NCLEX NGN Pre-Test Questions
4.6 (16 reviews)
Revision Question:
A nurse is caring for a patient admitted to the intensive care unit with suspected
sepsis. The patient’s vital signs are as follows:
Temperature: 102°F
Heart rate: 120 beats per minute
Blood pressure: 85/50 mmHg
Respiratory rate: 28 breaths per minute
The patient is also noticeably confused. Which of the following interventions
should the nurse prioritize?
A. Administer broad-spectrum antibiotics as prescribed.
B. Initiate aggressive intravenous fluid resuscitation.
C. Administer an antipyretic to reduce the fever.
D. Position the patient in high Fowler’s position.
Correct Answer: B. Initiate aggressive intravenous fluid resuscitation.
Rationale:
In the context of sepsis, the patient is exhibiting signs of septic shock, notably
hypotension (blood pressure 85/50 mmHg) and tachycardia (heart rate 120). The
confusion further suggests inadequate cerebral perfusion due to low blood
pressure. The most immediate life-threatening issue is the compromised
circulation, which can lead to multi-organ failure if not promptly addressed.
Aggressive intravenous fluid resuscitation is the priority because restoring
intravascular volume is critical to improve tissue perfusion and stabilize the
patient’s hemodynamic status. Although administering broad-spectrum antibiotics
is also essential in treating sepsis, it should follow the initial stabilization of the
patient’s circulation. The other options (reducing fever or positioning) do not
directly address the immediate need to correct hypotension and prevent shock
progression.
1/19
,2/19
, A client with a basilar skull fracture has B
clear fluid leaking from the ears. The nurse CSF contains glucose not protein.
should take which action first? a. Asses
the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze
looselyin the ears
d. Use an otoscope to assess
thetympanic membrane for rupture
A nurse is caring for a client who has just A
undergone cardioversion. Which ABC's of nursing. All other choices are correct, but not priority.
intervention is the nurse's priority after this
procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering
antidysrhythmicmedications
d. Monitoring the client's LOC
A client with diabetes mellitus who is B
scheduled to have blood drawn for
determination of the glycosylated hemoglobin
(HbA1c) level asks the nurse why the test is
necessary if he is performing blood glucose
monitoring at home. Which is the best
response for the nurse to provide?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at
riskfor hypoglycemia d Determine whether
the prescribed insulin dosage is correct
A nurse caring for a client with acquired B, D, E
immunodeficiency syndrome is monitoring A opportunistic respiratory infection associated with AIDs that causes dyspnea, nonproductive cough,
the client for signs of complications. Which of intermittent fever, fatigue, anorexia, tachypnea, wt. loss.
the following would cause the nurse to
suspect infection with Pneumocystis jirovec?
SATA a. Diarrhea
b. Tachypnea
c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus
Zidovudine is prescribed for a client with AIDS. C
The nurse tells the client that it is important to Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia.
report back to the clinic as scheduled for
which follow-up diagnostic?
a. Blood glucose checks
b. Blood pressure checks
c. Complete blood counts (CBC)
d. Electrocradiographic studies
3/19
4.6 (16 reviews)
Revision Question:
A nurse is caring for a patient admitted to the intensive care unit with suspected
sepsis. The patient’s vital signs are as follows:
Temperature: 102°F
Heart rate: 120 beats per minute
Blood pressure: 85/50 mmHg
Respiratory rate: 28 breaths per minute
The patient is also noticeably confused. Which of the following interventions
should the nurse prioritize?
A. Administer broad-spectrum antibiotics as prescribed.
B. Initiate aggressive intravenous fluid resuscitation.
C. Administer an antipyretic to reduce the fever.
D. Position the patient in high Fowler’s position.
Correct Answer: B. Initiate aggressive intravenous fluid resuscitation.
Rationale:
In the context of sepsis, the patient is exhibiting signs of septic shock, notably
hypotension (blood pressure 85/50 mmHg) and tachycardia (heart rate 120). The
confusion further suggests inadequate cerebral perfusion due to low blood
pressure. The most immediate life-threatening issue is the compromised
circulation, which can lead to multi-organ failure if not promptly addressed.
Aggressive intravenous fluid resuscitation is the priority because restoring
intravascular volume is critical to improve tissue perfusion and stabilize the
patient’s hemodynamic status. Although administering broad-spectrum antibiotics
is also essential in treating sepsis, it should follow the initial stabilization of the
patient’s circulation. The other options (reducing fever or positioning) do not
directly address the immediate need to correct hypotension and prevent shock
progression.
1/19
,2/19
, A client with a basilar skull fracture has B
clear fluid leaking from the ears. The nurse CSF contains glucose not protein.
should take which action first? a. Asses
the clear fluid for protein
b. Check the clear fluid for glucose
c. Place cotton calls or dry gauze
looselyin the ears
d. Use an otoscope to assess
thetympanic membrane for rupture
A nurse is caring for a client who has just A
undergone cardioversion. Which ABC's of nursing. All other choices are correct, but not priority.
intervention is the nurse's priority after this
procedure.
a. Administer oxygen
b. Monitoring the BP
c. Administering
antidysrhythmicmedications
d. Monitoring the client's LOC
A client with diabetes mellitus who is B
scheduled to have blood drawn for
determination of the glycosylated hemoglobin
(HbA1c) level asks the nurse why the test is
necessary if he is performing blood glucose
monitoring at home. Which is the best
response for the nurse to provide?
a. Detect diabetic complications
b. Assess long-term glycemic control
c. Determine whether the client is at
riskfor hypoglycemia d Determine whether
the prescribed insulin dosage is correct
A nurse caring for a client with acquired B, D, E
immunodeficiency syndrome is monitoring A opportunistic respiratory infection associated with AIDs that causes dyspnea, nonproductive cough,
the client for signs of complications. Which of intermittent fever, fatigue, anorexia, tachypnea, wt. loss.
the following would cause the nurse to
suspect infection with Pneumocystis jirovec?
SATA a. Diarrhea
b. Tachypnea
c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus
Zidovudine is prescribed for a client with AIDS. C
The nurse tells the client that it is important to Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia.
report back to the clinic as scheduled for
which follow-up diagnostic?
a. Blood glucose checks
b. Blood pressure checks
c. Complete blood counts (CBC)
d. Electrocradiographic studies
3/19
