NCLEX-PN Test #11

Question 1

While caring for a client with a fever, the nurse notes flushed skin and sweating. What is the nurse’s first action?

Accepted Answer

Check the client’s temperature.

Answer

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?

Accepted Answer

Provide a source of fast-acting glucose.

Answer

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?

Accepted Answer

Add humidification to the oxygen.

Answer

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?

Accepted Answer

Assess the client’s bowel sounds.

Answer

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?

Accepted Answer

Dark stools are an expected side effect of iron.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #11