NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
Extract:
The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.
Question 1 of 5
Which action should the nurse perform first?
Correct Answer: E
Rationale: Requesting staff presence ensures safety for de-escalation or intervention in an acute psychotic episode.
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 newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative.
Question 3 of 5
Click to highlight below the 3 findings that should concern the nurse.
| The client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. |
| The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. |
| The client received treatment for bacterial vaginosis during the second trimester. |
| The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative. |
Correct Answer: A,B,D
Rationale: Non-compliance with insulin , smoking , and excessive weight gain increase neonatal risks.
Extract:
Nurses' Notes
Vital Signs
Emergency Department
0800:
A 43-year-old client comes to the emergency department due to lower
back pain and bilateral leg weakness. The client reports that the
weakness began 3 days ago in the feet and has gradually worsened.
The client sought treatment today after becoming "so weak that I fell
while walking" and noticing new hand weakness and difficulty
swallowing. Back pain radiates down both legs and is rated as 5 on a
scale of 0-10. The client recently recovered from an illness with flu-like
symptoms. The client reports a history of hypertension and takes no
medications. Assessment of the lower extremities reveals muscle
strength of 2/5 and decreased sensation to pinprick. Achilles tendon
and patellar reflexes are decreased.
1000:
The client reports difficulty raising the arms and inability to squeeze the
fingers. The client reports chest tightness and difficulty breathing.
Question 4 of 5
For each intervention, click to specify if the intervention is appropriate or inappropriate for the care of the client.
| Intervention | Appropriate | Inappropriate |
|---|---|---|
| Ensure bedside suction is set up | ||
| Place a bag valve mask at the bedside | ||
| Ensure intubation equipment is available | ||
| Reposition the client in the bed every 2 hours | ||
| Place the client on continuous cardiac monitoring | ||
| Apply a sequential compression device to the legs | ||
| Mark the appropriate surgical site for a tracheotomy |
Correct Answer: A,B,C,D,E,F
Rationale: Suction , bag valve mask , intubation equipment , repositioning , cardiac monitoring , and compression devices prepare for GBS complications. Tracheotomy marking is premature.
Extract:
The nurse is caring for a 21-year-old client.
Nurses' Notes History and Physical Vital Signs
Emergency Department
0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur
Question 5 of 5
For each potential intervention, click to specify if the intervention is indicated or contraindicated for the care of the client.
Correct Answer: A,B,C,E
Rationale: Positive self-talk , identifying stressors , recognizing symptoms , and breathing exercises manage panic disorder. Isolation may worsen anxiety.