NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
Extract:
The nurse is caring for an 88-year-old client with pneumonia.
Nurses' Notes Vital Signs Medical-Surgical Unit
0800: The client has dyspnea that worsens on exertion, a productive cough, and fever. Crackles are heard in the bilateral lower lung lobes.
1000: The client is restless, coughs frequently, and struggles to breathe.
Question 1 of 5
The nurse should first Select... to Select... ...
Correct Answer: A,E
Rationale: Elevating the head of the bed promotes lung expansion to improve breathing in pneumonia.
Extract:
The nurse is caring for an infant in the clinic.
Nurses' Notes Clinic Visit: Age 4 Months
0800: The infant is playing with the hands and feet and making cooing sounds. The infant smiles and laughs appropriately when the caregiver provides a toy. No evidence of Moro, tonic, or rooting reflexes noted. The infant has weak muscle tone in the neck and does not hold the head up independently.
Clinic Visit: Age 6 Months
0930: The infant does not have head control. The caregiver reports that the infant babbles but does not use words or call the parent by any name. The infant does not point at desired objects. The caregiver also reports that the infant has begun to act afraid of unfamiliar people
Question 2 of 5
The nurse recognizes that the 6-month-old infant who ........ should be evaluated for........
Correct Answer: B,D
Rationale: Lack of head control at 6 months is concerning for cerebral palsy , as it indicates delayed motor development.
Extract:
The nurse is caring for a 69-year-old client.
Progress Notes Emergency Department
1100: The client is unconscious following a suicide attempt. The paramedics immediately initiate CPR.
1115: The nurse reviews the client's chart and is unable to find documentation of a durable power of attorney for health care.
Question 3 of 5
For each rationale, click to specify if the rationale is applicable or not applicable regarding the need to continue cardiopulmonary resuscitation.
| Rationale | Applicable | Not Applicable |
|---|---|---|
| The client is unconscious | ||
| The client is under the age of 70 | ||
| The client's toxicology report reveals no illegal substances | ||
| The client does not have a living will documented in the medical record |
Correct Answer: A,D
Rationale: Unconsciousness and no living will support continuing CPR unless a DNR exists. Age and toxicology are irrelevant.
Extract:
The nurse is caring for a 16-year-old client.
History and Physical Laboratory Results
Body System- Findings
General- The client comes to the emergency department with pain in the upper back, both knees, and the lower legs that is rated as 9 on a scale of 0-10; medical history includes sickle cell disease; the client reports attending an outdoor sports camp for the past 4 days; the client appears restless with frequent position changes and facial grimacing
Neurological- The client is alert and oriented to person, place, and time
Pulmonary- Vital signs: RR 24, SpOz 95% on room air, breath sounds are clear bilaterally Cardiovascular- Vital signs: T 98.4 F (36.9 C), P 120, BP 130/78; S1 and S2 are auscultated with no murmurs, continuous cardiac monitor shows sinus tachycardia
Gastrointestinal- The abdomen is soft and nontender with normal bowel sounds; the client vomited 30 mL of clear liquid
Musculoskeletal- The client has multiple, tender, bony points
Genitourinary- The client voided 50 mL of clear, amber-colored urine
Question 4 of 5
Click to highlight below the 4 findings that require immediate follow-up.
| Pain in the upper back, both knees, and the lower legs that is rated as 9 on a scale of 0-10; medical history includes sickle cell disease, the client reports attending an outdoor sports camp for the past 4 days |
| The client appears restless with frequent position changes and facial grimacing |
| Vital signs: RR 24, SpO2 95% on room air; breath sounds are clear bilaterally |
| Vital signs: T 98.4 F (36.9 C), P 120, BP 130/78; S1 and S2 are auscultated with no murmurs; continuous cardiac monitor shows sinus tachycardia |
| The client vomited 30 mL of clear liquid |
| The client has multiple, tender, bony points |
| The client voided 50 mL of clear, amber-colored urine |
Correct Answer: A,B,D,F
Rationale: Severe pain , distress signs , tachycardia , and bony tenderness indicate a sickle cell crisis, requiring urgent management.
Extract:
The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine
Question 5 of 5
For each potential prescription, click to specify if the prescription is anticipated or unanticipated for the care of the client.
| Potential Prescription | Anticipated | Unanticipated |
|---|---|---|
| Obtain daily weights | ||
| Maintain fluid restrictions | ||
| Administer loop diuretics | ||
| Maintain client on strict bed rest | ||
| Administer ibuprofen as needed for headache |
Correct Answer: A,B,C
Rationale: Daily weights , fluid restrictions , and diuretics manage fluid overload. Bed rest is unnecessary, and ibuprofen risks renal damage.