NCLEX Practice Set 10 (Standalone Q’s)

A 32-year-old female presents to the labor unit complaining of contractions every 5 minutes apart.

Nurse Notes:

Time 1000.
Client is having regular contractions every 5 minutes, rating pain 3/10 on pain scale. Fetal heart rate 130s baseline with moderate variability and accelerations.

1045.
Client requesting epidural as pain has increased to 6/10 on pain scale. IV fluid bolus started, and anesthesia notified.

1105.
Epidural placed by anesthesia. Fetal heart rate 130s baseline with moderate variability and accelerations.

1115.
Client calls out, complaining of dizziness, nausea, and cold sweats. Pain level 0/10. Fetal heart rate 105bpm with moderate variability, late decelerations noted.

1118.
Ephedrine IV given and IV bolus started.

1125.
Client is still nauseated and vomits a small amount of bile. The dizziness is worsening. Pain 0/10. Fetal heart rate 110bpm with moderate variability with late decelerations.

Vital Signs:

>Complete the sentence from the list below.

The nurse should recognize that the client is most likely experiencing (choose a, b, or c). With the priority intervention being (choose d, e, f, or g).

A client is admitted with a small bowel obstruction secondary to metastatic cancer. The physician orders total parenteral nutrition (TPN) given through a single lumen central venous catheter.

Nurse Notes:

Time 1330.
Client received to room 205 with TPN infusing. Reviewed the label on the infusion, noting it contains lipids, vitamins, minerals, carbohydrates in the form of dextrose, and proteins. Central venous catheter site without redness or tenderness.

Day 2 at 0800.
TPN infusing at ordered rate. Catheter site within normal limits.

Blood glucose checked (glucose = 185) and standing order insulin given.

Day 2 at 1100.
Rounded on client who states “I’m going to the bathroom a lot.” Physician notified and urinalysis ordered.

Day 2 at 1400.
Client calls out complaining of headache and feeling very thirsty.

Urinalysis results are back.

Urinalysis:

>The nurse concludes that the client is likely experiencing (choose a, b, c, or d). The best action for the nurse to take is (choose e, f, g, h, i) and (choose e, f, g, h, i).

A 45-year-old Caucasian female is admitted through the emergency room with complaints of abdominal pain with nausea and vomiting.

Nurse Notes:

Time 1400.
Client arrives to triage and is assessed. She reports increasing bouts of right-sided abdominal pain with nausea and vomiting, currently 7/10 on pain scale. Client is diaphoretic. There is tenderness upon palpation of right upper quadrant. The client has a positive Murphy’s sign. She also reports right shoulder pain 7/10.

CBC, liver function tests, amylase and lipase are drawn. Abdominal ultrasound ordered.

1445.
Labs and US results are back.

1455.
Physician reviews labs and ultrasound, and client is diagnosed with acute cholecystitis.

1700.
Client to OR for laparoscopic cholecystectomy.

1930.
Client received to post-surgical floor post cholecystectomy. Incisions within normal limits. IV infusing per order.

Day 2 post-op at 0900

Client reports feeling well, except for continued right shoulder pain, rating 6/10 on pain scale. She reports some mild incisional pain 3/10. Denies nausea/vomiting. She is tolerating diet well.

Postop labs repeated.

Vital Signs Initial:

Vital Signs Post-Op Day 2:

Lab Report Initial:

Lab Report Day 2 Postop:

Diagnostic Reports:

Abdominal ultrasound shows enlarged gallbladder with thickened wall of 5mm. Positive Murphy’s sign elicited with ultrasound probe.

>For each finding, click to specify if the finding indicates that the client’s status has improved or is unchanged since the onset of symptoms.

The nurse is admitting at 4-year-old Asian-American boy to the emergency room, who presents with fever x 5 days.

Nurse Notes:

1200.
The child is brought in by his parents, with reports of high fever for the past 3 days, and two days of moderate grade fever before that. Tylenol and Motrin have been alternated per pediatrician recommendation with minimal effectiveness. The child is assessed and noted to have reddened eyes without drainage, strawberry tongue with red oral mucosa, and redness/swelling of the hands and feet. Cervical lymphadenopathy is present upon palpation. A macular rash is present on the trunk and extremities, which appeared today per the mother’s report. Grade III cardiac murmur noted on auscultation.

Pediatric cardiologist consulted.

1215.
CBC with differential, electrolytes, blood cultures, rapid strep test, Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) are drawn. Tylenol administered.

1230.
Pediatric cardiologist performs bedside echocardiogram.

1300.
Lab results return.

Vital Signs:

Diagnostic Reports:

Echocardiogram: No congenital heart defect. Pericardial effusion noted. Mild dilation of left main coronary artery noted.

>Using the diagram below, select 2 actions to take, 1 potential condition, and 2 parameters to monitor.

A 55-year-old female with a history of hypothyroidism is brought to the emergency room by her son.

Nurse Notes:

0900.
Client appears confused, stating “Where am I?” Has dry skin that is cold to the touch. Her son reports that the client has been using multiple blankets at home as she has been feeling chilled.  Periorbital edema noted. Hypoactive bowel sounds. Client breathing is shallow with decreased breath sounds on auscultation. Per report, client has steadily been gaining weight.

0905.
Oxygen applied via nonrebreather with improvement in oxygen saturation to 95%

0910.
Arterial blood gases, chest x-ray, blood cultures, and electrocardiogram ordered by provider.

0920.
Client’s son reports his mother ran out of her thyroid medication several weeks ago and he is unsure if she ever restarted it.  Client increasingly confused and is trying to leave the room.

Vital Signs:

Lab Report:

Diagnostic Reports:

• Electrocardiogram shows sinus bradycardia.
• Chest X-ray unremarkable.
• ABG shows respiratory acidosis.

>Using the diagram below, select 2 actions to take, 1 potential condition, and 2 parameters to monitor.

A client has arrived in the post anesthesia care unit (PACU) after undergoing general anesthesia with halothane for a surgical procedure.

Nurse Notes:

Time 1000.
Client received to PACU with oral airway in place. IV infusing per order and IV site within normal limits. Surgical abdominal dressing clean, dry and intact. See flowsheet for vitals.

1015.
Client assessed and noted to be tachypneic and tachycardic. Generalized muscle rigidity noted. Peaked T waves noted on cardiac monitor.

1017.
Anesthesiologist called to bedside for further assessment. Oxygen per face mask applied and cooling measures commenced.

1020.
Anesthesia present at bedside.

Vital Signs:

>Complete the sentence from the list of options below.

The nurse should recognize that the client is most likely experiencing (choose a, b, c, or d). And she anticipates administering (choose e, f, g, or h).

A 28-year-old male currently home for semester break is admitted through the emergency room with complaints of a headache and neck stiffness.

Nurse Notes:

Time 1600.
Client placed into bed. He reports a headache that started yesterday and has steadily worsened, with little relief from pain medications. He also complains of neck stiffness and reports his last temperature was 99.8 degrees Fahrenheit at home. He states, “I think I am coming down with a cold or the flu, but the neck stiffness really bothers me, so I wanted to check it out.”

Nuchal rigidity noted on exam. Positive Kernig’s sign with attempted knee extension.

CBC, blood cultures drawn.

1620.
Lumbar puncture performed, with cloudy CSF collected.

1630.
Suspected diagnosis of meningitis made. Droplet precautions instituted.

1640.
Antibiotics hung. Client now appearing confused and agitated. Vomited x 1. Fundoscopic exam reveals papilledema.

1700.
Client noted to have generalized tonic-clonic seizure activity and is unresponsive

Vital Signs Initial:

Lab Report Initial:

Diagnostic Reports:

Lumbar puncture shows cloudy CSF, elevated protein, elevated WBC, and low glucose

>Complete the following sentence by choosing from the list of options.

Based on the data, the nurse determines the client’s status is (choose a, b, or c), with the likely reasoning being (choose d, e, or f).

An ambulance brings in a 50-year-old male who is complaining of nausea/vomiting and gastrointestinal cramping.

Nurse Notes:

1405.
Client placed in bed. Client with history of type 2 diabetes and myasthenia gravis. He takes insulin and pyridostigmine at home. He complains of nausea/vomiting, diarrhea, and lower abdominal cramping. Drooling from mouth and tearing of eyes noted. Constricted pupils noted on exam. Wheezing heard bilaterally on auscultation. Pain level 6/10.

Second large bore IV started. IV fluids infusing.

CXR and EKG ordered. CBC, electrolytes drawn.

1420.
Client continues to complain of significant abdominal cramping and has vomited x2 since arriving. Noted to be diaphoretic. Slight slurring of speech noted. Client restless and exhibiting confusion, pulling at IV lines. Shallow breathing and labored effort noted. Suctioning of mouth done secondary to excessive oral secretions. Oxygen applied per face mask.

1425.
Labs and diagnostic tests return.

Vital Signs:

Lab Report:

Diagnostic Reports:

• Electrocardiogram shows sinus tachycardia.
• Chest X-ray shows hyperexpanded lung fields.

>Using the diagram below, select 2 actions to take, 1 potential condition, and 2 parameters to monitor.

A 40-year-old male is brought to the emergency room via ambulance with facial drooping.

Nurse Notes:

0700.
Client noted to have facial drooping on right side, with inability to close eye or lips on right side. Complains of mild headache along with general facial pain on right side. Decreased sensation to light touch on the right side with normal sensation on the left. Has slight slurring of speech. Strength equal bilaterally in extremities. No rashes, sores, ulcers noted on skin assessment. Lung sounds clear bilaterally. S1 and S2 auscultated clearly.

Client’s wife reports that client had complained of forehead numbness yesterday along with right ear pain and had complained of his food having “no taste” last night during dinner. Previous medical history is hypertension x 3 years and history of frequent cold sores.

CBC, complete metabolic panel, Lyme antibody, RPR drawn. COVID-19 swab done.

0725.

CT scan of the head completed.

Vital Signs:

Lab Report:

Diagnostic Reports:

CT scan is unremarkable

>Using the diagram below, select 2 actions to take, 1 potential condition, and 2 parameters to monitor.