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
Nurses' Notes
Inpatient: Mental Health Unit
0900:
1200:
1500:
2000:
The client is inattentive, withdrawn, and depressed with low energy. The client's appearance is disheveled
with noted body odor. The client is declining breakfast and does not participate in group therapy. Education
was provided about the importance of participating in the treatment plan, and the client was encouraged to
shower.
The client is observed pacing back and forth in the room. The client is visibly upset and tearful and states, "I
can't live like this anymore. Everything in my life is going wrong." The client is encouraged to use deep
breathing and relaxation techniques to ease anxiety.
The client remains isolated to the room, pacing back and forth. The client rates depression as 6 on a scale of
0-10 and anxiety as 5 on a scale of 0-10.
The client was observed collecting blankets and storing them in the room behind the bed. When
approached, the client became defensive.
Question 1 of 5
The nurse has reviewed the information from the Nurses' Notes. Complete the following sentence/sentences by choosing from the list/lists of options. After removing the blankets from the client's room, the nurse should ----------------and ----------
Correct Answer: D,A
Rationale: After removing the blankets from the client's room, the nurse should notify the health are provider and initiate 1-to-1observation.This client is at high risk for imminent suicide. The client has severe depression, suicidal ideation with a plan, and access to lethal means (eg, blankets that can be used for self-hanging). This client requires constant visual ontact (ie, 1-to-1observation) to ensure safety 24 hours a day. The nurse should also notify the health care provider to assess for underlying psychiatric disorders (eg, psychosis) that could contribute to the situation.
Extract:
The nurse is performing a home health visit for an 84-year-old male.
History and Physical
Body System, Findings
General,
Client reports a 1-month-long history of fatigue and dyspnea that has worsened; he is unable to lie
flat and sleeps in a chair at night, medical history includes myocardial infarction, chronic heart
failure, chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus; client
was diagnosed with benign prostatic hyperplasia 8 months ago; client is adherent with prescribed
medications; client reports frequent consumption of donuts, hamburgers, steak, and fried chicken;
BMI is 34 kg/m?; client reports 6-Ib (2.7-kg) weight gain in 1 week
Neurological,
Alert and oriented to person, place, time, and situation
Pulmonary,
Vital signs: RR 24, SpOz 88% on room air; labored breathing, crackles in bilateral lung bases; client
expectorates frothy, pink-tinged sputum; client has a 40-year history of smoking 1 pack of cigarettes
per day
Cardiovascular,
Vital signs: T 98.8 F (37.1 C), P 98, BP 113/92; S1, S2, and S3 present; 3+ bilateral lower extremity
edema
Genitourinary, Concentrated yellow urine; client reports increased urinary hesitancy and urgency
Psychosocial,
Client reports being lonely and has depressed mental status
Question 2 of 5
Select 5 findings that require further investigation.
Correct Answer: A,B,D,E
Rationale: A client with chronic heart failure (HF) who reports worsening fatigue, dyspnea, orthopnea, and peripheral edema is likely
experiencing declining oxygenation due to fluid volume overload. Assessment findings that require further investigation
include:
• Orthopnea: Labored breathing in the supine position is a common manifestation in clients with HF due to pulmonary
edema. Clients with orthopnea often sleep on a chair or on propped-up pillows to decrease work of breathing.
Paroxysmal nocturnal dyspnea, which is waking up in the middle of the night with suffocation due to dyspnea, is another
characteristic finding in HF.
• Crackles on auscultation: Crackles are a manifestation of pulmonary edema caused by fluid in the alveoli. Pulmonary
edema is concerning for worsening HF and impaired gas exchange.
• Peripheral edema and rapid weight gain (ie, >5 Ib/week [2.3 kg/week]): These symptoms are concerning for fluid
volume overload
• Hypoxemia: Decreased capillary oxygen saturation (SpO, <95%) is a sign of inadequate gas exchange. This is most
likely related to pulmonary edema from HF exacerbation.
Question 3 of 5
For each finding below, click to specify if the finding is consistent with the disease process of chronic heart failure or chronic obstructive pulmonary disease. Each finding may support more than one disease process.
| Finding | Chronic Heart Failure | Chronic Obstructive Pulmonary Disease |
|---|---|---|
| Fatigue | ||
| Dyspnea | ||
| S3 heart tone | ||
| Rapid weight gain | ||
| Pink, frothy sputum | ||
| Barrel-shaped chest |
Correct Answer:
Rationale: Chronic heart failure (HF) is a progressive condition characterized by impaired ventricular function that leads to decreased
cardiac output and inadequate tissue perfusion as blood backs up into the lungs and systemic circulation. Common clinical
manifestations of HF include:
• Fatigue and dyspne secondary to impaired gas exchange
• An S3 (eg, ventricular gallop) heart tone, characteristic of HF, occurs during early diastole when blood from the atria
enters the ventricle and hits the less compliant (stiff) ventricular wall, creating an audible vibration
• Rapid weight gain (>5 lb/week [2.3 kg/week]) due to fluid volume overload
• Blood-tinged (ie, pink), frothy sputum due to mixing of blood from the ruptured high-pressured pulmonary veins with
transudative (clear alveolar fluid (pulmonary edema)
Chronic obstructive pulmonary disease (COP
D) is a progressive, irreversible respiratory tract condition characterized by
chronic airway inflammation, alveolar destruction and enlargement, and/or increased mucus production. Clients with COPD
have the following:
• Fatigue and dyspnea related to impaired gas exchange
• Appearance of a barrel-shaped chest due to the increased anteroposterior-to-transverse diameter ratio from
hyperinflation of the lungs
Extract:
The nurse is caring for a 58-year-old client.
Admission Note
Emergency Department
A client with colorectal cancer reports intractable bilious vomiting for the past day; it is accompanied by severe, colicky
abdominal pain. The client cannot tolerate oral intake and has not passed gas or had a bowel movement since the
symptoms began. The abdomen is distended, and bowel sounds are hyperactive.
Vital Signs
Emergency Department
T, 97.3 F (36.3 C)
P, 98
RR, 18
BP, 110/70
SpO2, 98% on room air
Question 4 of 5
The nurse is contributing to the client's plan of care. For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client.
| Potential Intervention | Indicated | Not Indicated |
|---|---|---|
| Administer antiemetic | ||
| Insert a nasogastric tube | ||
| Place the client on a soft diet | ||
| Obtain an abdominal CT scan | ||
| Administer a stimulant laxative |
Correct Answer:
Rationale: Small bowel obstruction (SBO) is an intestinal blockage that obstructs the flow of intestinal contents (eg, fluid, gas, fecal
material). The blockage may be due to mechanical (eg, surgical adhesions, hernias, tumors) or nonmechanical/functional (eg,
paralytic ileus) causes. As intestinal contents accumulate, clients develop abdominal distension, colicky abdominal pain,
bilious vomiting, and inability to pass flatus or stool.
Clients with SBO are at risk for fluid, electrolyte, and nutritional imbalances due to decreased intestinal absorption. Clients may
develop bowel necrosis and perforation due to impaired intestinal blood flow, which can lead to peritonitis and sepsis.
The practical nurse should anticipate assisting the registered nurse with the following interventions for a client with SBO:
• Inserting a nasogastric tube for gastrointestinal decompression to reduce abdominal distension and improve intestinal
blood flow
• Administering antiemetics (eg, ondansetron) to prevent further fluid and electrolyte imbalance from vomiting
• Preparing the client for abdominal CT scan to determine the size and location of intestinal obstruction
• Administering IV fluids to improve fluid volume status
In clients with SBO, bowel rest (ie, NPO status) with gastric decompression is prescribed; therefore, a soft diet is not
indicated. Stimulant laxatives increase intestinal motility and are not indicated for clients with intestinal obstruction due to
the risk for bowel perforation.
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
Which of the following statements by the client's parent indicates a correct understanding of the teaching about management for type 1 diabetes mellitus? Select all that apply
Correct Answer: A,B
Rationale: Clients with type 1 diabetes mellitus (DM) have impaired insulin production due to autoimmune destruction of pancreatic beta
cells. Because clients with type 1 DM do not produce insulin, lifelong insulin replacement is required. Insulin requirements
will change with growth and development
Insulin requirements may increase because stressful events (eg, illness) cause blood glucose levels to rise. When the
client is ill, the parent should be instructed to notify the health care provider, monitor blood glucose levels closely, test the urine
for ketones, increase insulin administration per sliding scale, and monitor for signs of dehydration