NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
Nurses' Notes
Outpatient Clinic
Initial
visit
The child recently started attending a new preschool and hit a teacher during lunch. The parent says, "My
child has never been aggressive before but has always been particular about food."
The client was born at full term without complications and has no significant medical history. The child
started babbling at age 6 months, and the parent reports that the first words were spoken around age 12
months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color.
The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vitals signs are
normal, and the client is tracking adequately on growth curves.
During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow
the parents gaze when the parent points to toys in the office. The child begins screaming and rocking back
and forth when the health care provider comes near.
Question 1 of 5
The client is diagnosed with autism spectrum disorder (ASD). The nurse recognizes that clients with ASD are at risk for which of the following complications? Select all that apply.
Correct Answer: A,BC,D,E
Rationale: Autism spectrum disorder (AS
D) begins in the developmental period, and symptoms tend to persist throughout the lifespan.
Clients with ASD are more prone to medical, psychiatric, and psychosocial impairments. These impairments include the
following:
• Impaired interpersonal relationships: Clients with ASD may be disinterested in social interaction and have difficulty
showing affection and interpreting conversation
• Learning difficulties: Clients with ASD may have trouble focusing on tasks and have a limited range of learning
interests (eg, preferring only math), making it challenging to engage them in other areas of learning (Option 2).
• Malnutrition: Clients with ASD can have a narrowed interest in foods, resulting in insufficient intake of necessary
nutrients. In addition, clients with ASD often experience gastrointestinal disturbances, including constipation and
diarrhea, due to narrowed food intake
• Self-harm behaviors: Changes in routine and environment can trigger repetitive or harmful behaviors (eg, head-
banging, hand-biting). When self-harm behaviors persist into adulthood, they may be preceded by suicide attempts
related to coexisting psychiatric comorbidities (eg, depression, anxiety)
• Sleep disturbances: Clients with ASD often experience difficulty falling and staying asleep. Hyperresponsiveness to
sensory stimulation (eg, lights, noises, sensations) can also contribute to disruptive sleeping patterns
Extract:
The nurse is caring for a 16-year-old client.History and Physical
Body System, Finding
General,
Client is brought to the emergency department due to nausea, vomiting, and abdominal pain that began 24 hr
ago. Client has type 1 diabetes mellitus and usually takes insulin. Parents state that the client was at an
overnight camp for the past 4 days and are unsure of how much insulin the client has been taking.
Neurological,
Client is lethargic but arousable to voice. The pupils are equal, round, and reactive to light and accommodation.
Integumentary,
Mucous membranes are dry, skin turgor is poor.
Pulmonary,
Vital signs are RR 36 and SpOz 95% on room air. Lung sounds are clear to auscultation. Deep respirations and a
fruity odor on the breath are noted.
Cardiovascular,
Vital signs are T 98.4 F (36.9 C), P 110, and BP 98/58. Pulses are 3+ on all extremities, and capillary refill time is
4 sec.
Gastrointestinal Normoactive bowel sounds are heard in all 4 quadrants; the abdomen is nontender.
Genitourinary,
Client voided dark yellow urine.
Endocrine,
Client is prescribed levothyroxine daily for hypothyroidism and has missed one dose of levothyroxine.
Psychosocial,
Parents state that the client has been sad and slightly withdrawn for the past 2 weeks after ending a romantic relationship.
Laboratory Results
Laboratory Test and Reference Range, 1000, 1600
Blood Chemistry.
Glucose (random)
≤200 mg/dL
(≤11.1 mmol/L),
504 mg/dL
(28.0 mmol/L),
164 mg/dL
(9.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L),
133 mEq/L
(133 mmol/L),
135 mEq/L
(135 mmol/L)
Chloride
98-106 mEq/L
(98-106 mmol/L),
101 mEq/L
(101 mmol/L),
102 mEq/L
(102 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.6 mEq/L
(5.6 mmol/L),
3.2 mEq/L
(3.2 mmol/L)
Arterial Blood Gases
Arterial pH
7.35-7.45
(7.35-7.45),
7.20
(7.20),
7.31
(7.31)
HCOg
21-28 mEq/L
(21-28 mmol/L),
13 mEq/L
(13 mmol/L),
18 mEq/L
(18 mmol/L)
PaCO,
35-45 mm Hg
(4.66-5.98 kPa),
30 mm Hg
(3.99 KPa),
32 mm Hg
(4.26 kPa)
PaO,
80-100 mm Hg
(10.64-13.33 KPa),
90 mm Hg
(11.97 kPa),
90 mm Hg
(11.97 kPa)
Nurses' Notes
1600:
0.9% sodium chloride and regular insulin IV are continuously infusing. Lung sounds are clear to auscultation. Urine output
is 90 mL over the past 2 hr.
Vital signs are T 99 F (37.2 C), P 105, RR 28, BP 110/72, and SpO, 95% on room air.
Question 2 of 5
The nurse has reviewed the information from the Laboratory Results and Nurses' Notes. Which of the following nursing actions are anticipated? Select all that apply
Correct Answer: A,B
Rationale: The goal of treatment of diabetic ketoacidosis (DK
A) is to normalize fluid volume, decrease blood glucose levels, balance electrolytes, and
correct metabolic acidosis. On administration of insulin, potassium and glucose shift from the extracellular space to the intracellular space.
Clients with DKA require potassium administration due to low intracellular potassium levels.
Insulin is administered to facilitate glucose transport into the intracellular space to resolve DKA and should be continued until the metabolic
acidosis resolves. When caring for clients with DKA, the nurse should anticipate:
• Adding 5% dextrose to continuous IV fluids when the serum blood glucose level reaches approximately 200 mg/dL (11.1 mmol/L) to
prevent hypoglycemia and cerebral edema resulting from levels decreasing too quickly (Option 1). This is done because insulin is still
required to resolve DKA. If the DKA is resolved, insulin can also be decreased instead of adding dextrose to the IV fluids.
• Administering potassium chloride for a client with hypokalemia and adequate urine output (ie, >30 mL/hr) to prevent life-threatening
arrhythmias
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 3 of 5
Select below the 4 findings that are most concerning at this time.
Correct Answer: B,C,D,F
Rationale: This client has multiple findings concerning for infective endocarditis (IE), which occurs when an infectious organism enters the
innermost layer of the heart (ie, endocardium) and forms a vegetation on a heart valve. Findings concerning for IE include:
• Recent tooth extraction: Dental procedures (eg, tooth extraction) increase the risk for infectious organisms entering the
bloodstream, potentially leading to IE. Other risk factors include a history of IV drug use, presence of a distant infection
(eg, leg cellulitis), or presence of a prosthetic heart valve
• Fever: Elevated temperature is a sign of infection, which is a common finding in clients with IE.
• Nontender, erythematous, macular lesions on the palms or soles (Janeway lesions): Janeway lesions are
characteristic of IE. They occur when turbulent blood flow through the heart valves causes pieces of endocardial
vegetation to break off, forming microemboli that travel through the arteries to end-capillaries and block blood flow.
• Nonblanching, thin, red/dark longitudinal lines under the nail beds (splinter hemorrhages): Like Janeway lesions,
splinter hemorrhages are caused by microemboli that break off from vegetative lesions in the heart and travel through the
arteries to end-capillaries and block blood flow.
Extract:
Nurses' Notes
Outpatient Clinic
Initial
visit
The child recently started attending a new preschool and hit a teacher during lunch. The parent says,
"My
child has never been aggressive before but has always been particular about food."
The client was born at full term without complications and has no significant medical history. The child
started babbling at age 6 months, and the parent reports that the first words were spoken around age 12
months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color.
The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vitals signs are
normal, and the client is tracking adequately on growth curves.
During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow
the parents gaze when the parent points to toys in the office. The child begins screaming and rocking back
and forth when the health care provider comes near.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
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)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%
Question 4 of 5
For each finding below, click to specify if the finding is consistent with the expected action of the medication carvedilol, enalapril, or furosemide. Each finding may support more than one medication.
| Finding | Carvedilol | Enalapril | Furosemide |
|---|---|---|---|
| Decreases heart rate | |||
| Increases urinary output | |||
| Decreases blood pressure | |||
| Increases oxygen saturation |
Correct Answer:
Rationale: Pharmacologic management of heart failure (HF) focuses on reducing cardiac workload and improving cardiac output.
• Beta-adrenergic antagonists ("beta blockers") (eg, carvedilol) reduce cardiac workload by inhibiting the action of
catecholamines (eg, epinephrine, norepinephrine) on beta-adrenergic receptors in the heart. Beta blockers decrease
myocardial oxygen demand by decreasing blood pressure and decreasing heart rate.
• Angiotensin-converting enzyme (ACE) inhibitors (eg, enalapril) alter the renin-angiotensin-aldosterone system by
inhibiting conversion of angiotensin I to angiotensin II, thereby preventing the release of aldosterone. Aldosterone, an
adrenal steroid hormone, retains sodium and water in addition to promoting vasoconstriction. By reducing circulating
aldosterone, ACE inhibitors promote vasodilation and as a result decrease blood pressure. ACE inhibitors also
decrease ventricular remodeling, an added benefit for clients with HF.
• Loop diuretics (eg, furosemide) prevent reabsorption of sodium and chloride in the kidneys, which increases urine
output and fluid excretion. Decreases in circulating fluid volume will decrease blood pressure and reduce pulmonary
edema (ie, increase oxygen saturation), as well as decrease cardiac preload.
Extract:
History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the
roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The
client admits having attempted to jump off the building and wishes the police had not intervened. The
client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The
client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time.
The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks,
and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings
of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client
reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Laboratory Results
Laboratory Test and Reference Range,Admission
Urine drug screen
Cocaine
Negative
Positive,
Opioid
Negative
Negative,
Amphetamines
Negative
Negative,
Marijuana
Negative
Positive,
Phencyclidine
Negative
Negative,
Benzodiazepines
Negative
Negative,
Barbiturates
Negative
Negative,
Breathalyzer
No alcoho detected
0.00
Question 5 of 5
The client is admitted to the inpatient mental health unit. For each potential intervention, click to specify if the intervention is appropriate or not appropriate for the care of the client.
| Potential Intervention | Appropriate | Not Appropriate |
|---|---|---|
| Assign the client to a shared room if available | ||
| Avoid placing utensils on the client's meal tray | ||
| Check on the client at frequent, irregular intervals | ||
| Perform frequent room searches for harmful objects | ||
| Perform mouth checks after medication administration | ||
| Encourage the client to participate in grooming and hygiene | ||
| Avoid discussion of suicidal thoughts when talking to the client |
Correct Answer:
Rationale: Appropriate interventions for the client with major depressive disorder who is experiencing suicidal ideation include the
following:
• Assigning the client to a shared room near the nurses' station to reduce social isolation and allow easier access to the
client
• Avoiding utensils on the client's meal tray that could be used for self-harm
• Checking on the client at frequent, irregular intervals (if not under 1-to-1 observation) to lessen predictability of staff
surveillance
• Performing frequent room searches for harmful objects to ensure client safety
• Performing mouth checks after medication administration to ensure the client has swallowed medication and is not
saving them for a future overdose attempt
• Encouraging the client to participate in grooming and hygiene because the client may exhibit loss of interest in daily
activities, decreased energy, and lack of motivation
Avoiding discussion of suicidal thoughts is not appropriate. Clients with suicidal ideation are often reluctant to disclose
their thoughts unless asked directly. The nurse should establish a nonjudgmental, therapeutic relationship that allows for open
communication.
It is not appropriate for the nurse to document that the client is not available for a safety check when the client is using the
restroom. The nurse must ensure that there is visual contact with the client during safety checks, even if the client is in the
restroom, to ensure safety.