NCLEX-PN Test #10 — Questions and Answers
Question 1: The nurse notices a client with pneumonia has an increased respiratory rate and difficulty speaking full sentences. What should the nurse do first?
- Check the client’s oxygen saturation level. (Correct answer)
- Provide warm liquids for comfort.
- Encourage the client to lie flat.
- Ask the client to take slower breaths.
Correct answer: Check the client’s oxygen saturation level.
Increased respiratory rate and difficulty speaking full sentences are signs of respiratory distress, indicating potential hypoxemia. Checking the client's oxygen saturation level provides immediate objective data on their oxygenation status. This crucial assessment guides further interventions and prioritizes care to ensure adequate oxygen delivery.
Question 2: A client taking furosemide reports dizziness when getting out of bed. What is the nurse’s best initial response?
- Teach the client to sit and stand up slowly. (Correct answer)
- Restrict all daily fluid intake.
- Encourage sudden position changes.
- Tell the client the dizziness is insignificant.
Correct answer: Teach the client to sit and stand up slowly.
Furosemide is a diuretic that can cause orthostatic hypotension, leading to dizziness when changing positions. Teaching the client to sit and stand up slowly allows the body to adjust to the change in blood pressure, preventing falls and injury. This is a vital safety intervention.
Question 3: The nurse is caring for a client with a new colostomy. The client asks what a healthy stoma should look like. What is the best response?
- Moist and pink to red in color. (Correct answer)
- Dry, pale, and gray.
- Black and sunken.
- Firm and yellow in color.
Correct answer: Moist and pink to red in color.
A healthy stoma should appear moist, shiny, and pink to beefy red, indicating adequate blood supply and viability. Any deviation from this color (e.g., pale, dusky, black) or texture (e.g., dry, sunken) could signal complications such as ischemia or necrosis, requiring immediate assessment.
Question 4: A client with anxiety is breathing rapidly and complaining of tingling in their fingers. What should the nurse do first?
- Encourage slow, controlled breathing. (Correct answer)
- Have the client drink a caffeinated beverage.
- Instruct the client to hold their breath for long periods.
- Place the client in a flat position.
Correct answer: Encourage slow, controlled breathing.
Rapid breathing (hyperventilation) due to anxiety can lead to respiratory alkalosis, causing symptoms like tingling in the fingers (paresthesia). Encouraging slow, controlled breathing helps the client retain carbon dioxide, which normalizes blood pH and alleviates these uncomfortable symptoms.
Question 5: A client on opioid pain medication reports constipation. What should the nurse recommend?
- Increase fiber and fluid intake. (Correct answer)
- Reduce physical activity.
- Take double the opioid dose.
- Avoid all fruits and vegetables.
Correct answer: Increase fiber and fluid intake.
Opioid medications commonly cause constipation by slowing gut motility. Increasing dietary fiber and fluid intake helps to soften stools and promote regular bowel movements. This is a primary non-pharmacological intervention to manage this common and uncomfortable side effect.
Question 6: A client with diabetes reports new numbness in their feet. What is the nurse’s best action?
- Report the finding to the healthcare provider. (Correct answer)
- Encourage the client to walk barefoot at home.
- Instruct the client to stop diabetes medications.
- Apply heat packs without assessment.
Correct answer: Report the finding to the healthcare provider.
New numbness in the feet for a client with diabetes is a significant finding that could indicate worsening peripheral neuropathy, a serious complication. Reporting this to the healthcare provider is crucial for further assessment, diagnosis, and adjustment of the treatment plan to prevent further nerve damage and complications.
Question 7: The nurse is caring for a client with suspected dehydration. Which assessment is most important?
- Measure the client’s urine output. (Correct answer)
- Offer warm soup frequently.
- Encourage caffeinated beverages.
- Place the client on fluid restriction.
Correct answer: Measure the client’s urine output.
Urine output is a direct and objective indicator of kidney perfusion and overall fluid status. In suspected dehydration, a decreased urine output (oliguria) is a key sign, making its measurement essential for assessing the severity of dehydration and guiding appropriate fluid replacement therapy.
Question 8: A client receiving IV antibiotics complains of sudden itching and flushing. What should the nurse do first?
- Stop the antibiotic infusion immediately. (Correct answer)
- Increase the antibiotic infusion rate.
- Give the next scheduled antibiotic dose early.
- Encourage the client to eat a snack.
Correct answer: Stop the antibiotic infusion immediately.
Sudden itching and flushing during an IV antibiotic infusion are classic signs of an allergic reaction, which can rapidly escalate to anaphylaxis. Stopping the infusion immediately prevents further exposure to the allergen and is the priority to ensure client safety and prevent a life-threatening event.
Question 9: During wound care, the nurse observes a sudden increase in yellow drainage. What should the nurse do first?
- Document the findings and notify the provider. (Correct answer)
- Remove the dressing and leave the wound exposed.
- Ignore the drainage unless odor develops.
- Apply ice directly to the wound.
Correct answer: Document the findings and notify the provider.
A sudden increase in yellow drainage from a wound can indicate a worsening infection or other complication. Documenting the observation provides a clear record, and notifying the provider ensures timely assessment and potential intervention, such as wound culture or antibiotic adjustment, to prevent further harm.
NCLEX-PN Test #10
The nurse notices a client with pneumonia has an increased respiratory rate and difficulty speaking full sentences.
What should the nurse do first?