NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
The nurse is caring for a 64-year-old client.
History and Physical
Body System, Findings
General ,
The client reports a 24-hour history of blurred vision and redness in the left eye with a left-sided headache.
This evening, the client developed acute, severe pain in the left eye accompanied by occasional nausea and
vomiting. The client reports no use of systemic or topical eye medications. Medical history includes
osteoarthritis and hypercholesterolemia.
Eye, Ear, Nose, and Throat (EENT),
The client wears eyeglasses to correct farsighted vision. Right eye: pupil 2 mm and reactive to light,
conjunctiva clear. Left eye: pupil 4 mm and nonreactive to light with red conjunctiva. Bilateral lens opacity is noted.
Pulmonary,
Vital signs are RR 20 and SpO, 96% on room air. The lungs are clear to auscultation bilaterally.
Cardiovascular,
Vital signs are T 99 F (37.2 C), P 88, and BP 140/82.
Psychosocial,
The client reports a great deal of emotional stress following the recent death of the client's spouse that is accompanied by lack of sleep, poor appetite, and a 7.9-lb (3.6-kg) weight loss within the past month. The client takes diphenhydramine for sleep.
Question 1 of 5
Select 5 findings that require immediate follow-up.
Correct Answer: A,D,E,F,G
Rationale: This client is experiencing signs of acute angle-closure glaucoma (ACG), a medical emergency characterized by a sudden elevation in
intraocular pressure (IOP). The onset of symptoms is typically sudden; however, acute ACG requires rapid intervention to prevent permane
vision loss. Manifestations of acute ACG include:
• Blurry vision
• Unilateral headache
• Sudden, severe eye pain
• Conjunctival redness
• Middilated pupils (4-6 mm) nonreactive to light
Extract:
The nurse is caring for a 20-year-old client.
Progress Notes
Clinic Visit
For the past week, the client has experienced flu-like symptoms, including low-grade fevers, headaches, nausea, vomiting, and, today,
diarrhea and dark urine. The client reports widespread itching but has no rash. Skin and scleras are jaundiced. No lymphadenopathy
is present, and the abdomen is nondistended with a palpable liver edge. The client returned from an international mission trip a few
weeks ago.
Vital signs are T 99.9 F (37.7 C), P 88, RR 18, BP 128/80, and SpOz 98% on room air.
Laboratory Results
Laboratory Test and Reference Range ,Current
Liver Function Tests
Total bilirubin, Increased
Alkaline phosphatase, Increased
Aspartate aminotransferase (AST), Increased
Alanine aminotransferase (ALT) ,Increased
Question 2 of 5
Complete the following sentence by choosing from the lists of options. The nurse suspects the client has ----------- and should implement ----------- precautions.
Correct Answer: D,E
Rationale: Hepatitis A is an infection that leads to widespread inflammation of the liver. Transmission occurs through the fecal-oral route and is commo
in areas with overcrowding and poor sanitation. Outbreaks frequently result from contaminated water or food, and the condition is seen
primarily in resource-limited countries. Symptoms develop abruptly, initially including nausea, vomiting, anorexia, fever, and right upper
quadrant pain. A few days later, dark urine (bilirubinuria) and/or pale stools (lacking bilirubin pigment) may be seen. These are usually
followed by jaundice and pruritus. In addition, laboratory results show elevated liver function tests.
Hand hygiene, especially after toileting and before meals, is the most important intervention for reducing the risk of hepatitis A infection.
Therefore, for a client hospitalized with hepatitis A, standard precautions (ie, hand hygiene, disinfection of equipment and surfaces) must be
implemented to prevent transmission. Additional precautions (eg, disposable gown, gloves) should be used as needed (eg, during procedure
Extract:
The nurse is caring for a 37-year-old client.
Admission Note
Antepartum Unit
1100:
The client, gravida 2 para 1 at 34 weeks gestation, is admitted to the hospital with right upper quadrant pain. The client
reports feeling extremely fatigued and nauseated and has vomited 3 times in the past 2 hours.
Physical examination shows right upper quadrant tenderness. Lower extremities have 2+ pitting edema; deep tendon
reflexes are 3+.
Laboratory Results
Laboratory Test and Reference Range, Admission
Hematology.
Platelets
150,000-400,000/mm3
(150-400 x 10°/L),
82,000/mm3
(82 x 10%/L)
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
9.6 g/dL
(96 g/L)
Blood Chemistry.
Creatinine
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L),
1.5 mg/dL
(114.4 umol/L)
Alanine aminotransferase
4-36 U/L
(0.07-0.60 ukat/L),
265 U/LI
(4.43 pkat/L)
Aspartate aminotransferase
0-35 U/LI
(0-0.58 ukat/L),
308 U/L
(5.14 ukat/L)
Lipase
0-160 U/L,
53 U/L
Amylase
30-220 U/L,
75 U/L
Urine Dipstick
Protein,
Increased
Vital Signs
1100
T,98.6 F (37 C)
P, 112
RR,20
BP,150/80
SpO2.98% on room air
Question 3 of 5
The nurse is reviewing the collected client data to assist with preparing the client's plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address the condition, and 2 parameters the nurse should monitor to measure the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome is a life-threatening pregnancy-related disorder that typically
occurs >20 weeks gestation. Although HELLP syndrome is often considered a variant of preeclampsia, clients can develop this syndrome
without hypertension or proteinuria. Clinical manifestations may include elevated liver enzymes, right upper quadrant pain (due to swelling of
the liver), malaise, nausea, and decreased platelet count.
Appropriate interventions include:
• Preparing the client for birth, which is the only definitive treatment
• Assisting with the initiation of magnesium sulfate infusion for seizure prophylaxis
• Administering antihypertensive medications PRN to help prevent stroke
• Evaluating deep tendon reflexes frequently to monitor for hyperreflexia and clonus, which may indicate increased central nervous
system irritability and precede eclampsia; hyporeflexia may indicate magnesium toxicity.
• Monitoring clotting factors to evaluate bleeding risk and monitor for disseminated intravascular coagulation, a complication of HELLP
syndrome
Extract:
History and Physical
Body System
Findings
General
Client reports a 1-week history of general malaise, fever and chills, night sweats, fatigue, and
poor appetite. Client has poorly controlled hypertension, hypercholesterolemia, and mitral
valve prolapse and regurgitation.
Eye, Ear, Nose, and
Throat (EENT)
Poor dental hygiene. Client reports having 2 teeth extracted 3 weeks ago.
Pulmonary
Vital signs are RR 18 and SpO, 96% on room air. Lungs are clear to auscultation bilaterally.
Cardiovascular
Vital signs are T 100.4 F (38 C), P 105, and BP 140/82. Sinus tachycardia with occasional
premature ventricular contractions on cardiac monitor. S1 and S2 heard on auscultation with
loud systolic murmur at the apex. Peripheral pulses 2+; no edema noted.
Integumentary
Small, erythematous macular lesions on both palms. Thin, brown longitudinal lines on several
nail beds.
Question 4 of 5
The nurse is preparing to administer the first dose of the prescribed IVPB antibiotic. Which 2 actions are most appropriate for the nurse to perform prior to initiating the infusion?
Correct Answer: B,C
Rationale: Antibiotic therapy is a critical component of treatment for clients with infective endocarditis (E). Before administering IV
antibiotics, the nurse should first obtain blood cultures to identify the infectious organism. Broad-spectrum antibiotics are
started initially. Targeted antibiotic therapy can be administered once the blood cultures identify the culprit organisms and their
antimicrobial susceptibilities. Before starting any medication, the nurse should ask about the client's medication allergies to
identify contraindications to therapy
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
Question 5 of 5
The client is diagnosed with hyperemesis gravidarum and is planning care with the registered nurse. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.
| Potential Intervention | Indicated | Contraindicated |
|---|---|---|
| Give clear liquids | ||
| Weigh the client daily | ||
| Obtain a 12-lead ECG | ||
| Administer enteral nutrition | ||
| Initiate a large-bore peripheral IV | ||
| Document strict intake and output | ||
| Auscultate the fetal heart rate intermittently |
Correct Answer:
Rationale: When caring for clients with hyperemesis gravidarum (HG), the primary goal is to alleviate vomiting, replenish fluids, and correct electrolyte
and nutritional imbalances. Once completed, resumption of oral intake can be attempted. Interventions that are indicated at this time
include:
• Weighing the client daily to monitor for additional weight loss
• Obtaining a 12-lead ECG to monitor for cardiac changes related to electrolyte imbalances (eg, hypokalemia)
• Initiating a large-bore peripheral IV (eg, 18-gauge) to allow for administration of fluids and medications
• Documenting strict intake and output (eg, emesis, urinary output) to monitor hydration status and kidney function
• Auscultating the fetal heart rate intermittently (eg, twice daily, once per shift) to verify fetal status. (Continuous fetal heart rate
monitoring is not indicated at this gestational age.)
Many clients with HG cannot tolerate anything by mouth and are typically placed on a short period of gut rest (ie, NPO status), if hospitalized.
Therefore, giving clear liquids is contraindicated during the initial treatment phase of HG but should be offered once nausea and vomiting
have stopped. For the same reasons, administering enteral nutrition (eg, tube feeding) is contraindicated initially for this client and is not
anticipated unless feedings by mouth and other treatment measures fail.