NCLEX PN Exam Practice Test with NGN Related

The nurse is caring for a 40-year-old client.
History Admission:
The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them. The clients mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.
On examination, the client is malodorous and disheveled and laughs for no apparent reason. He appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The client's speech is difficult to follow, and he repeatedly says in a monotone voice, "I said I'll find them." He later becomes angry and refuses to sit in a chair for the interview. I'll find them." He later becomes angry and refuses to sit in a chair for the interview.

Select to highlight below the 4 findings that require immediate follow up.

• A. The client is brought to the psychiatric emergency department by ambulance after being observed walking in the street and shouting at vehicles.
• B. The client states that aliens are trying to attack him and that he is now on a mission to find and kill them.
• C. The client's mother says that last year he believed that he was being watched by an unidentified government agency and subsequently broke up with his girlfriend, quit his job, and disconnected his phone.
• D. The mother has noticed that he no longer seems to care about activities that used to interest him, and last month she discovered that he had moved into the family garden shed with his dog.

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 finding below, click to specify if the finding is consistent with the disease process of pneumonia or pulmonary embolism.

• A. Dyspnea
• B. Confusion
• C. High fever
• D. Recent surgery
• E. Smoking history
• F. Purulent sputum

The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.

Which of the following findings indicate that the newborn's condition has declined? Select all that apply.

• A. Axillary temperature is 96.3 F (35.7 C) and respirations are 84/min
• B. Blood glucose level is 32 mg/dL (1.8 mmol/L) prior to feeding
• C. Newborn is jittery and has a high-pitched cry
• D. Newborn is turning toward the breast while in skin-to-skin contact with the mother
• E. One wet diaper and no stools are noted since birth

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

After collecting data on the client, which action should the nurse perform immediately?

• A. Alert the registered nurse
• B. Collect a blood specimen for serum magnesium level
• C. Perform fundal massage
• D. Request a prescription for IV fluids

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

Which of the following choices would be appropriate for the client's dietary needs? Select all that apply.

• A. Chicken nuggets, ketchup, and carrot sticks
• B. Grilled ham and cheese sandwich with pretzels
• C. Plain yogurt with oats, honey, and blueberries
• D. Slice of pepperoni pizza with a side salad
• E. Wheat toast with unsalted peanut butter and banana