NCLEX-PN Test #3 — Questions and Answers
Question 1: While caring for a client with anemia, the nurse notes increasing fatigue and pale skin. What should the nurse do first?
- Assess the client’s vital signs. (Correct answer)
- Offer the client a warm blanket.
- Encourage the client to increase activity.
- Provide a high-calorie snack.
Correct answer: Assess the client’s vital signs.
Increasing fatigue and pale skin in a client with anemia are signs that the anemia may be worsening or that the client is experiencing other complications. Assessing vital signs (e.g., heart rate, blood pressure, oxygen saturation) provides objective data to evaluate the client's physiological status and guide further interventions. This initial assessment helps determine the urgency and nature of the problem.
Question 2: A client with hypertension states they stopped taking their medication because they felt fine. What is the nurse’s best response?
- Explain that hypertension may have no symptoms but still needs treatment. (Correct answer)
- Tell them to restart the medication when symptoms return.
- Advise them to double the dose for missed days.
- Recommend stopping medication permanently.
Correct answer: Explain that hypertension may have no symptoms but still needs treatment.
Hypertension is often asymptomatic, meaning clients may feel fine despite having dangerously high blood pressure. It is crucial to educate the client that untreated hypertension can lead to severe long-term complications like heart attack, stroke, and kidney disease. Emphasizing the importance of consistent medication adherence, even without symptoms, is vital for preventing these adverse outcomes.
Question 3: A client receiving IV fluids complains of swelling and pain at the IV site. What should the nurse do first?
- Stop the IV infusion immediately. (Correct answer)
- Increase the IV rate to flush the line.
- Apply heat to the IV site.
- Ask the client to move their arm more.
Correct answer: Stop the IV infusion immediately.
Swelling and pain at an IV site are classic signs of infiltration, where IV fluid has leaked out of the vein and into the surrounding subcutaneous tissue. Stopping the IV infusion immediately prevents further fluid extravasation, reduces discomfort, and minimizes potential tissue damage. This is the priority action to ensure client safety and prevent complications.
Question 4: The nurse is reinforcing teaching for a client starting iron supplements. Which statement shows understanding?
- I may have dark stools while taking this medication. (Correct answer)
- I should take this medication with dairy products.
- I should stop taking it if constipation occurs.
- It must always be taken on a completely empty stomach.
Correct answer: I may have dark stools while taking this medication.
Dark, tarry stools are a common and expected side effect of iron supplements, caused by unabsorbed iron passing through the digestive system. Educating the client about this normal change helps prevent unnecessary alarm and ensures medication adherence. This understanding is crucial for clients starting iron therapy.
Question 5: A client with asthma begins to wheeze after activity. What is the nurse’s priority action?
- Administer the prescribed rescue inhaler. (Correct answer)
- Offer warm water to relax airway muscles.
- Encourage deep breathing exercises.
- Lower the head of the bed.
Correct answer: Administer the prescribed rescue inhaler.
Wheezing after activity in a client with asthma indicates bronchospasm and narrowing of the airways, requiring immediate intervention to open them. Administering the prescribed rescue inhaler (e.g., a short-acting beta-agonist) is the priority action. This medication rapidly dilates the bronchioles, relieving respiratory distress and improving breathing.
Question 6: A client with dehydration is receiving IV fluids. Which finding indicates improvement?
- Moist oral mucous membranes. (Correct answer)
- Dark, concentrated urine.
- Weak, rapid pulse.
- Increased thirst.
Correct answer: Moist oral mucous membranes.
Dehydration causes the body's mucous membranes to become dry. Moist oral mucous membranes are a key indicator that the client's hydration status is improving and fluid balance is being restored. Other options like dark urine, weak pulse, and increased thirst are signs of ongoing or worsening dehydration.
Question 7: A client receiving antibiotics develops watery diarrhea. What should the nurse do first?
- Report the symptom to the healthcare provider. (Correct answer)
- Encourage increased dairy intake.
- Provide an antidiarrheal medication immediately.
- Stop all medications without instruction.
Correct answer: Report the symptom to the healthcare provider.
Watery diarrhea while a client is receiving antibiotics can be a serious sign of Clostridioides difficile (C. diff) infection, which requires specific treatment and infection control measures. Reporting this symptom to the healthcare provider is the priority for prompt diagnosis and appropriate management. Ignoring it or self-treating could lead to severe complications.
Question 8: A client with a urinary tract infection reports burning during urination. What should the nurse encourage?
- Increase oral fluid intake. (Correct answer)
- Limit all fluids until symptoms improve.
- Avoid all warm beverages.
- Begin taking leftover antibiotics at home.
Correct answer: Increase oral fluid intake.
Increasing oral fluid intake helps to flush bacteria from the urinary tract, dilute urine, and reduce the concentration of irritants, which can alleviate the burning sensation during urination. This is a primary non-pharmacological intervention for urinary tract infections. Adequate hydration supports the body's natural defenses against infection.
Question 9: During wound care, the nurse notices yellow drainage. What should the nurse do first?
- Document the color, odor, and amount of drainage. (Correct answer)
- Remove all dressings and leave the wound open.
- Apply ice directly to the wound.
- Stop wound care completely.
Correct answer: Document the color, odor, and amount of drainage.
Yellow drainage from a wound can indicate the presence of pus or slough, suggesting infection or impaired healing. The nurse's first action is to thoroughly assess and document the characteristics of the drainage, including its color, odor, and amount. This objective data is crucial for the healthcare team to determine the wound's status and guide appropriate treatment decisions.
NCLEX-PN Test #3
While caring for a client with anemia, the nurse notes increasing fatigue and pale skin.
What should the nurse do first?