NCLEX-RN Test 1 NGN Questions With
Complete Solutions
The nurse receives handoff of care report on four
clients. Which client should the nurse assess first?
1. Client who had an emergency appendectomy 48
hours ago and is reporting hearing waves and
seeing fish swimming through the walls
- Hallucinations represent a serious safety
risk to the client and others because these may
compel clients to engage in behaviors or activities
that trigger self-injury or violence toward others
(eg, command hallucinations). Hallucinations
experienced by clients without a psychiatric illness
may indicate withdrawal from alcohol or
narcotics, which can be life-threatening without
prompt intervention. Nurses should promptly
assess clients with new or worsening hallucinations
The nurse precepting a graduate nurse (GN)
reviews age-related changes that increase older
adult clients' risk for respiratory infections. Which
of the following statements by the GN indicate a
correct understanding? Select all that apply.
1. "The ability to cough forcefully decreases."
2. "The chest wall may become less flexible (chest
wall stiffening)."
,3. "The immune system response is diminished."
4. "The mucous membranes become drier."
5. "The number and motility of cilia decrease."
Older adults experience expected, age-
related physiologic changes, several of which
increase their risk for respiratory illnesses and
infection.
With aging, mucus becomes thicker and more
difficult to clear because the mucous membranes
produce and secrete less mucus. Costal cartilage
becomes calcified, reducing lung compliance
and expansion (Option 2). The respiratory
muscles become weaker and the cough is less
forceful (Option 1). The number of respiratory
cilia is decreased, and they become less
effective in their brushing motion (Option 5). All
these changes reduce the body's ability to clear
mucus and pathogens.
The immune system of older adults is
also diminished as the function and quality of
lymphocytes (ie, T cells, B cells) are altered and
respiratory defenses (eg, mucus clearance) are
impaired (Option 3). The older adult's dry
mucous membranes are also more vulnerable to
respiratory pathogens and infection (Option 4).
,Complete the diagram by dragging from the
choices below to specify what condition the client
is most likely experiencing, 2 actions the nurse
should take to address the condition, and 2
parameters the nurse should monitor to assess the
client's progress.
Potential condition: Pancreatitis
Actions to take: Administer opioid analgesics,
Administer 0.9% sodium chloride
Parameters to monitor: pain level, blood glucose
level
Pancreatitis (ie, inflammation of the pancreas) is
characterized by severe pain after eating due to
the release of pancreatic enzymes (eg, lipase) in
and around the pancreas, causing inflammation
and autodigestion of pancreatic tissue. Pain is
usually located in the epigastric area and/or
left upper abdomen and may be partially
relieved by leaning forward, which decreases
abdominal tension. Serum lipase levels can
rise to >3 times the normal upper limit.
Alcohol use, gallstones, and markedly elevated
serum triglycerides are the common causes.
Management includes:
- Administering IV pain medications (eg, opioid
analgesics) and monitoring the client's pain level
, - Administering IV fluids (eg, 0.9% sodium
chloride) to prevent hypovolemia due to
dehydration and third spacing
- Monitoring blood glucose levels because
pancreatic damage and inflammation can
impair insulin release, leading to
hyperglycemia
The charge nurse is making client assignments for
the oncoming shift. Which client assignment
is most appropriate for a nurse who is 10 weeks
pregnant?
3. Client with a methicillin-
resistant Staphylococcus aureus wound infection
Health care workers (HCWs) who are pregnant do
not carry a high risk for contracting methicillin-
resistant Staphylococcus aureus (MRSA) as long as
appropriate infection precautions (ie, contact
precautions) are in place (Option 3). Even if the
HCW who is pregnant were to contract MRSA, there
are few known harmful effects to the fetus.
Because TORCH infections (Toxoplasmosis, Other
[eg, syphilis], Rubella, Cytomegalovirus, Herpes
Complete Solutions
The nurse receives handoff of care report on four
clients. Which client should the nurse assess first?
1. Client who had an emergency appendectomy 48
hours ago and is reporting hearing waves and
seeing fish swimming through the walls
- Hallucinations represent a serious safety
risk to the client and others because these may
compel clients to engage in behaviors or activities
that trigger self-injury or violence toward others
(eg, command hallucinations). Hallucinations
experienced by clients without a psychiatric illness
may indicate withdrawal from alcohol or
narcotics, which can be life-threatening without
prompt intervention. Nurses should promptly
assess clients with new or worsening hallucinations
The nurse precepting a graduate nurse (GN)
reviews age-related changes that increase older
adult clients' risk for respiratory infections. Which
of the following statements by the GN indicate a
correct understanding? Select all that apply.
1. "The ability to cough forcefully decreases."
2. "The chest wall may become less flexible (chest
wall stiffening)."
,3. "The immune system response is diminished."
4. "The mucous membranes become drier."
5. "The number and motility of cilia decrease."
Older adults experience expected, age-
related physiologic changes, several of which
increase their risk for respiratory illnesses and
infection.
With aging, mucus becomes thicker and more
difficult to clear because the mucous membranes
produce and secrete less mucus. Costal cartilage
becomes calcified, reducing lung compliance
and expansion (Option 2). The respiratory
muscles become weaker and the cough is less
forceful (Option 1). The number of respiratory
cilia is decreased, and they become less
effective in their brushing motion (Option 5). All
these changes reduce the body's ability to clear
mucus and pathogens.
The immune system of older adults is
also diminished as the function and quality of
lymphocytes (ie, T cells, B cells) are altered and
respiratory defenses (eg, mucus clearance) are
impaired (Option 3). The older adult's dry
mucous membranes are also more vulnerable to
respiratory pathogens and infection (Option 4).
,Complete the diagram by dragging from the
choices below to specify what condition the client
is most likely experiencing, 2 actions the nurse
should take to address the condition, and 2
parameters the nurse should monitor to assess the
client's progress.
Potential condition: Pancreatitis
Actions to take: Administer opioid analgesics,
Administer 0.9% sodium chloride
Parameters to monitor: pain level, blood glucose
level
Pancreatitis (ie, inflammation of the pancreas) is
characterized by severe pain after eating due to
the release of pancreatic enzymes (eg, lipase) in
and around the pancreas, causing inflammation
and autodigestion of pancreatic tissue. Pain is
usually located in the epigastric area and/or
left upper abdomen and may be partially
relieved by leaning forward, which decreases
abdominal tension. Serum lipase levels can
rise to >3 times the normal upper limit.
Alcohol use, gallstones, and markedly elevated
serum triglycerides are the common causes.
Management includes:
- Administering IV pain medications (eg, opioid
analgesics) and monitoring the client's pain level
, - Administering IV fluids (eg, 0.9% sodium
chloride) to prevent hypovolemia due to
dehydration and third spacing
- Monitoring blood glucose levels because
pancreatic damage and inflammation can
impair insulin release, leading to
hyperglycemia
The charge nurse is making client assignments for
the oncoming shift. Which client assignment
is most appropriate for a nurse who is 10 weeks
pregnant?
3. Client with a methicillin-
resistant Staphylococcus aureus wound infection
Health care workers (HCWs) who are pregnant do
not carry a high risk for contracting methicillin-
resistant Staphylococcus aureus (MRSA) as long as
appropriate infection precautions (ie, contact
precautions) are in place (Option 3). Even if the
HCW who is pregnant were to contract MRSA, there
are few known harmful effects to the fetus.
Because TORCH infections (Toxoplasmosis, Other
[eg, syphilis], Rubella, Cytomegalovirus, Herpes
