NCLEX-PN Test #13

Question 1

During assessment, a client with diabetes reports excessive thirst and frequent urination. What should the nurse do first?

Accepted Answer

Check the client’s blood glucose level.

Answer

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?

Accepted Answer

Sodium causes your body to retain fluid and increase blood pressure.

Answer

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?

Accepted Answer

Stop the IV infusion immediately.

Answer

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?

Accepted Answer

Assess bowel sounds in all four quadrants.

Answer

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?

Accepted Answer

Assess the client’s respiratory rate.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #13