NCLEX Questions, NCLEX PN Practice Test with NGN Questions, NCLEX-PN Questions, Nurselytic

Questions 85

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Practice Test with NGN Questions

Extract:

The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.


Question 1 of 5

The nurse should prioritize interventions for due to the risk of

Correct Answer: C

Rationale: The client's consumption of ≥4 alcoholic beverages per day indicates a risk of alcohol withdrawal, which can be life-threatening and requires prioritized intervention.

Extract:

The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900: The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO, 94% on room air.


Question 2 of 5

The nurse should prioritize administration of........... to...........

Correct Answer: B,D

Rationale: B to D: Naloxone reverses opioid intoxication to prevent respiratory failure. The client's obtundation, shallow breathing, and pinpoint pupils indicate opioid overdose, requiring urgent reversal to restore breathing. Thiamine is for alcohol-related conditions, and charcoal is for recent ingestions, not specified here.

Extract:

The nurse is caring for a client at a women’s health clinic.
History & Physical
Labor and delivery unit
0800:
A 28-year-old nulliparous female comes to the clinic for confirmation of suspected pregnancy due to amenorrhea and a positive home pregnancy test. The client's current exercise regimen includes indoor cycling and outdoor running. The client reports nausea, vomiting, and breast tenderness. She has a 28-day menstrual cycle, and her last menstrual period was March 10- 17. The health care provider notes a bluish-purple vaginal mucosa and cervix during pelvic examination and confirms a 12-week intrauterine pregnancy by sonography. A fetal heart rate of 155/min is detected with handheld Doppler.


Question 3 of 5

For each client finding, click to specify if the finding is consistent with presumptive, probable, or positive signs of pregnancy. Note: Each row must have one response option selected

Client Finding Presumptive Probable Positive
Amenorrhea
Chadwick sign
Fetal heart rate
Nausea/vomiting
Breast tenderness
Home pregnancy test
Fetus visible on ultrasound

Correct Answer: A: Presumptive, B: Probable, C: Positive, D: Presumptive, E: Presumptive, F: Probable, G: Positive

Rationale: Presumptive signs are subjective and may have other causes (e.g., amenorrhea, nausea/vomiting, breast tenderness). Probable signs are objective but not definitive (e.g., Chadwick sign, positive home pregnancy test). Positive signs confirm pregnancy (e.g., fetal heart rate, fetus visible on ultrasound).

Extract:

Nurses' Notes
0930:
The client reports shortness of breath and left-sided chest pain for 2 days. The client fractured the right femoral neck a month ago after a fall and decided against operative management. Since then, the client has been wheelchair dependent and takes acetaminophen for fracture pain management. The client was placed on continuous cardiac monitoring.

History and physical
Body System
Neurological
The client is awake, alert, and oriented to person, place, time, and situation; the client appears anxious

Pulmonary
Vital signs are RR 22, SpOz 89% on room air; bilateral breath sounds are clear; pain increases with inhalation; the client reports shortness of breath for the past 2 days; the client smoked 1 pack of cigarettes per day for 10 years.

Cardiovascular
Vital signs are T 99.8 F (37.7 C), P 110, BP 110/60; S1 and S2 are present; there are no murmurs, redness and edema of the right lower extremity are noted; sinus tachycardia is seen on the monitor, chest pain is reported as 7 on a scale of 0-10

Musculoskeletal
The client has osteoporosis, is wheelchair dependent, and is unable to bear weight on the right leg


Question 4 of 5

Based on the client's history and physical examination findings, which disease process is the most likely cause of this client's current condition?

Correct Answer: D

Rationale: The client's recent immobility (wheelchair dependence post-femoral fracture), right lower extremity redness and edema (suggesting DVT), dyspnea, chest pain, hypoxemia (SpO2 89%), and sinus tachycardia strongly indicate venous thromboembolism, likely a pulmonary embolism secondary to DVT.

Extract:

The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900: The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO, 94% on room air.


Question 5 of 5

What condition should the nurse suspect?

Correct Answer: B

Rationale: Opioid intoxication is indicated by pinpoint pupils, shallow breathing, obtundation, and hypotension, consistent with the client's history of chronic pain and positive opioid urine screen. Meningitis typically involves fever and neck stiffness, TIA involves focal neurological deficits, and Wernicke's involves confusion with ocular abnormalities and ataxia.

Similar Questions

Access More Questions!

NCLEX PN Basic


$89/ 30 days

 

NCLEX PN Premium


$150/ 90 days