NCLEX-PN
NCLEX PN Test Questions with NGN Questions
Extract:
Nurses' Notes
Initial Clinic Visit
1100:
The client has experienced enuresis at night for the past 2 weeks and frequently requests to use the
bathroom while at school. The client was previously toilet trained with no nighttime bed wetting for 6 months;
the client recently relocated to a new home and school where the client lives with parents.
The parent reports that the client has recently demonstrated fatigue, irritability, and multiple behavioral
outbursts that resemble past temper tantrums. The client frequently reports feeling thirsty. No dysuria or
urinary hesitancy is reported.
Weight and height were in the 40th percentiles at the previous visit a year ago. Growth charts today show
the client's weight in the 20th percentile and height in the 40th percentile.
The client appears tired and irritable. Dry mucous membranes are noted with no increased work of
breathing. The lungs are clear to auscultation bilaterally. No cardiac murmur is heard.
Question 1 of 5
Which of the following statements by the client's parent indicates a correct understanding of the teaching about management for type 1 diabetes mellitus? Select all that apply
Correct Answer: A,B
Rationale: Clients with type 1 diabetes mellitus (DM) have impaired insulin production due to autoimmune destruction of pancreatic beta
cells. Because clients with type 1 DM do not produce insulin, lifelong insulin replacement is required. Insulin requirements
will change with growth and development
Insulin requirements may increase because stressful events (eg, illness) cause blood glucose levels to rise. When the
client is ill, the parent should be instructed to notify the health care provider, monitor blood glucose levels closely, test the urine
for ketones, increase insulin administration per sliding scale, and monitor for signs of dehydration
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 2 of 5
Select 5 findings that require further investigation.
Correct Answer: A,B,D,E
Rationale: A client with chronic heart failure (HF) who reports worsening fatigue, dyspnea, orthopnea, and peripheral edema is likely
experiencing declining oxygenation due to fluid volume overload. Assessment findings that require further investigation
include:
• Orthopnea: Labored breathing in the supine position is a common manifestation in clients with HF due to pulmonary
edema. Clients with orthopnea often sleep on a chair or on propped-up pillows to decrease work of breathing.
Paroxysmal nocturnal dyspnea, which is waking up in the middle of the night with suffocation due to dyspnea, is another
characteristic finding in HF.
• Crackles on auscultation: Crackles are a manifestation of pulmonary edema caused by fluid in the alveoli. Pulmonary
edema is concerning for worsening HF and impaired gas exchange.
• Peripheral edema and rapid weight gain (ie, >5 Ib/week [2.3 kg/week]): These symptoms are concerning for fluid
volume overload
• Hypoxemia: Decreased capillary oxygen saturation (SpO, <95%) is a sign of inadequate gas exchange. This is most
likely related to pulmonary edema from HF exacerbation.
Extract:
History and Physical
Body System,Findings
General
Client has history of coronary artery disease, hypertension, hyperlipidemia, diverticulosis, and
osteoarthritis; Helicobacter pylori infection 2 years ago; client reports taking over-the-counter
ibuprofen every 8 hours for left knee pain for the past 2 weeks; daily medications include aspirin,
carvedilol, lisinopril, and atorvastatin
Neurological
Alert and oriented to person, place, time, and situation
Pulmonary
Vital signs: RR 20, SpO 96% on room air, lung sounds clear bilaterally; no shortness of breath;
client smokes 1 pack of cigarettes per day and smokes marijuana 1 or 2 times weekly
Cardiovascular
Vital signs: P 110, BP 90/62; no chest pain; S1 and S2 heard on auscultation; peripheral pulses
2+; client states feeling lightheaded and reports passing out about 1 hour ago
Gastrointestinal
Abdominal pain rated as 4 on a scale of 0-10; one episode of hematemesis; two episodes of
large, black, liquid stools in the morning
Musculoskeletal
Examination of the knees shows crepitus that is worse on the left; no swelling, warmth, or
erythema; range of motion is normal
Psychosocial
Client reports drinking 1 or 2 glasses of wine per day
Question 3 of 5
Select below the 5 findings that require follow-up.
Correct Answer: A,C,D,F,G
Rationale: A client with hematemesis and black stools is most likely experiencing an acute gastrointestinal (GI) bleed. GI bleeding is a
life-threatening condition that can lead to hemorrhagic shock without immediate intervention. The nurse should immediately
follow up on:
• Chronic NSAID use (eg, ibuprofen), a common cause of drug-induced upper GI bleeds that must be discontinued.
• Hypotension and tachycardia, manifestations of hypovolemia. Hypotension occurs with decreased cardiac output, and
tachycardia is a compensatory mechanism to promote maximum perfusion to vital organs. Because this client has a
history of hypertension, even borderline low blood pressure is considered abnormal.
• Syncope (ie, passing out), a clinical finding associated with hypovolemia caused by decreased perfusion to the brain.
• Hematemesis (ie, vomiting blood), indicative of bleeding in the upper GI tract (eg, stomach ulcers, esophageal varices).
• Dark/black and/or tarry stools, most often associated with upper GI bleeding; blood becomes partially digested as it
passes through the Gl tract, resulting in the dark color.
Extract:
The nurse is caring for a 68-year-old client in the emergency department.
Nurses' Notes,
Emergency Department
1020:
The client reports shortness of breath, a 2-lb weight gain over the past week, and lower extremity swelling. The client
reports slight chest discomfort during activity that is relieved with rest. Medical history is significant for hypertension.
myocardial infarction, heart failure, coronary artery disease, and chronic stable angina. Current medications include
metoprolol, furosemide, potassium chloride, lisinopril, and aspirin. The client takes all medications as prescribed except
one; he states, "I do not take that water pill because I got tired of having to go to the bathroom all the time."
S1 and S2 are present; a prominent S3 is heard. Respirations are labored with inspiratory crackles in the middle and at the
base of the lungs. The abdomen is soft and nontender with normoactive bowel sounds. There is 3+ pitting edema in the
bilateral lower extremities.
Vital Signs,
1020
T ,98.8 F (37.1 C)
P, 60
RR, 24
BP, 168/96
SpO2, 90% on room air
Laboratory Test and Reference Range, 1030
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),
6.5 mEq/L
(6.5 mmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L),
22 mg/dL
(7.85 mmol/L)
Creatinine
Male: 0.6-1.3 mg/dL
(53-114.9 umol/L),
1.5 mg/dL
(132.6 umol/L)
Female: 0.5-1.1 mg/dL
(44.2-97.2 umol/L)
Question 4 of 5
The nurse has reviewed the information from the Laboratory Results. Complete the following sentence/sentences by choosing from the list/lists of options.The nurse should prioritize interventions to treat ------------ due to the risk of ---------------------.
Correct Answer: A,B
Rationale: The client's laboratory results show hyperkalemia (ie, high potassium) and decreased kidney function, seen as elevated BUN and creatinine.
The kidneys balance potassium levels by eliminating excess potassium through urine. Clients with heart failure (HF) are at an increased risk fo
hyperkalemia due to poor kidney perfusion from decreased cardiac output and medication adverse effects. This client's decreased kidney
function and home medications, including lisinopril (ACE inhibitor) and supplemental potassium chloride, all increase the risk of hyperkalemia.
Because potassium is responsible for myocardial cell repolarization, hyper- or hypokalemia may lead to life-threatening dysrhythmias.
Therefore, the nurse should prioritize interventions to treat hyperkalemia due to the risk of dysrhythmias.
Extract:
Nurses' Notes
Initial Clinic Visit
1100:
The client has experienced enuresis at night for the past 2 weeks and frequently requests to use the
bathroom while at school. The client was previously toilet trained with no nighttime bed wetting for 6 months;
the client recently relocated to a new home and school where the client lives with parents.
The parent reports that the client has recently demonstrated fatigue, irritability, and multiple behavioral
outbursts that resemble past temper tantrums. The client frequently reports feeling thirsty. No dysuria or
urinary hesitancy is reported.
Weight and height were in the 40th percentiles at the previous visit a year ago. Growth charts today show
the client's weight in the 20th percentile and height in the 40th percentile.
The client appears tired and irritable. Dry mucous membranes are noted with no increased work of
breathing. The lungs are clear to auscultation bilaterally. No cardiac murmur is heard.
Question 5 of 5
The nurse has reviewed the information from the Laboratory Results.Three days later, the school nurse is called to the play area because the client is diaphoretic and becomes unconscious. The school nurse notices the clients medical alert bracelet and obtains a blood glucose level. Which action should the school nurse take after reading the blood glucose level?
Correct Answer: A
Rationale: Rapid growth and unpredictable eating patterns place a child with diabetes mellitus at high risk for hypoglycemia.
Hypoglycemia can occur rapidly and can be life-threatening. Clinical manifestations primarily result from lack of glucose to the
brain (and other vital organs) followed by rapid activation of the sympathetic nervous system:
• Pallor and diaphoresis
• Tremors
• Palpitations and tachycardia
• Altered mental status, irritability, slurred speech, confusion
• Dizziness
If hypoglycemia is suspected, the nurse should immediately obtain a blood glucose level. Clients with hypoglycemia who are
unconscious cannot tolerate oral carbohydrates.
Therefore, the nurse should rapidly administer glucagon by injection (eg.
subcutaneous, IM) or apply a glucose paste to the gums. Glucagon increases blood glucose levels by rapidly converting
stored glycogen in the liver into glucose, a process known as glycogenolysis