NCLEX-PN Test #18

Question 1

A client recovering from surgery reports feeling lightheaded upon standing. What should the nurse do first?

Accepted Answer

Assess the client’s blood pressure sitting and standing.

Answer

Encourage the client to walk more often.

Answer

Offer a large meal.

Answer

Ignore the symptom unless fainting occurs.

Question 2

A client with chronic kidney disease reports decreased urine output. What action should the nurse take first?

Accepted Answer

Review the client’s intake and output record.

Answer

Have the client lie flat in bed.

Answer

Encourage the client to drink more water.

Answer

Stop all fluids immediately.

Question 3

The nurse notices a client with COPD is using abdominal muscles to breathe. What should the nurse do first?

Accepted Answer

Place the client in high Fowler’s position.

Answer

Encourage shallow breathing.

Answer

Lower the head of the bed completely.

Answer

Provide a heavy meal to increase energy.

Question 4

A client taking an iron supplement reports dark stools. What should the nurse tell the client?

Accepted Answer

Dark stools are a normal side effect of iron supplements.

Answer

Dark stools mean the medication is not working.

Answer

Dark stools indicate internal bleeding.

Answer

Dark stools require stopping the medication.

Question 5

A confused client keeps pulling at their oxygen tubing. What should the nurse do first?

Accepted Answer

Secure or cover the oxygen tubing.

Answer

Ignore the behavior until tubing is removed.

Answer

Restrain the client immediately.

Answer

Remove the oxygen entirely.

Question 6

A client reports dizziness after taking their morning antihypertensive medication. What should the nurse suspect?

Accepted Answer

Low blood pressure from the medication.

Answer

High blood sugar.

Answer

Fluid overload.

Answer

Normal adaptation to medication.

Question 7

A diabetic client reports a new wound on the bottom of their foot. What should the nurse do?

Accepted Answer

Report the wound to the healthcare provider.

Answer

Encourage wearing tight shoes.

Answer

Tell the client to monitor it for a week.

Answer

Advise walking barefoot to toughen the skin.

Question 8

A client receiving IV antibiotics develops sudden itching and redness. What should the nurse do first?

Accepted Answer

Stop the IV antibiotic immediately.

Answer

Ignore the itching unless swelling occurs.

Answer

Increase the infusion rate.

Answer

Give a snack to soothe the stomach.

Question 9

During a respiratory assessment, a client with pneumonia has difficulty coughing up mucus. What should the nurse encourage?

Accepted Answer

Increase fluid intake throughout the day.

Answer

Avoid liquids until mucus improves.

Answer

Lie flat to help drainage.

Answer

Limit coughing to prevent fatigue.

A client recovering from surgery reports feeling lightheaded upon standing.What should the nurse do first?