NCLEX-PN
NCLEX PN Test Questions with NGN Questions
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.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
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)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%
Question 1 of 5
The nurse suspects the client is experiencing acute decompensated heart failure. Which of the following findings are consistent with this condition? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: The findings all support the diagnosis of acute decompensated heart failure (ADHF):
Crackles with auscultation: Indicative of pulmonary congestion due to fluid overload.
Decreased capillary oxygen saturation: Reflects impaired gas exchange from fluid in the lungs.
Elevated B-type natriuretic peptide (BNP): A level of 640 pg/mL is significantly elevated; BNP is released when the ventricles are stretched due to increased fluid volume.
Left ventricular ejection fraction of 30%: Normal is 55–70%. This reduced EF confirms systolic dysfunction, common in ADHF.
Lower extremity pitting edema: A classic sign of volume overload in right-sided or total heart failure.
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 2-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 parent's 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.
Emergency Department
3 years The client is brought to the emergency department by the parents, who report that the child became upset
later
and started banging the head against the wall several times. The parents report that the client has had
these episodes frequently; however, this time, the child was injured. The client has a laceration on the
forehead and is admitted for 24-hour observation.
Question 2 of 5
The nurse has reviewed the information from the Nurses' Notes. For each potential intervention, click to specify if the intervention is anticipated or not anticipated for the care of the client.
| Potential Intervention | Anticipated |
|---|---|
| Encourage the client to play with others in the playroom | |
| Follow a structured routine and schedule for providing care | |
| Consistently assign the same nursing staff to the client when possible | |
| Assign the client to a shared room with another client who has autism | |
| Use direct eve contact and therapeutic touch when talking to the client |
Correct Answer:
Rationale: Clients with autism spectrum disorder (AS
D) are often hesitant about changes and have a heightened behavioral response
when placed in an unfamiliar environment (eg, hospital). The nurse should consider the client's unique needs when planning
care. Anticipated interventions for decreasing anxiety and enhancing cooperation when caring for clients with ASD include:
• Following a structured routine and schedule for providing care to reduce distress and promote normalcy
• Consistently assigning the same nursing staff to the client when possible to facilitate trust and communication
because clients with ASD often have difficulties adjusting to changes in their surroundings
• Establishing a method for communication that is brief, concrete, and developmentally appropriate (eg, picture boards) to
decrease frustration due to impaired verbal and nonverbal communication
Clients with ASD are hypersensitive to environmental factors and may become distressed and overstimulated by noise and
activity.
Therefore, encouraging the client to play with others in the playroom and assigning the client to a shared room
with another client who has autism are not anticipated
Clients with ASD may be fearful of, or hypersensitive to, touch and direct eye contact. The nurse should use other means of
developing trust (eg, being consistent, conveying acceptance, using positive reinforcement).
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.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
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)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%
Question 3 of 5
For each potential intervention, click to specify if the intervention is expected or not expected for the care of the client.
| Potential Intervention | Expected | Not Expected |
|---|---|---|
| Daily weights | ||
| IV furosemide | ||
| Fluid restriction | ||
| Supplemental oxygen | ||
| Antihypertensive medications | ||
| Nebulized albuterol breathing treatments |
Correct Answer:
Rationale: Expected interventions for acute decompensated heart failure (HF) focus on reducing cardiac workload and improving
oxygenation. These include:
• Daily weights should be performed to monitor fluid volume status and guide treatment. Ideally, daily weights should be
performed at the same time of day, on the same scale, and with the client wearing the same amount of clothing.
• Diuretics (eg, furosemide) prevent reabsorption of sodium and chloride in the kidneys, which increases fluid excretion in
urine and decreases preload. Diuretics provide symptomatic relief by reducing pulmonary congestion and peripheral
edema. These are the cornerstone of therapy and often a priority after oxygen therapy.
• Fluid restriction is indicated to decrease circulating fluid volume and prevent excess strain on the heart.
• Supplemental oxygen should be administered to improve oxygen delivery in clients with HF due to impaired gas
exchange from pulmonary edema.
• Antihypertensive medications reduce cardiac workload and improve contractility by lowering blood pressure (ie,
afterload).
Nebulized albuterol is a bronchodilator administered to improve oxygenation in clients with reactive airway disease (eg.
asthma, chronic obstructive pulmonary disease). Bronchodilators will not improve oxygenation in clients with pulmonary
edema and are not expected for treatment of HF.
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 4 of 5
Complete the following sentence by choosing from the lists of options. The nurse should first address the client's -------followed by the client's --------------
Correct Answer: A,D
Rationale: Hyperglycemia in diabetic ketoacidosis (DK
A) causes osmotic diuresis that leads to severe dehydration. When hyperglycemia exceeds the
renal threshold of glucose absorption, glucosuria (excretion of glucose in urine) occurs. Water loss is increased due to osmotic diuresis
induced by glucosuria, and extreme dehydration, hypotension, and decreased organ perfusion occur.
The priority intervention in DKA is to initiate an IV fluid bolus with 0.9% sodium chloride followed by insulin administration to lower serum
glucose levels. Rapid fluid resuscitation should occur before insulin infusion because insulin shifts water, potassium, and glucose into the
cells, worsening extracellular dehydration and electrolyte imbalances.
Therefore, for clients with DKA, the nurse should first address
hypovolemia followed by hyperglycemia.
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 5 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