NCLEX-PN Test #7

Question 1

While assessing a client with dehydration, the nurse notes poor skin turgor. What should the nurse do first?

Accepted Answer

Assess the client’s vital signs.

Answer

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?

Accepted Answer

Check the client’s apical pulse.

Answer

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?

Accepted Answer

Pause the tube feeding immediately.

Answer

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?

Accepted Answer

Cold intolerance is expected due to a slowed metabolism.

Answer

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?

Accepted Answer

Assess the severity of the itching.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #7