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:
The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).
Laboratory Results
Laboratory Test and Reference Range, 0900
Glucose, serum (random)
≤200 mg/dL
(<11.1 mmol/L),
573 mg/dL
(31.8 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.7 mEq/L
(5.7 mmol/L)
Question 2 of 5
The nurse has reviewed the information from the Laboratory Results. The client is transferred to an inpatient care facility. Which of the following orders should the nurse expect for the client? Select all that apply
Correct Answer: A,B,C,G
Rationale: Management of diabetic ketoacidosis (DK
A) initially focuses on IV fluid resuscitation to reverse hypovolemia and then correction of
hyperglycemia, electrolyte abnormalities, and acid-base imbalance. Appropriate interventions include:
• Continuous insulin IV infusion to correct hyperglycemia. IV insulin has a more rapid onset of action than subcutaneous insulin, whic
allows faster and more precise management of the blood glucose level (Option 1).
• Continuous cardiac monitoring to detect dyshythmias related to metabolic acidosis or electrolyte abnormalities (Option 2).
• Hourly finger-stick blood glucose level checks to monitor for treatment effectiveness and detect any hypoglycemia related to the
insulin infusion (Option 3).
• Isotonic IV fluid (eg, 0.9% sodium chloride) to replace fluid losses and strict intake and output monitoring to evaluate the
effectiveness of fluid resuscitation and monitor for signs of acute kidney injury (Option 6).
• Frequent monitoring of arterial blood gas levels and electrolyte levels.
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
The nurse is preparing to administer the first dose of the prescribed IVPB antibiotic. Which 2 actions are most appropriate for the nurse to perform prior to initiating the infusion?
Correct Answer: B,C
Rationale: Antibiotic therapy is a critical component of treatment for clients with infective endocarditis (E). Before administering IV
antibiotics, the nurse should first obtain blood cultures to identify the infectious organism. Broad-spectrum antibiotics are
started initially. Targeted antibiotic therapy can be administered once the blood cultures identify the culprit organisms and their
antimicrobial susceptibilities. Before starting any medication, the nurse should ask about the client's medication allergies to
identify contraindications to therapy
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
Drag words from the choices below to fill in the blanks.The nurse recognizes that the client likely has hyperemesis gravidarum and should monitor for the following maternal complications:---------,------------------, AND -------------
Correct Answer: A,B,F
Rationale: Without appropriate treatment, clients with hyperemesis gravidarum are at risk for multiple complications, including:
• Insufficient gestational weight gain, which may be associated with fetal/newborn complications such as preterm birth and a small-for-
gestational-age infant
• Fluid and electrolyte imbalances (eg, hypokalemia) resulting from excessive vomiting and decreased fluid and nutritional intake, whic
could cause life-threatening complications (eg, cardiac dyshythmias) if not corrected
• Nutritional deficiencies (eg, protein, vitamin) resulting from decreased oral intake, which may lead to rare but serious complications
(eg, Wernicke encephalopathy from thiamine [vitamin B1] deficiency)
Extract:
Nurses' Notes
Outpatient Clinic
Initial
visit
The child recently started attending a new preschool and hit a teacher during lunch. The parent says, "My
child has never been aggressive before but has always been particular about food."
The client was born at full term without complications and has no significant medical history. The child
started babbling at age 6 months, and the parent reports that the first words were spoken around age 12
months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color.
The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vitals signs are
normal, and the client is tracking adequately on growth curves.
During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow
the parents gaze when the parent points to toys in the office. The child begins screaming and rocking back
and forth when the health care provider comes near.
Question 5 of 5
The client is diagnosed with autism spectrum disorder (ASD). The nurse recognizes that clients with ASD are at risk for which of the following complications? Select all that apply.
Correct Answer: A,BC,D,E
Rationale: Autism spectrum disorder (AS
D) begins in the developmental period, and symptoms tend to persist throughout the lifespan.
Clients with ASD are more prone to medical, psychiatric, and psychosocial impairments. These impairments include the
following:
• Impaired interpersonal relationships: Clients with ASD may be disinterested in social interaction and have difficulty
showing affection and interpreting conversation
• Learning difficulties: Clients with ASD may have trouble focusing on tasks and have a limited range of learning
interests (eg, preferring only math), making it challenging to engage them in other areas of learning (Option 2).
• Malnutrition: Clients with ASD can have a narrowed interest in foods, resulting in insufficient intake of necessary
nutrients. In addition, clients with ASD often experience gastrointestinal disturbances, including constipation and
diarrhea, due to narrowed food intake
• Self-harm behaviors: Changes in routine and environment can trigger repetitive or harmful behaviors (eg, head-
banging, hand-biting). When self-harm behaviors persist into adulthood, they may be preceded by suicide attempts
related to coexisting psychiatric comorbidities (eg, depression, anxiety)
• Sleep disturbances: Clients with ASD often experience difficulty falling and staying asleep. Hyperresponsiveness to
sensory stimulation (eg, lights, noises, sensations) can also contribute to disruptive sleeping patterns