NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
Extract:
The nurse is caring for a 43-year-old client.
Nurses' Notes Vital Signs
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
Question 1 of 5
Select the 4 complications the client is most at risk for developing.
Correct Answer: A,B,C,E
Rationale: Guillain-Barré syndrome risks include aspiration , pressure injuries , respiratory failure , and thromboembolism due to immobility and respiratory involvement.
Extract:
The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.
Question 2 of 5
For each nursing action, click to specify if the action is indicated or not indicated for the care of the newborn during a heel stick.
| Nursing Action | Indicated | Not Indicated |
|---|---|---|
| Warm the heel prior to initiating the procedure | ||
| Collect the first drop of blood for blood glucose testing | ||
| Draw blood by pricking the skin with a small-gauge needle | ||
| Obtain the blood specimen from the lateral aspect of the heel | ||
| Clean the heel with an alcohol pad prior to obtaining the blood specimen |
Correct Answer: A,C,D,E
Rationale: Warming the heel , using a needle , lateral heel site , and cleaning are standard. The first drop is discarded to avoid contamination.
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
For each finding below, click to specify if the finding is consistent with the disease process of spinal cord compression or syndrome of inappropriate antidiuretic hormone.
| Finding | Spinal Cord Compression | Syndrome of Inappropriate Antidiuretic Hormone |
|---|---|---|
| Back pain | ||
| Confusion | ||
| Constipation | ||
| Urinary retention | ||
| Numbness in lower extremities |
Correct Answer: A,B,C,D,E
Rationale: Back pain , constipation , urinary retention , and numbness are typical of spinal cord compression. Confusion is associated with SIADH.
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 4 of 5
Which of the following client findings are consistent with a cystic fibrosis exacerbation? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: Cystic fibrosis exacerbations often present with increased respiratory symptoms (A, C,
D), fever , and malabsorption issues due to pancreatic insufficiency.
Extract:
The nurse is caring for a 16-year-old client.
History and Physical Laboratory Results
Body System- Findings
General- The client comes to the emergency department with pain in the upper back, both knees, and the lower legs that is rated as 9 on a scale of 0-10; medical history includes sickle cell disease; the client reports attending an outdoor sports camp for the past 4 days; the client appears restless with frequent position changes and facial grimacing
Neurological- The client is alert and oriented to person, place, and time
Pulmonary- Vital signs: RR 24, SpOz 95% on room air, breath sounds are clear bilaterally Cardiovascular- Vital signs: T 98.4 F (36.9 C), P 120, BP 130/78; S1 and S2 are auscultated with no murmurs, continuous cardiac monitor shows sinus tachycardia
Gastrointestinal- The abdomen is soft and nontender with normal bowel sounds; the client vomited 30 mL of clear liquid
Musculoskeletal- The client has multiple, tender, bony points
Genitourinary- The client voided 50 mL of clear, amber-colored urine
Question 5 of 5
Click to highlight below the 4 findings that require immediate follow-up.
| Pain in the upper back, both knees, and the lower legs that is rated as 9 on a scale of 0-10; medical history includes sickle cell disease, the client reports attending an outdoor sports camp for the past 4 days |
| The client appears restless with frequent position changes and facial grimacing |
| Vital signs: RR 24, SpO2 95% on room air; breath sounds are clear bilaterally |
| Vital signs: T 98.4 F (36.9 C), P 120, BP 130/78; S1 and S2 are auscultated with no murmurs; continuous cardiac monitor shows sinus tachycardia |
| The client vomited 30 mL of clear liquid |
| The client has multiple, tender, bony points |
| The client voided 50 mL of clear, amber-colored urine |
Correct Answer: A,B,D,F
Rationale: Severe pain , distress signs , tachycardia , and bony tenderness indicate a sickle cell crisis, requiring urgent management.