NCLEX PN Practice Test with NGN Related

The nurse in the emergency department is caring for a 62-year-old client.
History and Physical
Neurological
The client is alert and oriented to time, place, person, and situation; the client reports sudden-onset right-sided facial drooping, speech is slurred; positive right-sided arm drift is seen
Eye, Ear, Nose, and Throat (EENT)
Bilateral pupils are equal, round, and reactive to light and accommodation

Pulmonary
Vital signs: RR 16, SpO, 95% on room air, lung sounds are clear bilaterally

Cardiovascular
Vital signs: T 99 F (37.2 C), P 86, BP 166/90; S1 and S2 are heard on auscultation; no murmurs are noted; the client has a history of hypertension

Musculoskeletal
Right-sided lower extremity weakness is seen

Endocrine
The client has diabetes mellitus

Psychosocial
The client reports drinking one glass of wine each evening with dinner, no tobacco use, and a history of major depression; the client takes sertraline.

Laboratory Results
During Admission
Blood Chemistry.
Glucose: 72 mg/dL (4.0 mmol/L)
Sodium: 133 mEq/L (133 mEq/L)
Chloride: 101 mEq/L (101 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)



Laboratory Test and Reference Range
Blood Chemistry.
Glucose 74-106 mg/dL (4.1-5.9 mmol/L)
Sodium 136-145 mEq/L (136-145 mmol/L)
Chloride 98-106 mEq/L(98-106 mmol/L)
Potassium 3.5-5.0 mEq/L (3.5-5.0 mmol/L

Diagnostic Results
Admission
CT scan of the head without contrast
1830:
No areas of hemorrhage are noted

The nurse is assisting the registered nurse in planning care for a client prescribed tissue plasminogen activator (tPA) therapy. Which of the following actions are appropriate prior to administration? Select all that apply.

• A. Ask the client's caretaker about a history of recent surgery or trauma
• B. Maintain BP ≤ 185/110
• C. Plan to initiate subcutaneous heparin immediately after tPA infusion is complete
• D. Review the client's current home medication list
• E. Verify the exact time the stroke symptoms started

Nurses' Notes
Emergency Department
A newborn is brought to the emergency department due to coughing and difficulty feeding. The client was born at home 6 hours ago via spontaneous vaginal birth. With each attempt to breastfeed, the client coughs, vomits, and "turns blue." The mother did not receive prenatal care. She reports a history of opioid use disorder but reports no opioid use during pregnancy.
Vital signs: T 98.6 F (37 C), P 120, RR 50, and SpO, 95% on room air. Abdominal distension is present. Ballard scoring estimates the client at 37 weeks gestation. Weight and length are consistent with the 25th and 50th percentiles for estimated age, respectively.
1 Hour Later
After attempting a bottle feed with 10 mL of formula, the client has a coughing episode, and there is formula mixed with saliva in the mouth. Coarse breath sounds are noted bilaterally with intercostal retractions. S1 and S2 are present with no murmurs. Neurologic examination shows normal neuromuscular findings.
A nasogastric tube insertion is attempted per prescription by the health care provider, and resistance is met at 10 cm of insertion.

During a diaper change, the client becomes cyanotic with frothy secretions from the mouth and nose. What action should nurse perform first?

• A. Activate the rapid response team
• B. Initiate rescue breathing with a bag valve mask
• C. Perform nasal and oropharyngeal suction
• D. Prepare the newborn for intubation

The nurse is caring for a client on the medical-surgical unit.
History
Admission
0500: The client is admitted with an abscess and cellulitis of the right leg. The abscess is noted on the lateral aspect of the right calf, with redness, swelling, and warmth extending from the knee to the ankle. The abscess was incised in the emergency department, and a moderate amount of purulent, yellowish-green drainage was noted. The leg was wrapped with gauze, and the client received the first dose of IV antibiotics and opioids for pain control.
The client reports chronic lower back pain and gastrosophageal reflux disease, and he was admitted to the hospital once last year for gastrointestinal bleeding. He is currently prescribed daily pantoprazole but takes it only a few times a week.
Vital signs: T 100.9 F (38.3 C), P 82, RR 14, BP 130/80, SpO, 95% on room air

Progress Notes
Medical-Surgical Unit
2300:
The client reports nausea, headache, and insomnia. The client is trembling, diaphoretic, and restless.
The client states, "I would sleep better if those mice and cats would stop climbing up and down the walls."
The upper portion of the clients dressing is saturated with yellowish-green drainage. The peripheral V was removed by the client, and dried blood is noted at the IV site. The IV catheter is on the floor. The client yelled and pushed the nurse's hands away during inspection of the IV site.
Vital signs: T 99 F (37.2 C), P 102, RR 18, BP 170/96, SpO≥ 95% on room air

The nurse recognizes that the client is most at risk for ___ related to ___

• A. Seizures
• B. Septic shock
• C. Hypovolemic shock
• D. Cellulitis
• E. Substance withdrawal
• F. Gastrointestinal bleeding

The nurse is caring for a 66-year-old client in the emergency department.
Nurses' Notes
Emergency Department
1930:
The client is admitted for cellulitis of the right arm due to V drug use. The client was diagnosed with HIV 25 years ago and is taking antiretroviral therapy but reports frequently skipping doses. This is the client's third admission to the hospital within the past 6 months for complications due to IV drug use.
2015:
While assisting with an IV catheter placement, the nurse accidentally sustains a needlestick injury.

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

• A. Wash the injury with soap and water
• B. Screen the client for hepatitis C virus
• C. Squeeze tissue to let the wound bleed
• D. Anticipate initiating antiretrovirals for the nurse
• E. Anticipate initiating oral antibiotics for the nurse
• F. Replace the cap on the needle prior to disposal

The nurse in the surgical unit is caring for a 57-year-old client who underwent an abdominal hysterectomy.
Progress Notes
1 Day Postoperative
0800:
The client underwent total abdominal hysterectomy with bilateral oophorectomy and tumor debulking 1 day ago for treatment of ovarian cancer. She has had four episodes of vomiting with bilious emesis over the past 12 hours, which have continued despite V antiemetic administration. The client has been receiving V broad-spectrum antibiotics since the procedure. The skin is warm. A low transverse abdominal incision is present; staples are clean and dry. Chest expansion is symmetric; respirations are unlabored: diminished breath sounds are auscultated in bilateral lower lobes. Radial pulses 2+ bilaterally, capillary refill <3 seconds in all four extremities; no peripheral edema is noted. The client reports frequent hot flashes occurring roughly every hour, starting last night. The abdomen is markedly distended and tender to palpation. Bowel sounds are absent in all four quadrants; the client reports no flatus. Urine is clear yellow with moderate output. The client reports incontinence with coughing or during episodes of vomiting.

The health care provider suspects that the client is experiencing postoperative ileus. The nurse should prepare the client for and provide.

• A. A digital rectal examination
• B. Abdominal and pelvic x-rays
• C. An emergency small bowel resection
• D. Enteral tube feedings
• E. Total parenteral nutrition
• F. Small sips of clear liquids