NCLEX-PN Test #8

Question 1

A client with hypertension reports a persistent dry cough after starting an ACE inhibitor. What should the nurse do?

Accepted Answer

Report the symptom to the healthcare provider.

Answer

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?

Accepted Answer

Review the client’s intake and output record.

Answer

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?

Accepted Answer

Check the client’s oxygen saturation level.

Answer

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?

Accepted Answer

Avoid taking more than the recommended daily dose.

Answer

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?

Accepted Answer

Reposition the client at least every two hours.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #8