NCLEX-PN Test #6 1

Question 1

A nurse is caring for a client who is receiving IV potassium chloride. Which finding requires the nurse to stop the infusion and notify the provider?

Accepted Answer

Burning sensation at the IV site with surrounding redness

Answer

Serum potassium level of 3.8 mEq/L

Answer

Urine output of 35 mL/hr

Answer

Heart rate of 72 beats per minute

Question 2

A client with type 1 diabetes mellitus reports feeling shaky and sweaty before lunch. The nurse checks the blood glucose and finds it is 58 mg/dL. What is the priority nursing action?

Accepted Answer

Give 15–20 grams of fast-acting carbohydrate orally

Answer

Administer the scheduled insulin dose

Answer

Notify the provider immediately

Answer

Encourage the client to eat their full lunch right away

Question 3

The nurse is preparing to administer medications and notes that a client's apical heart rate is 52 beats per minute. The client is prescribed digoxin 0.125 mg PO daily. What should the nurse do?

Accepted Answer

Hold the digoxin and notify the provider

Answer

Administer the digoxin as ordered

Answer

Give half the digoxin dose and reassess in one hour

Answer

Obtain a 12-lead ECG before administering

Question 4

A nurse is caring for a postoperative client who had abdominal surgery 8 hours ago. The client reports pain rated 7/10 and has not received any analgesics. Which action is most appropriate?

Accepted Answer

Assess the client's pain further and administer the prescribed analgesic

Answer

Encourage the client to use relaxation techniques and reassess in 1 hour

Answer

Notify the surgeon that the client is in pain

Answer

Reposition the client and apply a warm compress to the abdomen

Question 5

A client is admitted with suspected appendicitis. The client suddenly reports that the pain has completely resolved. How should the nurse interpret this finding?

Accepted Answer

The client may have appendix perforation, which is a medical emergency

Answer

The appendicitis has resolved without surgery

Answer

The analgesic administered earlier is working effectively

Answer

The client's symptoms were likely caused by gas pain

Question 6

The nurse is caring for a client in Buck's traction for a fractured hip. Which action is essential in caring for this client?

Accepted Answer

Ensure the weights hang freely and do not rest on the floor or bed

Answer

Remove the traction weights for 1 hour each shift to relieve skin pressure

Answer

Keep the affected leg in a position of internal rotation

Answer

Elevate the head of the bed to 90 degrees to improve alignment