NCLEX-PN
NCLEX PN Practice Test with NGN Questions
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.
Nurses' Notes
0920:
Nebulized administration of albuterol (salbutamol) and ipratropium bromide completed. Client continues to have a dry cough. Breath sounds are clear to auscultation; no intercostal retractions are visible.
Vital signs: RR 24, SpO2 96% on 6 L humidified oxygen via nasal cannula.
Question 1 of 5
Select the findings that indicate the client is progressing as expected.
Correct Answer: C,D,E
Rationale: C: Clear breath sounds indicate improved airflow. D: Absence of intercostal retractions suggests reduced respiratory effort. E: RR 24 and SpO2 96% reflect improved oxygenation and respiratory status post-treatment.
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 2 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 in the surgical unit is caring for a 57-year-old client who underwent an abdominal hysterectomy.
Progress Notes
1 Day Postoperative
0800:
The client underwent total abdominal hysterectomy with bilateral oophorectomy and tumor debulking 1 day ago for treatment of ovarian cancer. She has had four episodes of vomiting with bilious emesis over the past 12 hours, which have continued despite V antiemetic administration. The client has been receiving V broad-spectrum antibiotics since the procedure. The skin is warm. A low transverse abdominal incision is present; staples are clean and dry. Chest expansion is symmetric; respirations are unlabored: diminished breath sounds are auscultated in bilateral lower lobes. Radial pulses 2+ bilaterally, capillary refill <3 seconds in all four extremities; no peripheral edema is noted. The client reports frequent hot flashes occurring roughly every hour, starting last night. The abdomen is markedly distended and tender to palpation. Bowel sounds are absent in all four quadrants; the client reports no flatus. Urine is clear yellow with moderate output. The client reports incontinence with coughing or during episodes of vomiting.
Question 3 of 5
Select the findings that require immediate follow up.
Correct Answer: B,E
Rationale: B: Requires follow-up - Persistent vomiting despite antiemetics suggests a postoperative complication like ileus or obstruction. E: Requires follow-up - Abdominal distension and tenderness indicate potential ileus or obstruction, requiring urgent evaluation. A, C, D: Do not require immediate follow-up as they are expected or less urgent.
Extract:
The nurse is caring for a 58-year-old client on a medical-surgical unit.
History and Physical
General
The client is vomiting bright red blood; medical history includes alcohol use disorder, liver cirrhosis, and hypertension; the client was admitted a year ago for alcohol-induced acute pancreatitis
Neurological
The client is oriented to person and place; the pupils are equal, round, and reactive to light and accommodation
Eye, Ear, Nose, and Throat (EENT)
Yellow scleras are noted
Pulmonary
Vital signs are RR 18, SpO 94% on room air
Cardiovascular
Vital signs are T 99 F (37.2 C), P 102, BP 90/40; S1 and S2 are heard on auscultation; peripheral pulses are 2+ in all extremities; 1+ edema is noted at the bilateral lower extremities
Gastrointestinal
The abdomen is distended and nontender to palpation; the flanks are dull to percussion; bowel sounds are hypoactive; distended veins are present around the umbilicus
Genitourinary
Client is voiding amber-colored urine
Nurses’ notes.
Postoperative Day 1
1000:
The client underwent banding of esophageal varices 1 day ago. Today, the client is somnolent and oriented to person only. Speech is slurred. Flapping tremors are present in the clients arms and hands. The abdomen is soft and distended; bowel sounds are present. Dark-colored stool is noted. Amber-colored urine is noted. Vital signs are T 98.2 F (36.8 C), P 85, RR 24, BP 132/76, SpOz 94% on room air.
Question 4 of 5
For each finding, specify if the finding is expected or unexpected for this client.
| Finding | Expected | Unexpected |
|---|---|---|
| Respiratory | ||
| Neurological | ||
| Genitourinary | ||
| Cardiovascular | ||
| Gastrointestinal | ||
| Musculoskeletal |
Correct Answer: A: Expected, B: Expected, C: Expected, D: Expected, E: Expected, F: Unexpected
Rationale:
A) Expected: RR 24 is slightly elevated but consistent with cirrhosis and post-op status.
B) Expected: Somnolence, disorientation, slurred speech, and flapping tremors indicate hepatic encephalopathy, common in cirrhosis.
C) Expected: Amber urine is typical in cirrhosis due to dehydration or bilirubin.
D) Expected: Stabilized vitals (BP 132/76, P 85) are post-treatment improvements. E) Expected: Dark stool is from variceal bleeding or banding, and distended abdomen is from ascites. F) Unexpected: No musculoskeletal issues (e.g., tremors are neurological) are noted.
Extract:
The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.
Question 5 of 5
The nurse should prioritize interventions for due to the risk of
Correct Answer: C
Rationale: The client's consumption of ≥4 alcoholic beverages per day indicates a risk of alcohol withdrawal, which can be life-threatening and requires prioritized intervention.