NCLEX-PN Test #13 — Questions and Answers
Question 1: During assessment, a client with diabetes reports excessive thirst and frequent urination. What should the nurse do first?
- Check the client’s blood glucose level. (Correct answer)
- Restrict the client’s fluid intake.
- Give the next scheduled insulin dose early.
- Encourage the client to lie down and rest.
Correct answer: Check the client’s blood glucose level.
Excessive thirst (polydipsia) and frequent urination (polyuria) are hallmark symptoms of hyperglycemia, or high blood glucose, in clients with diabetes. The nurse's priority is to check the client's blood glucose level to confirm hyperglycemia and guide immediate treatment, such as insulin administration. This assessment is crucial for managing the client's diabetic condition.
Question 2: A client with hypertension asks why they must avoid high-sodium foods. What is the nurse’s best explanation?
- Sodium causes your body to retain fluid and increase blood pressure. (Correct answer)
- Sodium reduces the effectiveness of all medications.
- Sodium causes dizziness in most people.
- Sodium lowers the heart rate significantly.
Correct answer: Sodium causes your body to retain fluid and increase blood pressure.
Sodium causes the body to retain water, which increases the total blood volume circulating through the blood vessels. This increased volume puts more pressure on the arterial walls, leading to an elevation in blood pressure. Therefore, reducing sodium intake is a key dietary recommendation for managing hypertension.
Question 3: A client receiving IV antibiotics reports swelling and tenderness at the IV site. What should the nurse do first?
- Stop the IV infusion immediately. (Correct answer)
- Increase the IV flow rate.
- Ask the client to massage the site.
- Apply an ice pack without assessing.
Correct answer: Stop the IV infusion immediately.
Swelling and tenderness at an IV site indicate a potential complication such as infiltration (fluid leaking into surrounding tissue) or phlebitis (inflammation of the vein). Stopping the IV infusion immediately is crucial to prevent further tissue damage, medication extravasation, or worsening of the inflammatory process. After stopping, the nurse would then assess the site and implement appropriate interventions.
Question 4: A postoperative client has decreased bowel sounds and abdominal bloating. What is the nurse’s priority action?
- Assess bowel sounds in all four quadrants. (Correct answer)
- Provide a high-fiber meal immediately.
- Encourage immediate ambulation without assessment.
- Restrict all oral intake.
Correct answer: Assess bowel sounds in all four quadrants.
Decreased bowel sounds and abdominal bloating in a postoperative client can indicate a paralytic ileus, where bowel motility is temporarily absent. Assessing bowel sounds in all four quadrants provides a comprehensive picture of bowel activity and helps determine the extent of the issue. This assessment guides further interventions, such as NPO status or ambulation.
Question 5: A client taking an opioid reports feeling very drowsy. What should the nurse assess first?
- Assess the client’s respiratory rate. (Correct answer)
- Give another opioid dose to promote tolerance.
- Encourage the client to stay awake.
- Give warm fluids to increase alertness.
Correct answer: Assess the client’s respiratory rate.
Drowsiness is a common side effect of opioid medications and can be a precursor to more severe central nervous system depression, including respiratory depression. The nurse's priority is to assess the client's respiratory rate to ensure their breathing is not compromised. This aligns with the principle of prioritizing airway and breathing.
Question 6: The nurse is reinforcing teaching for a client prescribed a diuretic. Which statement indicates correct understanding?
- I will take my diuretic in the morning. (Correct answer)
- I should take it right before bedtime.
- I will stop taking it if I urinate too much.
- I should restrict fluids while on this medication.
Correct answer: I will take my diuretic in the morning.
Diuretics increase urine production, which can lead to frequent urination. Taking a diuretic in the morning helps prevent nocturia, which is the need to urinate frequently during the night. This promotes better sleep and reduces the risk of falls associated with nighttime bathroom trips.
Question 7: A client with respiratory infection has thick, sticky mucus. What should the nurse encourage?
- Increase daily fluid intake. (Correct answer)
- Avoid all fluids until the cough stops.
- Lie completely flat to rest the lungs.
- Take deep breaths without fluids.
Correct answer: Increase daily fluid intake.
Increased fluid intake helps to thin thick, sticky mucus, making it less viscous and easier for the client to cough up and clear from their airways. This improves respiratory function and helps prevent further complications like pneumonia. Hydration is a crucial intervention for clients with respiratory infections.
Question 8: The nurse is caring for a client with possible dehydration. Which finding is most concerning?
- Very low urine output. (Correct answer)
- Warm hands and feet.
- Slightly dry lips.
- Mild thirst after walking.
Correct answer: Very low urine output.
Very low urine output (oliguria) is a significant and concerning indicator of dehydration, as it suggests reduced kidney perfusion and potential acute kidney injury. While dry lips and thirst are also signs, oliguria reflects a more severe systemic impact of fluid deficit. This finding requires immediate nursing intervention to restore fluid balance.
Question 9: A postoperative client reports pain at the incision site. What should the nurse do first?
- Assess the surgical incision. (Correct answer)
- Give pain medication immediately without assessing.
- Ignore the pain unless fever develops.
- Have the client ambulate immediately.
Correct answer: Assess the surgical incision.
Before administering pain medication, the nurse must first assess the surgical incision to identify the cause of the pain and rule out any complications. The pain could be due to infection, dehiscence, or other issues requiring specific interventions beyond just pain relief. This follows the nursing process of assessment before intervention.
NCLEX-PN Test #13
During assessment, a client with diabetes reports excessive thirst and frequent urination.
What should the nurse do first?