NCLEX Questions, NCLEX PN Test Questions with NGN Questions, NCLEX-PN Questions, Nurselytic

Questions 85

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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 1 of 5

Complete the following sentence/sentences by choosing from the list of options. The nurse recognizes that the client is most likely experiencing ----------interventions to prevent ---------

Correct Answer: F,B

Rationale: The nurse recognizes that the client is most likely experiencing infective endocarditis (lE) and should prioritize interventions
to prevent systemic emboli.
The client is most likely experiencing IE based on the history of a recent dental procedure and clinical findings of infection (eg,
fever, flu-like symptoms), microemboli (eg, splinter hemorrhages, Janeway lesions), and cardiac murmur. In addition to
microemboli, larger pieces of vegetation can break off the heart valve and embolize to various organs, causing life-threatening
complications (eg, stroke, spleen/kidney infarction).

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.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L)|
133 mEq/L (133 mmol/L)|
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%



Question 2 of 5

Drag words from the choices below to fill in the blanks. The nurse should prioritize interventions for acute decompensated heart failure to reduce the risk of the client developing-----------------------and ------------------

Correct Answer: D,E

Rationale: Dyshythmias due to structural changes (eg, cardiomegaly, ventricular hypertrophy) that alter electrical activity of the
heart. Common dysrhythmias associated with HF include atrial fibrillation, life-threatening ventricular tachycardia, and
ventricular fibrillation.
• Acute kidney injury (AKI) due to hypoperfusion of vital organs (ie, decreased renal perfusion) secondary to decreased
cardiac output. Decreased glomerular filtration can cause electrolyte imbalances (eg, hyperkalemia) related to AKI that
can also be a precipitating factor for dyshythmias.
• Pleural effusions can develop when fluid moves from capillaries to free spaces in the thoracic cavity as hydrostatic
pressure in the pulmonary veins increases (back pressure).

Question 3 of 5

For each finding below, click to specify if the finding is consistent with the expected action of the medication carvedilol, enalapril, or furosemide. Each finding may support more than one medication.

FindingCarvedilolEnalaprilFurosemide
Decreases heart rate
Increases urinary output
Decreases blood pressure
Increases oxygen saturation

Correct Answer:

Rationale: Pharmacologic management of heart failure (HF) focuses on reducing cardiac workload and improving cardiac output.
• Beta-adrenergic antagonists ("beta blockers") (eg, carvedilol) reduce cardiac workload by inhibiting the action of
catecholamines (eg, epinephrine, norepinephrine) on beta-adrenergic receptors in the heart. Beta blockers decrease
myocardial oxygen demand by decreasing blood pressure and decreasing heart rate.
• Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril) alter the renin-angiotensin-aldosterone system by
inhibiting conversion of angiotensin I to angiotensin II, thereby preventing the release of aldosterone. Aldosterone, an
adrenal steroid hormone, retains sodium and water in addition to promoting vasoconstriction. By reducing circulating
aldosterone, ACE inhibitors promote vasodilation and as a result decrease blood pressure. ACE inhibitors also
decrease ventricular remodeling, an added benefit for clients with HF.
• Loop diuretics (eg, furosemide) prevent reabsorption of sodium and chloride in the kidneys, which increases urine
output and fluid excretion. Decreases in circulating fluid volume will decrease blood pressure and reduce pulmonary
edema (ie, increase oxygen saturation), as well as decrease cardiac preload.

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).


Question 4 of 5

For each potential finding below, click to specify if the finding is consistent with the disease process of diabetic ketoacidosis, ruptured appendix, or ruptured ectopic pregnancy. Each finding may support more than one disease process.

Finding Diabetic ketoacidosis Ruptured appendix Ruptured ectopic pregnancy
Polyuria
Vomiting
Tachypnea
Tachycardia
Hyperglycemia
Abdominal pain

Correct Answer:

Rationale: Diabetic ketoacidosis (DK
A) is a complication of diabetes mellitus that results from lack of insulin. Insulin is required to transport glucose
into cells for energy, which means that lack of insulin leads to intracellular starvation despite the high level of glucose circulating in the blood
(hyperglycemia). Physiologic responses to hyperglycemia include osmotic diuresis (polyuria) for reduction of blood glucose levels and
breakdown of fat into acidic ketone bodies for energy. This leads to states of dehydration (as evidenced by tachycardia), electrolyte
imbalance, and metabolic acidosis. Ketoacidosis leads to tachypnea and deep respirations (Kussmaul respirations), as well as abdominal
pain and vomiting.
Appendicitis is an inflammation of the appendix often resulting from obstruction by fecal matter. Appendiceal obstruction traps colonic fluid
and mucus, causing increased intraluminal pressure and inflammation. This impairs perfusion of the appendix, resulting in swelling and
ischemia. Clinical manifestations include fever, abdominal pain, rebound abdominal tenderness, tachycardia, nausea, and vomiting.
Abdominal pain usually begins near the umbilicus and migrates to the right lower quadrant (eg, McBurney point). Tachypnea, as well as a
compensatory response, can be present, especially if there is a ruptured appendix or evidence of sepsis causing lactic acidosis (metabolic
acidosis).

Extract:

The nurse is caring for a 68-year-old client in the emergency department.
Nurses' Notes,

Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.

Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air


Question 5 of 5

Drag words from the choices below to fill in the blank/blanks. The nurse should immediately follow up on the client's-----------------------and-----------

Correct Answer: C,B

Rationale: Heart failure (HF) is a chronic, progressive condition characterized by impaired ventricular function that leads to decreased cardiac output and
causes blood to back up into the lungs and systemic circulation. This results in fluid volume overload that is commonly treated with diuretics,
such as furosemide (ie, "water pill"), that remove excess fluid through increased urination.
A client with HF who is experiencing dyspnea, inspiratory crackles, weight gain, and peripheral edema is demonstrating fluid volume overload
from a probable acute HF exacerbation. The nurse should immediately follow up on potentially life-threatening findings such as the client's:
• Blood pressure, which is moderately elevated and requires urgent intervention with medications (eg, diuretics). Fluid overload causes
increased pressure in the blood vessels, leading to hypertension that increases afterload. This is especially concerning for HF because
the heart muscle is already weak and cannot withstand additional afterload.
• Respiratory findings (ie, capillary oxygen saturation [SpOz) 90% on room air, inspiratory crackles, tachypnea, dyspnea, labored
respirations) because these likely indicate pulmonary edema. Crackles are a manifestation of pulmonary edema caused by fluid in the
alveoli that leads to impaired gas exchange and hypoxemia.
(Incorrect) Weiaht aain and lower extremity edema are also indicators of fluid volume overload however these findinas are not directly life

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