NCLEX PN Practice Test with NGN Related

The nurse is caring for an 82-year-old client in the emergency department.
Nurses' Notes
0930:
The client reports shortness of breath and left-sided chest pain for 2 days. The client fractured the right femoral neck a month ago after a fall and decided against operative management. Since then, the client has been wheelchair dependent and takes acetaminophen for fracture pain management. The client was placed on continuous cardiac monitoring.

History and physical
Body System
Neurological
The client is awake, alert, and oriented to person, place, time, and situation; the client appears anxious

Pulmonary
Vital signs are RR 22, SpOz 89% on room air; bilateral breath sounds are clear; pain increases with inhalation; the client reports shortness of breath for the past 2 days; the client smoked 1 pack of cigarettes per day for 10 years.

Cardiovascular
Vital signs are T 99.8 F (37.7 C), P 110, BP 110/60; S1 and S2 are present; there are no murmurs, redness and edema of the right lower extremity are noted; sinus tachycardia is seen on the monitor, chest pain is reported as 7 on a scale of 0-10

Musculoskeletal
The client has osteoporosis, is wheelchair dependent, and is unable to bear weight on the right leg

Diagnostic Results
CT pulmonary angiography
1030: Pulmonary embolism is confirmed

Lower extremity doppler ultrasound
1100: Deep venous thrombosis is noted in the right lower extremity.

Which of the following statements by the nurse indicate a correct understanding of heparin therapy? Select all that apply.

• A. Clients who have had recent surgeries or have a history of hemorrhagic stroke should not receive heparin.
• B. Heparin is administered via IV infusion pump.
• C. Heparin requires two licensed health care personnel to verify the infusion rate.
• D. Heparin should be discontinued if platelets decrease significantly.
• E. I will collect a blood specimen for a complete blood count and coagulation panel before heparin is initiated.
• F. The heparin dose is adjusted based on frequently checked PT/INR results.

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

Which of the following complications are related to liver cirrhosis? Select all that apply.

• A. Abdominal ascites
• B. Coagulopathies
• C. Esophageal varices
• D. Hepatic encephalopathy
• E. Malnutrition

The nurse is caring for an 8-year-old client who was brought to the emergency department after
becoming short of breath at school.
History and Physical
General
Well-nourished child; currently sitting in the tripod position; patches of dry, scaly, reddened skin are present in the creases of bilateral elbows and behind both knees; client reports that these areas itch

Neurological
Alert and oriented to person, place, and time

Eye, Ear, Nose, andThroat (EENT)
Pupils equal, round, and reactive to light and accommodation; client reports no nasal congestion

Pulmonary
Vital signs: RR 34, SpO 92% on room air, airway patent, intercostal retractions noted during inspiration; expiratory wheezes auscultated bilaterally; dry, spasmodic cough is noted; no stridor; difficulty speaking in complete sentences

Cardiovascular
Vital signs: T 98.8 F (37.1 C), P 110, BP 94/60; S1 and S2 heard on auscultation; nom murmurs noted; peripheral pulses 2+; capillary refill 3 seconds; no edema

Gastrointestinal
Abdomen soft; bowel sounds normal

Psychosocial
Client appears anxious and is crying, client speaks in short phrases, stating, "left my medicine at a friend's house" and "feels like I can't breathe"; client cannot remember the name of the prescribed home medication; client's parents were notified and are en route to hospital

Select the findings that require immediate follow up.

• A. Well-nourished child; currently sitting in the tripod position; patches of dry, scaly, reddened skin are present in the creases of bilateral elbows and behind both knees
• B. Vital signs: RR 34, SpO 92% on room air
• C. airway patent, intercostal retractions noted during inspiration; expiratory wheezes auscultated bilaterally
• D. difficulty speaking in complete sentences
• E. Vital signs: T 98.8 F (37.1 C), P 110, BP 94/60; S1 and S2 heard on auscultation
• F. capillary refill 3 seconds; no edema
• G. Client appears anxious and is crying

The nurse in an inpatient mental health unit is caring for a 43-year-old client.
History
Admission:
The client comes to the inpatient psychiatric facility for an evaluation. The client is having distressing nightmares, flashbacks, and feelings of being "on edge" since a severe motor vehicle collision 6 months ago that resulted in the death of the client's sibling. The client blames self for the sibling's death and verbalizes feelings of guilt. The client reports an inability to sleep well and being quick to anger, both of which led to job loss and the client seeking help. The client reports a loss of interest in previously enjoyed activities, such as working out and interacting with friends. The client has started smoking cigarettes daily since the collision and typically consumes ≥4 alcoholic beverages per day. Mental status examination reveals an irritable, guarded, and easily distracted mood. The client's appearance is well- kept, and grooming and hygiene are appropriate. The client’s speech is hyperverbal yet coherent, and thought process is organized. The client admits to feelings of hopelessness after the death of the sibling. The client reports occasionally seeing "shadows" but no visual hallucinations. The client has no homicidal ideations or history of violence toward others.
Vital signs: P 78, RR 17, BP 132/78.

The nurse suspects that the client is experiencing posttraumatic stress disorder. Which of the following symptoms are consistent with this condition? Select all that apply.

• A. Euphoric mood
• B. Flashbacks
• C. Hypervigilance
• D. Irritability
• E. Nightmares
• F. Self-blame

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