NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
The nurse is caring for a 64-year-old client.
History and Physical
Body System, Findings
General ,
The client reports a 24-hour history of blurred vision and redness in the left eye with a left-sided headache.
This evening, the client developed acute, severe pain in the left eye accompanied by occasional nausea and
vomiting. The client reports no use of systemic or topical eye medications. Medical history includes
osteoarthritis and hypercholesterolemia.
Eye, Ear, Nose, and Throat (EENT),
The client wears eyeglasses to correct farsighted vision. Right eye: pupil 2 mm and reactive to light,
conjunctiva clear. Left eye: pupil 4 mm and nonreactive to light with red conjunctiva. Bilateral lens opacity is noted.
Pulmonary,
Vital signs are RR 20 and SpO, 96% on room air. The lungs are clear to auscultation bilaterally.
Cardiovascular,
Vital signs are T 99 F (37.2 C), P 88, and BP 140/82.
Psychosocial,
The client reports a great deal of emotional stress following the recent death of the client's spouse that is accompanied by lack of sleep, poor appetite, and a 7.9-lb (3.6-kg) weight loss within the past month. The client takes diphenhydramine for sleep.
Question 1 of 5
Complete the following sentence by choosing from the lists of options. The nurse suspects that the client's current symptoms are due to ------------------------- and that the client is at increased risk for permanent vision loss due to--------------------------
Correct Answer: E,F
Rationale: Acute angle-closure glaucoma results from a significant increase in intraocular pressure (IOP) (>50 mm Hg) due to impaired aqueous
humor drainage. In susceptible individuals (eg, those with a narrow anterior chamber angle), dilation of the pupil causes the iris to press
against the lens, preventing flow of aqueous humor through the pupil. This causes the iris to bulge forward, closing the anterior chamber
angle and blocking drainage of aqueous humor through the trabecular meshwork. The rise in IOP leads to immediate optic nerve ischem
potentially resulting in permanent vision loss.
Extract:
History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Laboratory Results
Laboratory Test and Reference Range,Admission
Urine drug screen
Cocaine
Negative
Positive,
Opioid
Negative
Negative,
Amphetamines
Negative
Negative,
Marijuana
Negative
Positive,
Phencyclidine
Negative
Negative,
Benzodiazepines
Negative
Negative,
Barbiturates
Negative
Negative,
Breathalyzer
No alcoho detected
0.00
Nurses' Notes
Inpatient: Mental Health Unit
0900:
1200:
1500:
2000:
The client is inattentive, withdrawn, and depressed with low energy. The client's appearance is disheveled
with noted body odor. The client is declining breakfast and does not participate in group therapy. Education
was provided about the importance of participating in the treatment plan, and the client was encouraged to
shower.
The client is observed pacing back and forth in the room. The client is visibly upset and tearful and states, "I
can't live like this anymore. Everything in my life is going wrong." The client is encouraged to use deep
breathing and relaxation techniques to ease anxiety.
The client remains isolated to the room, pacing back and forth. The client rates depression as 6 on a scale of
0-10 and anxiety as 5 on a scale of 0-10.
The client was observed collecting blankets and storing them in the room behind the bed. When
approached, the client became defensive.
Question 2 of 5
The nurse has reviewed the information from the Nurses' Notes. Complete the following sentence/sentences by choosing from the list/lists of options. After removing the blankets from the client's room, the nurse should ----------------and ----------
Correct Answer: D,A
Rationale: After removing the blankets from the client's room, the nurse should notify the health are provider and initiate 1-to-1observation.This client is at high risk for imminent suicide. The client has severe depression, suicidal ideation with a plan, and access to lethal means (eg, blankets that can be used for self-hanging). This client requires constant visual ontact (ie, 1-to-1observation) to ensure safety 24 hours a day. The nurse should also notify the health care provider to assess for underlying psychiatric disorders (eg, psychosis) that could contribute to the situation.
Extract:
History and Physical
Body System
Findings
General
Client reports a 1-week history of general malaise, fever and chills, night sweats, fatigue, and
poor appetite. Client has poorly controlled hypertension, hypercholesterolemia, and mitral
valve prolapse and regurgitation.
Eye, Ear, Nose, and
Throat (EENT)
Poor dental hygiene. Client reports having 2 teeth extracted 3 weeks ago.
Pulmonary
Vital signs are RR 18 and SpO, 96% on room air. Lungs are clear to auscultation bilaterally.
Cardiovascular
Vital signs are T 100.4 F (38 C), P 105, and BP 140/82. Sinus tachycardia with occasional
premature ventricular contractions on cardiac monitor. S1 and S2 heard on auscultation with
loud systolic murmur at the apex. Peripheral pulses 2+; no edema noted.
Integumentary
Small, erythematous macular lesions on both palms. Thin, brown longitudinal lines on several
nail beds.
Question 3 of 5
For each potential prescription, click to specify whether the prescription is expected or not expected for the care of the client.
| Potential Prescription | Expected | Not expected |
|---|---|---|
| Administer IV antibiotics | ||
| Prepare client for echocardiography | ||
| Initiate low-flow supplemental oxygen | ||
| Gather supplies for pericardiocentesis | ||
| Place peripherally inserted central catheter (PICC) | ||
| Collect a blood specimen for culture and sensitivity |
Correct Answer:
Rationale: Expected prescriptions for clients with suspected infective endocarditis (IE) include:
• Administering IV antibiotics to kill the infectious pathogen
• Preparing the client for echocardiography to identify valvular dysfunction, chamber enlargement, and vegetations
• Placing a peripherally inserted central catheter for long-term IV antibiotic therapy
• Collecting a blood specimen for culture and sensitivity to identify the infectious pathogen
Initiating low-flow supplemental oxygen is not expected because the client is not exhibiting signs of respiratory distress.
Pericardiocentesis is performed to remove excess fluid from the pericardial cavity and prevent progression to cardiac
tamponade. Pericardial effusions are not commonly expected with IE. Furthermore, this client is not exhibiting signs of
pericardial effusion (eg, muffled heart sounds, substernal pain).
Therefore, gathering supplies for pericardiocentesis is not
expected.
Extract:
History
Labor and Delivery Unit
Admission: The client, gravida 1 para 0, at 16 weeks gestation with a twin pregnancy reports nausea and vomiting for the past
several weeks. The client also reports dry heaving, increasing weakness, light-headedness, and an inability to tolerate
oral intake for the past 24 hours. In addition, the client has had occasional right-sided, shooting pain from the abdomen
to the groin that occurs with sudden position changes. The pain quickly resolves without intervention per the client's
report. She has had no contractions or vaginal bleeding and has felt no fetal movement during this pregnancy. The
client has a history of childhood asthma and is currently taking no asthma medications. The client reports no other
pregnancy complications.
Physical
Prepregnancy,12 Weeks Gestation 16 Weeks Gestation(Prenatal Visit),(Labor and Delivery Admission)
Height ,5 ft 5 in (165.1 cm),5 ft 5 in (165.1 cm)|, 5 ft 5 in (165.1 cm)
Weight, 145 lb (65.8 kg),148 lb (67.1 kg),138 lb (62.6 kg)
BMI, 24.1 kg/m2, 24.6 kg/m2,23.0 kg/m2
Vital Signs
12 Weeks Gestation(Prenatal Visit),16 Weeks Gestation(Labor and Delivery Admission)
T,98.7 F (37.1 C),99.8 F (37.7 C)
P,70,101
RR,14,18
BP,122/78,90/55
SpO2,99% on room air,96% on room air
Laboratory Results
Laboratory Test and Reference Range, 16 Weeks Gestation
Blood Chemistry.
Sodium
136-145 mEq/L
(136-145 mmol/L)|,
136 mEq/L
(136 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
2.7 mEq/L
(2.7 mmol/L)
TSH
0.3-5.0 uU/mL
(0.3-5.0 mU/L),
0.4 pu/mL
(0.4 mU/L)
Hematology.
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
16 g/dL
(160 g/L)
Hematocrit (pregnant)
>33%
(>0.33),
49%
(0.49)
Urinalysis
Specific gravity
1.005-1.030
1.030,
Ketones
Not present,
Present
Giucose
Not present,
Not present
Nitrites
Not present,
Not present
Question 4 of 5
The client is diagnosed with hyperemesis gravidarum and is planning care with the registered nurse. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.
| Potential Intervention | Indicated | Contraindicated |
|---|---|---|
| Give clear liquids | ||
| Weigh the client daily | ||
| Obtain a 12-lead ECG | ||
| Administer enteral nutrition | ||
| Initiate a large-bore peripheral IV | ||
| Document strict intake and output | ||
| Auscultate the fetal heart rate intermittently |
Correct Answer:
Rationale: When caring for clients with hyperemesis gravidarum (HG), the primary goal is to alleviate vomiting, replenish fluids, and correct electrolyte
and nutritional imbalances. Once completed, resumption of oral intake can be attempted. Interventions that are indicated at this time
include:
• Weighing the client daily to monitor for additional weight loss
• Obtaining a 12-lead ECG to monitor for cardiac changes related to electrolyte imbalances (eg, hypokalemia)
• Initiating a large-bore peripheral IV (eg, 18-gauge) to allow for administration of fluids and medications
• Documenting strict intake and output (eg, emesis, urinary output) to monitor hydration status and kidney function
• Auscultating the fetal heart rate intermittently (eg, twice daily, once per shift) to verify fetal status. (Continuous fetal heart rate
monitoring is not indicated at this gestational age.)
Many clients with HG cannot tolerate anything by mouth and are typically placed on a short period of gut rest (ie, NPO status), if hospitalized.
Therefore, giving clear liquids is contraindicated during the initial treatment phase of HG but should be offered once nausea and vomiting
have stopped. For the same reasons, administering enteral nutrition (eg, tube feeding) is contraindicated initially for this client and is not
anticipated unless feedings by mouth and other treatment measures fail.
Extract:
The nurse is performing a home health visit for an 84-year-old male.
History and Physical
Body System, Findings
General,
Client reports a 1-month-long history of fatigue and dyspnea that has worsened; he is unable to lie
flat and sleeps in a chair at night, medical history includes myocardial infarction, chronic heart
failure, chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus; client
was diagnosed with benign prostatic hyperplasia 8 months ago; client is adherent with prescribed
medications; client reports frequent consumption of donuts, hamburgers, steak, and fried chicken;
BMI is 34 kg/m?; client reports 6-Ib (2.7-kg) weight gain in 1 week
Neurological,
Alert and oriented to person, place, time, and situation
Pulmonary,
Vital signs: RR 24, SpOz 88% on room air; labored breathing, crackles in bilateral lung bases; client
expectorates frothy, pink-tinged sputum; client has a 40-year history of smoking 1 pack of cigarettes
per day
Cardiovascular,
Vital signs: T 98.8 F (37.1 C), P 98, BP 113/92; S1, S2, and S3 present; 3+ bilateral lower extremity
edema
Genitourinary, Concentrated yellow urine; client reports increased urinary hesitancy and urgency
Psychosocial,
Client reports being lonely and has depressed mental status
Question 5 of 5
The health care provider has confirmed that the client is experiencing an exacerbation of heart failure. For each potential prescription, click to specify if the prescription is expected or unexpected for the care of the client.
| Potential Prescription, Expected, Unexpected |
| Perform daily weights |
| Administer furosemide |
| Apply compression stockings |
| Encourage the client to limit mobility |
| Encourage increased oral fluid intake |
Correct Answer:
Rationale: Heart failure (F) exacerbation management focuses on improving oxygenation and reducing fluid overload. Expected
prescriptions include:
• Performing daily weights to monitor fluid volume status and guide treatment. Ideally, daily weights should be performed
at the same time of day, on the same scale, and with the client wearing the same amount/type of clothes. Rapid weight
gain (ie, >5 lb/week [(2.3 kg/week]) should be communicated to the health care provider immediately.
• Administering loop diuretics (eg, furosemide, torsemide, bumetanide) to prevent reabsorption of sodium and chloride in
the kidneys, which increases fluid excretion and urine output. This provides symptom relief by reducing pulmonary
congestion and peripheral edema.
• Applying compression stockings, a common nopharmacological intervention, to promote venous blood return and
reduce peripheral edema.
Limiting mobility is unexpected for a client with increased fluid volume. The client should be encouraged to ambulate
frequently to promote venous return, exercise cardiac muscle, and reduce risk of deep venous thrombosis.
Increasing oral fluid intake is unexpected for a client with hypervolemia (ie, heart failure exacerbation) because it
exacerbates existing symptoms (eg, edema, pulmonary congestion).