NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
The nurse is caring for a 68-year-old client in the emergency department.
Nurses' Notes,
Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.
Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air
Laboratory Test and Reference Range, 1030
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),
6.5 mEq/L
(6.5 mmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L),
22 mg/dL
(7.85 mmol/L)
Creatinine
Male: 0.6-1.3 mg/dL
(53-114.9 umol/L),
1.5 mg/dL
(132.6 umol/L)
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L)
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.The nurse should prioritize interventions to treat ------------ due to the risk of ---------------------.
Correct Answer: A,B
Rationale: The client's laboratory results show hyperkalemia (ie, high potassium) and decreased kidney function, seen as elevated BUN and creatinine.
The kidneys balance potassium levels by eliminating excess potassium through urine. Clients with heart failure (HF) are at an increased risk fo
hyperkalemia due to poor kidney perfusion from decreased cardiac output and medication adverse effects. This client's decreased kidney
function and home medications, including lisinopril (ACE inhibitor) and supplemental potassium chloride, all increase the risk of hyperkalemia.
Because potassium is responsible for myocardial cell repolarization, hyper- or hypokalemia may lead to life-threatening dysrhythmias.
Therefore, the nurse should prioritize interventions to treat hyperkalemia due to the risk of dysrhythmias.
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
Question 2 of 5
Drag words from the choices below to fill in the blank/blanks.The nurse understands that the client is most at risk for------------and------------
Correct Answer: E,C
Rationale: The nurse understands that the client is most at risk for respiratory failure and decreased cardiac output.
Decreased cardiac output is the most concerning complication in a client with a tension pneumothorax. The trapped air in a tension
pneumothorax causes increased pressure, compressing the affected lung more until it is completely collapsed and then compressing the
heart and great vessels (vena cava, aorta), ultimately inhibiting venous return.
If the pleural pressure continues to increase, eventually the pleural cavity will crowd the trachea, forcing it to deviate (shift) to the unaffected
side where the unaffected lung can be compressed. Clients are at high risk for respiratory failure due to hypoxemia. Without treatment, the
lungs cannot meet the demands for oxygenation and the client will die.
Extract:
History and Physical
Body System Findings
General
The client comes to the emergency department with fatigue, shortness of breath, dry cough, and
exertional dyspnea for 1 week; the client is homeless; medical history includes chronic heart failure,
uncontrolled hypertension, coronary artery disease, and type 2 diabetes mellitus
Pulmonary
Vital signs: RR 22, SpO, 88% on room air, the client is dyspneic but can speak in full sentences;
lung auscultation reveals decreased breath sounds at the lung bases and bilateral crackles; the
client reports smoking 1 pack of cigarettes per day for 35 years; the client was hospitalized for
pneumonia 6 months ago
Cardiovascular
Vital signs: T 99 F (37.2 C), P 90, BP 170/100; continuous cardiac monitor shows sinus rhythm with
occasional premature ventricular contractions; S1, S2, and S3 are heard on auscultation; bilateral
lower extremity pitting edema is noted
Question 3 of 5
Select below the 5 findings that are most concerning.
Correct Answer: B,D,E
Rationale: The client comes to the emergency department with fatigue, shortness of breath, dry cough, and
exertional dyspnea for 1 week; the client is homeless; medical history includes chronic heart
failure, uncontrolled hypertension, coronary artery disease, and type 2 diabetes mellitus
Vital signs: RR 22, SpOz 88% on room air; the client is dyspneic but can speak in full
sentences; lung auscultation reveals decreased breath sounds at the lung bases and bilateral
crackles; the client reports smoking 1 pack of cigarettes per day for 35 years; the client was
hospitalized for pneumonia 6 months ago
Vital signs: T 99 F (37.2
C), P 90, BP 170/100; continuous cardiac monitor shows sinus rhythm
with occasional premature ventricular contractions; S1, S2, and S3 are heard on auscultation;
bilateral lower extremity pitting edema is noted
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 4 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.
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 5 of 5
Select below the 6 findings that require follow-up.
Correct Answer: A,C,D,E,F,G
Rationale: The nurse should follow up on the following findings:
irritability may manifest as behavioral outbursts.
• Frequent urination and nocturnal enuresis: Frequent urination and involuntary voiding in a child who was previously
toilet trained for at least 6 months indicate excessive urination (ie, polyuria), which is a characteristic finding of multiple
medical conditions (eg, diabetes mellitus [DM], diabetes insipidus).
• Increased thirst and dry mucous membranes: Increased thirst (ie, polydipsia) and dry mucous membranes are signs
of dehydration. Dehydration in the presence of polyuria and weight loss is concerning for DM.
• Weight loss: Weight loss is a common finding in clients with DM because the body is unable to use glucose and instead
breaks down protein and fat stores for energy.
• Fatigue, irritability, and multiple behavioral outbursts: Fatigue and irritability in a client with polydipsia and polyuria
may indicate an energy deficit from altered glucose metabolism related to DM. In a 6-year-old client, fatigue and