NCLEX PN Exam Practice Test with NGN Related

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.
1030:
The client is breathless while speaking. Respirations are shallow and
labored. The client is diaphoretic. The skin is pale and cool. No
audible wheezing or stridor is present.

Which of the following statements by the client's spouse indicate that the teaching has been effective? Select all that apply.

• A. My children and I need to get tested because we could become paralyzed, too.'
• B. My spouse may have neurologic deficits for several months.'
• C. My spouse may need a temporary feeding tube for nutrition while on the ventilator.'
• D. Our children should refrain from getting a yearly flu vaccine.'
• E. This was most likely triggered by the recent flu-like illness.'

Which of the following statements by the client indicate that teaching has been effective? Select all that apply.

• A. I plan to take a 20-minute brisk walk twice daily.'
• B. I should bake or broil foods instead of frying them.'
• C. I should eat white bread instead of multigrain bread.'
• D. I will avoid straining when passing a bowel movement.'
• E. I will drink at least 1 L (1000 mL) of fluid daily.'

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.

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

• A. The client is unconscious
• B. The client is under the age of 70
• C. The client's toxicology report reveals no illegal substances
• D. The client does not have a living will documented in the medical record

The nurse is caring for a 68-year-old client who is brought to the emergency department due to confusion.
History and Physical Body System Findings
General- Client's adult child reports the confusion started this morning, following 3 days of fever and productive cough; medical history includes small bowel resection 10 days ago, chronic heart failure, and coronary artery disease
Neurological- Client is drowsy and oriented to person only, but intermittently agitated Integumentary- Small abdominal surgical incision is present over lower left quadrant, edges are well approximated, and no redness or drainage is noted
Pulmonary- Vital signs are RR 24 and SpO 90% on room air; labored breathing is observed, and crackles and diminished breath sounds are auscultated over right lower chest; client is expectorating yellow sputum; history includes smoking a pack of cigarettes daily for the past 40 years
Cardiovascular- Vital signs are T 102.9 F (39.4 C), P 110, and BP 110/70; S1 and S2 are heard on auscultation; bilateral lower extremity edema is 1+; ECG shows sinus tachycardia
Gastrointestinal- Normoactive bowel sounds are auscultated; client's last bowel movement was 1 day ago
Genitourinary- Client voided concentrated yellow urine

For each potential intervention, click to specify if the intervention is expected or unexpected for the care of the client.

• A. Administer antipyretics
• B. Administer IV antibiotics
• C. Implement strict bed rest
• D. Implement NPO restrictions
• E. Implement airborne precautions
• F. Prepare client for bedside thoracentesis
• G. Administer oxygen to maintain SpO2 ≥ 95%

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

The nurse recognizes that the 6-month-old infant who ........ should be evaluated for........

• A. Does not use words
• B. Lacks control of the head
• C. Does not point at desired objects
• D. Cerebral palsy
• E. Hearing Impairment
• F. Autism spectrum disorder