NCLEX-PN Test #8 — Questions and Answers
Question 1: A client with hypertension reports a persistent dry cough after starting an ACE inhibitor. What should the nurse do?
- Report the symptom to the healthcare provider. (Correct answer)
- Advise the client to double the dose.
- Instruct the client to stop the medication immediately.
- Encourage drinking carbonated beverages.
Correct answer: Report the symptom to the healthcare provider.
A persistent dry cough is a common and well-known side effect of ACE inhibitors, occurring in about 5-20% of clients. While not typically life-threatening, it can be very bothersome and affect medication compliance. The nurse should report this symptom to the healthcare provider, who may consider switching the client to an alternative antihypertensive medication, such as an ARB.
Question 2: A client with chronic kidney disease reports decreased urine output. What should the nurse do first?
- Review the client’s intake and output record. (Correct answer)
- Restrict all oral fluids immediately.
- Encourage high-protein supplements.
- Ignore the finding unless edema appears.
Correct answer: Review the client’s intake and output record.
Decreased urine output in a client with chronic kidney disease is a critical finding that could indicate worsening kidney function or fluid imbalance. The nurse's first action should be to review the client's intake and output (I&O) record to establish a baseline and identify any trends or discrepancies. This comprehensive assessment helps determine the potential cause and guides further interventions.
Question 3: During morning rounds, a client with COPD appears more lethargic than usual. What should the nurse do first?
- Check the client’s oxygen saturation level. (Correct answer)
- Offer a caffeinated beverage.
- Lower the client’s oxygen flow rate.
- Encourage vigorous activity.
Correct answer: Check the client’s oxygen saturation level.
Lethargy in a client with COPD can be a sign of worsening respiratory status, such as hypoxemia (low oxygen levels) or hypercapnia (high carbon dioxide levels). The immediate priority is to assess the client's oxygen saturation level using a pulse oximeter to determine if they are adequately oxygenated. This assessment guides the need for oxygen therapy adjustments or further respiratory interventions.
Question 4: A client with a fever is prescribed acetaminophen. Which teaching is most important?
- Avoid taking more than the recommended daily dose. (Correct answer)
- Take it only on an empty stomach.
- Store it in a warm environment.
- Always take it with caffeinated beverages.
Correct answer: Avoid taking more than the recommended daily dose.
Acetaminophen (Tylenol) is primarily metabolized by the liver, and exceeding the recommended daily dose can lead to severe liver damage, including acute liver failure. It is crucial for clients to understand the importance of not exceeding the maximum daily dose and to be aware of other medications that may also contain acetaminophen to prevent accidental overdose.
Question 5: The nurse is caring for a client at risk for pressure injuries. Which action is most important?
- Reposition the client at least every two hours. (Correct answer)
- Use only plastic pads under the client.
- Keep the client in the same position for comfort.
- Apply lotion every hour instead of repositioning.
Correct answer: Reposition the client at least every two hours.
Repositioning a client at least every two hours is the most critical intervention to prevent pressure injuries. This action redistributes pressure from bony prominences, allowing blood flow to return to compressed tissues and preventing prolonged ischemia that leads to skin breakdown. Consistent repositioning is a cornerstone of effective pressure injury prevention.
Question 6: A client who recently began antidepressant therapy reports increased energy but persistent sadness. What is the nurse’s priority?
- Notify the healthcare provider immediately. (Correct answer)
- Encourage the client to exercise vigorously.
- Tell the client they should feel better within hours.
- Advise the client to skip doses occasionally.
Correct answer: Notify the healthcare provider immediately.
When a client on antidepressant therapy reports increased energy but persistent sadness, it is a critical warning sign for an increased risk of suicide. Antidepressants can sometimes increase energy levels before improving mood, potentially giving a client with suicidal ideation the energy to act on those thoughts. The nurse must notify the healthcare provider immediately for urgent assessment and intervention.
Question 7: A client with diabetes asks why foot inspections are necessary. What is the nurse’s best response?
- You may not feel injuries due to decreased sensation in your feet. (Correct answer)
- Inspecting your feet prevents all infections completely.
- Foot care is optional if your blood sugar is normal.
- Walking barefoot strengthens your foot muscles.
Correct answer: You may not feel injuries due to decreased sensation in your feet.
Diabetes often causes peripheral neuropathy, which impairs nerve function and reduces sensation in the feet. This means that minor injuries like cuts, blisters, or pressure sores may go unnoticed, leading to delayed treatment, infection, and potential severe complications. Daily foot inspections are crucial for early detection and prevention of these issues.
Question 8: A client receiving IV antibiotics suddenly develops hives. What should the nurse do first?
- Stop the IV infusion immediately. (Correct answer)
- Increase the infusion rate.
- Ask the client to take deep breaths.
- Continue the infusion until symptoms worsen.
Correct answer: Stop the IV infusion immediately.
Hives (urticaria) developing during an IV antibiotic infusion are a sign of an allergic reaction, which can rapidly progress to anaphylaxis. The immediate priority is to stop the infusion to prevent further exposure to the allergen. After stopping, the nurse should assess the client for other symptoms and prepare to administer emergency medications as ordered.
Question 9: A postoperative client reports severe abdominal pain that is increasing. What should the nurse do first?
- Assess the client’s abdomen for tenderness and distention. (Correct answer)
- Offer a strong pain medication first.
- Have the client ambulate immediately.
- Ignore the pain unless vomiting occurs.
Correct answer: Assess the client’s abdomen for tenderness and distention.
Increasing severe abdominal pain postoperatively requires immediate assessment to identify the underlying cause, which could range from gas pain to serious complications like hemorrhage, peritonitis, or bowel obstruction. Assessing the abdomen for tenderness, distention, bowel sounds, and surgical site integrity provides crucial information to guide appropriate interventions and notify the healthcare provider.
NCLEX-PN Test #8
A client with hypertension reports a persistent dry cough after starting an ACE inhibitor.
What should the nurse do?