NCLEX-PN Test #6 — Questions and Answers
Question 1: The nurse notes that a client receiving oxygen by nasal cannula has dry nasal passages. What should the nurse do first?
- Add humidity to the client’s oxygen. (Correct answer)
- Lower the client’s oxygen flow rate.
- Encourage the client to drink coffee.
- Apply petroleum jelly inside the nostrils.
Correct answer: Add humidity to the client’s oxygen.
Oxygen therapy, especially when delivered via nasal cannula, can have a drying effect on the nasal passages and mucous membranes, leading to discomfort, irritation, and potential tissue breakdown. Adding humidity to the oxygen flow helps to moisten the inspired air, preventing dryness and maintaining the integrity of the nasal mucosa. This is the most appropriate initial intervention.
Question 2: A client taking a new blood pressure medication reports feeling lightheaded. What is the nurse’s best initial action?
- Check the client’s blood pressure. (Correct answer)
- Encourage vigorous exercise.
- Stop the medication immediately.
- Give the client a salty snack.
Correct answer: Check the client’s blood pressure.
Feeling lightheaded after starting a new blood pressure medication suggests a potential drop in blood pressure, possibly orthostatic hypotension. The nurse's best initial action is to check the client's blood pressure to confirm hypotension. This objective assessment provides crucial data to determine the severity of the issue and guide appropriate interventions, such as notifying the provider or adjusting the medication.
Question 3: A client with a new leg cast reports increasing pain unrelieved by medication. What should the nurse do first?
- Assess circulation, movement, and sensation. (Correct answer)
- Apply ice directly inside the cast.
- Elevate the leg above the heart without assessment.
- Reassure the client this is normal.
Correct answer: Assess circulation, movement, and sensation.
Increasing pain unrelieved by medication in a new cast is a red flag for potential complications like compartment syndrome or neurovascular compromise. The nurse's first action must be to perform a thorough neurovascular assessment (checking circulation, movement, and sensation) to identify any emergent issues. This assessment is critical for preventing irreversible tissue damage.
Question 4: The nurse is reinforcing teaching for a client prescribed a liquid antibiotic. Which statement shows understanding?
- I will shake the bottle before each dose. (Correct answer)
- I should store it on a sunny windowsill.
- I will stop the medication when I feel better.
- I will mix it with alcohol for better taste.
Correct answer: I will shake the bottle before each dose.
Many liquid medications, especially suspensions, contain medication particles that can settle at the bottom of the bottle over time. Shaking the bottle before each dose ensures that the medication is evenly distributed throughout the liquid. This guarantees that the client receives the correct and consistent dosage with every administration, maximizing therapeutic effect.
Question 5: A client with a respiratory infection has thick sputum. Which intervention is most helpful?
- Encourage increased fluid intake. (Correct answer)
- Reduce all fluid intake until coughing stops.
- Have the client lie flat during coughing.
- Limit the client’s movement.
Correct answer: Encourage increased fluid intake.
Increased fluid intake helps to thin thick respiratory secretions, making them less viscous and easier for the client to cough up and clear from their airways. This intervention improves airway patency, reduces the effort of breathing, and can prevent further complications from retained secretions. Hydration is a key component of respiratory care for thick sputum.
Question 6: The nurse is caring for a client who has not had a bowel movement in three days. Which action should the nurse take first?
- Assess bowel sounds in all four quadrants. (Correct answer)
- Administer a laxative without assessment.
- Encourage the client to ignore the symptoms.
- Place the client on fluid restriction.
Correct answer: Assess bowel sounds in all four quadrants.
Before intervening for a client who has not had a bowel movement, the nurse must first assess the client's bowel sounds in all four quadrants. This assessment helps determine the presence and quality of bowel activity, ruling out potential complications like an ileus or obstruction. The assessment findings will then guide the most appropriate and safe interventions for constipation.
Question 7: A client with diabetes reports cold, clammy skin and shakiness. What should the nurse do first?
- Provide a fast-acting carbohydrate source. (Correct answer)
- Have the client perform deep breathing exercises.
- Encourage the client to take their insulin early.
- Offer a high-protein meal only.
Correct answer: Provide a fast-acting carbohydrate source.
Cold, clammy skin and shakiness are classic symptoms of hypoglycemia (low blood sugar), which is a medical emergency in clients with diabetes. The immediate priority is to provide a fast-acting carbohydrate source (e.g., juice, glucose tablets) to rapidly raise blood glucose levels. This prevents further decline and potential complications such as seizures or loss of consciousness.
Question 8: A postoperative client reports nausea. What should the nurse do first?
- Assess the severity and frequency of the nausea. (Correct answer)
- Give a large meal immediately.
- Lower the head of the bed completely.
- Ignore the complaint until vomiting occurs.
Correct answer: Assess the severity and frequency of the nausea.
Before implementing any intervention for nausea, the nurse's first action is to assess the severity, frequency, and potential triggers of the client's nausea. This comprehensive assessment provides crucial information to understand the client's experience and helps the nurse select the most appropriate and effective antiemetic or non-pharmacological intervention. Ignoring the complaint is inappropriate and unsafe.
Question 9: While reviewing wound care instructions, the client asks how often to change the dressing. What should the nurse say?
- Follow the frequency ordered by your healthcare provider. (Correct answer)
- Change the dressing every hour for cleanliness.
- Only change the dressing when it is completely falling off.
- Never replace the dressing once it is applied.
Correct answer: Follow the frequency ordered by your healthcare provider.
Wound care, including dressing changes, is a medical intervention that requires specific instructions from the healthcare provider. The frequency is determined by factors like wound type, healing stage, and client condition to optimize healing and prevent complications. Nurses must adhere to these orders and educate clients to do the same, as improper frequency can lead to infection or delayed healing.
NCLEX-PN Test #6
The nurse notes that a client receiving oxygen by nasal cannula has dry nasal passages.
What should the nurse do first?