NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
The nurse is caring for a 24-year-old client.
Nurses' Notes
Emergency Department
1300:
The client is brought to the emergency department after a motor vehicle collision in which the driver's side airbag deployed.
The client was driving the vehicle and was not restrained by a seat belt. The client reports shortness of breath and chest
pain on inspiration and expiration.
History and Physical
Body System ,Findings
Neurological,
Awake, alert, and oriented to person; pupils equal, round, and reactive to light and accommodation; client is
agitated and moves all extremities spontaneously but does not follow commands
Integumentary, Superficial lacerations to the face; diffuse bruising noted on upper extremities and chest wall
Pulmonary,
Vital signs: RR 30, SpOz 92% via nonrebreather mask; unilateral chest wall expansion observed on inspiration;
left-sided tracheal deviation noted; breath sounds diminished throughout the right lung field
Cardiovascular,
Vital signs: P 104, BP 90/58; S1 and S2 heard on auscultation; all pulses palpable; no extremity peripheral edema
noted
Psychosocial ,Alcohol odor noted on the client's breath
Diagnostic Results
Chest X-ray
Accumulation of air in the pleural cavity, tracheal deviation to the left. Findings consistent with a tension pneumothorax.
Question 1 of 5
One hour after chest tube insertion, the client becomes agitated and knocks over the chest tube collection device. The device is damaged. and the tubing becomes disconnected. Which action should the nurse perform first?
Correct Answer: D
Rationale: If a chest tube becomes disconnected from a damaged drainage system, the priority is to restore the water seal, according to facility policy. A
safe, temporary way to accomplish this is to immerse the distal end of the tube (ie, farthest from the client) into a bottle of sterile saline
or sterile water while someone obtains a new water seal collection device. Some facilities may use shodded (rubber-tipped) hemostats to
temporarily clamp the tube until a new water seal device is obtained. However, clamping the tube can quickly cause a pneumothorax and
should be done only very briefly (Option 4).
Question 2 of 5
The nurse has reviewed the information from the Diagnostic Results. The nurse should help prepare the client for which intervention?
Correct Answer: A
Rationale: The treatment for a pneumothorax is a chest tube connected to a water seal chamber, often to wall suction. The water seal drainage syste
prevents air from reentering the pleural space through the chest wall, allows reestablishment of negative pressure, and promotes movement
of air from the pleural space (Option 1).
Extract:
The nurse is caring for a 68-year-old client in the emergency department.
Nurses' Notes,
Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.
Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air
Laboratory Test and Reference Range, 1030
Sodium
136-145 mEq/L
(136-145 mmol/L),
133 mEq/L
(133 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
6.5 mEq/L
(6.5 mmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L),
22 mg/dL
(7.85 mmol/L)
Creatinine
Male: 0.6-1.3 mg/dL
(53-114.9 umol/L),
1.5 mg/dL
(132.6 umol/L)
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L)
Question 3 of 5
The nurse has reviewed the information from the Nurses' Notes, Vital Signs, and Laboratory Results.The nurse is reviewing the client's response to potassium-lowering therapies. Which finding is unexpected and requires follow-up by the nurse?
Correct Answer: A
Rationale: Treatment for hyperkalemia includes administration of calcium gluconate, furosemide, albuterol nebulizer, and insulin with dextrose. These
therapies may cause rapid shifts in fluid volume, blood glucose, and serum electrolytes. Insulin shifts available glucose and potassium into
the cell, lowering serum potassium levels; however, too much insulin and not enough dextrose cause hypoglycemia (eg, blood glucose 50
mg/dL [2.7 mmol/L]). Clients with kidney disease have an increased risk of hypoglycemia because insulin may accumulate.
The nurse should understand that a low blood glucose level and symptoms suspicious for hypoglycemia (eg, diaphoresis) require follow-u
to prevent seizures, coma, and death due to lack of circulating glucose (Option 1). This client requires an additional dose of dextrose.
(Option 2) This client's blood pressure is 146/88 mm Hg and heart rate is within normal limits. This is an improvement from the initial blood
pressure and represents a therapeutic response to furosemide administration. Blood pressure should be lowered slowly to avoid hypotensior
Extract:
The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).
Laboratory Results
Laboratory Test and Reference Range, 0900
Glucose, serum (random)
≤200 mg/dL
(<11.1 mmol/L),
573 mg/dL
(31.8 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.7 mEq/L
(5.7 mmol/L)
Question 4 of 5
The nurse reinforces teaching about managing diabetes mellitus during an acute illness. For each of the statements made by the client,click to specify whether the statement indicates correct understanding or incorrect understanding
| Client Statements | Correct | Incorrect |
|---|---|---|
| I should not take insulin if I cannot eat due to nausea. | ||
| I should drink extra fluids to stay hydrated when I am experiencing an illness. | ||
| I will check my blood glucose levels more frequently if I am experiencing an illness | ||
| I need to check my urine for ketones if my blood glucose levels are persistently elevated | ||
| I will reduce my carbohydrate intake if I experience high blood glucose levels during an illness. |
Correct Answer:
Rationale: When a client with diabetes mellitus experiences an infection or another illness, the release of stress hormones can cause increased insulin
resistance, which increases the blood glucose level and leads the body to break down fats for energy (ketosis). This can precipitate diabeti
ketoacidosis (DK
A) as break down of fatty acids produces ketones. Interventions for managing diabetes mellitus and preventing DKA durin
an illness include:
• Increasing fluid intake to help clear ketones from the system and prevent dehydration during illness
• Checking blood glucose levels more frequently (eg, every 4 hr) to monitor for hyperglycemia
• Monitoring the urine for ketones if blood glucose levels are persistently elevated (>240 mg/dL [13.3 mmol/L]) for early detection of
impending DKA
• Consuming beverages that contain glucose and replacing electrolytes if nausea and vomiting are present
• Notifying the health care provider of persistently elevated blood glucose levels, ketones in the urine, high fever, nausea, vomiting, or
diarrhea
Extract:
History,
Labor and Delivery Unit
Admission: The client, gravida 1 para 0, at 16 weeks gestation with a twin pregnancy reports nausea and vomiting for the past
several weeks. The client also reports dry heaving, increasing weakness, light-headedness, and an inability to tolerate
oral intake for the past 24 hours. In addition, the client has had occasional right-sided, shooting pain from the abdomen
to the groin that occurs with sudden position changes. The pain quickly resolves without intervention per the client's
report. She has had no contractions or vaginal bleeding and has felt no fetal movement during this pregnancy. The
client has a history of childhood asthma and is currently taking no asthma medications. The client reports no other
pregnancy complications.
Physical,
Prepregnancy,12 Weeks Gestation 16 Weeks Gestation(Prenatal Visit),(Labor and Delivery Admission)
Height ,5 ft 5 in (165.1 cm),5 ft 5 in (165.1 cm)|, 5 ft 5 in (165.1 cm)
Weight, 145 lb (65.8 kg),148 lb (67.1 kg),138 lb (62.6 kg)
BMI, 24.1 kg/m2, 24.6 kg/m2,23.0 kg/m2
Vital Signs,
12 Weeks Gestation(Prenatal Visit),16 Weeks Gestation(Labor and Delivery Admission)
T,98.7 F (37.1 C),99.8 F (37.7 C)
P,70,101
RR,14,18
BP,122/78,90/55
SpO2,99% on room air,96% on room air
Laboratory Results,
Laboratory Test and Reference Range, 16 Weeks Gestation
Blood Chemistry.
Sodium
136-145 mEq/L
(136-145 mmol/L)|,
136 mEq/L
(136 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
2.7 mEq/L
(2.7 mmol/L)
TSH
0.3-5.0 uU/mL
(0.3-5.0 mU/L),
0.4 pu/mL
(0.4 mU/L)
Hematology.
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
16 g/dL
(160 g/L)
Hematocrit (pregnant)
>33%
(>0.33),
49%
(0.49)
Urinalysis
Specific gravity
1.005-1.030
1.030,
Ketones
Not present,
Present
Giucose
Not present,
Not present
Nitrites
Not present,
Not present
Prescriptions,
10 mEq/hr potassium chloride in dextrose 5% and sodium chloride 0.45% IV continuously
• 1000 mg calcium carbonate q6h
• 10 mL multivitamin and 0.6 mg folic acid once daily
• 12.5 mg promethazine q6h
Question 5 of 5
The nurse has reviewed the information from the Prescriptions. The client received 2 L of lactated Ringer solution IV, 100 mg thiamine IV, and vitamin B, plus doxylamine IV shortly after arrival due to reports of severe nausea and vomiting. Click to highlight below the prescription that the nurse should anticipate completing next when planning care with the registered nurse.
Correct Answer: A
Rationale: Clients with hyperemesis gravidarum (HG) may require hospitalization if experiencing hypovolemia and electrolyte abnormalities. On
admission, clients with HG usually receive fluid replacement (eg, lactated Ringer solution) and antiemetics (eg, doxylamine and vitamin Bg).
Thiamine (vitamin B,) is often administered in initial fluids to prevent Wernicke encephalopathy.
For clients with HG experiencing hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) due to vomiting, it is critical to administer potassium
chloride promptly. Hypokalemia can have multiple potentially serious effects that, without intervention, put the client at immediate risk for
death; such effects include cardiac dyshythmia, respiratory muscle weakness causing respiratory failure, and impaired gastrointestinal
motility causing constipation and ileus