NCLEX-PN
NCLEX PN Test Questions with NGN Questions
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 1 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:
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 2 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.
Question 3 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:
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 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 5 of 5
Select 5 findings that require immediate follow-up.
Correct Answer: A,D,E,F,G
Rationale: This client is experiencing signs of acute angle-closure glaucoma (ACG), a medical emergency characterized by a sudden elevation in
intraocular pressure (IOP). The onset of symptoms is typically sudden; however, acute ACG requires rapid intervention to prevent permane
vision loss. Manifestations of acute ACG include:
• Blurry vision
• Unilateral headache
• Sudden, severe eye pain
• Conjunctival redness
• Middilated pupils (4-6 mm) nonreactive to light