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

Following the AHA chain of survival, after activating emergency response and ensuring scene safety, the nurse should check for a pulse (no more than 10 seconds). If no pulse is detected, high-quality CPR should begin immediately with 30 compressions followed by 2 breaths.

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

Restraints require a provider order and must only be used after all less-restrictive measures (reorientation, bed alarm, sitter, low bed) have been tried and failed. Restraints can cause injury, increased agitation, and pressure injuries. A family member's permission does not replace a provider order.

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

These are signs of an acute hemolytic transfusion reaction, the most dangerous type. The nurse must immediately stop the transfusion, keep the IV line open with normal saline (using new tubing), notify the provider and blood bank, and monitor for signs of shock and renal failure. Removing the IV would eliminate access for emergency treatment.

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

Continuous bubbling in the water-seal chamber (not the suction control chamber) indicates a possible air leak. The nurse should assess the source by momentarily clamping the tube near the client — if bubbling stops, the leak is in the system; if it continues, the leak is at the insertion site or within the lung. Clamping indefinitely can cause tension pneumothorax.

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

During a seizure, the priority is safety. The client should be turned to the lateral position (recovery position) to prevent aspiration and protect the airway. Nothing should be inserted into the mouth during an active seizure (aspiration and broken teeth risk). Restraining limbs can cause fractures. Medication is administered per order once safety is established.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #4 1