NCLEX-PN
NCLEX PN Practice Test with NGN Questions
Extract:
The nurse is caring for an 82-year-old client in the emergency department.
Nurses' Notes
0930:
The client reports shortness of breath and left-sided chest pain for 2 days. The client fractured the right femoral neck a month ago after a fall and decided against operative management. Since then, the client has been wheelchair dependent and takes acetaminophen for fracture pain management. The client was placed on continuous cardiac monitoring.
History and physical
Body System
Neurological
The client is awake, alert, and oriented to person, place, time, and situation; the client appears anxious
Pulmonary
Vital signs are RR 22, SpOz 89% on room air; bilateral breath sounds are clear; pain increases with inhalation; the client reports shortness of breath for the past 2 days; the client smoked 1 pack of cigarettes per day for 10 years.
Cardiovascular
Vital signs are T 99.8 F (37.7 C), P 110, BP 110/60; S1 and S2 are present; there are no murmurs, redness and edema of the right lower extremity are noted; sinus tachycardia is seen on the monitor, chest pain is reported as 7 on a scale of 0-10
Musculoskeletal
The client has osteoporosis, is wheelchair dependent, and is unable to bear weight on the right leg
Diagnostic Results
CT pulmonary angiography
1030: Pulmonary embolism is confirmed
Lower extremity doppler ultrasound
1100: Deep venous thrombosis is noted in the right lower extremity.
Question 1 of 5
For each potential prescription, click to specify if the prescription is anticipated or contraindicated for the care of the client.
Correct Answer: A,B,D
Rationale: A: Heparin infusion is anticipated to treat pulmonary embolism and DVT by preventing further clot formation. B: Acetaminophen is anticipated for pain management, as it is safe for this client. C: Physical therapy is contraindicated due to the acute PE and DVT, as mobilization could dislodge clots. D: Supplemental oxygen is anticipated to correct hypoxemia (SpO2 89%). E: Sequential compression devices are contraindicated, as DVT is already present, and they could dislodge the clot.
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 2 of 5
For each potential intervention, click to specify if the potential intervention is appropriate or not appropriate for the care of client.
| Potential Intervention | Appropriate | Not Appropriate |
|---|---|---|
| Elevate the affected extremity | ||
| Apply pressure to the affected area | ||
| Discontinue the potassium chloride infusion | ||
| Aspirate the potassium chloride from the IV catheter | ||
| Leave the IV catheter in place for potential antidote administration |
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 52-year-old client on the orthopedic unit.
Nurses' Notes
Postoperative Day 1
0900:
The client's left leg was placed in balanced suspension skeletal traction for a fractured femur 12 hours ago. The client is positioned supine in the center of the bed with the foot of the bed elevated 15 degrees. Traction ropes are free of frays, centered in the pulleys, and moving freely with attached weights resting on the bed frame.
Serous drainage noted around the pin sites. Left foot slightly cool to the touch with posterior tibial and dorsalis pedis pulses palpable at 2+ and capillary refill <2 seconds in the toes. Client has normal sensation and movement of the left toes. Client rates left leg pain as 8 on a scale of 0-10.
Vital signs are T 100.4 F (38 C), P 110, RR 18, and BP 132/68. Weight is 173 lb (78.5 kg).
Question 3 of 5
Select the 2 findings that require immediate follow-up.
Correct Answer: G,E
Rationale: Serous drainage (G) and a slightly cool foot (E) require immediate follow-up due to potential infection or compromised circulation.
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
Nurses' Notes
Outpatient Clinic
0930:
Client received radioactive iodine therapy 6 months ago. Client reports absence of heart palpitations and anxiety. No evidence of fine hand tremor.
Client reports weight gain of 10.5 lbs (4.8 kg) within the past 3 months. Client reports feeling more fatigued during the day and requests to speak to the health care provider about feeling depressed.
Question 4 of 5
Following a routine laboratory draw, the nurse suspects that the client is experiencing primary hypothyroidism as evidenced by........... and ........
Correct Answer: A,D
Rationale: Primary hypothyroidism is characterized by increased TSH due to the pituitary gland's attempt to stimulate the thyroid and decreased T3 and T4 levels due to reduced thyroid hormone production.
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
Question 5 of 5
For each finding below, click to specify if the finding is consistent with the disease process of anaphylaxis or asthma exacerbation.
| Finding | Anaphylaxis | Asthma Exacerbation |
|---|---|---|
| Stridor | ||
| Wheezing | ||
| Tachycardia | ||
| Hypotension | ||
| Generalized flushing and itching |
Correct Answer: B,C: Asthma; C,D,E: Anaphylaxis
Rationale: B: Wheezing is characteristic of asthma exacerbation due to bronchoconstriction. C: Tachycardia can occur in both asthma (from hypoxia or stress) and anaphylaxis (from systemic reaction). D: Hypotension is typical in anaphylaxis due to vasodilation and fluid shifts. E: Generalized flushing and itching are hallmarks of anaphylaxis due to histamine release.