NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
Extract:
The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn
Question 1 of 5
For each potential intervention, click to specify if the intervention is indicated or not indicated for the care the client.
Correct Answer: A,C,D,E,F
Rationale: Cleansing the body , removing identifiers , notifying donation organizations , allowing family presence , and removing invasive devices are standard postmortem care. Staples should remain for autopsy or funeral preparation.
Extract:
The nurse is contacting a client at 28 weeks gestation to review laboratory results and schedule a follow-up prenatal visit. Laboratory Results Laboratory Test and Reference Range 12 Weeks Gestation 26 Weeks Gestation 28 Weeks Gestation
WBC (prostent) 5,000-1多份 (5.0-15.0 × 10°/L) 8,900/mm3 (8.9 × 10°/L) 16,500 /mm° (16.5 × 10%/L)
Hemoglobin (pregnant) 11-16 g/dL (110-160 g/L) 13 g/dL (130 g/L) 10.8 g/dL (108 g/L) Hematocrit (pregnant) 33%-47% (0.33-0.47) 39% (0.39) 32% (0.32)
Chlamydia Negative Positive Negative Hemoglobin A1c 4.0%-5.9% 5.1%
1-hour oral glucose challenge test <140 mg/dL (7.8 mmol/L) 175 mg/dL (9.7 mmol/L)
3-hour oral glucose tolerance test Fasting: <110 mg/dL (6.1 mmol/L) 1 hour: <180 mg/dL (10.0 mmol/L) 2 hour: <140 mg/dL (7.8 mmol/L 3 hour: <70-115 mg/dL (<6.4 mmol/L) Fasting: 115 mg/dL (6.4 mmol/L) 1 hour: 205 mg/dL (11.4 mmol/L) 2 hour: 162 mg/dL (9.0 mg/dL) 3 hour: 135 mg/dL (7.5 mg/dL)
Question 2 of 5
The nurse should be most concerned about the client's. and anticipate the client's need for
Correct Answer: D,E
Rationale: Blood glucose levels are critical in gestational diabetes, requiring insulin to manage hyperglycemia.
Extract:
The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.
Question 3 of 5
Which of the following findings indicate that the newborn's condition has declined? Select all that apply.
Correct Answer: A,B,C
Rationale: Hypothermia , hypoglycemia , and jitteriness indicate decline, requiring intervention.
Extract:
Question 4 of 5
Click to highlight below the findings indicating that the client is improving.
| Abdominal dressing removed. Wound is clean, dry, and intact with no bleeding or foul-smelling drainage. |
| Fundus is firm, midline, and at the umbilicus. Urine output was $500 \mathrm{~mL}$ over the past 4 hours. |
| Client states that she is too tired and sore to ambulate in room with nursing assistance. |
| Client states that she cannot properly latch the newborn during breastfeeding. |
| Tolerating oral labetalol; systolic BP has been 110-130 mm Hg and diastolic BP has been 70-80 mm Hg over the past 12 hours. |
| Client reports no headaches and remains free of seizures. |
Correct Answer: A,B,E,F
Rationale: Clean wound , normal fundus and urine output , stable blood pressure , and absence of headaches/seizures indicate improvement.
Extract:
Question 5 of 5
For each event, click to specify whether the event is a sentinel event or a near-miss event.
Correct Answer: A,B,E,F
Rationale: Sentinel events cause harm: fall with fracture , wrong-site procedure , suicide , and anaphylaxis . Near-misses (C,
D) are caught before harm.