NCLEX-PN Practice Test 2
10 free NCLEX-PN practice questions in the real exam format, covering the official content areas, with an explanation for every answer.
Question 1 of 10
Reduction of Risk PotentialMedical Record
Day 0, 2200 — Resident asleep by 2130, her usual routine. At evening care she was oriented to person and place and followed 2-step directions. Continent with toileting every 2 hours while awake.
Day 1, 0600 — AP reports the resident was incontinent of urine twice overnight, which is new for her. Urine in the brief was dark and strong-smelling. Slept poorly; awake from 0200 to 0400 asking for her husband. Temperature 37.6 °C (99.7 °F).
Day 1, 0930 — Urine dipstick done per standing order on a voided specimen (see Laboratory Results).
Day 1, 1000 — AP reports a change in behavior. Resident is pulling at her gown and calling for her late husband; oriented to person only (her baseline is person and place). Drifts off mid-sentence and cannot keep her attention on simple questions. Wearing her glasses and hearing aids. Temperature 38.3 °C (100.9 °F), heart rate 104/min, respiratory rate 22/min. Blood pressure 108/62 mm Hg (usually 130s/70s). SpO2 95% on room air; lung sounds clear in all fields. Voided 120 mL of cloudy, foul-smelling urine since 0600. Skin intact over the sacrum and heels. Walks to the bathroom with her walker and 1 assist, her usual level. Bed in low position; call light within reach.
84-year-old female, long-term care resident for 2 years. Weight 128 lb (58 kg). No fluid restriction.
History: Alzheimer disease, mild to moderate, diagnosed 4 years ago. Baseline: oriented to person and place, recognizes her daughter, follows 1-step and 2-step directions; Brief Interview for Mental Status (BIMS) score 10 three months ago. Hypertension. Overactive bladder. Osteoarthritis of both knees. Osteoporosis; fall 5 months ago without injury. Hearing loss (bilateral hearing aids); wears glasses.
Allergy: sulfonamide antibiotics (hives). Code status: full code. Daughter is health care power of attorney.
| Time | Temperature | Heart rate | Respiratory rate | Blood pressure | SpO2 |
|---|---|---|---|---|---|
| Day 0, 0800 (routine) | 36.7 °C (98.1 °F) | 76/min | 16/min | 134/76 mm Hg | 97% room air |
| Day 1, 0600 | 37.6 °C (99.7 °F) | 92/min | 18/min | 124/70 mm Hg | 96% room air |
| Day 1, 1000 | 38.3 °C (100.9 °F) | 104/min | 22/min | 108/62 mm Hg | 95% room air |
| Test | Result | Reference range |
|---|---|---|
| WBC (routine, 14 days ago) | 7,100/mm³ | 5,000–10,000/mm³ |
| Hemoglobin (14 days ago) | 12.4 g/dL | 12.0–16.0 g/dL |
| Sodium (14 days ago) | 139 mEq/L | 135–145 mEq/L |
| Blood urea nitrogen (BUN) (14 days ago) | 15 mg/dL | 10–20 mg/dL |
| Creatinine (14 days ago) | 0.8 mg/dL | 0.5–1.1 mg/dL |
| Urine dipstick (Day 1, 0930): appearance | Dark amber, cloudy | Pale to yellow, clear |
| Urine dipstick: leukocyte esterase | Positive (2+) | Negative |
| Urine dipstick: nitrite | Positive | Negative |
| Urine dipstick: blood | Trace | Negative |
| Urine dipstick: specific gravity | 1.028 | 1.005–1.030 |
Current orders and MAR: • Amlodipine 5 mg PO daily at 0900 • Donepezil 10 mg PO at bedtime • Oxybutynin 5 mg PO twice daily (0900 and 2100) • Calcium carbonate 600 mg with vitamin D3 400 units PO twice daily • Acetaminophen 650 mg PO every 6 hours PRN pain (maximum 3 g in 24 hours) • Diphenhydramine 25 mg PO at bedtime PRN sleep • Vital signs every shift • Urine dipstick PRN for suspected urinary tract infection (standing order) • Toileting every 2 hours while awake • Fall precautions: bed in low position, floor mat at bedside • Notify the provider for temperature 38.0 °C (100.4 °F) or higher or any change in mental status
The nurse is caring for an 84-year-old resident of a long-term care facility who has Alzheimer disease. At 1000, the assistive personnel (AP) reports that the resident "is not acting like herself." The nurse collects data, reviews the medical record and documents the 1000 note.
Click to highlight the findings in the 1000 note that require follow-up.