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).
Question 1 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.
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:
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.
Question 2 of 5
The client is diagnosed with autism spectrum disorder (ASD). The nurse recognizes that clients with ASD are at risk for which of the following complications? Select all that apply.
Correct Answer: A,BC,D,E
Rationale: Autism spectrum disorder (AS
D) begins in the developmental period, and symptoms tend to persist throughout the lifespan.
Clients with ASD are more prone to medical, psychiatric, and psychosocial impairments. These impairments include the
following:
• Impaired interpersonal relationships: Clients with ASD may be disinterested in social interaction and have difficulty
showing affection and interpreting conversation
• Learning difficulties: Clients with ASD may have trouble focusing on tasks and have a limited range of learning
interests (eg, preferring only math), making it challenging to engage them in other areas of learning (Option 2).
• Malnutrition: Clients with ASD can have a narrowed interest in foods, resulting in insufficient intake of necessary
nutrients. In addition, clients with ASD often experience gastrointestinal disturbances, including constipation and
diarrhea, due to narrowed food intake
• Self-harm behaviors: Changes in routine and environment can trigger repetitive or harmful behaviors (eg, head-
banging, hand-biting). When self-harm behaviors persist into adulthood, they may be preceded by suicide attempts
related to coexisting psychiatric comorbidities (eg, depression, anxiety)
• Sleep disturbances: Clients with ASD often experience difficulty falling and staying asleep. Hyperresponsiveness to
sensory stimulation (eg, lights, noises, sensations) can also contribute to disruptive sleeping patterns
Extract:
History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Laboratory Results
Laboratory Test and Reference Range,Admission
Urine drug screen
Cocaine
Negative
Positive,
Opioid
Negative
Negative,
Amphetamines
Negative
Negative,
Marijuana
Negative
Positive,
Phencyclidine
Negative
Negative,
Benzodiazepines
Negative
Negative,
Barbiturates
Negative
Negative,
Breathalyzer
No alcoho detected
0.00
Question 3 of 5
Complete the following sentence/sentences by choosing from the list/lists of options. he nurse should prioritize interventions for------- due to the client's -----
Correct Answer: B,E
Rationale: The nurse should prioritize interventions for suicidal behavior due to the client's thoughts of self-harm.
This client has several predisposing factors that increase the risk of suicide, including a psychiatric disorder, previous suicide
attempt, stressful life events (eg, divorce), and substance use. However, the strongest single factor predictive of suicide is the
history of a prior suicide attempt (eg, jumping off a building). The nurse should anticipate implementation of suicide
precautions (eg, 1-to-1 observation).
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
Question 4 of 5
Select 5 findings that require immediate follow-up.
Correct Answer: A,B,C,D,F
Rationale: The nurse should immediately follow up on the following findings:
• Hypoxemia (eg, SpO, 92% on 100% oxygen [nonrebreather mask]) indicates an abnormality with ventilation and/or perfusion.
• Unilateral chest wall expansion on inspiration indicates one side of the lung is not inflating. This is usually due to lung collapse,
which could be due to an internal airway dysfunction (eg, mucous plug blocking air entry) or external compression (eg, pneumothorax).
• Tracheal deviation (ie, displacement of the trachea to one side) occurs when pressure from one side of the chest is higher than the
other, pushing the mediastinal structures to the side with less pressure. This is usually due to a large hemothorax or pneumothorax.
• Diminished breath sounds indicate the lung is not adequately expanding (eg, atelectasis, pneumothorax).
• Hypotension (eg, BP 90/58 mm Hg) occurs from several mechanisms, including compression of the heart (eg, cardiac tamponade)
and/or great vessels (eg, tension pneumothorax), inadequate ventricular filling between heartbeats (eg, supraventricular tachycardia),
volume depletion, and other conditions
Extract:
Nurses' Notes
Initial Clinic Visit
1100:
The client has experienced enuresis at night for the past 2 weeks and frequently requests to use the
bathroom while at school. The client was previously toilet trained with no nighttime bed wetting for 6 months;
the client recently relocated to a new home and school where the client lives with parents.
The parent reports that the client has recently demonstrated fatigue, irritability, and multiple behavioral
outbursts that resemble past temper tantrums. The client frequently reports feeling thirsty. No dysuria or
urinary hesitancy is reported.
Weight and height were in the 40th percentiles at the previous visit a year ago. Growth charts today show
the client's weight in the 20th percentile and height in the 40th percentile.
The client appears tired and irritable. Dry mucous membranes are noted with no increased work of
breathing. The lungs are clear to auscultation bilaterally. No cardiac murmur is heard.
Question 5 of 5
The nurse has reviewed the information from the Laboratory Results.Three days later, the school nurse is called to the play area because the client is diaphoretic and becomes unconscious. The school nurse notices the clients medical alert bracelet and obtains a blood glucose level. Which action should the school nurse take after reading the blood glucose level?
Correct Answer: A
Rationale: Rapid growth and unpredictable eating patterns place a child with diabetes mellitus at high risk for hypoglycemia.
Hypoglycemia can occur rapidly and can be life-threatening. Clinical manifestations primarily result from lack of glucose to the
brain (and other vital organs) followed by rapid activation of the sympathetic nervous system:
• Pallor and diaphoresis
• Tremors
• Palpitations and tachycardia
• Altered mental status, irritability, slurred speech, confusion
• Dizziness
If hypoglycemia is suspected, the nurse should immediately obtain a blood glucose level. Clients with hypoglycemia who are
unconscious cannot tolerate oral carbohydrates.
Therefore, the nurse should rapidly administer glucagon by injection (eg.
subcutaneous, IM) or apply a glucose paste to the gums. Glucagon increases blood glucose levels by rapidly converting
stored glycogen in the liver into glucose, a process known as glycogenolysis