NCLEX-PN
NCLEX PN Practice Test with NGN Questions
Extract:
The nurse is caring for an 84-year-old client with dementia.
Nurses' Notes
Medical-Surgical Unit
Day 1: The left antecubital peripheral IV insertion site has no erythema or edema, and the catheter flushes easily. The dressing is clean, dry, and intact. Potassium chloride infusion is initiated.
Day 3: Potassium chloride is infusing. The area surrounding the IV site is taut, edematous, blanched, and cool to the touch. Small, fluid-filled vesicles are noted around the IV site. Capillary refill distal to the IV site is >3 seconds. The client is grimacing and unable to verbally report pain.
Question 1 of 5
For each potential intervention, click to specify if the potential intervention is appropriate or not appropriate for the care of client.
Correct Answer: A: Appropriate, B: Not Appropriate, C: Appropriate, D: Not Appropriate, E: Appropriate
Rationale: The symptoms suggest IV infiltration with potassium chloride, which is caustic. Elevating the extremity (
A) reduces swelling. Discontinuing the infusion (
C) prevents further damage. Leaving the catheter in place (E) allows for potential antidote administration. Applying pressure (
B) may worsen tissue damage, and aspirating (
D) is not standard for infiltration.
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 an 8-year-old client who was brought to the emergency department after
becoming short of breath at school.
History and Physical
General
Well-nourished child; currently sitting in the tripod position; patches of dry, scaly, reddened skin are present in the creases of bilateral elbows and behind both knees; client reports that these areas itch
Neurological
Alert and oriented to person, place, and time
Eye, Ear, Nose, andThroat (EENT)
Pupils equal, round, and reactive to light and accommodation; client reports no nasal congestion
Pulmonary
Vital signs: RR 34, SpO 92% on room air, airway patent, intercostal retractions noted during inspiration; expiratory wheezes auscultated bilaterally; dry, spasmodic cough is noted; no stridor; difficulty speaking in complete sentences
Cardiovascular
Vital signs: T 98.8 F (37.1 C), P 110, BP 94/60; S1 and S2 heard on auscultation; nom murmurs noted; peripheral pulses 2+; capillary refill 3 seconds; no edema
Gastrointestinal
Abdomen soft; bowel sounds normal
Psychosocial
Client appears anxious and is crying, client speaks in short phrases, stating, "left my medicine at a friend's house" and "feels like I can't breathe"; client cannot remember the name of the prescribed home medication; client's parents were notified and are en route to hospital
Progress Notes
0910:
Client's parents were spoken to over the phone. Last evening, the client spent the night at a friend's housewhere some family members smoke cigarettes and have a pet cat that lives in the home.
Medical history:
No accidents or injuries were reported, vaccinations are up to date, mild persistent asthma was diagnosed at age 7, and client has atopic dermatitis.
Allergies: No known allergies.
Family history:
Client is an only child. Parents report having no known medical conditions. Paternal grandfather died of chronic obstructive pulmonary disease, and maternal grandmother has heart disease.
Social history:
Client lives with parents; they do not smoke cigarettes. There are no pets in the client's home.
Current medications:
Beclomethasone inhaler 2 puffs twice a day, albuterol (salbutamol) inhaler 2 puffs
every 4 hours as needed for quick relief of symptoms.
Question 3 of 5
The nurse receives the following prescriptions. Which 3 actions should the nurse prioritize?
Correct Answer: A,B,E
Rationale: A: Nebulized albuterol and ipratropium are first-line treatments for acute asthma exacerbation to relieve bronchospasm. B: Prednisone reduces inflammation and prevents worsening. E: Titrating oxygen to >95% corrects hypoxia, a critical concern with SpO2 at 92%.
Extract:
The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92
Question 4 of 5
For each finding below, click to specify if the finding is consistent with the disease process of hyperthyroidism or hypothyroidism. Each finding may support more than one disease process. Note: Each column must have at least one response option selected.
| Finding | Hyperthyroidism | Hypothyroidism |
|---|---|---|
| Weight gain | ||
| Tachycardia | ||
| Constipation | ||
| Exophthalmos | ||
| Heat intolerance | ||
| Fine hand tremor |
Correct Answer: A: Hypothyroidism, B: Hyperthyroidism, C: Hypothyroidism, D: Hyperthyroidism, E: Hyperthyroidism, F: Hyperthyroidism
Rationale: Hyperthyroidism is characterized by increased metabolic rate, leading to tachycardia, exophthalmos, heat intolerance, and fine hand tremor. Hypothyroidism, with a decreased metabolic rate, is associated with weight gain and constipation.
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 5 of 5
The nurse recognizes that the client is most at risk for ___ related to ___
Correct Answer: A,E
Rationale: Seizures are a significant risk in alcohol withdrawal syndrome, which is suggested by the client's symptoms of trembling, diaphoresis, restlessness, and hallucinations.