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

Burning at the IV site with redness indicates phlebitis or extravasation. IV potassium chloride is a vesicant and can cause severe tissue damage if it infiltrates. The infusion must be stopped immediately and the provider notified. The other findings are within normal or acceptable limits.

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

A blood glucose of 58 mg/dL indicates hypoglycemia. The priority is to treat it with 15–20 g of fast-acting carbohydrate (e.g., 4 oz juice or glucose tablets) if the client is conscious and able to swallow. Insulin would worsen hypoglycemia. A full meal is not the first step — rapid glucose correction is.

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

Digoxin should be held if the apical heart rate is below 60 beats per minute in an adult, and the provider must be notified. Giving the medication could cause further bradycardia or toxicity. Administering a partial dose is never appropriate without a provider order.

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

Postoperative pain management is essential for recovery. The nurse should assess pain characteristics and then administer the prescribed analgesic. Delegating to non-pharmacologic methods alone is insufficient for a 7/10 pain rating. The surgeon only needs notification if pain is uncontrolled after prescribed treatment.

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

Sudden relief of pain in appendicitis is a serious warning sign that the appendix may have perforated. Perforation releases pressure temporarily but leads to peritonitis, a life-threatening emergency. The nurse must notify the provider immediately and prepare for urgent intervention.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #6 1