NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
Extract:
The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.
Question 1 of 5
Select to highlight below the 4 findings that require immediate follow up.
Correct Answer: A,B,C,D
Rationale: Dangerous behavior , delusions with violent intent , paranoid history , and social withdrawal indicate acute psychosis requiring urgent intervention.
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
Which of the following findings indicate that the newborn's condition has declined? Select all that apply.
Correct Answer: A,B,C
Rationale: Hypothermia , hypoglycemia , and jitteriness indicate decline, requiring intervention.
Extract:
The nurse is contacting a client at 28 weeks gestation to review laboratory results and schedule a follow-up prenatal visit. Laboratory Results Laboratory Test and Reference Range 12 Weeks Gestation 26 Weeks Gestation 28 Weeks Gestation
WBC (prostent) 5,000-1多份 (5.0-15.0 × 10°/L) 8,900/mm3 (8.9 × 10°/L) 16,500 /mm° (16.5 × 10%/L)
Hemoglobin (pregnant) 11-16 g/dL (110-160 g/L) 13 g/dL (130 g/L) 10.8 g/dL (108 g/L) Hematocrit (pregnant) 33%-47% (0.33-0.47) 39% (0.39) 32% (0.32)
Chlamydia Negative Positive Negative Hemoglobin A1c 4.0%-5.9% 5.1%
1-hour oral glucose challenge test <140 mg/dL (7.8 mmol/L) 175 mg/dL (9.7 mmol/L)
3-hour oral glucose tolerance test Fasting: <110 mg/dL (6.1 mmol/L) 1 hour: <180 mg/dL (10.0 mmol/L) 2 hour: <140 mg/dL (7.8 mmol/L 3 hour: <70-115 mg/dL (<6.4 mmol/L) Fasting: 115 mg/dL (6.4 mmol/L) 1 hour: 205 mg/dL (11.4 mmol/L) 2 hour: 162 mg/dL (9.0 mg/dL) 3 hour: 135 mg/dL (7.5 mg/dL)
Question 3 of 5
Which clinical findings require further follow-up? Select all that apply.
Correct Answer: A,D,E
Rationale: Crepitus suggests fracture, jitteriness indicates hypoglycemia, and decreased Moro reflex may indicate nerve injury.
Question 4 of 5
Which of the following potential complications could occur as a result of the diagnosis? Select all that apply.
Correct Answer: B,C,E
Rationale: Gestational diabetes increases risks for macrosomia , shoulder dystocia , and polyhydramnios .
Question 5 of 5
The client, gravida 3 para 2, at 38 weeks gestation is admitted at 0700 for induction of labor. Which action is a priority?
Correct Answer: C
Rationale: Checking blood glucose is critical during labor induction to manage gestational diabetes.