NCLEX-PN
NCLEX PN Test Questions with NGN Questions
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 1 of 5
Drag words from the choices below to fill in the blanks. The nurse gathers supplies for medication administration. The nurse recognizes that the priority prescriptions are -------and ----------
Correct Answer: E,B
Rationale: The priority intervention for management of diabetic ketoacidosis is fluid resuscitation with isotonic IV fluid, typically starting with large-voli
0.9% sodium chloride IV boluses (eg, 1 L/hr) to prevent life-threatening hypovolemic shock. Fluid resuscitation also helps normalize
glucose and electrolyte levels via hemodilution. After initial large-volume boluses are complete, either hypotonic or isotonic IV fluids are
administered at continuous rate. Administration of regular insulin continuous IV infusion is also essential to correct hyperglycemia.
Extract:
The nurse is caring for a 24-year-old client.
Nurses' Notes
Emergency Department
1300:
The client is brought to the emergency department after a motor vehicle collision in which the driver's side airbag deployed.
The client was driving the vehicle and was not restrained by a seat belt. The client reports shortness of breath and chest
pain on inspiration and expiration.
History and Physical
Body System ,Findings
Neurological,
Awake, alert, and oriented to person; pupils equal, round, and reactive to light and accommodation; client is
agitated and moves all extremities spontaneously but does not follow commands
Integumentary, Superficial lacerations to the face; diffuse bruising noted on upper extremities and chest wall
Pulmonary,
Vital signs: RR 30, SpOz 92% via nonrebreather mask; unilateral chest wall expansion observed on inspiration;
left-sided tracheal deviation noted; breath sounds diminished throughout the right lung field
Cardiovascular,
Vital signs: P 104, BP 90/58; S1 and S2 heard on auscultation; all pulses palpable; no extremity peripheral edema
noted
Psychosocial ,Alcohol odor noted on the client's breath
Diagnostic Results
Chest X-ray
Accumulation of air in the pleural cavity, tracheal deviation to the left. Findings consistent with a tension pneumothorax.
Question 2 of 5
One hour after chest tube insertion, the client becomes agitated and knocks over the chest tube collection device. The device is damaged. and the tubing becomes disconnected. Which action should the nurse perform first?
Correct Answer: D
Rationale: If a chest tube becomes disconnected from a damaged drainage system, the priority is to restore the water seal, according to facility policy. A
safe, temporary way to accomplish this is to immerse the distal end of the tube (ie, farthest from the client) into a bottle of sterile saline
or sterile water while someone obtains a new water seal collection device. Some facilities may use shodded (rubber-tipped) hemostats to
temporarily clamp the tube until a new water seal device is obtained. However, clamping the tube can quickly cause a pneumothorax and
should be done only very briefly (Option 4).
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 3 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).
Extract:
History and Physical
Body System,Findings
General
Client has history of coronary artery disease, hypertension, hyperlipidemia, diverticulosis, and
osteoarthritis; Helicobacter pylori infection 2 years ago; client reports taking over-the-counter
ibuprofen every 8 hours for left knee pain for the past 2 weeks; daily medications include aspirin,
carvedilol, lisinopril, and atorvastatin
Neurological
Alert and oriented to person, place, time, and situation
Pulmonary
Vital signs: RR 20, SpO 96% on room air, lung sounds clear bilaterally; no shortness of breath;
client smokes 1 pack of cigarettes per day and smokes marijuana 1 or 2 times weekly
Cardiovascular
Vital signs: P 110, BP 90/62; no chest pain; S1 and S2 heard on auscultation; peripheral pulses
2+; client states feeling lightheaded and reports passing out about 1 hour ago
Gastrointestinal
Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis; two episodes of
large, black, liquid stools in the morning
Musculoskeletal
Examination of the knees shows crepitus that is worse on the left; no swelling, warmth, or
erythema; range of motion is normal
Psychosocial
Client reports drinking 1 or 2 glasses of wine per day
Question 4 of 5
The nurse has reviewed the information from the Laboratory Results. The health care provider suspects the client is experiencing upper gastrointestinal bleeding. For each potential prescription, click to specify whether the prescription is anticipated or unanticipated for the care of the client.
| Potential Prescription | Anticipated |
|---|---|
| Place the client on NPO status | |
| Administer isotonic IV fluid bolus | |
| Administer proton pump inhibitor IV | |
| Collect blood samples for type and crossmatch | |
| Administer heparin for deep venous thrombosis prophylaxis |
Correct Answer:
Rationale: Anticipated prescriptions for a client with upper gastrointestinal (GI) bleeding include:
• Placing the client on NPO status to reduce the risk of continued bleeding and vomiting. NPO status is important to
initiate prior to esophagogastroduodenoscopy to reduce aspiration risk.
• Administering an isotonic IV fluid bolus to restore circulating fluid volume and maintain perfusion of vital organs.
• Administering a proton pump inhibitor IV (eg, pantoprazole) to reduce gastric acid secretion and prevent further
irritation and breakdown of suspected peptic ulcers.
• Collecting blood samples for type and crossmatch to ensure blood type compatibility before initiating a blood
transfusion. This client's hemoglobin and hematocrit levels are low, and the client continues to have active bleeding.
Therefore, a blood transfusion should be anticipated to increase blood volume and improve oxygenation and perfusion.
Administering heparin for deep venous thrombosis prophylaxis is not anticipated. Anticoagulation will prolong bleeding
and increase risk for hemorrhagic shock. Anticoagulation is contraindicated for clients with active GI bleeding.
Extract:
The nurse is caring for a 16-year-old client.History and Physical
Body System, Finding
General,
Client is brought to the emergency department due to nausea, vomiting, and abdominal pain that began 24 hr
ago. Client has type 1 diabetes mellitus and usually takes insulin. Parents state that the client was at an
overnight camp for the past 4 days and are unsure of how much insulin the client has been taking.
Neurological,
Client is lethargic but arousable to voice. The pupils are equal, round, and reactive to light and accommodation.
Integumentary,
Mucous membranes are dry, skin turgor is poor.
Pulmonary,
Vital signs are RR 36 and SpOz 95% on room air. Lung sounds are clear to auscultation. Deep respirations and a
fruity odor on the breath are noted.
Cardiovascular,
Vital signs are T 98.4 F (36.9 C), P 110, and BP 98/58. Pulses are 3+ on all extremities, and capillary refill time is
4 sec.
Gastrointestinal Normoactive bowel sounds are heard in all 4 quadrants; the abdomen is nontender.
Genitourinary,
Client voided dark yellow urine.
Endocrine,
Client is prescribed levothyroxine daily for hypothyroidism and has missed one dose of levothyroxine.
Psychosocial,
Parents state that the client has been sad and slightly withdrawn for the past 2 weeks after ending a romantic relationship.
Laboratory Results
Laboratory Test and Reference Range, 1000, 1600
Blood Chemistry.
Glucose (random)
≤200 mg/dL
(≤11.1 mmol/L),
504 mg/dL
(28.0 mmol/L),
164 mg/dL
(9.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L),
133 mEq/L
(133 mmol/L),
135 mEq/L
(135 mmol/L)
Chloride
98-106 mEq/L
(98-106 mmol/L),
101 mEq/L
(101 mmol/L),
102 mEq/L
(102 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.6 mEq/L
(5.6 mmol/L),
3.2 mEq/L
(3.2 mmol/L)
Arterial Blood Gases
Arterial pH
7.35-7.45
(7.35-7.45),
7.20
(7.20),
7.31
(7.31)
HCOg
21-28 mEq/L
(21-28 mmol/L),
13 mEq/L
(13 mmol/L),
18 mEq/L
(18 mmol/L)
PaCO,
35-45 mm Hg
(4.66-5.98 kPa),
30 mm Hg
(3.99 KPa),
32 mm Hg
(4.26 kPa)
PaO,
80-100 mm Hg
(10.64-13.33 KPa),
90 mm Hg
(11.97 kPa),
90 mm Hg
(11.97 kPa)
Nurses' Notes
1600:
0.9% sodium chloride and regular insulin IV are continuously infusing. Lung sounds are clear to auscultation. Urine output
is 90 mL over the past 2 hr.
Vital signs are T 99 F (37.2 C), P 105, RR 28, BP 110/72, and SpO, 95% on room air.
Question 5 of 5
Drag words from the choices below to fill in the blank/blanks. The nurse understands that treatment for diabetic ketoacidosis is resolved when the-----------,--------, and ----------
Correct Answer: B,D,E
Rationale: Diabetic ketoacidosis (DK
A) causes anion gap metabolic acidosis generated by the ketoacid anions and beta-hydroxybutyrate. Anion gap is
calculated based on electrolyte levels to determine the balance of cations and anions (le, acids and bases).
IV insulin infusion may be discontinued on resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200
mg/dL (11.1 mmol/L). However, measurement of serum glucose alone is inappropriate for monitoring the response to treatment because
ketosis and acidemia may still be present. With fluid resuscitation and correction of hyperosmolality and hyperglycemia, ketoacids disappear
and the anion gap and arterial blood gas results normalize, pointing to resolution of metabolic acidosis and ketonuria ie, ketones in
urine.