NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
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 1 of 5
The client is most likely experiencing ....... and is at risk for.......
Correct Answer: C,E
Rationale: Severe pain and tachycardia suggest a sickle cell pain episode , with risk for ischemic organ damage due to vaso-occlusion.
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 2 of 5
Click to highlight below the assessment findings that require immediate follow-up?
| 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 |
| Alert and oriented to person, place, and time; no neurologic deficits |
| Vital signs: RR 30, SpO2 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 |
| 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 seconds; mild finger clubbing noted |
| 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' |
Correct Answer: A,C,D,E
Rationale: Findings A, C, D, and E indicate urgent issues: shortness of breath with a history of cystic fibrosis , low oxygen saturation and respiratory distress , fever and tachycardia , and malabsorption symptoms require immediate intervention.
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 3 of 5
The nurse should notify the health care provider about which client data?
Correct Answer: A
Rationale: Miosis suggests opioid overdose, requiring immediate provider notification.
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 4 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 caring for a 23-year-old client. Nurses' Notes Vital Signs Medication Administration Record
Inpatient Unit Admission:
The client was found alone in a public park shouting at people who were not present. The client told the staff, "There's nothing wrong with me. It's just the effects of the microchip that was implanted in my head." The client is not oriented to place or time. Day 7: The client has developed confusion, fever, and diaphoresis. Speech is slurred Muscular rigidity is observed in all extremities. Deep tendon reflexes are 2+; no clonus is noted
Question 5 of 5
The nurse recognizes that the client is most likely experiencing which is a complication of
Correct Answer: C,F
Rationale: Neuroleptic malignant syndrome is a complication of antipsychotics like olanzapine , presenting with fever, rigidity, and confusion.