NCLEX-PN Test #4 1

Question 1

A nurse finds an unresponsive adult client in the hallway. After confirming unresponsiveness and calling for help, the nurse should next:

Accepted Answer

Check for a pulse and begin CPR if absent

Answer

Begin rescue breathing immediately

Answer

Place the client in the recovery position

Answer

Obtain the client's medication record

Question 2

A nurse is caring for a client who is confused and trying to climb out of bed. A wrist restraint is being considered. Which action must the nurse take before applying the restraint?

Accepted Answer

Obtain a provider order and attempt less-restrictive alternatives first

Answer

Apply the restraint immediately to prevent falls

Answer

Notify the charge nurse and wait for shift change

Answer

Ask a family member for permission before consulting the provider

Question 3

A nurse is administering a blood transfusion. Fifteen minutes into the infusion, the client develops chills, flank pain, and dark urine. What is the nurse's immediate action?

Accepted Answer

Stop the transfusion, maintain IV access with normal saline, and notify the provider

Answer

Slow the transfusion rate and administer diphenhydramine

Answer

Stop the transfusion and remove the IV catheter

Answer

Continue the transfusion and apply warm blankets for the chills

Question 4

A nurse is caring for a client with a chest tube for a pneumothorax. The nurse notes continuous bubbling in the water-seal chamber. Which action should the nurse take?

Accepted Answer

Assess for an air leak by momentarily clamping the tube near the client

Answer

Document as expected and continue monitoring

Answer

Clamp the chest tube immediately

Answer

Increase suction to the drainage system

Question 5

A client with a history of seizures is found having a generalized tonic-clonic seizure. Which nursing action has the highest priority?

Accepted Answer

Position the client on their side and protect the head

Answer

Insert an oral airway to prevent the tongue from obstructing the airway

Answer

Restrain the client's arms and legs to prevent injury

Answer

Administer a stat dose of diazepam per standing order

Question 6

A nurse receives a SBAR report that a client who had abdominal surgery 6 hours ago has a blood pressure of 88/52 mmHg, heart rate of 122 bpm, and increasing abdominal distension. What is the priority nursing action?

Accepted Answer

Notify the provider immediately with SBAR communication

Answer

Reassess vitals in 15 minutes to confirm the trend

Answer

Administer the PRN analgesic for abdominal pain

Answer

Place the client in a high-Fowler's position and increase O2