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

Questions 85

NCLEX-PN

NCLEX-PN Test Bank

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 of the following statements by the parent indicate a correct understanding of the teaching? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Monitoring vision , follow-up tests , expecting hematuria , and avoiding infections are correct. Lifelong medication is not typical.

Extract:

The nurse is caring for a 6-year-old client accompanied by the parents.
History and Physical
Body System
Findings
General
Client is brought to the emergency department due to
shortness of breath; medical history includes cystic fibrosis
and many previous hospital admissions for pneumonia; in the
3rd percentile for height and weight
Neurological
Alert and oriented to person, place, and time; no neurologic
deficits
Pulmonary
Vital signs: RR 30, SpO, 87% on room air; moderate
subcostal retractions; bilateral wheezing and coarse crackles
throughout lung fields with fine inspiratory crackles at left lung
base; paroxysmal coughing that produces thick, yellow,
blood-tinged sputum; parents report that the client has begun
to become "winded" after showering and other activities Cardiovascular
Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm
and dry; peripheral pulses palpable 2+; capillary refill 3
econds; mild finger clubbing noted
Gastrointestinal
Abdomen soft with normoactive bowel sounds; parent states,
"Swallowing the enzyme capsules is very difficult for my child,
and I have noticed an increase in greasy, bulky stools"


Question 2 of 5

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

Potential InterventionIndicatedNot Indicated
Administer antibiotics
Administer a bronchodilator
Perform chest physiotherapy
Administer nebulized hypertonic saline
Place the client on airborne isolation precautions

Correct Answer: A,B,C,D

Rationale: Antibiotics treat bacterial pneumonia, bronchodilators relieve wheezing, chest physiotherapy aids mucus clearance, and hypertonic saline thins mucus. Airborne isolation is not indicated for bacterial pneumonia.

Extract:

The nurse is caring for a 69-year-old client.
Progress Notes Emergency Department
1100: The client is unconscious following a suicide attempt. The paramedics immediately initiate CPR.
1115: The nurse reviews the client's chart and is unable to find documentation of a durable power of attorney for health care.


Question 3 of 5

For each rationale, click to specify if the rationale is applicable or not applicable regarding the need to continue cardiopulmonary resuscitation.

RationaleApplicableNot Applicable
The client is unconscious
The client is under the age of 70
The client's toxicology report reveals no illegal substances
The client does not have a living will documented in the medical record

Correct Answer: A,D

Rationale: Unconsciousness and no living will support continuing CPR unless a DNR exists. Age and toxicology are irrelevant.

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 4 of 5

Which 3 findings require immediate follow-up?

Cardiovascular findings
Genitourinary symptoms
Musculoskeletal symptoms
Neurologic symptoms
Vital signs

Correct Answer: B,C,D

Rationale: Urinary retention , trouble walking , and decreased sensation suggest spinal cord compression, requiring urgent intervention.

Extract:

The nurse is assisting the registered nurse with caring for a client who is at 36 weeks gestation. History and Physical Vital Signs
General - Client is gravida 2 para 1 at 36 weeks gestation; reports a throbbing headache rated as / on a scale of 0-10, blurred vision, and epigastric pain; client states that she took 1000 mg of acetaminophen 2 hours ago with no relief, medical history includes seasonal allergies and exercise-induced asthma
Neurological -Patellar deep tendon reflexes 2+ bilaterally, clonus absent
Cardiovascular -Heart tones normal; facial edema noted; +2 pitting edema in bilateral upper extremities; +3 pitting edema in bilateral lower extremities
Gastrointestinal -Client reports fetal movement, no contractions noted; soft uterine resting tone on palpation
Genitourinary -Cervical examination: 1 cm dilated, 0% effaced, -3 fetal station, cephalic fetal presentation, amniotic membranes intact; cesarean birth 5 years ago at 40 weeks gestation for breech fetal presentation, resulting in delivery of healthy newborn


Question 5 of 5

Which of the following findings are clinical manifestations of preeclampsia? Select all that apply.

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

Rationale: Preeclampsia manifests with epigastric pain , edema , hypertension , proteinuria , headaches , and visual disturbances .

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