NCLEX-PN Test #12

Question 1

The nurse observes a client with heart failure has 2+ pitting edema in both legs. What should the nurse do first?

Accepted Answer

Obtain the client’s daily weight.

Answer

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?

Accepted Answer

Instruct the client to take the medication with meals.

Answer

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?

Accepted Answer

The client is attempting to control air trapping.

Answer

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?

Accepted Answer

Exercise helps lower blood pressure naturally.

Answer

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?

Accepted Answer

Keep the drainage bag below bladder level.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #12