NCLEX-PN
NCLEX PN Test Questions with NGN Questions
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 1 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
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
The nurse suspects the client is experiencing acute decompensated heart failure. Which of the following findings are consistent with this condition? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: The findings all support the diagnosis of acute decompensated heart failure (ADHF):
Crackles with auscultation: Indicative of pulmonary congestion due to fluid overload.
Decreased capillary oxygen saturation: Reflects impaired gas exchange from fluid in the lungs.
Elevated B-type natriuretic peptide (BNP): A level of 640 pg/mL is significantly elevated; BNP is released when the ventricles are stretched due to increased fluid volume.
Left ventricular ejection fraction of 30%: Normal is 55–70%. This reduced EF confirms systolic dysfunction, common in ADHF.
Lower extremity pitting edema: A classic sign of volume overload in right-sided or total heart failure.
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 3 of 5
The practical nurse is assisting the registered nurse with preparing the client's plan of care. Which of the following interventions are appropriate to include in the plan of care? Select all that apply.
Correct Answer: A,B,C,D
Rationale: In addition to ophthalmic medications (eg, beta blockers, cholinergic medications) and oral or IV carbonic anhydrase inhibitors, clients with
acute angle-closure glaucoma (ACG) require the following measures to prevent further vision loss and ensure safety:
• Administration of an osmotic diuretic (eg, mannitol) to reduce intraocular pressure (IOP). Mannitol increases plasma oncotic
pressure, pulling water from the extravascular space into the intravascular space. This fluid, along with the diuretic, is excreted through
the kidneys, thereby reducing IOP. This is similar to the management of cerebral (brain) edema (Option 1).
• Administration of an antiemetic medication (eg, ondansetron) to alleviate nausea because vomiting can cause a sharp increase in IOP,
further worsening acute ACG (Option 2)
• Implementation of fall precautions (eg, provide nonskid socks, turn on bed alarm, clear a pathway to the bathroom) to ensure client
safety. Many eye drops cause blurred vision for several minutes after administration, worsening the client's already impaired vision
(Option 3).
• Instruction to avoid activities that increase IOP (eg, bending/stooping, straining, coughing, blowing the nose, laughing) (Option 4)
(Option 5) Applying a pressure patch to the eye is typically done as a postoperative intervention for ocular surgeries (eg, corneal
transolantation) and is not necessary to include in the olan of care for this client.
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 4 of 5
Which of the following prescriptions are indicated for this client? Select all that apply.
Correct Answer: A,B,C,E
Rationale: This client's medical history includes hypertension, myocardial infarction, heart failure (HF), coronary artery disease, and chronic stable
angina, which place the client at high risk for several complications. When assisting in planning care for a client with a history of HF who is
experiencing dyspnea and chest discomfort, the nurse should anticipate the following prescriptions:
• A 12-lead ECG to assist in identifying acute dyshythmias and acute coronary syndromes (eg, myocardial infarction, unstable angina)
(Option 1)
• Chest x-ray to visualize pulmonary congestion, cardiomegaly, and the presence of other potential causes for the client's dyspnea (eg,
pneumonia, pleural effusion). Common causes of pleural effusions include HF (Option 2).
• The client's current weight to establish a baseline indicator of fluid volume status (Option 3)
• Serum electrolyte levels to identify fluid and electrolyte imbalances that may impair myocardial contractility (Option 5)
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 5 of 5
For each finding below, click to specify if the finding is consistent with the disease process of acute upper gastrointestinal bleed or acute lower gastrointestinal bleed. Each finding may support more than one disease process.
| Finding | Acute Upper Gastrointestinal Bleed | Acute Lower Gastrointestinal Bleed |
|---|---|---|
| Melena | ||
| NSAID use | ||
| Hematemesis | ||
| History of diverticulosis | ||
| History of Helicobacter pylori infection |
Correct Answer:
Rationale: Upper gastrointestinal (Gl) bleeding can occur in the esophagus (eg, esophageal varices or in the stomach and duodenum
(eg, peptic ulcer). Findings associated with upper GI bleeding include the following:
• Melena (ie, dark, tarry stools) is due to the release of iron (heme) as blood passes through the entire GI tract and
hemoglobin becomes partially digested
• NSAID use increases the risk of peptic ulcer formation by inhibiting cyclooxygenase-1, an enzyme that helps protect the
stomach lining and promote platelet aggregation.
• Hematemesis (ie, vomiting blood) is due to the presence of blood in the upper GI tract (eg, esophagus, stomach,
duodenum); the blood usually has a coffee ground appearance due to digestion by gastric acid
• Helicobacter pylori infection increases gastric secretions, promoting peptic ulcer formation.
Lower Gl bleeding occurs in structures past the duodenum (eg, small and large intestine, rectum, anus) and is commonly
associated with inflammatory (eg, Crohn disease, ulcerative colitis, diverticulosis) or vascular (eg, hemorrhoids) conditions.
Diverticulosis is a condition where diverticula (ie, hollow outpouchings from the intestine) develop, usually in the large
intestine and occasionally in the small intestine. Diverticula weaken the intestinal wall and increase the risk for GI bleeding.