NCLEX-PN
NCLEX PN Exam Practice Test with NGN Questions
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 1 of 5
Which prescription should the nurse implement first?
Correct Answer: A
Rationale: Albuterol is prioritized to relieve acute bronchospasm and improve airflow in respiratory distress.
Question 2 of 5
Which of the following client findings are consistent with a cystic fibrosis exacerbation? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: Cystic fibrosis exacerbations often present with increased respiratory symptoms (A, C,
D), fever , and malabsorption issues due to pancreatic insufficiency.
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 3 of 5
The nurse should prioritize interventions for........... to prevent .........
Correct Answer: B,E
Rationale: Spinal cord compression interventions aim to prevent paralysis due to nerve damage.
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 4 of 5
For each potential intervention, click to specify if the intervention is indicated or not indicated for the care the client.
| Potential Intervention | Indicated | Not Indicated |
|---|---|---|
| Cleanse the client's body thoroughly | ||
| Remove the client's abdominal staples | ||
| Remove identifying name tags from the client | ||
| Notify the organ and tissue donation organization | ||
| Allow the family to be present during postmortem care | ||
| Remove the drains, urinary catheter, and peripheral IV catheters |
Correct Answer: A,C,D,E,F
Rationale: Cleansing the body , removing identifiers , notifying donation organizations , allowing family presence , and removing invasive devices are standard postmortem care. Staples should remain for autopsy or funeral preparation.
Extract:
The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.
Question 5 of 5
For each potential intervention, click to specify the intervention is expected or not expected for the care of the client at this time.
| Potential Intervention | Indicated | Not Indicated |
|---|---|---|
| Keep NPO | ||
| Maintain IV fluids | ||
| Administer antibiotics | ||
| Apply heating pad to abdomen | ||
| Verify consent for abdominal surgery |
Correct Answer: A,B,C
Rationale: NPO status , IV fluids , and antibiotics are expected for acute diverticulitis. Heating pads worsen inflammation, and surgery is not immediate.