NCLEX-PN
NCLEX PN Test Questions with NGN Questions
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
Prescriptions
Home Medication Record
Medication, Scheduled
Pravastatin 20 mg PO once daily, 2100
Furosemide 40 mg PO once daily, 0900
Tamsulosin 0.4 mg PO once daily, 0900
Potassium chloride 20 mg PO once daily, 0900
Metformin 1000 mg PO bid, 0900, 2100
Carvedilol 6.25 mg PO bid;hold for systolic blood pressure ≤100 mm Hg and/or HR <65/min, 0900, 2100
Sacubitril 97 mg/valsartan 103 mg PO bid, 0900, 2100
Question 1 of 5
Drag words from the choices below to fill in the blank/blanks.The nurse recognizes that furosemide was effective as evidenced by------------,-----------------, and ------------------
Correct Answer: A,B,E
Rationale: Loop diuretics (eg, furosemide) block renal reabsorption of sodium, chloride, and potassium, which increases fluid excretion
in the urine (ie, diuresis). Diuresis decreases intravascular volume, resulting in decreased peripheral edema (eg, from 3+ to
2+). In addition, as fluid volume decreases, pulmonary congestion improves, thereby resulting in improved oxygen exchange
and reduced work of breathing
Extract:
The nurse is caring for a 37-year-old client.
Admission Note
Antepartum Unit
1100:
The client, gravida 2 para 1 at 34 weeks gestation, is admitted to the hospital with right upper quadrant pain. The client
reports feeling extremely fatigued and nauseated and has vomited 3 times in the past 2 hours.
Physical examination shows right upper quadrant tenderness. Lower extremities have 2+ pitting edema; deep tendon
reflexes are 3+.
Laboratory Results
Laboratory Test and Reference Range, Admission
Hematology.
Platelets
150,000-400,000/mm3
(150-400 x 10°/L),
82,000/mm3
(82 x 10%/L)
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
9.6 g/dL
(96 g/L)
Blood Chemistry.
Creatinine
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L),
1.5 mg/dL
(114.4 umol/L)
Alanine aminotransferase
4-36 U/L
(0.07-0.60 ukat/L),
265 U/LI
(4.43 pkat/L)
Aspartate aminotransferase
0-35 U/LI
(0-0.58 ukat/L),
308 U/L
(5.14 ukat/L)
Lipase
0-160 U/L,
53 U/L
Amylase
30-220 U/L,
75 U/L
Urine Dipstick
Protein,
Increased
Vital Signs
1100
T,98.6 F (37 C)
P, 112
RR,20
BP,150/80
SpO2.98% on room air
Question 2 of 5
The nurse is reviewing the collected client data to assist with preparing the client's plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address the condition, and 2 parameters the nurse should monitor to measure the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome is a life-threatening pregnancy-related disorder that typically
occurs >20 weeks gestation. Although HELLP syndrome is often considered a variant of preeclampsia, clients can develop this syndrome
without hypertension or proteinuria. Clinical manifestations may include elevated liver enzymes, right upper quadrant pain (due to swelling of
the liver), malaise, nausea, and decreased platelet count.
Appropriate interventions include:
• Preparing the client for birth, which is the only definitive treatment
• Assisting with the initiation of magnesium sulfate infusion for seizure prophylaxis
• Administering antihypertensive medications PRN to help prevent stroke
• Evaluating deep tendon reflexes frequently to monitor for hyperreflexia and clonus, which may indicate increased central nervous
system irritability and precede eclampsia; hyporeflexia may indicate magnesium toxicity.
• Monitoring clotting factors to evaluate bleeding risk and monitor for disseminated intravascular coagulation, a complication of HELLP
syndrome
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
Select below the 4 findings that are most concerning at this time.
Correct Answer: B,C,D,F
Rationale: This client has multiple findings concerning for infective endocarditis (IE), which occurs when an infectious organism enters the
innermost layer of the heart (ie, endocardium) and forms a vegetation on a heart valve. Findings concerning for IE include:
• Recent tooth extraction: Dental procedures (eg, tooth extraction) increase the risk for infectious organisms entering the
bloodstream, potentially leading to IE. Other risk factors include a history of IV drug use, presence of a distant infection
(eg, leg cellulitis), or presence of a prosthetic heart valve
• Fever: Elevated temperature is a sign of infection, which is a common finding in clients with IE.
• Nontender, erythematous, macular lesions on the palms or soles (Janeway lesions): Janeway lesions are
characteristic of IE. They occur when turbulent blood flow through the heart valves causes pieces of endocardial
vegetation to break off, forming microemboli that travel through the arteries to end-capillaries and block blood flow.
• Nonblanching, thin, red/dark longitudinal lines under the nail beds (splinter hemorrhages): Like Janeway lesions,
splinter hemorrhages are caused by microemboli that break off from vegetative lesions in the heart and travel through the
arteries to end-capillaries and block blood flow.
Extract:
The nurse is caring for a 58-year-old client.
Admission Note
Emergency Department
A client with colorectal cancer reports intractable bilious vomiting for the past day; it is accompanied by severe, colicky
abdominal pain. The client cannot tolerate oral intake and has not passed gas or had a bowel movement since the
symptoms began. The abdomen is distended, and bowel sounds are hyperactive.
Vital Signs
Emergency Department
T, 97.3 F (36.3 C)
P, 98
RR, 18
BP, 110/70
SpO2, 98% on room air
Question 4 of 5
The nurse is contributing to the client's plan of care. 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 |
|---|---|---|
| Administer antiemetic | ||
| Insert a nasogastric tube | ||
| Place the client on a soft diet | ||
| Obtain an abdominal CT scan | ||
| Administer a stimulant laxative |
Correct Answer:
Rationale: Small bowel obstruction (SBO) is an intestinal blockage that obstructs the flow of intestinal contents (eg, fluid, gas, fecal
material). The blockage may be due to mechanical (eg, surgical adhesions, hernias, tumors) or nonmechanical/functional (eg,
paralytic ileus) causes. As intestinal contents accumulate, clients develop abdominal distension, colicky abdominal pain,
bilious vomiting, and inability to pass flatus or stool.
Clients with SBO are at risk for fluid, electrolyte, and nutritional imbalances due to decreased intestinal absorption. Clients may
develop bowel necrosis and perforation due to impaired intestinal blood flow, which can lead to peritonitis and sepsis.
The practical nurse should anticipate assisting the registered nurse with the following interventions for a client with SBO:
• Inserting a nasogastric tube for gastrointestinal decompression to reduce abdominal distension and improve intestinal
blood flow
• Administering antiemetics (eg, ondansetron) to prevent further fluid and electrolyte imbalance from vomiting
• Preparing the client for abdominal CT scan to determine the size and location of intestinal obstruction
• Administering IV fluids to improve fluid volume status
In clients with SBO, bowel rest (ie, NPO status) with gastric decompression is prescribed; therefore, a soft diet is not
indicated. Stimulant laxatives increase intestinal motility and are not indicated for clients with intestinal obstruction due to
the risk for bowel perforation.
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
Prescriptions,
10 mEq/hr potassium chloride in dextrose 5% and sodium chloride 0.45% IV continuously
• 1000 mg calcium carbonate q6h
• 10 mL multivitamin and 0.6 mg folic acid once daily
• 12.5 mg promethazine q6h
Question 5 of 5
The nurse is reinforcing home care teaching to the client. Which statement by the client requires the nurse to provide further instruction?
Correct Answer: D
Rationale: Self-management of hyperemesis gravidarum is an important component of discharge teaching. The goal of home care is to prevent nausea
and vomiting and promote appropriate nutritional intake and weight gain, which can support a healthy pregnancy.
Some triggers for nausea and vomiting include an empty or overly full stomach, strong food odors, and greasy or fatty foods. It is often
recommended that clients eat cold or bland foods due to the increased aromas associated with hot foods.
Therefore, the nurse should
provide further teaching to this client who plans to eat hot soup because this may precipitate nausea (Option 4). The nurse can suggest
eating foods such as toast, crackers, nuts, or cold cereal.