces shoulder dystocia. Which of the following interventions should be assisting
nurse implement?
Answer: • document the time the fetal head was born
• flex the clients legs back against the abdomen and apply downward pressure above the
symphysis pubis
• request additional assistance from other nurses ASAP
23. A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe,
right lower abdominal pain & dizziness. Which of the following additional assessment findings
will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy?
Answer: • blood pressure 82/64
• pulse 120/min
• shoulder pain
24. The nurse is collecting data on a client who has arrived at the clinic for pregnancy
confirmation and prenatal evaluation. Which of the following findings indicate diagnostic
evidence (positive signs) of pregnancy?
Answer: • fetal heart tones detected by doppler devise
• visualization of fetus via ultrasound
