NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
Nurses' Notes
Initial Clinic Visit
1100:
The client has experienced enuresis at night for the past 2 weeks and frequently requests to use the
bathroom while at school. The client was previously toilet trained with no nighttime bed wetting for 6 months;
the client recently relocated to a new home and school where the client lives with parents.
The parent reports that the client has recently demonstrated fatigue, irritability, and multiple behavioral
outbursts that resemble past temper tantrums. The client frequently reports feeling thirsty. No dysuria or
urinary hesitancy is reported.
Weight and height were in the 40th percentiles at the previous visit a year ago. Growth charts today show
the client's weight in the 20th percentile and height in the 40th percentile.
The client appears tired and irritable. Dry mucous membranes are noted with no increased work of
breathing. The lungs are clear to auscultation bilaterally. No cardiac murmur is heard.
Question 1 of 5
The nurse has reviewed the information from the Laboratory Results. Complete the following sentence/sentences by choosing from the list/lists of options. Complete the following sentence by choosing from the lists of options . The client is most likely experiencing---------- and requires ------------- to prevent-------------
Correct Answer: B,D,F
Rationale: The client is most likely experiencing diabetes mellitus (DM) and requires blood glucose management to prevent
hyperglycemia.
A urinalysis positive for glucose and ketones are manifestations that should raise suspicion of DM. Ketones are produced
when the body cannot use glucose for energy and breaks down fat stores instead. Ketonuria is a sign of diabetic ketoacidosis
(DK
A), a life-threatening complication of DM. Clients with new-onset type 1 DM often present with DKA. Blood glucose
management in those with type 1 DM will require insulin administration.
Extract:
The nurse is caring for a 20-year-old client.
Progress Notes
Clinic Visit
For the past week, the client has experienced flu-like symptoms, including low-grade fevers, headaches, nausea, vomiting, and, today,
diarrhea and dark urine. The client reports widespread itching but has no rash. Skin and scleras are jaundiced. No lymphadenopathy
is present, and the abdomen is nondistended with a palpable liver edge. The client returned from an international mission trip a few
weeks ago.
Vital signs are T 99.9 F (37.7 C), P 88, RR 18, BP 128/80, and SpOz 98% on room air.
Laboratory Results
Laboratory Test and Reference Range ,Current
Liver Function Tests
Total bilirubin, Increased
Alkaline phosphatase, Increased
Aspartate aminotransferase (AST), Increased
Alanine aminotransferase (ALT) ,Increased
Question 2 of 5
Complete the following sentence by choosing from the lists of options. The nurse suspects the client has ----------- and should implement ----------- precautions.
Correct Answer: D,E
Rationale: Hepatitis A is an infection that leads to widespread inflammation of the liver. Transmission occurs through the fecal-oral route and is commo
in areas with overcrowding and poor sanitation. Outbreaks frequently result from contaminated water or food, and the condition is seen
primarily in resource-limited countries. Symptoms develop abruptly, initially including nausea, vomiting, anorexia, fever, and right upper
quadrant pain. A few days later, dark urine (bilirubinuria) and/or pale stools (lacking bilirubin pigment) may be seen. These are usually
followed by jaundice and pruritus. In addition, laboratory results show elevated liver function tests.
Hand hygiene, especially after toileting and before meals, is the most important intervention for reducing the risk of hepatitis A infection.
Therefore, for a client hospitalized with hepatitis A, standard precautions (ie, hand hygiene, disinfection of equipment and surfaces) must be
implemented to prevent transmission. Additional precautions (eg, disposable gown, gloves) should be used as needed (eg, during procedure
Extract:
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.
Question 3 of 5
Select 4 clinical findings that require immediate follow-up.
Correct Answer: A,B,C,E
Rationale: Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the pancreas. Glucose requires insulin
to be transported from the extracellular space into the cell. Without insulin, glucose continues to circulate in the extracellular space, causing
serum hyperglycemia and intracellular glucose starvation that can lead to diabetic ketoacidosis (DK
A).
In DKA, the body breaks down fat for energy (ie, ketosis). This leads to high levels of ketones in the blood, which can cause life-threatening
metabolic acidosis. Clinical findings concerning for DKA require immediate follow-up and include:
• Nausea, vomiting, and abdominal pain—a common presentation of DKA (especially in children) that can be related to delayed gastric
emptying and/or ileus from electrolyte abnormalities and metabolic acidosis
• Neurologic symptoms (eg, lethargy, obtundation) due to progressive hyperglycemia and acidosis
• Signs of dehydration (eg, dry mucous membranes, prolonged P3 sec] capillary refill time) due to osmotic water loss caused by
glucose in the urine
Extract:
History
Labor and Delivery Unit
Admission: The client, gravida 1 para 0, at 16 weeks gestation with a twin pregnancy reports nausea and vomiting for the past
several weeks. The client also reports dry heaving, increasing weakness, light-headedness, and an inability to tolerate
oral intake for the past 24 hours. In addition, the client has had occasional right-sided, shooting pain from the abdomen
to the groin that occurs with sudden position changes. The pain quickly resolves without intervention per the client's
report. She has had no contractions or vaginal bleeding and has felt no fetal movement during this pregnancy. The
client has a history of childhood asthma and is currently taking no asthma medications. The client reports no other
pregnancy complications.
Physical
Prepregnancy,12 Weeks Gestation 16 Weeks Gestation(Prenatal Visit),(Labor and Delivery Admission)
Height ,5 ft 5 in (165.1 cm),5 ft 5 in (165.1 cm)|, 5 ft 5 in (165.1 cm)
Weight, 145 lb (65.8 kg),148 lb (67.1 kg),138 lb (62.6 kg)
BMI, 24.1 kg/m2, 24.6 kg/m2,23.0 kg/m2
Vital Signs
12 Weeks Gestation(Prenatal Visit),16 Weeks Gestation(Labor and Delivery Admission)
T,98.7 F (37.1 C),99.8 F (37.7 C)
P,70,101
RR,14,18
BP,122/78,90/55
SpO2,99% on room air,96% on room air
Laboratory Results
Laboratory Test and Reference Range, 16 Weeks Gestation
Blood Chemistry.
Sodium
136-145 mEq/L
(136-145 mmol/L)|,
136 mEq/L
(136 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
2.7 mEq/L
(2.7 mmol/L)
TSH
0.3-5.0 uU/mL
(0.3-5.0 mU/L),
0.4 pu/mL
(0.4 mU/L)
Hematology.
Hemoglobin (pregnant)
>11 g/dL
(>110 g/L),
16 g/dL
(160 g/L)
Hematocrit (pregnant)
>33%
(>0.33),
49%
(0.49)
Urinalysis
Specific gravity
1.005-1.030
1.030,
Ketones
Not present,
Present
Giucose
Not present,
Not present
Nitrites
Not present,
Not present
Question 4 of 5
The client is diagnosed with hyperemesis gravidarum and is planning care with the registered nurse. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.
| Potential Intervention | Indicated | Contraindicated |
|---|---|---|
| Give clear liquids | ||
| Weigh the client daily | ||
| Obtain a 12-lead ECG | ||
| Administer enteral nutrition | ||
| Initiate a large-bore peripheral IV | ||
| Document strict intake and output | ||
| Auscultate the fetal heart rate intermittently |
Correct Answer:
Rationale: When caring for clients with hyperemesis gravidarum (HG), the primary goal is to alleviate vomiting, replenish fluids, and correct electrolyte
and nutritional imbalances. Once completed, resumption of oral intake can be attempted. Interventions that are indicated at this time
include:
• Weighing the client daily to monitor for additional weight loss
• Obtaining a 12-lead ECG to monitor for cardiac changes related to electrolyte imbalances (eg, hypokalemia)
• Initiating a large-bore peripheral IV (eg, 18-gauge) to allow for administration of fluids and medications
• Documenting strict intake and output (eg, emesis, urinary output) to monitor hydration status and kidney function
• Auscultating the fetal heart rate intermittently (eg, twice daily, once per shift) to verify fetal status. (Continuous fetal heart rate
monitoring is not indicated at this gestational age.)
Many clients with HG cannot tolerate anything by mouth and are typically placed on a short period of gut rest (ie, NPO status), if hospitalized.
Therefore, giving clear liquids is contraindicated during the initial treatment phase of HG but should be offered once nausea and vomiting
have stopped. For the same reasons, administering enteral nutrition (eg, tube feeding) is contraindicated initially for this client and is not
anticipated unless feedings by mouth and other treatment measures fail.
Extract:
The nurse is caring for a 20-year-old female client.
Nurses' Notes
Urgent Care Clinic
0845: The parent brought the client to the clinic due to vomiting and weakness. The parent states that the client has experienced
sore throat and nasal congestion for the past week. The client has had 4 episodes of emesis during the past 24 hours and
diffuse, constant abdominal pain. The parent also reports that the client has had increased thirst and urine output over the
past 2 months.
The client's last menstrual period ended approximately 6 weeks ago with no abnormalities. Pregnancy status is unknown. The
client does not take any medications and does not use tobacco, alcohol, or recreational substances. Family history includes
hypertension and diabetes mellitus.
The client appears drowsy and is oriented to person and time only. The abdomen is soft without rigidity or rebound
tenderness, and bowel sounds are normal. No blood is present in emesis. Respirations are rapid and deep. Breath sounds
are clear.
Vital signs are T 98.8 F (37.1 C), P 128, RR 30, and BP 88/60 mm Hg.
Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L).
Laboratory Results
Laboratory Test and Reference Range, 0900
Glucose, serum (random)
≤200 mg/dL
(<11.1 mmol/L),
573 mg/dL
(31.8 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.7 mEq/L
(5.7 mmol/L)
Question 5 of 5
The nurse reinforces teaching about managing diabetes mellitus during an acute illness. For each of the statements made by the client,click to specify whether the statement indicates correct understanding or incorrect understanding
| Client Statements | Correct | Incorrect |
|---|---|---|
| I should not take insulin if I cannot eat due to nausea. | ||
| I should drink extra fluids to stay hydrated when I am experiencing an illness. | ||
| I will check my blood glucose levels more frequently if I am experiencing an illness | ||
| I need to check my urine for ketones if my blood glucose levels are persistently elevated | ||
| I will reduce my carbohydrate intake if I experience high blood glucose levels during an illness. |
Correct Answer:
Rationale: When a client with diabetes mellitus experiences an infection or another illness, the release of stress hormones can cause increased insulin
resistance, which increases the blood glucose level and leads the body to break down fats for energy (ketosis). This can precipitate diabeti
ketoacidosis (DK
A) as break down of fatty acids produces ketones. Interventions for managing diabetes mellitus and preventing DKA durin
an illness include:
• Increasing fluid intake to help clear ketones from the system and prevent dehydration during illness
• Checking blood glucose levels more frequently (eg, every 4 hr) to monitor for hyperglycemia
• Monitoring the urine for ketones if blood glucose levels are persistently elevated (>240 mg/dL [13.3 mmol/L]) for early detection of
impending DKA
• Consuming beverages that contain glucose and replacing electrolytes if nausea and vomiting are present
• Notifying the health care provider of persistently elevated blood glucose levels, ketones in the urine, high fever, nausea, vomiting, or
diarrhea