NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
Extract:
The nurse is caring for a 6-year-old client accompanied by the parents.
History and Physical
Body System
Findings
General
Client is brought to the emergency department due to
shortness of breath; medical history includes cystic fibrosis
and many previous hospital admissions for pneumonia; in the
3rd percentile for height and weight
Neurological
Alert and oriented to person, place, and time; no neurologic
deficits
Pulmonary
Vital signs: RR 30, SpO, 87% on room air; moderate
subcostal retractions; bilateral wheezing and coarse crackles
throughout lung fields with fine inspiratory crackles at left lung
base; paroxysmal coughing that produces thick, yellow,
blood-tinged sputum; parents report that the client has begun
to become "winded" after showering and other activities Cardiovascular
Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm
and dry; peripheral pulses palpable 2+; capillary refill 3
econds; mild finger clubbing noted
Gastrointestinal
Abdomen soft with normoactive bowel sounds; parent states,
"Swallowing the enzyme capsules is very difficult for my child,
and I have noticed an increase in greasy, bulky stools"
Question 1 of 5
For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client.
Correct Answer: A,B,C,D
Rationale: Antibiotics treat bacterial pneumonia, bronchodilators relieve wheezing, chest physiotherapy aids mucus clearance, and hypertonic saline thins mucus. Airborne isolation is not indicated for bacterial pneumonia.
Extract:
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower
back pain and bilateral leg weakness. The client reports that the
weakness began 3 days ago in the feet and has gradually worsened.
The client sought treatment today after becoming "so weak that I fell
while walking" and noticing new hand weakness and difficulty
swallowing. Back pain radiates down both legs and is rated as 5 on a
scale of 0-10. The client recently recovered from an illness with flu-like
symptoms. The client reports a history of hypertension and takes no
medications. Assessment of the lower extremities reveals muscle
strength of 2/5 and decreased sensation to pinprick. Achilles tendon
and patellar reflexes are decreased.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.
1030:
The client is breathless while speaking. Respirations are shallow and
labored. The client is diaphoretic. The skin is pale and cool. No
audible wheezing or stridor is present.
Question 2 of 5
Which of the following statements by the client's spouse indicate that the teaching has been effective? Select all that apply.
Correct Answer: B,C,E
Rationale: Prolonged deficits , feeding tube need , and viral trigger are accurate. GBS is not contagious , and flu vaccines are recommended.
Extract:
The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days
Question 3 of 5
The nurse should prioritize interventions for........... to prevent .........
Correct Answer: B,E
Rationale: Spinal cord compression interventions aim to prevent paralysis due to nerve damage.
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 4 of 5
After collecting data on the client, which action should the nurse perform immediately?
Correct Answer: A
Rationale: Alerting the registered nurse ensures rapid escalation of care for potential postpartum complications in preeclampsia.
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
Which complication of schizophrenia should the nurse be most concerned about?
Correct Answer: C
Rationale: Self-harm is the most urgent complication due to potential for immediate danger.