NCLEX-PN Test #4 — Questions and Answers
Question 1: A practical nurse is caring for a client who is short of breath and anxious. Which action should the nurse take first?
- Elevate the head of the bed. (Correct answer)
- Call the client's family to the bedside.
- Encourage the client to drink fluids.
- Ask the client to rate their anxiety.
Correct answer: Elevate the head of the bed.
Elevating the head of the bed (Fowler's position) immediately promotes lung expansion and reduces pressure on the diaphragm, making it easier for the client to breathe. This simple, non-invasive intervention can quickly alleviate shortness of breath and, consequently, reduce anxiety. Addressing the physiological need for oxygen is the priority.
Question 2: Before administering digoxin to an adult client, which assessment finding would require the nurse to hold the medication and notify the provider?
- Apical pulse of 54 beats per minute. (Correct answer)
- Blood pressure of 138/82 mm Hg.
- Respiratory rate of 20 breaths per minute.
- Temperature of 37.2 C (99 F).
Correct answer: Apical pulse of 54 beats per minute.
Digoxin is a cardiac glycoside that slows the heart rate. An apical pulse of 54 beats per minute is below the typical safe threshold of 60 bpm for administering digoxin in adults. Administering the medication with a pre-existing bradycardia could further depress cardiac function, leading to dangerous adverse effects and requiring immediate notification of the provider.
Question 3: A client on opioid analgesics reports new constipation. Which instruction by the nurse is most appropriate?
- Increase fluid and fiber intake and walk daily as tolerated. (Correct answer)
- Avoid drinking water after taking the medication.
- Lie in bed as much as possible.
- Double the opioid dose for pain control.
Correct answer: Increase fluid and fiber intake and walk daily as tolerated.
Opioid analgesics commonly cause constipation by slowing gastrointestinal motility. Increasing fluid and fiber intake adds bulk and softens stool, while daily ambulation stimulates bowel activity. These non-pharmacological interventions are highly effective in preventing and managing opioid-induced constipation, promoting regular bowel movements and client comfort.
Question 4: Which action by the practical nurse helps prevent falls in an older adult client who is unsteady when walking?
- Place the call light within easy reach and respond promptly. (Correct answer)
- Encourage the client to walk alone to maintain independence.
- Raise all side rails and leave the room.
- Keep the room lights off to promote rest.
Correct answer: Place the call light within easy reach and respond promptly.
Placing the call light within easy reach and responding promptly ensures that an unsteady older adult client can request assistance when needed. This significantly reduces the likelihood of them attempting to get out of bed or move unassisted, which is a primary cause of falls. It empowers the client while prioritizing their safety.
Question 5: A client with a new colostomy asks the nurse how to care for the stoma. Which response is most accurate?
- The stoma should look moist and pink to red in color. (Correct answer)
- The stoma should be dry and gray in color.
- You should scrub the stoma firmly each day.
- Any bleeding from the stoma is always normal.
Correct answer: The stoma should look moist and pink to red in color.
A healthy, viable stoma should appear moist, shiny, and pink to red in color, indicating adequate blood supply and tissue perfusion. Any deviation from this, such as a dry, dusky, or gray appearance, could signal compromised circulation or necrosis. Understanding these characteristics is crucial for proper stoma care and early identification of complications.
Question 6: The nurse is reinforcing teaching about insulin self-administration. Which statement by the client shows a correct understanding?
- I will rotate injection sites within the same area, like my abdomen. (Correct answer)
- I will use the same spot every day so it is less painful.
- I will inject only into my upper arm muscles.
- I can stop my insulin when my blood sugar feels normal.
Correct answer: I will rotate injection sites within the same area, like my abdomen.
Rotating insulin injection sites within the same anatomical area (e.g., abdomen, thighs) helps prevent lipohypertrophy (fat accumulation) or lipoatrophy (fat breakdown). These tissue changes can impair insulin absorption and lead to unpredictable blood glucose levels. Consistent rotation ensures optimal medication effectiveness and reduces local tissue damage.
Question 7: Which finding in a post-operative client should the practical nurse report to the registered nurse or provider immediately?
- A surgical dressing that is suddenly saturated with bright red blood. (Correct answer)
- Mild pain controlled with prescribed analgesics.
- Small amount of dried drainage on the old dressing.
- Temperature of 37.4 C (99.3 F).
Correct answer: A surgical dressing that is suddenly saturated with bright red blood.
A surgical dressing suddenly saturated with bright red blood indicates active hemorrhage, which is a critical and potentially life-threatening complication. This finding suggests significant blood loss and requires immediate reporting to the registered nurse or provider for urgent assessment and intervention. Prompt action is essential to prevent further compromise.
Question 8: A client receiving an IV antibiotic develops itching and hives. What is the nurse's priority action?
- Stop the IV infusion immediately. (Correct answer)
- Document the reaction and continue the infusion.
- Tell the client this is an expected side effect.
- Ask the client to drink more fluids.
Correct answer: Stop the IV infusion immediately.
Itching and hives developing after an IV antibiotic infusion are classic signs of an allergic reaction, which can rapidly progress to a severe systemic response like anaphylaxis. Stopping the IV infusion immediately is the priority action to prevent further exposure to the allergen. This ensures client safety and allows for prompt management of the allergic response.
Question 9: When providing care for a client in isolation for an airborne infection, which item is essential for the nurse to wear?
- An N95 respirator mask. (Correct answer)
- Only clean gloves.
- A cloth face covering.
- Regular eyeglasses.
Correct answer: An N95 respirator mask.
Airborne infections, such as tuberculosis or measles, are spread through very small particles that can remain suspended in the air. An N95 respirator mask provides a tight seal and filters out these tiny airborne particles, offering essential respiratory protection for the nurse. This is a critical component of airborne precautions to prevent disease transmission.
NCLEX-PN Test #4
A practical nurse is caring for a client who is short of breath and anxious.
Which action should the nurse take first?