NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
The nurse is caring for a 64-year-old client.
History and Physical
Body System, Findings
General ,
The client reports a 24-hour history of blurred vision and redness in the left eye with a left-sided headache.
This evening, the client developed acute, severe pain in the left eye accompanied by occasional nausea and
vomiting. The client reports no use of systemic or topical eye medications. Medical history includes
osteoarthritis and hypercholesterolemia.
Eye, Ear, Nose, and Throat (EENT),
The client wears eyeglasses to correct farsighted vision. Right eye: pupil 2 mm and reactive to light,
conjunctiva clear. Left eye: pupil 4 mm and nonreactive to light with red conjunctiva. Bilateral lens opacity is noted.
Pulmonary,
Vital signs are RR 20 and SpO, 96% on room air. The lungs are clear to auscultation bilaterally.
Cardiovascular,
Vital signs are T 99 F (37.2 C), P 88, and BP 140/82.
Psychosocial,
The client reports a great deal of emotional stress following the recent death of the client's spouse that is accompanied by lack of sleep, poor appetite, and a 7.9-lb (3.6-kg) weight loss within the past month. The client takes diphenhydramine for sleep.
Question 1 of 5
The nurse reinforces discharge teaching to the client after laser peripheral iridotomy. Which of the following client statements indicate an understanding of the teaching? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: Laser peripheral iridotomy is a surgical intervention for acute angle-closure glaucoma (ACG) that involves creating a small hole in the iris to
prevent the drainage pathway from closing and improve movement of aqueous humor into regular outflow channels. Ophthalmic alpha-
adrenergic agonists (eg, apraclonidine, brimonidine) are administered postoperatively to reduce aqueous humor production and prevent an
elevation in intraocular pressure.
Important considerations for the administration of ophthalmic drops include:
• Pulling the lower eyelid down by gently pressing on the lower orbital bone to expose the conjunctival sac (Option 1)
• Applying pressure over the inner corner of the eye (eg, lacrimal duct) after each medication to avoid systemic absorption (Option 2)
• Waiting at least 5 minutes before instilling a different medication into the same eye to allow absorption of the first medication and to
avoid overflow with multiple drops (Option 4)
• Holding the dropper ½*% in (1-2 cm) above the conjunctival sac to prevent contamination of the dropper and infection of the eye
(Option 5)
Clients should also be instructed to consult with their health care provider before taking over-the-counter medications (eg, decongestants,
anticholinergics, antihistamines) because a subsequent episode of acute ACG may be triggered by certain medications (Option 3).
Extract:
The nurse is caring for a 16-year-old client. History and Physical
Body System, Finding
General,
Client is brought to the emergency department due to nausea, vomiting, and abdominal pain that began 24 hr
ago. Client has type 1 diabetes mellitus and usually takes insulin. Parents state that the client was at an
overnight camp for the past 4 days and are unsure of how much insulin the client has been taking.
Neurological,
Client is lethargic but arousable to voice. The pupils are equal, round, and reactive to light and accommodation.
Integumentary,
Mucous membranes are dry, skin turgor is poor.
Pulmonary,
Vital signs are RR 36 and SpOz 95% on room air. Lung sounds are clear to auscultation. Deep respirations and a
fruity odor on the breath are noted.
Cardiovascular,
Vital signs are T 98.4 F (36.9 C), P 110, and BP 98/58. Pulses are 3+ on all extremities, and capillary refill time is
4 sec.
Gastrointestinal Normoactive bowel sounds are heard in all 4 quadrants; the abdomen is nontender.
Genitourinary,
Client voided dark yellow urine.
Endocrine,
Client is prescribed levothyroxine daily for hypothyroidism and has missed one dose of levothyroxine.
Psychosocial,
Parents state that the client has been sad and slightly withdrawn for the past 2 weeks after ending a romantic relationship.
Laboratory Results
Laboratory Test and Reference Range, 1000, 1600
Blood Chemistry.
Glucose (random)
≤200 mg/dL
(≤11.1 mmol/L),
504 mg/dL
(28.0 mmol/L),
164 mg/dL
(9.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L),
133 mEq/L
(133 mmol/L),
135 mEq/L
(135 mmol/L)
Chloride
98-106 mEq/L
(98-106 mmol/L),
101 mEq/L
(101 mmol/L),
102 mEq/L
(102 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L),
5.6 mEq/L
(5.6 mmol/L),
3.2 mEq/L
(3.2 mmol/L)
Arterial Blood Gases
Arterial pH
7.35-7.45
(7.35-7.45),
7.20
(7.20),
7.31
(7.31)
HCOg
21-28 mEq/L
(21-28 mmol/L),
13 mEq/L
(13 mmol/L),
18 mEq/L
(18 mmol/L)
PaCO,
35-45 mm Hg
(4.66-5.98 kPa),
30 mm Hg
(3.99 KPa),
32 mm Hg
(4.26 kPa)
PaO,
80-100 mm Hg
(10.64-13.33 KPa),
90 mm Hg
(11.97 kPa),
90 mm Hg
(11.97 kPa)
Question 2 of 5
The nurse has reviewed the information from the Laboratory Results., For each client finding below, click to specify if the finding is consistent with the disease process of diabetic ketoacidosis or hyperosmolar hyperglycemic state. Each finding may support more than one disease process.
| Client Finding | Diabetic Ketoacidosis | Hyperosmolar Hyperglycemia State |
|---|---|---|
| P 110 | ||
| pH 7.2 | ||
| BP 98/58 | ||
| Poor skin turgor | ||
| Fruity breath odor | ||
| Positive urine ketones | ||
| Kussmaul respiration |
Correct Answer:
Rationale: Diabetic ketoacidosis (DK
A) and hyperosmolar hyperglycemic state (HHS) are potentially life-threatening complications of diabetes mellitus
(DM). Clients with a decreased level of consciousness, hyperglycemia, electrolyte imbalances, and signs of dehydration should be evaluate
for both DKA and HHS.
DKA is more common in type 1 DM caused by hypoinsulinemia, resulting in hyperglycemia, metabolic acidosis (le, low pH), ketosis (le,
positive ketones in the urine and fruity odor on the breath), and severe dehydration (eg, poor skin turgor, tachycardia, hypotension)
due to osmotic water loss caused by glucosuria. Glucose and potassium are unable to enter the cell due to lack of insulin, causing electroly
imbalances. Kussmaul respirations are deep, rapid breaths that compensate for metabolic acidosis by expelling carbon dioxide (le, an acid)
HHS is characterized by high plasma osmolality and extreme hyperglycemia. Osmolality is increased with dehydration. HHS is more
common in type 2 DM due to a small amount of insulin available to prevent ketosis.
Therefore, clients with HHS have a near normal pH leve
and minimal to no urine ketones. Osmotic diuresis and polyuria create a significant fluid volume deficit, causing electrolyte imbalances and
dehydration (eg, poor skin turgor, tachycardia, hypotension), which can lead to hypovolemic shock.
Educational objective:
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 3 of 5
The nurse is reinforcing teaching to the client and the parents about management of type 1 diabetes mellitus and prescribed insulin therapy. For each potential instruction, click to specify whether the instruction is appropriate or not appropriate to include in the teaching
| Potential Instruction | Appropriate | Not Appropriate |
|---|---|---|
| Track carbohydrate intake | ||
| Rotate insulin injection sites | ||
| Wear a medical alert bracelet | ||
| Demonstrate insulin injections on a doll | ||
| Store unopened insulin vials at room temperature |
Correct Answer:
Rationale: Type 1 diabetes mellitus (DM) is characterized by insulin deficiency and management requires insulin therapy for blood glucose
control. The nurse should provide dietary teaching and instructions for insulin administration. Appropriate instructions to
include in the teaching include:
• Track carbohydrate intake to guide insulin administration and maintain blood glucose levels. Exogenous insulin
administration increases the risk of hypoglycemia. Carbohydrate intake should be relatively consistent each day to avoid
hyperglycemia or hypoglycemia.
• Rotate insulin injection sites to prevent tissue scarring or loss of subcutaneous tissue (ie, lipoatrophy).
• Wear a medical alert bracelet to indicate type 1 DM in the event of hypoglycemia and unconsciousness.
• Demonstrate insulin injections on a doll before performing injections on the child to help prepare the client and family.
Insulin vials that remain unopened should be stored in the refrigerator until opened and can be used up to the expiration date.
Once opened, the vial can be stored at room temperature for approximately 1 month. Injections are less painful when the vial
is stored at room temperature, and lipodystrophy is less likely. Storing the unopened vials at room temperature is not
appropriate to include in the teaching
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 4 of 5
Complete the following sentence/sentences by choosing from the list/lists of options. The nurse should recognize that the client is most likely experiencing--------------as evidenced by------------------
Correct Answer: C,E
Rationale: The nurse should recognize that the client is most likely experiencing a heart failure (HF) exacerbation, as evidenced by
orthopnea. Orthopnea (ie, labored breathing in the supine position), decreased capillary oxygen saturation, extra heart tones
(eg, S3), bilateral lower extremity edema, >5 lb [2.3 kg] weight gain in 1 week, and adventitious lung sounds (eg, crackles)
indicate fluid overload
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.
Question 5 of 5
The client returns to the clinic 6 months after starting behavioral therapy. Which statement by the parent indicates a need for further therapy?
Correct Answer: A
Rationale: Early childhood intervention programs (eg, behavioral therapy) are a critical component for clients with autism spectrum
disorder and can have positive long-term effects on presenting symptoms and social skills. Therapy helps increase
communication and language skills; improve focus, social skills, memory, and academic functioning; and decrease problematic
behaviors through positive reinforcement and other behavioral approaches
When evaluating the outcomes of therapy, the nurse should recognize that clients who demonstrate narrowed, restricted
interests (eg, eating the same foods) indicate a need for additional therapy