NCLEX-PN Test #12 — Questions and Answers
Question 1: The nurse observes a client with heart failure has 2+ pitting edema in both legs. What should the nurse do first?
- Obtain the client’s daily weight. (Correct answer)
- Encourage the client to walk more frequently.
- Provide salt-rich snacks.
- Apply heat packs to both legs.
Correct answer: Obtain the client’s daily weight.
Pitting edema in a client with heart failure indicates fluid retention. Daily weights are the most accurate and objective measure of fluid balance and are crucial for monitoring the effectiveness of diuretic therapy and detecting worsening fluid overload. This assessment helps guide treatment decisions.
Question 2: A client taking potassium supplements reports nausea. What is the nurse’s best initial action?
- Instruct the client to take the medication with meals. (Correct answer)
- Have the client stop the medication immediately.
- Double the next potassium dose.
- Recommend lying flat after taking the medication.
Correct answer: Instruct the client to take the medication with meals.
Potassium supplements can be irritating to the gastrointestinal tract and commonly cause nausea, vomiting, or stomach upset. Instructing the client to take the medication with meals or a full glass of water helps to buffer the stomach and minimize these uncomfortable side effects, improving adherence.
Question 3: During assessment, a client with COPD has pursed-lip breathing. What does this indicate?
- The client is attempting to control air trapping. (Correct answer)
- The client is becoming dehydrated.
- The client is overusing accessory muscles unnecessarily.
- The client has developed a new cardiac problem.
Correct answer: The client is attempting to control air trapping.
Pursed-lip breathing is a compensatory mechanism used by clients with COPD to prolong exhalation. This technique creates back pressure in the airways, which helps to keep them open and prevent air trapping. By improving gas exchange and reducing dyspnea, it helps the client breathe more effectively.
Question 4: A client with a new diagnosis of hypertension asks why daily exercise is recommended. What is the best explanation?
- Exercise helps lower blood pressure naturally. (Correct answer)
- Exercise eliminates the need for medication completely.
- Exercise increases sodium levels in the blood.
- Exercise reduces the need for hydration.
Correct answer: Exercise helps lower blood pressure naturally.
Regular physical activity strengthens the heart, making it more efficient at pumping blood, which naturally lowers blood pressure. Exercise also helps manage weight, reduce stress, and improve overall cardiovascular health. These combined benefits contribute significantly to blood pressure control and overall well-being.
Question 5: The nurse is providing care to a client with a urinary catheter. Which action helps prevent infection?
- Keep the drainage bag below bladder level. (Correct answer)
- Disconnect the catheter tubing daily.
- Clamp the catheter when the bag is half full.
- Hang the drainage bag on the side rail.
Correct answer: Keep the drainage bag below bladder level.
Keeping the drainage bag below bladder level prevents the backflow of urine into the bladder, which can introduce bacteria and lead to urinary tract infections. Gravity ensures that urine flows continuously away from the bladder, maintaining a closed system. This simple action is a fundamental principle of infection control for clients with indwelling catheters.
Question 6: A client receiving an opioid for postoperative pain becomes unusually drowsy. What should the nurse do first?
- Assess the client’s respiratory rate. (Correct answer)
- Feed the client a meal to increase alertness.
- Provide a warm blanket.
- Ignore the drowsiness unless the client becomes unconscious.
Correct answer: Assess the client’s respiratory rate.
Opioids can cause respiratory depression, and unusual drowsiness is a key warning sign that this serious side effect may be developing. Assessing the client's respiratory rate is the nurse's first priority to determine the severity of the depression and intervene promptly. This aligns with the ABCs (Airway, Breathing, Circulation) of patient assessment.
Question 7: A client receiving IV fluids reports pain and redness at the IV site. What should the nurse suspect?
- Phlebitis. (Correct answer)
- Hypoglycemia.
- Fluid overload.
- Electrolyte imbalance.
Correct answer: Phlebitis.
Pain and redness at an IV site are classic signs of phlebitis, which is inflammation of the vein. This condition can be caused by mechanical irritation from the catheter, chemical irritation from the IV solution, or bacterial infection. The nurse should assess the site further and intervene to prevent complications.
Question 8: A client with anxiety begins rapid, shallow breathing. What is the nurse’s first action?
- Encourage slow, deep breathing. (Correct answer)
- Encourage the client to breathe faster.
- Place the client completely flat.
- Offer caffeinated beverages.
Correct answer: Encourage slow, deep breathing.
Rapid, shallow breathing during anxiety can lead to hyperventilation, causing a decrease in carbon dioxide levels and potentially respiratory alkalosis. Encouraging slow, deep breathing helps to normalize CO2 levels, calm the client, and alleviate symptoms like dizziness or tingling. This intervention directly addresses the physiological response to anxiety.
Question 9: A client recovering from surgery reports new warmth and redness around the incision. What should the nurse do first?
- Assess the incision and notify the provider. (Correct answer)
- Cover the incision with ice.
- Advise the client to scratch the area.
- Ignore the symptom unless fever develops.
Correct answer: Assess the incision and notify the provider.
New warmth and redness around a surgical incision are potential signs of inflammation or infection. The nurse's first action is to thoroughly assess the incision for other signs like drainage, swelling, or dehiscence, and then notify the provider. This ensures timely evaluation and appropriate intervention to prevent complications.
NCLEX-PN Test #12
The nurse observes a client with heart failure has 2+ pitting edema in both legs.
What should the nurse do first?