NCLEX PN Exam Practice Test with NGN

Question 1 of 5.

Extract:The nurse is caring for a 21-year-old client. Nurses' Notes History and Physical Vital Signs Emergency Department 0800: The client comes to the emergency department due to fear of having a heart attack. The client reports, "I was taking the bus home from work when my chest started feeling really tight. I'm lucky my friend was there and able to help me get to the hospital. What if my friend is not there next time?" The client describes experiencing similar episodes recently at random places and times and worries about when or where the next attack will occur

Which of the following statements by the nurse are appropriate to include in the teaching? Select all that apply

Question 2 of 5.

Extract:The nurse is caring for a 6-year-old client accompanied by the parents. History and Physical Body System Findings General Client is brought to the emergency department due to shortness of breath; medical history includes cystic fibrosis and many previous hospital admissions for pneumonia; in the 3rd percentile for height and weight Neurological Alert and oriented to person, place, and time; no neurologic deficits Pulmonary Vital signs: RR 30, SpO, 87% on room air; moderate subcostal retractions; bilateral wheezing and coarse crackles throughout lung fields with fine inspiratory crackles at left lung base; paroxysmal coughing that produces thick, yellow, blood-tinged sputum; parents report that the client has begun to become "winded" after showering and other activities Cardiovascular Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm and dry; peripheral pulses palpable 2+; capillary refill 3 econds; mild finger clubbing noted Gastrointestinal Abdomen soft with normoactive bowel sounds; parent states, "Swallowing the enzyme capsules is very difficult for my child, and I have noticed an increase in greasy, bulky stools"

Click to highlight below the assessment findings that require immediate follow-up?

Question 3 of 5.

Extract:The nurse is caring for a 6-year-old client accompanied by the parents. History and Physical Body System Findings General Client is brought to the emergency department due to shortness of breath; medical history includes cystic fibrosis and many previous hospital admissions for pneumonia; in the 3rd percentile for height and weight Neurological Alert and oriented to person, place, and time; no neurologic deficits Pulmonary Vital signs: RR 30, SpO, 87% on room air; moderate subcostal retractions; bilateral wheezing and coarse crackles throughout lung fields with fine inspiratory crackles at left lung base; paroxysmal coughing that produces thick, yellow, blood-tinged sputum; parents report that the client has begun to become "winded" after showering and other activities Cardiovascular Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm and dry; peripheral pulses palpable 2+; capillary refill 3 econds; mild finger clubbing noted Gastrointestinal Abdomen soft with normoactive bowel sounds; parent states, "Swallowing the enzyme capsules is very difficult for my child, and I have noticed an increase in greasy, bulky stools"

Which of the following client findings are consistent with a cystic fibrosis exacerbation? Select all that apply.

Question 4 of 5.

Extract:The nurse is caring for a 6-year-old client accompanied by the parents. History and Physical Body System Findings General Client is brought to the emergency department due to shortness of breath; medical history includes cystic fibrosis and many previous hospital admissions for pneumonia; in the 3rd percentile for height and weight Neurological Alert and oriented to person, place, and time; no neurologic deficits Pulmonary Vital signs: RR 30, SpO, 87% on room air; moderate subcostal retractions; bilateral wheezing and coarse crackles throughout lung fields with fine inspiratory crackles at left lung base; paroxysmal coughing that produces thick, yellow, blood-tinged sputum; parents report that the client has begun to become "winded" after showering and other activities Cardiovascular Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm and dry; peripheral pulses palpable 2+; capillary refill 3 econds; mild finger clubbing noted Gastrointestinal Abdomen soft with normoactive bowel sounds; parent states, "Swallowing the enzyme capsules is very difficult for my child, and I have noticed an increase in greasy, bulky stools"

The nurse should prioritize interventions for Select...

Question 5 of 5.

Extract:The nurse is caring for a 6-year-old client accompanied by the parents. History and Physical Body System Findings General Client is brought to the emergency department due to shortness of breath; medical history includes cystic fibrosis and many previous hospital admissions for pneumonia; in the 3rd percentile for height and weight Neurological Alert and oriented to person, place, and time; no neurologic deficits Pulmonary Vital signs: RR 30, SpO, 87% on room air; moderate subcostal retractions; bilateral wheezing and coarse crackles throughout lung fields with fine inspiratory crackles at left lung base; paroxysmal coughing that produces thick, yellow, blood-tinged sputum; parents report that the client has begun to become "winded" after showering and other activities Cardiovascular Vital signs: T 101.7 F (38.7 C), P 130, BP 94/58; skin warm and dry; peripheral pulses palpable 2+; capillary refill 3 econds; mild finger clubbing noted Gastrointestinal Abdomen soft with normoactive bowel sounds; parent states, "Swallowing the enzyme capsules is very difficult for my child, and I have noticed an increase in greasy, bulky stools"

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