NCLEX-RN TEST 1 NGN EXAM 2024 QUESTIONS AND
VERIFIED CORRECT ANSWERS WITH COMPLETE
SOLUTIONS UPDATED GRADED A++
The nurse witnesses the collapse of a child while outdoors. The child is not
breathing and has a pulse of 50/min. The nurse calls emergency services and
initiates rescue breathing. After 2 minutes of rescue breaths, the child is still not
breathing and is pale with a pulse of 30/min. What is the nurse's next action?
1. Initiate chest compressions
Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse
remains <60/min and there are signs of poor perfusion (skin pallor), the nurse should
initiate chest compressions and reassess the pulse every 2 minutes
The charger nurse is responsible for making room assignments multiple clients.
Which pari of client assignments to a shared room is appropriate?
3. Client who had a bowel resection 1 day ago and client with asthma exacerbation.
When making room assignments, it is important to remember that a client with an active
or suspected infection should not be paired with a client who has a fresh surgical wound
or is immunocompromised. A client having an asthma exacerbation does not have an
infection and is not at risk for spreading infection to a client who had a recent bowel
resection surgery.
The clinic nurse is assessing a client who is being treated for depression and
suicidal ideation. Which client statement best indicates that the client is not
currently at risk for suicide?
2. "I plan to attend my grandchild's graduation next month"
Clients receiving treatment for depression and suicidal ideation must be carefully
monitored for indications of increasing suicidal intent. During a client interview, the
,nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less likely to
attempt death by suicide
The nurse is caring for a client who had an anterior wall myocardial infarction 2
days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is
in ventricular trigeminy. What is the nurse's priority intervention?
1. Administer potassium supplement
In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third
heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy
(eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular
tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances,
emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5
mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by
administering the prescribed potassium replacement (Option 1). Health care providers
(HCPs) often prescribe electrolyte replacement algorithms to clients at risk for
electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a
contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight
<99.2 lb [45 kg]).
The nurse cares for a client with a terminal disease who created a do not attempt
resuscitation (DNAR) directive. The client stops breathing and loses their pulse.
,The client's adult child states, "Please, do whatever you can to save them!"
Which intervention is appropriate?
3. Explain the client's resuscitation directive to the client's child
Clients can create a do not attempt resuscitation (DNAR) directive instructing that CPR
and other life-saving measures be withheld. With an advance directive in place, the
client's wishes should be followed, even if they conflict with the wishes of loved ones
The nurse in the cardiac intensive care unit receives report on 4 clients. Which
client should the nurse assess first?
2. Client who underwent coronary artery stent placement via femoral approach 3 hours
ago and is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary
stent placement using the femoral approach is at increased risk for retroperitoneal
hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can
exacerbate potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation,
and diminished distal pulses can be early signs of bleeding into the retroperitoneal
space and require immediate intervention (eg, notify health care provider, serial
complete blood count, CT scan of the abdomen)
The nurse is reviewing the medical history of a client who has sustained a right
tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to
hinder healing?
4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate circulation, and
age. A client with peripheral arterial disease has decreased perfusion to the extremities
due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is
not supplied with the oxygen and nutrients required for healing
, Based on the nursing assessment progress notes, what is the correct staging of
the client's pressure injury? Click on the exhibit button for additional information.
WRONG
2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister,
or shallow crater). The skin blisters or forms an open sore, and the area around the sore
may be red and irritated. (shallow, open ulcer, red-pink wound with no sloughing and
possible intact or ruptured blister)
Stage 1: Intact skin with nonblanchable redness
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the
dermis or epidermis; the wound bed is red or pink and may be shiny or dry
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or
bone; tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar
(scabbing, dead tissue) may be present; undermining and tunneling may be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
A client with type 1 diabetes mellitus has prescriptions for NPH insulin and
regular insulin. At 0730, the client's blood glucose level is 322 mg/dL (17.9
mmol/L), and the breakfast tray has arrived. What action should the nurse take?
Click the exhibit button for additional information.
4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in
the same syringe, drawing up the regular insulin first
Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and
rapid-acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should be drawn
into the syringe before intermediate-acting insulin to avoid cross-contaminating
multidose vials (mnemonic - RN: Regular before NPH).
To prepare the mixed dose:
VERIFIED CORRECT ANSWERS WITH COMPLETE
SOLUTIONS UPDATED GRADED A++
The nurse witnesses the collapse of a child while outdoors. The child is not
breathing and has a pulse of 50/min. The nurse calls emergency services and
initiates rescue breathing. After 2 minutes of rescue breaths, the child is still not
breathing and is pale with a pulse of 30/min. What is the nurse's next action?
1. Initiate chest compressions
Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse
remains <60/min and there are signs of poor perfusion (skin pallor), the nurse should
initiate chest compressions and reassess the pulse every 2 minutes
The charger nurse is responsible for making room assignments multiple clients.
Which pari of client assignments to a shared room is appropriate?
3. Client who had a bowel resection 1 day ago and client with asthma exacerbation.
When making room assignments, it is important to remember that a client with an active
or suspected infection should not be paired with a client who has a fresh surgical wound
or is immunocompromised. A client having an asthma exacerbation does not have an
infection and is not at risk for spreading infection to a client who had a recent bowel
resection surgery.
The clinic nurse is assessing a client who is being treated for depression and
suicidal ideation. Which client statement best indicates that the client is not
currently at risk for suicide?
2. "I plan to attend my grandchild's graduation next month"
Clients receiving treatment for depression and suicidal ideation must be carefully
monitored for indications of increasing suicidal intent. During a client interview, the
,nurse should assess:
- Access to psychiatric medications
- Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less likely to
attempt death by suicide
The nurse is caring for a client who had an anterior wall myocardial infarction 2
days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is
in ventricular trigeminy. What is the nurse's priority intervention?
1. Administer potassium supplement
In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third
heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy
(eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular
tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances,
emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5
mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by
administering the prescribed potassium replacement (Option 1). Health care providers
(HCPs) often prescribe electrolyte replacement algorithms to clients at risk for
electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a
contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight
<99.2 lb [45 kg]).
The nurse cares for a client with a terminal disease who created a do not attempt
resuscitation (DNAR) directive. The client stops breathing and loses their pulse.
,The client's adult child states, "Please, do whatever you can to save them!"
Which intervention is appropriate?
3. Explain the client's resuscitation directive to the client's child
Clients can create a do not attempt resuscitation (DNAR) directive instructing that CPR
and other life-saving measures be withheld. With an advance directive in place, the
client's wishes should be followed, even if they conflict with the wishes of loved ones
The nurse in the cardiac intensive care unit receives report on 4 clients. Which
client should the nurse assess first?
2. Client who underwent coronary artery stent placement via femoral approach 3 hours
ago and is reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary
stent placement using the femoral approach is at increased risk for retroperitoneal
hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can
exacerbate potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation,
and diminished distal pulses can be early signs of bleeding into the retroperitoneal
space and require immediate intervention (eg, notify health care provider, serial
complete blood count, CT scan of the abdomen)
The nurse is reviewing the medical history of a client who has sustained a right
tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to
hinder healing?
4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate circulation, and
age. A client with peripheral arterial disease has decreased perfusion to the extremities
due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is
not supplied with the oxygen and nutrients required for healing
, Based on the nursing assessment progress notes, what is the correct staging of
the client's pressure injury? Click on the exhibit button for additional information.
WRONG
2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister,
or shallow crater). The skin blisters or forms an open sore, and the area around the sore
may be red and irritated. (shallow, open ulcer, red-pink wound with no sloughing and
possible intact or ruptured blister)
Stage 1: Intact skin with nonblanchable redness
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the
dermis or epidermis; the wound bed is red or pink and may be shiny or dry
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or
bone; tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar
(scabbing, dead tissue) may be present; undermining and tunneling may be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
A client with type 1 diabetes mellitus has prescriptions for NPH insulin and
regular insulin. At 0730, the client's blood glucose level is 322 mg/dL (17.9
mmol/L), and the breakfast tray has arrived. What action should the nurse take?
Click the exhibit button for additional information.
4. Administer 37 units of insulin: 25 units of NPH mixed with 12 units of regular insulin in
the same syringe, drawing up the regular insulin first
Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and
rapid-acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should be drawn
into the syringe before intermediate-acting insulin to avoid cross-contaminating
multidose vials (mnemonic - RN: Regular before NPH).
To prepare the mixed dose:
