NCLEX-PN Test #11 — Questions and Answers
Question 1: While caring for a client with a fever, the nurse notes flushed skin and sweating. What is the nurse’s first action?
- Check the client’s temperature. (Correct answer)
- Apply ice packs to the entire body.
- Restrict all oral fluids.
- Place the client in a warm blanket.
Correct answer: Check the client’s temperature.
Flushed skin and sweating are common physiological responses to fever as the body attempts to cool itself. The nurse's first action should be to objectively confirm the client's temperature to establish a baseline. This accurate assessment guides appropriate fever-reducing interventions and monitors the client's response.
Question 2: A client with diabetes reports feeling shaky and sweaty. What should the nurse do first?
- Provide a source of fast-acting glucose. (Correct answer)
- Encourage the client to walk outside.
- Give the next scheduled insulin dose early.
- Have the client lie flat with no food.
Correct answer: Provide a source of fast-acting glucose.
Shaky and sweaty are classic symptoms of hypoglycemia (low blood sugar), a dangerous condition for clients with diabetes. Providing a fast-acting glucose source, such as juice or glucose tablets, is the immediate priority to rapidly raise blood sugar levels and prevent further complications like loss of consciousness or seizures.
Question 3: The nurse notes a client receiving oxygen has dry, cracked lips. Which action is most appropriate?
- Add humidification to the oxygen. (Correct answer)
- Increase the oxygen flow rate.
- Apply petroleum jelly inside the nose.
- Encourage the client to breathe faster.
Correct answer: Add humidification to the oxygen.
Oxygen therapy, especially at higher flow rates, can be very drying to mucous membranes, leading to dry, cracked lips and nasal passages. Adding humidification to the oxygen system helps to moisten the inspired air, preventing and alleviating dryness and discomfort for the client.
Question 4: A postoperative client reports abdominal bloating. What should the nurse do first?
- Assess the client’s bowel sounds. (Correct answer)
- Give a high-fat meal immediately.
- Encourage complete bed rest.
- Ignore the symptom unless vomiting begins.
Correct answer: Assess the client’s bowel sounds.
Abdominal bloating post-surgery can indicate ileus or decreased bowel motility, which is common due to anesthesia and pain medication. Assessing bowel sounds provides crucial information about the return of peristalsis. This helps the nurse determine the appropriate intervention, such as encouraging ambulation or notifying the provider.
Question 5: A client taking an iron supplement reports dark stools. What should the nurse explain?
- Dark stools are an expected side effect of iron. (Correct answer)
- Dark stools mean the dose is too strong.
- Dark stools indicate internal bleeding.
- Dark stools mean the medication is not working.
Correct answer: Dark stools are an expected side effect of iron.
Iron supplements commonly cause stools to appear dark green or black due to the unabsorbed iron. This is a benign and expected side effect of the medication. Clients should be educated about this to prevent unnecessary alarm about potential gastrointestinal bleeding.
Question 6: A client taking a diuretic reports leg cramps. What should the nurse suspect first?
- Possible low potassium level. (Correct answer)
- Improved muscle tone.
- Excessive fluid intake.
- Normal adaptation to medication.
Correct answer: Possible low potassium level.
Diuretics, particularly loop and thiazide diuretics, can lead to increased excretion of potassium, resulting in hypokalemia. Leg cramps are a common symptom of low potassium, making it the primary concern for a client on diuretic therapy. The nurse should assess for other signs and symptoms of hypokalemia.
Question 7: A client with pneumonia has thick sputum and difficulty coughing. What should the nurse encourage?
- Increase daily fluid intake. (Correct answer)
- Avoid fluids until the cough stops.
- Limit activity to prevent coughing.
- Drink high-caffeine beverages only.
Correct answer: Increase daily fluid intake.
Increasing fluid intake helps to thin thick respiratory secretions, making them easier to mobilize and cough up. This is a crucial intervention for clients with pneumonia to prevent mucus plugging and improve airway clearance, which is vital for effective breathing and recovery.
Question 8: During a blood transfusion, the client develops chills and back pain. What is the nurse’s priority?
- Stop the blood transfusion immediately. (Correct answer)
- Increase the transfusion rate.
- Give warm fluids quickly.
- Wait to see if symptoms worsen.
Correct answer: Stop the blood transfusion immediately.
Chills and back pain during a blood transfusion are classic signs of an acute hemolytic transfusion reaction, a life-threatening emergency. The nurse's priority is to immediately stop the transfusion to prevent further harm. This action minimizes the client's exposure to incompatible blood and allows for prompt management of the reaction.
Question 9: The nurse is reviewing dietary teaching for a client with high cholesterol. Which choice shows correct understanding?
- I will choose baked foods instead of fried foods. (Correct answer)
- I will use extra butter for flavor.
- I will avoid vegetables to reduce fiber.
- I will choose only high-fat meats.
Correct answer: I will choose baked foods instead of fried foods.
Choosing baked foods over fried foods significantly reduces the intake of unhealthy saturated and trans fats, which contribute to high cholesterol levels. This dietary modification demonstrates an understanding of how to manage cholesterol through healthier food preparation choices, promoting cardiovascular health.
NCLEX-PN Test #11
While caring for a client with a fever, the nurse notes flushed skin and sweating.
What is the nurse’s first action?