NCLEX-PN Test #10

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?

Accepted Answer

Check the client’s oxygen saturation level.

Answer

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?

Accepted Answer

Teach the client to sit and stand up slowly.

Answer

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?

Accepted Answer

Moist and pink to red in color.

Answer

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?

Accepted Answer

Encourage slow, controlled breathing.

Answer

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?

Accepted Answer

Increase fiber and fluid intake.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #10