NCLEX-PN Test #5 — Questions and Answers
Question 1: A client with influenza reports increased shortness of breath and chest tightness. Which action should the nurse take first?
- Assess lung sounds immediately. (Correct answer)
- Offer warm fluids for throat comfort.
- Encourage the client to ambulate.
- Lower the room temperature.
Correct answer: Assess lung sounds immediately.
The client's report of increased shortness of breath and chest tightness indicates potential respiratory distress, which is a priority concern. Assessing lung sounds immediately provides crucial information about the client's respiratory status, helping the nurse determine the severity of the problem and guide subsequent interventions. This aligns with the ABCs (Airway, Breathing, Circulation) of nursing assessment, prioritizing life-threatening issues.
Question 2: A client taking a diuretic reports dizziness when standing. What is the nurse’s best initial response?
- Teach the client to rise slowly from sitting or lying positions. (Correct answer)
- Encourage rapid position changes.
- Increase sodium intake significantly.
- Stop the medication without provider approval.
Correct answer: Teach the client to rise slowly from sitting or lying positions.
Dizziness when standing, especially in a client taking a diuretic, is a common symptom of orthostatic hypotension. Diuretics can cause fluid loss, leading to a drop in blood pressure upon standing. Teaching the client to change positions slowly allows the body to compensate for these blood pressure changes, preventing falls and improving safety by mitigating the effects of orthostatic hypotension.
Question 3: A confused client repeatedly tries to pull out their IV line. Which action is most appropriate?
- Cover the IV site with a protective dressing. (Correct answer)
- Apply wrist restraints immediately.
- Discontinue the IV line entirely.
- Ignore the behavior unless the IV is removed.
Correct answer: Cover the IV site with a protective dressing.
A confused client attempting to pull out an IV line poses a risk of dislodgement, infection, and loss of venous access. Covering the IV site with a protective dressing, such as a net dressing or an IV site protector, is the least restrictive and most appropriate initial intervention. This protects the site while allowing for continued IV therapy, prioritizing client safety and comfort without immediately resorting to more restrictive measures like restraints.
Question 4: The nurse is reinforcing dietary teaching for a client with high cholesterol. Which statement shows understanding?
- I will choose baked or grilled foods instead of fried foods. (Correct answer)
- I will increase butter intake for extra flavor.
- I will drink whole milk daily.
- I will avoid all fruits because they contain sugar.
Correct answer: I will choose baked or grilled foods instead of fried foods.
Fried foods are high in unhealthy saturated and trans fats, which contribute to elevated cholesterol levels. Choosing baked or grilled options significantly reduces the intake of these fats, promoting heart health and aiding in cholesterol management. This dietary modification is a key component of managing high cholesterol.
Question 5: A client reports burning at the IV site where an antibiotic is infusing. What should the nurse do first?
- Stop the infusion immediately. (Correct answer)
- Increase the infusion rate.
- Apply cold compresses without assessing.
- Ignore it because mild burning is normal.
Correct answer: Stop the infusion immediately.
Burning at an IV site can indicate serious complications such as infiltration, phlebitis, or extravasation, which can lead to tissue damage. Stopping the infusion immediately prevents further medication delivery into potentially compromised tissue. This allows for prompt assessment of the site and appropriate intervention to prevent harm.
Question 6: A client with diabetes reports numbness in both feet. What is the nurse’s best action?
- Report the symptom to the healthcare provider. (Correct answer)
- Encourage tight shoes for support.
- Advise stopping all diabetes medications.
- Recommend massaging the feet vigorously.
Correct answer: Report the symptom to the healthcare provider.
Numbness in the feet, known as peripheral neuropathy, is a common and serious complication of diabetes. This condition can lead to undetected injuries, infections, and even amputations if not properly managed. Reporting this symptom to the healthcare provider is crucial for further assessment, diagnosis, and initiation of appropriate interventions to prevent progression and complications.
Question 7: A postoperative client has not voided six hours after surgery. What should the nurse do first?
- Assess the bladder for distention. (Correct answer)
- Provide additional oral fluids immediately.
- Restrict all fluids.
- Instruct the client to ambulate for 30 minutes.
Correct answer: Assess the bladder for distention.
Postoperative clients are at high risk for urinary retention due to the effects of anesthesia, pain medications, and surgical trauma. Assessing the bladder for distention (e.g., palpation, bladder scan) is the priority action to determine if the client is retaining urine. Identifying retention early allows for timely intervention and prevents complications like bladder damage or infection.
Question 8: A client prescribed a new antihistamine reports drowsiness. What should the nurse tell the client?
- Avoid driving or operating machinery until you know how it affects you. (Correct answer)
- Double the dose if symptoms persist.
- Take it only on an empty stomach at night.
- Ignore drowsinessu2014it will resolve immediately.
Correct answer: Avoid driving or operating machinery until you know how it affects you.
Drowsiness is a common side effect of many antihistamines, which can impair a person's ability to react quickly and make sound judgments. Advising the client to avoid driving or operating machinery is a critical safety measure. This precaution ensures the client does not put themselves or others at risk until they understand how the medication affects them.
Question 9: A client with pneumonia has thick secretions and difficulty coughing. What action should the nurse take first?
- Encourage increased oral fluid intake. (Correct answer)
- Lower the client’s fluid intake.
- Place the client completely flat.
- Ask the client to avoid coughing to rest the lungs.
Correct answer: Encourage increased oral fluid intake.
Increased oral fluid intake helps to thin thick respiratory secretions, making them less viscous and easier to cough up and clear from the airways. This action improves lung ventilation and oxygenation, reducing the client's work of breathing and preventing further respiratory complications in pneumonia. Hydration is a fundamental intervention for managing respiratory secretions.
NCLEX-PN Test #5
A client with influenza reports increased shortness of breath and chest tightness.
Which action should the nurse take first?