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:
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 2 of 5
The nurse has reviewed the information from the Nurses' Notes, Vital Signs, and Laboratory Results.The nurse is reviewing the client's response to potassium-lowering therapies. Which finding is unexpected and requires follow-up by the nurse?
Correct Answer: A
Rationale: Treatment for hyperkalemia includes administration of calcium gluconate, furosemide, albuterol nebulizer, and insulin with dextrose. These
therapies may cause rapid shifts in fluid volume, blood glucose, and serum electrolytes. Insulin shifts available glucose and potassium into
the cell, lowering serum potassium levels; however, too much insulin and not enough dextrose cause hypoglycemia (eg, blood glucose 50
mg/dL [2.7 mmol/L]). Clients with kidney disease have an increased risk of hypoglycemia because insulin may accumulate.
The nurse should understand that a low blood glucose level and symptoms suspicious for hypoglycemia (eg, diaphoresis) require follow-u
to prevent seizures, coma, and death due to lack of circulating glucose (Option 1). This client requires an additional dose of dextrose.
(Option 2) This client's blood pressure is 146/88 mm Hg and heart rate is within normal limits. This is an improvement from the initial blood
pressure and represents a therapeutic response to furosemide administration. Blood pressure should be lowered slowly to avoid hypotensior
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
Prescriptions,
10 mEq/hr potassium chloride in dextrose 5% and sodium chloride 0.45% IV continuously
• 1000 mg calcium carbonate q6h
• 10 mL multivitamin and 0.6 mg folic acid once daily
• 12.5 mg promethazine q6h
Question 3 of 5
The nurse is reinforcing home care teaching to the client. Which statement by the client requires the nurse to provide further instruction?
Correct Answer: D
Rationale: Self-management of hyperemesis gravidarum is an important component of discharge teaching. The goal of home care is to prevent nausea
and vomiting and promote appropriate nutritional intake and weight gain, which can support a healthy pregnancy.
Some triggers for nausea and vomiting include an empty or overly full stomach, strong food odors, and greasy or fatty foods. It is often
recommended that clients eat cold or bland foods due to the increased aromas associated with hot foods.
Therefore, the nurse should
provide further teaching to this client who plans to eat hot soup because this may precipitate nausea (Option 4). The nurse can suggest
eating foods such as toast, crackers, nuts, or cold cereal.
Extract:
History and Physical
Body System,Findings
General
Client has history of coronary artery disease, hypertension, hyperlipidemia, diverticulosis, and
osteoarthritis; Helicobacter pylori infection 2 years ago; client reports taking over-the-counter
ibuprofen every 8 hours for left knee pain for the past 2 weeks; daily medications include aspirin,
carvedilol, lisinopril, and atorvastatin
Neurological
Alert and oriented to person, place, time, and situation
Pulmonary
Vital signs: RR 20, SpO 96% on room air, lung sounds clear bilaterally; no shortness of breath;
client smokes 1 pack of cigarettes per day and smokes marijuana 1 or 2 times weekly
Cardiovascular
Vital signs: P 110, BP 90/62; no chest pain; S1 and S2 heard on auscultation; peripheral pulses
2+; client states feeling lightheaded and reports passing out about 1 hour ago
Gastrointestinal
Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis; two episodes of
large, black, liquid stools in the morning
Musculoskeletal
Examination of the knees shows crepitus that is worse on the left; no swelling, warmth, or
erythema; range of motion is normal
Psychosocial
Client reports drinking 1 or 2 glasses of wine per day
Question 4 of 5
The nurse is reinforcing discharge teaching to the client. Which of the following client statements indicate that the teaching has been effective? Select all that apply.
Correct Answer: D,E
Rationale: It is important that clients with peptic ulcer disease understand the signs and symptoms of a recurrence of gastrointestinal
bleeding (ie, melena, hematemesis). If these symptoms occur, the client should immediately notify the health care provider
to prevent life-threatening complications (eg, hemorrhagic shock) (Option 4).
To prevent new peptic ulcer formation or exacerbation, the nurse should instruct clients to limit activities that stimulate
production of gastric acid and impair ulcer healing (eg, smoking). Varenicline is a partial nicotine agonist that aids in smoking
cessation and may be useful for this client
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 5 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.