NCLEX-PN Test #4

Question 1

A practical nurse is caring for a client who is short of breath and anxious. Which action should the nurse take first?

Accepted Answer

Elevate the head of the bed.

Answer

Call the client's family to the bedside.

Answer

Encourage the client to drink fluids.

Answer

Ask the client to rate their anxiety.

Question 2

Before administering digoxin to an adult client, which assessment finding would require the nurse to hold the medication and notify the provider?

Accepted Answer

Apical pulse of 54 beats per minute.

Answer

Blood pressure of 138/82 mm Hg.

Answer

Respiratory rate of 20 breaths per minute.

Answer

Temperature of 37.2 C (99 F).

Question 3

A client on opioid analgesics reports new constipation. Which instruction by the nurse is most appropriate?

Accepted Answer

Increase fluid and fiber intake and walk daily as tolerated.

Answer

Avoid drinking water after taking the medication.

Answer

Lie in bed as much as possible.

Answer

Double the opioid dose for pain control.

Question 4

Which action by the practical nurse helps prevent falls in an older adult client who is unsteady when walking?

Accepted Answer

Place the call light within easy reach and respond promptly.

Answer

Encourage the client to walk alone to maintain independence.

Answer

Raise all side rails and leave the room.

Answer

Keep the room lights off to promote rest.

Question 5

A client with a new colostomy asks the nurse how to care for the stoma. Which response is most accurate?

Accepted Answer

The stoma should look moist and pink to red in color.

Answer

The stoma should be dry and gray in color.

Answer

You should scrub the stoma firmly each day.

Answer

Any bleeding from the stoma is always normal.

Question 6

The nurse is reinforcing teaching about insulin self-administration. Which statement by the client shows a correct understanding?

Accepted Answer

I will rotate injection sites within the same area, like my abdomen.

Answer

I will use the same spot every day so it is less painful.

Answer

I will inject only into my upper arm muscles.

Answer

I can stop my insulin when my blood sugar feels normal.

Question 7

Which finding in a post-operative client should the practical nurse report to the registered nurse or provider immediately?

Accepted Answer

A surgical dressing that is suddenly saturated with bright red blood.

Answer

Mild pain controlled with prescribed analgesics.

Answer

Small amount of dried drainage on the old dressing.

Answer

Temperature of 37.4 C (99.3 F).

Question 8

A client receiving an IV antibiotic develops itching and hives. What is the nurse's priority action?

Accepted Answer

Stop the IV infusion immediately.

Answer

Document the reaction and continue the infusion.

Answer

Tell the client this is an expected side effect.

Answer

Ask the client to drink more fluids.

Question 9

When providing care for a client in isolation for an airborne infection, which item is essential for the nurse to wear?

Accepted Answer

An N95 respirator mask.

Answer

Only clean gloves.

Answer

A cloth face covering.

Answer

Regular eyeglasses.

A practical nurse is caring for a client who is short of breath and anxious.Which action should the nurse take first?