NCLEX-PN Test #5

Question 1

A client with influenza reports increased shortness of breath and chest tightness. Which action should the nurse take first?

Accepted Answer

Assess lung sounds immediately.

Answer

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?

Accepted Answer

Teach the client to rise slowly from sitting or lying positions.

Answer

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?

Accepted Answer

Cover the IV site with a protective dressing.

Answer

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?

Accepted Answer

I will choose baked or grilled foods instead of fried foods.

Answer

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?

Accepted Answer

Stop the infusion immediately.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #5