NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
The nurse is caring for a 24-year-old client.
Nurses' Notes
Emergency Department
1300:
The client is brought to the emergency department after a motor vehicle collision in which the driver's side airbag deployed.
The client was driving the vehicle and was not restrained by a seat belt. The client reports shortness of breath and chest
pain on inspiration and expiration.
History and Physical
Body System ,Findings
Neurological,
Awake, alert, and oriented to person; pupils equal, round, and reactive to light and accommodation; client is
agitated and moves all extremities spontaneously but does not follow commands
Integumentary, Superficial lacerations to the face; diffuse bruising noted on upper extremities and chest wall
Pulmonary,
Vital signs: RR 30, SpOz 92% via nonrebreather mask; unilateral chest wall expansion observed on inspiration;
left-sided tracheal deviation noted; breath sounds diminished throughout the right lung field
Cardiovascular,
Vital signs: P 104, BP 90/58; S1 and S2 heard on auscultation; all pulses palpable; no extremity peripheral edema
noted
Psychosocial ,Alcohol odor noted on the client's breath
Diagnostic Results
Chest X-ray
Accumulation of air in the pleural cavity, tracheal deviation to the left. Findings consistent with a tension pneumothorax.
Question 1 of 5
The nurse has reviewed the information from the Diagnostic Results. The nurse should help prepare the client for which intervention?
Correct Answer: A
Rationale: The treatment for a pneumothorax is a chest tube connected to a water seal chamber, often to wall suction. The water seal drainage syste
prevents air from reentering the pleural space through the chest wall, allows reestablishment of negative pressure, and promotes movement
of air from the pleural space (Option 1).
Extract:
The nurse is caring for a 64-year-old client.
History and Physical
Body System, Findings
General ,
The client reports a 24-hour history of blurred vision and redness in the left eye with a left-sided headache.
This evening, the client developed acute, severe pain in the left eye accompanied by occasional nausea and
vomiting. The client reports no use of systemic or topical eye medications. Medical history includes
osteoarthritis and hypercholesterolemia.
Eye, Ear, Nose, and Throat (EENT),
The client wears eyeglasses to correct farsighted vision. Right eye: pupil 2 mm and reactive to light,
conjunctiva clear. Left eye: pupil 4 mm and nonreactive to light with red conjunctiva. Bilateral lens opacity is noted.
Pulmonary,
Vital signs are RR 20 and SpO, 96% on room air. The lungs are clear to auscultation bilaterally.
Cardiovascular,
Vital signs are T 99 F (37.2 C), P 88, and BP 140/82.
Psychosocial,
The client reports a great deal of emotional stress following the recent death of the client's spouse that is accompanied by lack of sleep, poor appetite, and a 7.9-lb (3.6-kg) weight loss within the past month. The client takes diphenhydramine for sleep.
Question 2 of 5
For each finding below, click to specify if the finding is consistent with the disease process of acute angle-closure glaucoma, cataracts, or macular degeneration. Each finding may support more than one disease process.
| Finding | Acute Angle-Closure Glaucoma | Cataracts | Macular Degeneration |
|---|---|---|---|
| Blind spots | |||
| Opaque lens | |||
| Blurred vision | |||
| Unilateral headache | |||
| Conjunctival redness | |||
| Nausea and vomiting | |||
| Increased intraocular pressure |
Correct Answer:
Rationale: Acute angle-closure glaucoma (ACG) is the sudden onset of increased intraocular pressure (IOP) due to impaired aqueous humor drainag
through the angle of the anterior chamber. Acute ACG typically occurs spontaneously but may be triggered by impaired aqueous outflow frol
pupillary dilation (eg, emotional excitement, medications (decongestants, anticholinergics, antihistamines], darkness). As IOP increases,
clients report seeing halos around lights and/or develop blurry vision, unilateral headache, conjunctival redness, and nausea and
vomiting. Increased IOP damages the optic nerve, and the cornea becomes edematous; therefore, light cannot travel effectively from the
cornea to the optic nerve, causing halos to be seen.
Cataracts are a slowly progressive pacification of the lens that results from oxidative damage. Refractive changes in the lens cause clients
to initially develop difficulty reading fine print because of the opaque lens. As the cataract progresses, clients develop painless, blurry visio
and have difficulty with nighttime driving because they see a glare and halos around lights. Halos and glare occur because light cannot
travel through the opacified lens effectively and instead disperses in various angles.
Age-related macular degeneration (AM
D) is a progressive, incurable disease of the eye characterized by deterioration of the macula, the
central portion of the retina. This deterioration causes visual disturbances (wavy or blurred vision), blind spots, or loss of the central field
vision; peripheral vision remains intact. AMD has a vascular pathogenesis that is unrelated to increased IOP. Clients with AMD have a norm
cornea, lens, and optic nerve; therefore, halos are not seen.
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)
Question 3 of 5
The nurse has reviewed the information from the Laboratory Results., For each client finding below, click to specify if the finding is consistent with the disease process of diabetic ketoacidosis or hyperosmolar hyperglycemic state. Each finding may support more than one disease process.
| Client Finding | Diabetic Ketoacidosis | Hyperosmolar Hyperglycemia State |
|---|---|---|
| P 110 | ||
| pH 7.2 | ||
| BP 98/58 | ||
| Poor skin turgor | ||
| Fruity breath odor | ||
| Positive urine ketones | ||
| Kussmaul respiration |
Correct Answer:
Rationale: Diabetic ketoacidosis (DK
A) and hyperosmolar hyperglycemic state (HHS) are potentially life-threatening complications of diabetes mellitus
(DM). Clients with a decreased level of consciousness, hyperglycemia, electrolyte imbalances, and signs of dehydration should be evaluate
for both DKA and HHS.
DKA is more common in type 1 DM caused by hypoinsulinemia, resulting in hyperglycemia, metabolic acidosis (le, low pH), ketosis (le,
positive ketones in the urine and fruity odor on the breath), and severe dehydration (eg, poor skin turgor, tachycardia, hypotension)
due to osmotic water loss caused by glucosuria. Glucose and potassium are unable to enter the cell due to lack of insulin, causing electroly
imbalances. Kussmaul respirations are deep, rapid breaths that compensate for metabolic acidosis by expelling carbon dioxide (le, an acid)
HHS is characterized by high plasma osmolality and extreme hyperglycemia. Osmolality is increased with dehydration. HHS is more
common in type 2 DM due to a small amount of insulin available to prevent ketosis.
Therefore, clients with HHS have a near normal pH leve
and minimal to no urine ketones. Osmotic diuresis and polyuria create a significant fluid volume deficit, causing electrolyte imbalances and
dehydration (eg, poor skin turgor, tachycardia, hypotension), which can lead to hypovolemic shock.
Educational objective:
Extract:
History and Physical
Body System,Findings
General
Client has history of coronary artery disease, hypertension, hyperlipidemia, diverticulosis, and
osteoarthritis; Helicobacter pylori infection 2 years ago; client reports taking over-the-counter
ibuprofen every 8 hours for left knee pain for the past 2 weeks; daily medications include aspirin,
carvedilol, lisinopril, and atorvastatin
Neurological
Alert and oriented to person, place, time, and situation
Pulmonary
Vital signs: RR 20, SpO 96% on room air, lung sounds clear bilaterally; no shortness of breath;
client smokes 1 pack of cigarettes per day and smokes marijuana 1 or 2 times weekly
Cardiovascular
Vital signs: P 110, BP 90/62; no chest pain; S1 and S2 heard on auscultation; peripheral pulses
2+; client states feeling lightheaded and reports passing out about 1 hour ago
Gastrointestinal
Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis; two episodes of
large, black, liquid stools in the morning
Musculoskeletal
Examination of the knees shows crepitus that is worse on the left; no swelling, warmth, or
erythema; range of motion is normal
Psychosocial
Client reports drinking 1 or 2 glasses of wine per day
Question 4 of 5
The nurse has reviewed the information from the Laboratory Results. The health care provider suspects the client is experiencing upper gastrointestinal bleeding. For each potential prescription, click to specify whether the prescription is anticipated or unanticipated for the care of the client.
| Potential Prescription | Anticipated |
|---|---|
| Place the client on NPO status | |
| Administer isotonic IV fluid bolus | |
| Administer proton pump inhibitor IV | |
| Collect blood samples for type and crossmatch | |
| Administer heparin for deep venous thrombosis prophylaxis |
Correct Answer:
Rationale: Anticipated prescriptions for a client with upper gastrointestinal (GI) bleeding include:
• Placing the client on NPO status to reduce the risk of continued bleeding and vomiting. NPO status is important to
initiate prior to esophagogastroduodenoscopy to reduce aspiration risk.
• Administering an isotonic IV fluid bolus to restore circulating fluid volume and maintain perfusion of vital organs.
• Administering a proton pump inhibitor IV (eg, pantoprazole) to reduce gastric acid secretion and prevent further
irritation and breakdown of suspected peptic ulcers.
• Collecting blood samples for type and crossmatch to ensure blood type compatibility before initiating a blood
transfusion. This client's hemoglobin and hematocrit levels are low, and the client continues to have active bleeding.
Therefore, a blood transfusion should be anticipated to increase blood volume and improve oxygenation and perfusion.
Administering heparin for deep venous thrombosis prophylaxis is not anticipated. Anticoagulation will prolong bleeding
and increase risk for hemorrhagic shock. Anticoagulation is contraindicated for clients with active GI bleeding.
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.