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

Questions 85

NCLEX-PN

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NCLEX PN Exam Practice Test with NGN Questions

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 1 of 5

Which condition does the nurse suspect?

Correct Answer: A

Rationale: Cola-colored urine, edema, and recent infection point to acute postinfectious glomerulonephritis.

Extract:

The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days


Question 2 of 5

For each potential intervention, click to specify if the intervention is expected or not expected for the care of the client.

Potential InterventionExpectedNot expected
Administer corticosteroids
Initiate seizure precautions
Administer an oral stool softener
Perform intermittent urinary catheterization
Perform frequent neuromuscular evaluations
Prepare client for surgical spinal cord decompression

Correct Answer: A,C,D,E,F

Rationale: Corticosteroids , stool softeners , catheterization , neuromuscular checks , and surgery are expected for spinal cord compression. Seizure precautions are not routine.

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 3 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 43-year-old client.
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


Question 4 of 5

Which finding is the most concerning to the nurse at this time?

Correct Answer: B

Rationale: Difficulty swallowing indicates bulbar involvement in Guillain-Barré syndrome, risking aspiration and requiring urgent intervention.

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 PrescriptionAnticipatedUnanticipated
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.

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