NCLEX-PN
NCLEX PN Test Questions with NGN Questions
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 1 of 5
The nurse has reviewed the information from the Laboratory Results. Which of the following conditions should the nurse suspect? Select all that apply.
Correct Answer: B,E
Rationale: Major depressive disorder (MD
D) is characterized by a persistent (duration ≥2 weeks) depression in mood (eg, sadness,
social withdrawal) that interferes with daily life. This client has several clinical manifestations of MDD, including loss of interest
in daily activities, significant change in appetite or weight, persistent feelings of worthlessness, recurrent thoughts of self-harm,
inattention, and fatigue. MDD is a significant risk factor for suicide
Substance use disorder is the recurrent use of alcohol and/or recreational drugs that results in interpersonal dysfunction,
impaired control, and physical effects (eg, withdrawal). This client's urine drug screen is positive for cocaine and marijuana
Therefore, the nurse should further investigate the client's substance use (eg, amount, frequency, route of administration, date
of last use, perceived benefits, negative consequences)
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 2 of 5
One hour after chest tube insertion, the client becomes agitated and knocks over the chest tube collection device. The device is damaged. and the tubing becomes disconnected. Which action should the nurse perform first?
Correct Answer: D
Rationale: If a chest tube becomes disconnected from a damaged drainage system, the priority is to restore the water seal, according to facility policy. A
safe, temporary way to accomplish this is to immerse the distal end of the tube (ie, farthest from the client) into a bottle of sterile saline
or sterile water while someone obtains a new water seal collection device. Some facilities may use shodded (rubber-tipped) hemostats to
temporarily clamp the tube until a new water seal device is obtained. However, clamping the tube can quickly cause a pneumothorax and
should be done only very briefly (Option 4).
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 3 of 5
The practical nurse is assisting the registered nurse with preparing the client's plan of care. Which of the following interventions are appropriate to include in the plan of care? Select all that apply.
Correct Answer: A,B,C,D
Rationale: In addition to ophthalmic medications (eg, beta blockers, cholinergic medications) and oral or IV carbonic anhydrase inhibitors, clients with
acute angle-closure glaucoma (ACG) require the following measures to prevent further vision loss and ensure safety:
• Administration of an osmotic diuretic (eg, mannitol) to reduce intraocular pressure (IOP). Mannitol increases plasma oncotic
pressure, pulling water from the extravascular space into the intravascular space. This fluid, along with the diuretic, is excreted through
the kidneys, thereby reducing IOP. This is similar to the management of cerebral (brain) edema (Option 1).
• Administration of an antiemetic medication (eg, ondansetron) to alleviate nausea because vomiting can cause a sharp increase in IOP,
further worsening acute ACG (Option 2)
• Implementation of fall precautions (eg, provide nonskid socks, turn on bed alarm, clear a pathway to the bathroom) to ensure client
safety. Many eye drops cause blurred vision for several minutes after administration, worsening the client's already impaired vision
(Option 3).
• Instruction to avoid activities that increase IOP (eg, bending/stooping, straining, coughing, blowing the nose, laughing) (Option 4)
(Option 5) Applying a pressure patch to the eye is typically done as a postoperative intervention for ocular surgeries (eg, corneal
transolantation) and is not necessary to include in the olan of care for this client.
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 4 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 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 5 of 5
Complete the following sentences by choosing from the lists of options. The client is diagnosed with acute primary angle-closure glaucoma. The nurse anticipates a prescription of ------------ ophthalmic drops to ------------------
Correct Answer: C,E
Rationale: Treatment of acute angle-closure glaucoma (ACG) primarily involves reducing intraocular pressure (IOP) by decreasing aqueous humor
production and increasing aqueous humor outflow. Beta-adrenergic antagonists ("beta blockers") (eg, timolol, betaxolol), alpha-adrenergic
agonists (eg, apracionidine, brimonidine), and carbonic anhydrase inhibitors (eg, acetazolamide) reduce aqueous humor production, while
cholinergic medications (eg, pilocarpine) cause pupillary constriction by acting on smooth muscle of the iris and increasing outflow of aqueous
humor. Prostaglandin agonists (eg, latanoprost, bimatoprost) also increase outflow of aqueous humor.
Ophthalmic beta-adrenergic antagonist medications typically cause minimal visual disturbances and are used as first-line treatment.
Nonselective beta-adrenergic antagonists (eg, timolol) exert their action on both beta-1 (eg, heart) and beta-2 (eg, lungs) adrenoreceptors. B
blocking the action of beta-2 adrenergic receptors, these medications can cause bronchospasms in those with lung disease (eg, chronic
obstructive pulmonary disease, asthma).