NCLEX PN Practice Test with NGN Practice Question
Scenario/Extract:
The nurse is caring for a 58-year-old client on a medical-surgical unit.
History and Physical
General
The client is vomiting bright red blood; medical history includes alcohol use disorder, liver cirrhosis, and hypertension; the client was admitted a year ago for alcohol-induced acute pancreatitis
Neurological
The client is oriented to person and place; the pupils are equal, round, and reactive to light and accommodation
Eye, Ear, Nose, and Throat (EENT)
Yellow scleras are noted
Pulmonary
Vital signs are RR 18, SpO 94% on room air
Cardiovascular
Vital signs are T 99 F (37.2 C), P 102, BP 90/40; S1 and S2 are heard on auscultation; peripheral pulses are 2+ in all extremities; 1+ edema is noted at the bilateral lower extremities
Gastrointestinal
The abdomen is distended and nontender to palpation; the flanks are dull to percussion; bowel sounds are hypoactive; distended veins are present around the umbilicus
Genitourinary
Client is voiding amber-colored urine
Which of the following findings require immediate follow-up? Select all that apply.
Correct Answer: B,C,E
Rationale: B: Distended abdomen suggests ascites, common in cirrhosis, requiring urgent evaluation. C: Hypotension (90/40) indicates potential shock, especially with bleeding. E: Vomiting blood (hematemesis) is a medical emergency in cirrhosis, suggesting variceal bleeding. A is normal, D is less urgent, and F indicates jaundice but is not immediately life-threatening.
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