NCLEX-PN
NCLEX PN Practice Test with NGN Questions
Extract:
Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO, 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.
1 Hour Later
After attempting a bottle feed with 10 mL of formula, the client has a coughing episode, and there is formula mixed with saliva in the mouth. Coarse breath sounds are noted bilaterally with intercostal retractions. S1 and S2 are present with no murmurs. Neurologic examination shows normal neuromuscular findings.
A nasogastric tube insertion is attempted per prescription by the health care provider, and resistance is met at 10 cm of insertion.
Question 1 of 5
During a diaper change, the client becomes cyanotic with frothy secretions from the mouth and nose. What action should nurse perform first?
Correct Answer: C
Rationale: Suctioning clears the airway of frothy secretions, addressing the immediate cause of cyanosis. This is the first priority before other interventions.
Extract:
The nurse is caring for a client on the medical-surgical unit.
History
Admission
0500: The client is admitted with an abscess and cellulitis of the right leg. The abscess is noted on the lateral aspect of the right calf, with redness, swelling, and warmth extending from the knee to the ankle. The abscess was incised in the emergency department, and a moderate amount of purulent, yellowish-green drainage was noted. The leg was wrapped with gauze, and the client received the first dose of IV antibiotics and opioids for pain control.
The client reports chronic lower back pain and gastrosophageal reflux disease, and he was admitted to the hospital once last year for gastrointestinal bleeding. He is currently prescribed daily pantoprazole but takes it only a few times a week.
Vital signs: T 100.9 F (38.3 C), P 82, RR 14, BP 130/80, SpO, 95% on room air
Progress Notes
Medical-Surgical Unit
2300:
The client reports nausea, headache, and insomnia. The client is trembling, diaphoretic, and restless.
The client states, "I would sleep better if those mice and cats would stop climbing up and down the walls."
The upper portion of the clients dressing is saturated with yellowish-green drainage. The peripheral V was removed by the client, and dried blood is noted at the IV site. The IV catheter is on the floor. The client yelled and pushed the nurse's hands away during inspection of the IV site.
Vital signs: T 99 F (37.2 C), P 102, RR 18, BP 170/96, SpO≥ 95% on room air
Question 2 of 5
The client is preparing for discharge after treatment for cellulitis and alcohol withdrawal syndrome. The client expresses motivation to stop using alcohol and is prescribed naltrexone. Which of the following client statements indicate progress toward the goal of abstinence and long-term recovery? Select all that apply.
Correct Answer: A,B,E
Rationale: A: Acknowledging alcohol's negative impact shows insight. B: Joining a recovery program supports sobriety. E: Having a plan to manage cravings (e.g., calling a sponsor) indicates commitment. C is incorrect as it suggests continued drinking, and D blames others without addressing personal responsibility.
Extract:
The nurse is caring for a 58-year-old client on a medical-surgical unit.
History and Physical
General
The client is vomiting bright red blood; medical history includes alcohol use disorder, liver cirrhosis, and hypertension; the client was admitted a year ago for alcohol-induced acute pancreatitis
Neurological
The client is oriented to person and place; the pupils are equal, round, and reactive to light and accommodation
Eye, Ear, Nose, and Throat (EENT)
Yellow scleras are noted
Pulmonary
Vital signs are RR 18, SpO 94% on room air
Cardiovascular
Vital signs are T 99 F (37.2 C), P 102, BP 90/40; S1 and S2 are heard on auscultation; peripheral pulses are 2+ in all extremities; 1+ edema is noted at the bilateral lower extremities
Gastrointestinal
The abdomen is distended and nontender to palpation; the flanks are dull to percussion; bowel sounds are hypoactive; distended veins are present around the umbilicus
Genitourinary
Client is voiding amber-colored urine
Question 3 of 5
Complete the following sentence by choosing from the lists of options. The nurse should prioritize interventions for ___ due to the risk of ___.
Correct Answer: B,E
Rationale: The client is vomiting bright red blood and has low BP (90/40) and elevated pulse (102), indicating hypovolemia (E) from bleeding esophageal varices (
B), which is confirmed later. Prioritizing interventions for esophageal varices addresses the bleeding source, and hypovolemia addresses the life-threatening volume loss.
Extract:
The nurse is caring for a 52-year-old client on the orthopedic unit.
Nurses' Notes
Postoperative Day 1
0900:
The client's left leg was placed in balanced suspension skeletal traction for a fractured femur 12 hours ago. The client is positioned supine in the center of the bed with the foot of the bed elevated 15 degrees. Traction ropes are free of frays, centered in the pulleys, and moving freely with attached weights resting on the bed frame.
Serous drainage noted around the pin sites. Left foot slightly cool to the touch with posterior tibial and dorsalis pedis pulses palpable at 2+ and capillary refill <2 seconds in the toes. Client has normal sensationand movement of the left toes. Client rates left leg pain as 8 on a scale of 0-10.
Vital signs are T 100.4 F (38 C), P 110, RR 18, and BP 132/68. Weight is 173 lb (78.5 kg).
Postoperative Day 15
0800:
The client is increasingly tearful and states, "Life is going on without me while I am lying in this bed. I miss my friends." Left leg is in balanced suspension traction. Weights are hanging freely from the traction device. A 1-inch area of purple discoloration is noted on the right heel. Pin sites are free of erythema, swelling, and purulent drainage. Perineum is reddened with areas of excoriation and erythematous papules. External urinary catheter is in place. Scapula and sacrum are free of erythema.
Vital signs are T 98.8 F (37.1 C), P 100, RR 16, and BP 122/72. Weight is 164 lb (74. 4 kg).
Question 4 of 5
The nurse has reviewed the information from the Nurses' Notes. The nurse reinforces client teaching. Which statement by the client indicates a need for further teaching?
Correct Answer: C
Rationale: Resting the heel on a rolled towel may increase pressure on the wound, worsening the purple discoloration noted on the right heel. The other statements reflect appropriate understanding of nutritional needs, catheter care, and mobility assistance.
Extract:
The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.
Nurses' Notes
Inpatient - Mental Health Unit
2100:
Client appears anxious and withdrawn, and states, "I am afraid to sleep at night because I get nightmares about my sibling." The client would not elaborate on the content of the nightmares.
1200:
Client attended the first session of cognitive-behavioral therapy.
1300:
Client was observed yelling at peers in the day room because someone changed the television channel. The client is irritable with poor impulse control.
1700: Client appears to be having a panic attack and was found shaking in the room in tears after waking up from a nightmare. The client reports heart palpitations and appears diaphoretic.
Vital signs: P 112/min, RR 20, BP 155/98.
Question 5 of 5
During the acute phase of a panic attack, the nurse should..... and........
Correct Answer: A,D
Rationale: During a panic attack, staying with the client (
A) provides safety and support, and reassuring them of their safety (
D) helps reduce anxiety. Privacy (
B), discussing triggers (
C), teaching (E), or offering a phone (F) are not appropriate during the acute phase.