NCLEX-PN Test #7 — Questions and Answers
Question 1: While assessing a client with dehydration, the nurse notes poor skin turgor. What should the nurse do first?
- Assess the client’s vital signs. (Correct answer)
- Restrict all fluid intake.
- Encourage caffeinated beverages.
- Apply warm packs to the skin.
Correct answer: Assess the client’s vital signs.
Poor skin turgor is a key indicator of dehydration, which can significantly impact a client's physiological stability. Assessing vital signs, such as heart rate, blood pressure, and respiratory rate, provides crucial information about the severity of fluid deficit and the client's hemodynamic status. This initial assessment helps the nurse prioritize interventions and determine the urgency of further medical attention.
Question 2: A client prescribed a beta blocker reports feeling unusually tired. What should the nurse do first?
- Check the client’s apical pulse. (Correct answer)
- Stop the medication immediately.
- Encourage strenuous exercise.
- Tell the client to ignore the fatigue.
Correct answer: Check the client’s apical pulse.
Beta blockers are known to decrease heart rate, and fatigue is a common side effect. Checking the client's apical pulse is crucial to assess their heart rate and rhythm before administering the medication or reporting the symptom. A significantly low pulse rate might indicate the need to hold the medication or notify the healthcare provider, as it could exacerbate fatigue or lead to other adverse effects.
Question 3: A client with a gastrostomy tube reports nausea during the feeding. What should the nurse do first?
- Pause the tube feeding immediately. (Correct answer)
- Increase the feeding rate.
- Place the client in a flat position.
- Flush the tube with a large volume of water.
Correct answer: Pause the tube feeding immediately.
Nausea during a tube feeding can indicate intolerance, overfilling of the stomach, or a potential complication like aspiration. The immediate priority is to pause the feeding to prevent further discomfort and reduce the risk of aspiration. After pausing, the nurse should assess the client for other symptoms and determine the cause before resuming or modifying the feeding plan.
Question 4: A client with hypothyroidism reports feeling unusually cold. Which explanation should the nurse provide?
- Cold intolerance is expected due to a slowed metabolism. (Correct answer)
- It indicates the thyroid medication is working too quickly.
- It means the client should stop all medications.
- It indicates dehydration and low fluid intake.
Correct answer: Cold intolerance is expected due to a slowed metabolism.
Hypothyroidism is characterized by an underactive thyroid gland, which leads to a decreased metabolic rate throughout the body. A slowed metabolism results in reduced heat production, making individuals with hypothyroidism more sensitive to cold temperatures and causing cold intolerance. This is a classic and expected symptom of the condition, helping the client understand their experience.
Question 5: A client receiving an opioid reports intense itching. What should the nurse do first?
- Assess the severity of the itching. (Correct answer)
- Stop the opioid immediately without evaluation.
- Give another opioid to counteract itching.
- Ignore the symptom unless a rash appears.
Correct answer: Assess the severity of the itching.
Itching (pruritus) is a common side effect of opioid medications, often due to histamine release. The nurse's first action should be to assess the severity and characteristics of the itching, as well as check for any associated rash or signs of a more severe allergic reaction. This assessment guides further interventions, such as notifying the provider for an antihistamine order or evaluating for other causes.
Question 6: A diabetic client asks why foot care is important. What is the nurse’s best explanation?
- Reduced sensation increases the risk of injury and infection. (Correct answer)
- Feet must stay completely dry at all times.
- Toenails should be cut very short regularly.
- Walking barefoot helps toughen the skin.
Correct answer: Reduced sensation increases the risk of injury and infection.
Diabetes can cause peripheral neuropathy, leading to decreased sensation in the feet. This reduced sensation means clients may not feel cuts, blisters, or pressure points, increasing their risk of unnoticed injuries that can easily become infected. Regular foot care and inspection are vital to detect and prevent these issues early, preventing serious complications like amputation.
Question 7: A postoperative client reports increasing incisional pain. What should the nurse do first?
- Inspect the surgical incision. (Correct answer)
- Double the client’s pain medication dose.
- Have the client ambulate immediately.
- Apply ice without assessment.
Correct answer: Inspect the surgical incision.
Increasing incisional pain postoperatively requires immediate assessment to rule out complications. The nurse should first inspect the incision for signs of infection, dehiscence, hematoma, or other issues that could be causing the increased pain. This assessment guides appropriate interventions, such as administering pain medication, notifying the provider, or applying specific treatments.
Question 8: A client with a urinary catheter develops cloudy, foul-smelling urine. What should the nurse do first?
- Report findings to the healthcare provider. (Correct answer)
- Remove the catheter immediately without instructions.
- Tell the client this is normal urine appearance.
- Increase the catheter drainage bag height.
Correct answer: Report findings to the healthcare provider.
Cloudy, foul-smelling urine in a client with a urinary catheter is a strong indicator of a urinary tract infection (UTI). This is a significant finding that requires prompt medical attention. The nurse's first action is to report these findings to the healthcare provider so that appropriate diagnostic tests (e.g., urinalysis, urine culture) and treatment can be initiated.
Question 9: A client receiving steroids asks why blood glucose monitoring is required. What is the nurse’s best response?
- Steroids can raise blood glucose levels. (Correct answer)
- Steroids always lower blood glucose levels.
- Monitoring is only necessary at bedtime.
- Monitoring prevents weight gain.
Correct answer: Steroids can raise blood glucose levels.
Steroids, particularly glucocorticoids, are known to induce hyperglycemia by increasing glucose production in the liver and decreasing insulin sensitivity in peripheral tissues. This effect can occur in both diabetic and non-diabetic individuals. Therefore, blood glucose monitoring is essential to detect and manage steroid-induced hyperglycemia, preventing complications.
NCLEX-PN Test #7
While assessing a client with dehydration, the nurse notes poor skin turgor.
What should the nurse do first?