NCLEX-PNFree Practical Nurses Licensure Examination practice test

Correct answer: D. Begin dressing with the affected (left) side first

When dressing a client who has unilateral weakness or paralysis, the affected limb should be dressed first. This approach makes the process easier because the affected extremity has less range of motion; threading it through a sleeve or pant leg is simpler before the garment is partially secured by the stronger side. Conversely, the unaffected side is always undressed first when removing clothing. The practical nurse promotes independence and dignity by encouraging the client to participate as much as safely possible.

Correct answer: A. Ice chips

Cool or cold substances such as ice chips provide mild topical analgesia by numbing the operative site and promote vasoconstriction, which can reduce localized swelling and lower the risk of bleeding. Ice chips are safe as long as the child is alert and able to swallow. The nurse monitors for signs of hemorrhage such as repeated swallowing, spitting blood, or a rising heart rate. Warm liquids are avoided in the early postoperative period because heat causes vasodilation and increases bleeding risk. Dairy products can thicken secretions and prompt throat clearing, potentially irritating the surgical site. Routine oropharyngeal suctioning is contraindicated after tonsillectomy because the suction catheter may traumatize the healing tissue.

Correct answer: A. Stage II

A Stage II pressure injury is defined by partial-thickness loss of skin involving the epidermis and dermis. It presents as a shallow, open wound with a pink or red wound bed, or as an intact or ruptured serum-filled blister. The description of a pink, open area resembling a burst blister without deeper tissue exposure is consistent with Stage II. The practical nurse documents the findings, applies prescribed wound care, initiates pressure-relief measures, and reports any deterioration to the supervising nurse or provider. Stage I injuries have intact, nonblanchable erythematous skin without any open area. Stage III injuries extend through the dermis into subcutaneous fat. Stage IV injuries expose muscle, bone, or deeper structures.

Correct answer: A. Elevate the head and upper body to a semi-upright position

Elevating the head and upper torso promotes optimal chest expansion, reduces venous return, and decreases the work of breathing in a child with a congenital cardiac defect. Reverse Trendelenburg positioning achieves this same effect by tilting the body so the head is higher than the feet. Maintaining head elevation with extra pillows during sleep helps sustain airway patency and reduces nocturnal respiratory effort. Maintaining NPO status is not indicated for tachypnea alone; it would not address the acute respiratory symptoms and could compromise nutrition. Sims' position is a lateral recumbent position that does not promote chest expansion and is not appropriate for managing acute respiratory distress in this setting.

Correct answer: B. "There is no single prescribed diet for Crohn disease. Try to eat a balanced diet and avoid foods that are greasy, spicy, or high in fiber during a flare."

No universal diet eliminates Crohn disease activity, but during acute flares clients generally tolerate small, frequent meals better than large ones, and benefit from avoiding foods that are high in fiber, fatty, spicy, or otherwise irritating to the bowel. A well-balanced, individually tailored diet supports nutritional status while minimizing gastrointestinal symptoms. The practical nurse reinforces provider-recommended guidelines and encourages the client to identify personal trigger foods. Gluten restriction is unnecessary unless celiac disease or documented gluten sensitivity coexists with Crohn disease. One meal per day is inadequate and increases the risk of malnutrition and fatigue. Large amounts of dairy can worsen symptoms in clients with lactose intolerance, which is common in inflammatory bowel disease.

Correct answer: C. Side-lying with the head slightly elevated

Following jaw fixation surgery, edema, bleeding, and the risk of vomiting create significant airway hazards. Positioning the client on the side with the head slightly elevated facilitates drainage of secretions and vomitus away from the airway, reducing aspiration risk. The practical nurse monitors airway patency closely and notifies the nurse or provider of any signs of respiratory compromise or excessive bleeding. High Fowler's position may allow lung expansion but does not adequately protect the airway if the client vomits. Supine positioning allows secretions to pool in the oropharynx and increases aspiration risk. Prone positioning is impractical after jaw fixation and impairs access to the airway.

Correct answer: A. Orange juice

Vitamin C is required for collagen synthesis, and collagen is the structural protein that gives strength to healing wound tissue. Orange juice is among the richest dietary sources of vitamin C and therefore best supports tissue repair in the postoperative period. Milk provides protein, which is important for tissue regeneration, but it supplies minimal vitamin C for collagen formation. Diet cola offers no nutrients that contribute to wound healing. Apple juice contains some nutrients but far less vitamin C than orange juice, making it an inferior choice for promoting collagen production.

Correct answer: C. Stage I

Stage I pressure injury is identified by intact skin with localized, nonblanchable erythema over a bony prominence. The area may feel warmer, cooler, firmer, or softer than surrounding tissue and may be tender. Nonblanchable redness indicates underlying tissue damage despite an unbroken skin surface. The practical nurse documents the findings, initiates pressure relief measures, and reports changes to the supervising nurse to prevent progression. Stage II injuries involve partial-thickness skin loss and an open wound or blister. Stage III injuries extend into subcutaneous tissue with visible adipose. Stage IV injuries expose muscle, bone, tendon, or ligament.

Correct answer: D. Stage III

Stage III pressure injury is characterized by full-thickness skin loss extending into subcutaneous tissue, with possible tunneling or undermining and the presence of slough or granulation tissue. Adipose tissue may be visible, but muscle, bone, and deep supporting structures are not exposed. The 4 cm depth with tunneling and visible subcutaneous fat in the absence of exposed bone or muscle is consistent with Stage III. The practical nurse monitors the wound, carries out prescribed wound care, and reports signs of infection or deterioration to the provider. Stage II injuries are superficial, involving only partial-thickness dermis without subcutaneous exposure. Stage I injuries present with intact skin. Stage IV injuries expose bone, tendon, or muscle.

Correct answer: A. 960 mL

Total volume is calculated by multiplying the hourly rate by the number of hours: 120 mL/hr × 8 hr = 960 mL. The practical nurse verifies the infusion rate, documents intake accurately, and monitors for signs of fluid imbalance. 1,200 mL represents 120 mL/hr over 10 hours, not 8. 800 mL would result from 100 mL/hr over 8 hours. 780 mL does not correspond to any straightforward calculation using the given rate.