NCLEX-PN
NCLEX PN Practice Test with NGN Questions
Extract:
The nurse is caring for a client on the medical-surgical unit.
History
Admission
0500: The client is admitted with an abscess and cellulitis of the right leg. The abscess is noted on the lateral aspect of the right calf, with redness, swelling, and warmth extending from the knee to the ankle. The abscess was incised in the emergency department, and a moderate amount of purulent, yellowish-green drainage was noted. The leg was wrapped with gauze, and the client received the first dose of IV antibiotics and opioids for pain control.
The client reports chronic lower back pain and gastrosophageal reflux disease, and he was admitted to the hospital once last year for gastrointestinal bleeding. He is currently prescribed daily pantoprazole but takes it only a few times a week.
Vital signs: T 100.9 F (38.3 C), P 82, RR 14, BP 130/80, SpO, 95% on room air
Progress Notes
Medical-Surgical Unit
2300:
The client reports nausea, headache, and insomnia. The client is trembling, diaphoretic, and restless.
The client states, "I would sleep better if those mice and cats would stop climbing up and down the walls."
The upper portion of the clients dressing is saturated with yellowish-green drainage. The peripheral V was removed by the client, and dried blood is noted at the IV site. The IV catheter is on the floor. The client yelled and pushed the nurse's hands away during inspection of the IV site.
Vital signs: T 99 F (37.2 C), P 102, RR 18, BP 170/96, SpO≥ 95% on room air
Question 1 of 5
The nurse recognizes that the client is most at risk for ___ related to ___
Correct Answer: A,E
Rationale: Seizures are a significant risk in alcohol withdrawal syndrome, which is suggested by the client's symptoms of trembling, diaphoresis, restlessness, and hallucinations.
Extract:
The nurse is caring for a 52-year-old client on the orthopedic unit.
Nurses' Notes
Postoperative Day 1
0900:
The client's left leg was placed in balanced suspension skeletal traction for a fractured femur 12 hours ago. The client is positioned supine in the center of the bed with the foot of the bed elevated 15 degrees. Traction ropes are free of frays, centered in the pulleys, and moving freely with attached weights resting on the bed frame.
Serous drainage noted around the pin sites. Left foot slightly cool to the touch with posterior tibial and dorsalis pedis pulses palpable at 2+ and capillary refill <2 seconds in the toes. Client has normal sensation and movement of the left toes. Client rates left leg pain as 8 on a scale of 0-10.
Vital signs are T 100.4 F (38 C), P 110, RR 18, and BP 132/68. Weight is 173 lb (78.5 kg).
Question 2 of 5
The client is at risk for which of the following complications? Select all that apply.
Correct Answer: A,C,D,E
Rationale: The client is at risk for atelectasis (
A) due to immobility, constipation (
C) from reduced activity and medications, deep venous thrombosis (
D) due to immobility, and osteomyelitis (E) from pin site infection.
Extract:
The nurse is caring for an 84-year-old client with dementia.
Nurses' Notes
Medical-Surgical Unit
Day 1: The left antecubital peripheral IV insertion site has no erythema or edema, and the catheter flushes easily. The dressing is clean, dry, and intact. Potassium chloride infusion is initiated.
Day 3: Potassium chloride is infusing. The area surrounding the IV site is taut, edematous, blanched, and cool to the touch. Small, fluid-filled vesicles are noted around the IV site. Capillary refill distal to the IV site is >3 seconds. The client is grimacing and unable to verbally report pain.
Question 3 of 5
For each potential intervention, click to specify if the potential intervention is appropriate or not appropriate for the care of client.
| Potential Intervention | Appropriate | Not Appropriate |
|---|---|---|
| Elevate the affected extremity | ||
| Apply pressure to the affected area | ||
| Discontinue the potassium chloride infusion | ||
| Aspirate the potassium chloride from the IV catheter | ||
| Leave the IV catheter in place for potential antidote administration |
Correct Answer: A: Appropriate, B: Not Appropriate, C: Appropriate, D: Not Appropriate, E: Appropriate
Rationale: The symptoms suggest IV infiltration with potassium chloride, which is caustic. Elevating the extremity (
A) reduces swelling. Discontinuing the infusion (
C) prevents further damage. Leaving the catheter in place (E) allows for potential antidote administration. Applying pressure (
B) may worsen tissue damage, and aspirating (
D) is not standard for infiltration.
Extract:
The nurse is caring for a 25-year-old female client.
History and Physical
Body System
General
Client reports jitteriness, anxiety, and palpitations for the past 2 months. Fine hand tremor is noted. Client reports insomnia for approximately 1 week.
Integumentary
Client is diaphoretic.
Eye, Ear, Nose, andThroat (EENT)
Exophthalmos is noted. Goiter is present.
Gastrointestinal
Client reports 10 lb (4.5 kg) weight loss over the past month. Bowel sounds are normoactive. Client reports diarrhea for the past few days.
Reproductive
Last menstrual period was 3 months ago.
Vital Signs
T 99.2 F (37.3 C)
P 164
RR 22
BP 156/92
Nurses' Notes
Outpatient Clinic
0930:
Client received radioactive iodine therapy 6 months ago. Client reports absence of heart palpitations and anxiety. No evidence of fine hand tremor.
Client reports weight gain of 10.5 lbs (4.8 kg) within the past 3 months. Client reports feeling more fatigued during the day and requests to speak to the health care provider about feeling depressed.
Question 4 of 5
Following a routine laboratory draw, the nurse suspects that the client is experiencing primary hypothyroidism as evidenced by........... and ........
Correct Answer: A,D
Rationale: Primary hypothyroidism is characterized by increased TSH due to the pituitary gland's attempt to stimulate the thyroid and decreased T3 and T4 levels due to reduced thyroid hormone production.
Extract:
The nurse is caring for a 6-hour-old newborn.
Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO, 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.
1 Hour Later
After attempting a bottle feed with 10 mL of formula, the client has a coughing episode, and there is formula mixed with saliva in the mouth. Coarse breath sounds are noted bilaterally with intercostal retractions. S1 and S2 are present with no murmurs. Neurologic examination shows normal neuromuscular findings.
A nasogastric tube insertion is attempted per prescription by the health care provider, and resistance is met at 10 cm of insertion.
Question 5 of 5
The nurse recognizes that the client is most likely experiencing a tracheoesophageal fistula with esophageal atresia and will require interventions to prevent ___ and ___
Correct Answer: B,C
Rationale: Tracheoesophageal fistula can lead to aspiration pneumonia due to food entering the lungs and dehydration from inability to feed properly. These are the most immediate risks requiring intervention.