NCLEX-PN ACTUAL EXAM 2024 QUESTIONS WITH ANSWERS 100%

NCLEX-PN ACTUAL EXAM 2024 QUESTIONS WITH ANSWERS 100% A nurse is collecting data on a 58 year old client with blurred vision and reduced visual fields. The nurse finds which clinical manifestation MOST concerning? A) Difficulty adjusting to dimmed lights B) Extreme eye pain C) Gradual loss of peripheral vision D) Opaque appearance of lens - ANSWERS B, glaucoma is characterized by increased intraocular pressure (IOP) resulting in compression of the optic nerve. When IOP increases rapidly sudden onset of severe eye pain can occur. Gradual loss of vision and difficulty adjusting to lights are not considered emergency situations. Opaque lenses are characteristics of cataracts which is not a medical emergency. The nurse is caring for a patient with diabetes mellitus. The client is alert and oriented but appears shaky and pale. The client's capillary blood glucose is 50 mg/dL (2.8 mmol/L). Which of the following actions should the nurse take next? A) Administer 1 mg glucagon IM to the patient B) Give the patient 4 oz (120 mL of regular soda. C) Prepare 50 mL of dextrose 50% in water IV push. D) Repeat the capillary blood glucose level to verify accuracy. - ANSWERS B, hypoglycemia occurs when blood glucose levels fall below 70 mg/dL. Conscious clients should be given 15 g of a simple carbohydrate (ex. 4 oz regular soda) to quickly increase the blood glucose level. IV dextrose and IM glucagon are given to patient who can not digest an oral simple carbohydrate. The blood glucose should be rechecked 15 minutes after administration of a simple carbohydrate to check effectiveness. The nurse is reviewing medical histories with several clients during a community health screening event. Which of the following client statements indicate a risk factor for cervical cancer? SATA A) "I have had four sexual partners during my lifetime." B) "I have smoked cigarettes for many years." C) "I never use birth control pills because my partners wore condoms." D) "I received treatment for chlamydia when I was younger." E) "I tested positive for human papillomavirus a few years ago." - ANSWERS A, B, D, E, the most important risk factor for cervical cancer is persistent human papillomavirus (HPV) infection. Other risks factors for cervical cancer include multiple sex partners (>1), smoking tobacco, being infected with other STIs (chlamydia). As these all increase the likelihood of HPV infection. Condoms help prevent HPV, and not taking oral birth control is associated with a decreased risk of cervical cancer. The nurse in the emergency department is caring for a 66 year old client. GENERAL: The client comes to the ED with fatigue, SOB, dry cough, and exertional dyspnea for 1 week; the client is homeless; medical history includes chronic heart failure, uncontrolled hypertension, CAD, and type 2 DM PULMONARY: VS: RR 22, SpO2 88% on RA; the client is dyspneic but can speak in full sentences; lung auscultation reveals bilateral crackles; the client reports smoking 1 pack of cigarettes per day for 35 years; the client was hospitalized with pneumonia 6 months ago. CARDIOVASCULAR: VS: T 99 F (37.2 C), P 90, BP 170/100; continuous cardiac monitor shows sinus rhythm with occasional premature ventricular contractions; S1, S2, and S3 are heard on auscultation; bilateral lower extremity pitting edema is noted. Highlight below the 5 findings that are MOST concerning. - ANSWERS SpO2 88% on RA (hypoxia), lung auscultation reveals bilateral crackles (pulmonary edema), BP 170/100 (HTN), S3 are heard on auscultation (abnormal heart sounds), bilateral lower extremity pitting edema (peripheral edema). Smoking and homelessness require follow-up to ensure the client receives appropriate resources and support, but they do not require immediate intervention. Decreased O2, crackles, extra heart tones, HTN, peripheral edema require further intervention due to concern of fluid overload and impaired gas exchange characteristics of HF. The nurse has reviewed the information from the Laboratory Results and Diagnostic Results, the nurse suspects the client is experiencing acute decompensated HF. Which of the following findings are consistent with this condition? SATA A) Crackles with auscultation B) Decreased capillary oxygen saturation C) Elevated b-type natriuretic peptide D) left ventricular ejection fraction 30% E) Lower extremity pitting edema - ANSWERS A, B, C, D, E, Decompensated HF is characterized by pulmonary congestion (crackles, decreased O2, fluid overload [peripheral edema]). In addition clients will have an elevated b-type natriuretic peptide and low ejection fraction (<50%). The nurse should prioritize interventions for acute decompensated heart failure to reduce the risk of the client developing ____________ and ____________. Disseminated intravascular coagulation Bacterial endocarditis Empyema Dysrhythmias Acute kidney injury (AKI) - ANSWERS Dysrhythmias and Acute kidney injury (AKI). Dysrhythmias are due to structural changes altering the electrical activity of the heart. AKI is due to hypo-perfusion (decreased perfusion) of vital organs secondary to decreased cardiac output. Both complications of decompensated HF. Empyema is pus in the pleural cavity due to bacteria in the lungs, HF can cause pleural effusions, but empyema is not an expected finding. Bacterial endocarditis can precipitate HF, but this client shows no signs of infection. DIC is a life threatening condition from abnormal blood clotting. Caused by sepsis and trauma, HF is not a common cause. For each potential intervention, click to specify if the intervention is expected or not expected for the care of the client. Potential interventions: Daily weights, IV furosemide, Fluid restriction, Supplemental oxygen, Antihypertensive medications, nebulized albuterol breathing treatments. - ANSWERS Expected: Daily weights, IV furosemide, Fluid restriction, Supplemental oxygen, Antihypertensive medications. Not expected:nebulized albuterol breathing treatments Expected interventions for decompensated HF focus on reducing the cardiac workload and improving oxygenation. Nebulized albuterol is a bronchodilator to improve oxygenation in clients with reactive airway disease (COPD, asthma). They will not improve oxygenation in clients with pulmonary edema and are NOT expected for treatment of HF. For the findings below, click to specify if the finding is consistent with the expected action of the medication carvedilol, enalapril, or furosemide. May support more than one medication. Decreases HR Increased urinary output Decreases BP Increases O2 saturation - ANSWERS Carvedilol: Decreases HR and Decreases BP Enalapril: Decreases BP Furosemide: Increased urinary output, Decreases BP and Increases O2 saturation Beta blockers (carvedilol) reduce cardiac workload and decrease myocardial oxygen demand by DECREASING BP and DECREASING HR