NCLEX-PN Test #2 — Questions and Answers
Question 1: A client with Type 2 diabetes becomes sweaty and shaky during morning care. What should the nurse do first?
- Give the client a source of fast-acting sugar. (Correct answer)
- Call dietary to send the client’s breakfast tray.
- Have the client lie down and rest.
- Check the client’s urine for ketones.
Correct answer: Give the client a source of fast-acting sugar.
Sweating and shakiness are classic signs of hypoglycemia (low blood sugar) in a client with diabetes. The priority is to immediately administer a source of fast-acting sugar, such as juice or glucose tablets, to rapidly raise blood glucose levels. This prevents further complications and quickly alleviates the acute symptoms of hypoglycemia.
Question 2: A client prescribed furosemide reports leg cramps. Which assessment is most important?
- Assess the client for possible hypokalemia. (Correct answer)
- Ask the client about daily exercise habits.
- Evaluate the client’s hydration level only.
- Encourage increased protein intake.
Correct answer: Assess the client for possible hypokalemia.
Furosemide is a loop diuretic that promotes the excretion of potassium, among other electrolytes. Leg cramps are a common symptom of hypokalemia (low potassium levels). Therefore, assessing for hypokalemia is the most important action to identify the potential cause of the client's symptoms and guide appropriate intervention.
Question 3: The nurse is caring for a client on contact precautions. Which action is necessary?
- Wear gloves and gown upon entering the room. (Correct answer)
- Keep the door closed at all times.
- Wear only a mask for protection.
- Place the client in a negative-pressure room.
Correct answer: Wear gloves and gown upon entering the room.
Contact precautions are implemented to prevent the spread of infectious agents transmitted by direct or indirect contact. Wearing gloves and a gown upon entering the room creates a barrier, preventing the nurse's skin and clothing from becoming contaminated. This is a fundamental practice to protect both the healthcare worker and other clients from pathogen transmission.
Question 4: A client receiving morphine IV develops slow respirations. What is the priority action?
- Stop the opioid infusion and assess respirations. (Correct answer)
- Increase the infusion rate of the opioid.
- Encourage the client to cough deeply.
- Provide warm fluids to stimulate breathing.
Correct answer: Stop the opioid infusion and assess respirations.
Slow respirations are a critical sign of opioid-induced respiratory depression, which can be life-threatening. The priority action is to immediately stop the opioid infusion to prevent further central nervous system depression. This allows the nurse to assess the client's respiratory status without additional medication contributing to the problem, and then intervene as needed.
Question 5: Which sign indicates that a client with pneumonia is improving?
- Increased oxygen saturation and reduced coughing. (Correct answer)
- More frequent productive coughing episodes.
- Rising temperature throughout the day.
- Increasing fatigue with minimal activity.
Correct answer: Increased oxygen saturation and reduced coughing.
Pneumonia impairs gas exchange in the lungs, leading to decreased oxygen saturation and often increased coughing as the body tries to clear secretions. As a client improves, their lungs become clearer, leading to better oxygenation (increased oxygen saturation) and a reduction in the inflammatory response and mucus production (reduced coughing). These are direct indicators of resolving infection and improved respiratory function.
Question 6: A client receiving a blood transfusion develops chills and fever. What is the nurse’s first action?
- Stop the transfusion immediately. (Correct answer)
- Increase the infusion rate to complete the blood quickly.
- Give the client warm blankets.
- Call the laboratory to request another unit.
Correct answer: Stop the transfusion immediately.
Chills and fever during a blood transfusion are classic signs of a potential transfusion reaction, which can range from mild to severe and life-threatening. The nurse's immediate priority is to stop the transfusion to prevent further administration of the potentially harmful blood product. This action minimizes the client's exposure and allows for prompt assessment and intervention.
Question 7: The nurse prepares to administer an intramuscular injection to an adult. Which site is preferred?
- Ventrogluteal site. (Correct answer)
- Dorsogluteal site.
- Upper outer triceps.
- Anterior thigh only.
Correct answer: Ventrogluteal site.
The ventrogluteal site is the preferred site for intramuscular injections in adults due to its large muscle mass and distance from major nerves and blood vessels. This anatomical location minimizes the risk of injury to nerves, blood vessels, and bone, making it a safer and less painful option compared to other sites.
Question 8: A client with heart failure reports sudden weight gain. What should the nurse do?
- Report the weight gain to the provider. (Correct answer)
- Encourage the client to increase sodium intake.
- Advise more frequent rest periods.
- Have the client drink more fluids.
Correct answer: Report the weight gain to the provider.
Sudden weight gain in a client with heart failure often indicates fluid retention, which is a sign of worsening cardiac function and potential decompensation. This change can lead to increased symptoms like shortness of breath and edema. Reporting this to the provider promptly is crucial for timely assessment and adjustment of the client's treatment plan to prevent further complications.
Question 9: Before giving an antibiotic, which action is most important?
- Collect ordered cultures before administration. (Correct answer)
- Check the client’s vaccination record.
- Ask the client to fast before the dose.
- Administer all other medications first.
Correct answer: Collect ordered cultures before administration.
Collecting ordered cultures (e.g., blood, urine, sputum) before administering antibiotics is crucial for accurate diagnosis and effective treatment. Administering antibiotics first can alter the growth of microorganisms in the culture, leading to false-negative results or inaccurate identification of the causative pathogen. This ensures the most appropriate antibiotic is chosen for the specific infection.
NCLEX-PN Test #2
A client with Type 2 diabetes becomes sweaty and shaky during morning care.
What should the nurse do first?