NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
History and Physical
Body System
Findings
General
Client reports a 1-week history of general malaise, fever and chills, night sweats, fatigue, and
poor appetite. Client has poorly controlled hypertension, hypercholesterolemia, and mitral
valve prolapse and regurgitation.
Eye, Ear, Nose, and
Throat (EENT)
Poor dental hygiene. Client reports having 2 teeth extracted 3 weeks ago.
Pulmonary
Vital signs are RR 18 and SpO, 96% on room air. Lungs are clear to auscultation bilaterally.
Cardiovascular
Vital signs are T 100.4 F (38 C), P 105, and BP 140/82. Sinus tachycardia with occasional
premature ventricular contractions on cardiac monitor. S1 and S2 heard on auscultation with
loud systolic murmur at the apex. Peripheral pulses 2+; no edema noted.
Integumentary
Small, erythematous macular lesions on both palms. Thin, brown longitudinal lines on several
nail beds.
Question 1 of 5
The nurse is preparing to administer the first dose of the prescribed IVPB antibiotic. Which 2 actions are most appropriate for the nurse to perform prior to initiating the infusion?
Correct Answer: B,C
Rationale: Antibiotic therapy is a critical component of treatment for clients with infective endocarditis (E). Before administering IV
antibiotics, the nurse should first obtain blood cultures to identify the infectious organism. Broad-spectrum antibiotics are
started initially. Targeted antibiotic therapy can be administered once the blood cultures identify the culprit organisms and their
antimicrobial susceptibilities. Before starting any medication, the nurse should ask about the client's medication allergies to
identify contraindications to therapy
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.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
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)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%
Question 2 of 5
For each potential intervention, click to specify if the intervention is expected or not expected for the care of the client.
| Potential Intervention | Expected | Not Expected |
|---|---|---|
| Daily weights | ||
| IV furosemide | ||
| Fluid restriction | ||
| Supplemental oxygen | ||
| Antihypertensive medications | ||
| Nebulized albuterol breathing treatments |
Correct Answer:
Rationale: Expected interventions for acute decompensated heart failure (HF) focus on reducing cardiac workload and improving
oxygenation. These include:
• Daily weights should be performed to monitor fluid volume status and guide treatment. Ideally, daily weights should be
performed at the same time of day, on the same scale, and with the client wearing the same amount of clothing.
• Diuretics (eg, furosemide) prevent reabsorption of sodium and chloride in the kidneys, which increases fluid excretion in
urine and decreases preload. Diuretics provide symptomatic relief by reducing pulmonary congestion and peripheral
edema. These are the cornerstone of therapy and often a priority after oxygen therapy.
• Fluid restriction is indicated to decrease circulating fluid volume and prevent excess strain on the heart.
• Supplemental oxygen should be administered to improve oxygen delivery in clients with HF due to impaired gas
exchange from pulmonary edema.
• Antihypertensive medications reduce cardiac workload and improve contractility by lowering blood pressure (ie,
afterload).
Nebulized albuterol is a bronchodilator administered to improve oxygenation in clients with reactive airway disease (eg.
asthma, chronic obstructive pulmonary disease). Bronchodilators will not improve oxygenation in clients with pulmonary
edema and are not expected for treatment of HF.
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 3 of 5
Drag words from the choices below to fill in the blanks. The nurse gathers supplies for medication administration. The nurse recognizes that the priority prescriptions are -------and ----------
Correct Answer: E,B
Rationale: The priority intervention for management of diabetic ketoacidosis is fluid resuscitation with isotonic IV fluid, typically starting with large-voli
0.9% sodium chloride IV boluses (eg, 1 L/hr) to prevent life-threatening hypovolemic shock. Fluid resuscitation also helps normalize
glucose and electrolyte levels via hemodilution. After initial large-volume boluses are complete, either hypotonic or isotonic IV fluids are
administered at continuous rate. Administration of regular insulin continuous IV infusion is also essential to correct hyperglycemia.
Extract:
Nurses Notes
Emergency Department
0900:
The client has new-onset tremors, extreme restlessness, nausea, and anxiety. The client recently had a back
injury and was prescribed tramadol. The client also takes sertraline for major depression. On examination,
the client is flushed and diaphoretic. The client's voice is tremulous. Mild rigidity and tremors are noted in the
lower extremities. Deep tendon reflexes are 3+. Pupillary dilation and ocular clonus are present.
Vital Signs
0900
T
100.9 F (38.3 C)
P
125
RR
20
BP
160/100
Sp02
99% on room air
Laboratory Results
Laboratory Test and Reference Range
0900
TSH
0.3-5 uU/mL
(0.3-5 mU/L)
2 pU/mL
(2 mU/L)
WBC
5000-10,000/mm3
(5.0-10.0 × 10%/L)
7800/mm3
(7.8 × 10%L)
Question 4 of 5
The nurse is caring for a 42-year-old client in the emergency department. The nurse is reviewing the collected client data to assist with preparing the client's plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to measure the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: Serotonin syndrome (ie, serotonin toxicity) is a life-threatening condition caused by excess serotonin in the central nervous
system. Tramadol is an analgesic medication with serotonergic activity that can lead to serotonin syndrome when taken with a
selective serotonin reuptake inhibitor (eg, sertraline).
Clinical manifestations include mental status changes (eg, anxiety, restlessness, agitation), autonomic dysregulation (eg,
diaphoresis, tachycardia, hypertension, hyperthermia), and neuromuscular hyperactivity. Treatment involves discontinuing all
serotonergic medications (eg, sertraline, tramadol) and administering a benzodiazepine to improve agitation and
decrease muscle contraction (eg, clonus), which reduces temperature.
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 5 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.