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 caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.
Question 2 of 5
Which action should the nurse perform first?
Correct Answer: E
Rationale: Requesting staff presence ensures safety for de-escalation or intervention in an acute psychotic episode.
Extract:
The nurse is caring for an 88-year-old client with pneumonia.
Nurses' Notes Vital Signs Medical-Surgical Unit
0800: The client has dyspnea that worsens on exertion, a productive cough, and fever. Crackles are heard in the bilateral lower lung lobes.
1000: The client is restless, coughs frequently, and struggles to breathe.
Question 3 of 5
The nurse should first Select... to Select... ...
| Elevate the head of the bed |
| Administer albuterol nebulizer |
| Assist the client to drink clear fluids |
| Thin secretions |
| Increase lung expansion |
| Relax bronchial smooth muscles |
Correct Answer: A,E
Rationale: Elevating the head of the bed promotes lung expansion to improve breathing in pneumonia.
Extract:
The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine
Question 4 of 5
Which of the following statements by the parent indicate a correct understanding of the teaching? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Monitoring vision , follow-up tests , expecting hematuria , and avoiding infections are correct. Lifelong medication is not typical.
Extract:
The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.
Question 5 of 5
For each finding, click to specify whether the finding indicates that the client's status has improved or not improved.
| Finding | Improved | Not Improved |
|---|---|---|
| Client is seen talking alone in the hallway | ||
| Client is seen playing board games with peers | ||
| Client asks the technician for hygiene supplies | ||
| Client states, 'The voices are a part of my illness.' | ||
| Client refuses to take medication from a new nurse | ||
| Client is willing to eat food that is prepackaged only |
Correct Answer: B,C,D
Rationale: Social interaction , hygiene requests , and insight into illness show improvement. Talking alone , medication refusal , and food paranoia indicate ongoing symptoms.