NCLEX-PN Test #3

Question 1

While caring for a client with anemia, the nurse notes increasing fatigue and pale skin. What should the nurse do first?

Accepted Answer

Assess the client’s vital signs.

Answer

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?

Accepted Answer

Explain that hypertension may have no symptoms but still needs treatment.

Answer

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?

Accepted Answer

Stop the IV infusion immediately.

Answer

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?

Accepted Answer

I may have dark stools while taking this medication.

Answer

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?

Accepted Answer

Administer the prescribed rescue inhaler.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #3