NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
Extract:
The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.
Question 1 of 5
Click to highlight below the findings that are most concerning at this time.
Correct Answer: A,C
Rationale: Severe abdominal pain with nausea and tenderness with occult blood suggest acute diverticulitis, requiring urgent evaluation.
Extract:
The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn
Question 2 of 5
Which finding is a priority for the nurse?
Correct Answer: A
Rationale: Elevated blood pressure is a critical finding in suspected preeclampsia, indicating a risk for severe complications.
Question 3 of 5
For each potential intervention, click to specify if the Intervention is indicated or not indicated for the care of the client.
| Potential Intervention | Indicated | Not Indicated |
|---|---|---|
| Initiate seizure precautions | ||
| Encourage frequent ambulation | ||
| Start a magnesium sulfate infusion | ||
| Prepare to administer antihypertensives |
Correct Answer: A,C,D
Rationale: Seizure precautions , magnesium sulfate , and antihypertensives are indicated for preeclampsia with severe features. Ambulation is not prioritized due to risk of falls.
Extract:
The nurse is caring for a 55-year-old client in the clinic.
History and Physical
Body System
Findings: General - The client reports cramping pain in the left calf that has worsened over the past year. The pain is precipitated by walking and is partially relieved with rest. The client reports difficulty walking more than 3 blocks. Height: 72 in (182.9 cm), weight: 250 lb (113.4 kg), BMI: 33.9 kg/m?
Pulmonary- Vital signs are RR 16, SpO, 97% on room air. Client reports smoking 1 pack of cigarettes daily for the past 35 years. Breath sounds are mildly decreased throughout with mild prolonged expiration. Client has a history of chronic obstructive pulmonary disease.
Cardiovascular- Vital signs are T 98.8 F (37.1 C), P 82, BP 146/82. S1 and S2 heard on auscultation. The left lower extremity (LLE) is cooler to touch than the right and appears shiny with sparse hair. LLE pulses: femoral 2+, popliteal 1+, posterior tibia 1+, dorsalis pedis audible with Doppler. LLE capillary refill >3 sec. Client has a history of hypertension.
Gastrointestinal- Client is obese. No tenderness, guarding, masses, bruits, or hepatosplenomegaly.
Question 4 of 5
Which of the following statements should the nurse include in the teaching? Select all that apply.
Correct Answer: B,C,E
Rationale: Healthy diet , foot inspections , and supervised walking are appropriate. Elevation is for venous issues, and heating blankets risk burns in poor perfusion.
Extract:
The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.
Question 5 of 5
The nurse recognizes the client has most likely developed .........anticipate assisting with.........
Correct Answer: A,F
Rationale: A palpable mass and fever suggest an abscess , requiring a CT scan for confirmation.