NCLEX PN Practice Test with NGN Related

The nurse is caring for an 8-year-old client who was brought to the emergency department after
becoming short of breath at school.
Nurses' Notes
0920:
Nebulized administration of albuterol (salbutamol) and ipratropium bromide completed. Client continues to have a dry cough. Breath sounds are clear to auscultation; no intercostal retractions are visible.
Vital signs: RR 24, SpO2 96% on 6 L humidified oxygen via nasal cannula.

Select the findings that indicate the client is progressing as expected.

• A. Nebulized administration of albuterol (salbutamol) and ipratropium bromide completed
• B. Client continues to have a dry cough
• C. Breath sounds are clear to auscultation
• D. no intercostal retractions are visible
• E. Vital signs: RR 24, SpO2 96% on 6 L humidified oxygen via nasal cannula

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 nurse is assisting the registered nurse with developing the plan of care. For each potential intervention, click to specify the intervention is anticipated or unanticipated for the care of the client.

• A. Insert a rectal tube
• B. Advance to a regular diet
• C. Place the client on strict bed rest
• D. Measure abdominal girth frequently
• E. Request a nonopioid pain medication
• F. Apply a cold pack to the abdomen for pain

The nurse in the emergency department is caring for a 62-year-old client.
Progress Notes
Emergency Department
0900:
The client is brought to the emergency department by a family member after being found confused and lethargic. On arrival, the client is obtunded and does not respond to verbal stimuli.
Medical history includes major depressive disorder and chronic neck and back pain after a motor vehicle collision 2 years ago. The family member states that the client takes multiple medications but does not know which kind. The client was divorced a few months ago.
Physical examination shows 1-mm pupils, shallow breathing, and reduced bowel sounds. Fingerstick blood glucose is 78 mg/dL (4.3 mmol/L). ECG reveals normal sinus rhythm. Breath alcohol test is negative.
Vital signs: T 98.1 F (36.7 C), P 62, RR 8, BP 80/40, SpO2 94% on room air.
1800:
The client is awake, alert, and oriented to person, place, time, and situation. The client is experiencing severe withdrawal symptoms and is admitted for supervised detoxification.

Laboratory Results
Urine Drug Screen
On admission
Cocaine- Negative
Opioids- Positive
Amphetamines- Negative
Marijuana- Positive
Phencyclidine-Negative
Benzodiazepines- Negative
Barbiturates- Negative
Laboratory Test and Reference Range
Cocaine- Negative
Opioids- Negative
Amphetamines- Negative
Marijuana- Negative
Phencyclidine- Negative
Benzodiazepines- Negative
Barbiturates- Negative

The nurse has reviewed the information from the Progress Notes and Laboratory Results. For each potential intervention, click to specify if the intervention is expected or unexpected for the care of the client.

• A. Initiate seizure precautions
• B. Monitor the client for suicidal ideation
• C. Administer antidiarrheal and antiemetic medications as needed
• D. Use a standardized scoring scale to assess for withdrawal symptoms

The nurse is evaluating the client's use of hearing aids. Nurses' Notes
The client reports keeping hearing aids in a box in the bedside table when asleep. The client demonstrates pulling the top of the ear down and back to insert the hearing aid. When the device makes a whistling sound, the client reports turning the volume up. Every few days, when the aids are dirty, the client washes them gently with a wet washcloth. Before taking a break from the hearing aids over the weekend, the client removes the battery

Select 3 findings that require follow-up.

• A. The client reports keeping hearing aids in a box in the bedside table when asleep.
• B. The client demonstrates pulling the top of the ear down and back to insert the hearing aid.
• C. When the device makes a whistling sound, the client reports turning the volume up.
• D. Every few days, when the aids are dirty, the client washes them gently with a wet washcloth.
• E. Before taking a break from the hearing aids over the weekend, the client removes the battery.

The nurse is caring for a 58-year-old client on a medical-surgical unit.
History and Physical
General
The client is vomiting bright red blood; medical history includes alcohol use disorder, liver cirrhosis, and hypertension; the client was admitted a year ago for alcohol-induced acute pancreatitis

Neurological
The client is oriented to person and place; the pupils are equal, round, and reactive to light and accommodation

Eye, Ear, Nose, and Throat (EENT)
Yellow scleras are noted

Pulmonary
Vital signs are RR 18, SpO 94% on room air

Cardiovascular
Vital signs are T 99 F (37.2 C), P 102, BP 90/40; S1 and S2 are heard on auscultation; peripheral pulses are 2+ in all extremities; 1+ edema is noted at the bilateral lower extremities

Gastrointestinal
The abdomen is distended and nontender to palpation; the flanks are dull to percussion; bowel sounds are hypoactive; distended veins are present around the umbilicus

Genitourinary
Client is voiding amber-colored urine

The health care provider confirms that the client is experiencing bleeding from esophageal varices secondary to complications from liver cirrhosis. For each potential prescription, specify if the prescription is anticipated or unanticipated for the care of this client.

• A. Maintain NPO status
• B. Start octreotide infusion
• C. Administer IV fluid bolus
• D. Transfuse packed RBCs
• E. Gather supplies for paracentesis
• F. Prepare client for esophagogastroduodenoscopy