NCLEX-PN Test #9 — Questions and Answers
Question 1: The nurse notices that a client receiving IV fluids has swelling and coolness at the insertion site. What should the nurse do first?
- Stop the IV infusion immediately. (Correct answer)
- Increase the IV flow rate.
- Apply heat without assessing the site.
- Ignore the finding unless pain occurs.
Correct answer: Stop the IV infusion immediately.
Swelling and coolness at an IV insertion site are classic signs of infiltration, where the IV fluid leaks into the surrounding subcutaneous tissue. The immediate priority is to stop the infusion to prevent further fluid extravasation and tissue damage. After stopping, the nurse should remove the catheter, elevate the extremity, and apply a warm or cold compress as appropriate.
Question 2: A client newly diagnosed with heart failure asks why they need to limit sodium. What is the nurse’s best explanation?
- Sodium increases fluid retention and worsens heart failure. (Correct answer)
- Sodium decreases blood pressure drastically.
- Sodium improves muscle strength.
- Sodium prevents fatigue during activity.
Correct answer: Sodium increases fluid retention and worsens heart failure.
In heart failure, the heart's pumping ability is compromised. High sodium intake leads to increased fluid retention in the body, which elevates blood volume and places an extra burden on the already weakened heart. This increased workload can worsen heart failure symptoms like edema, shortness of breath, and fatigue. Limiting sodium helps manage fluid balance and reduce cardiac workload.
Question 3: A diabetic client reports blurred vision. What should the nurse do first?
- Check the client’s blood glucose level. (Correct answer)
- Encourage the client to take a nap.
- Provide high-sugar snacks.
- Have the client stop all diabetes medications.
Correct answer: Check the client’s blood glucose level.
Blurred vision in a diabetic client can be a symptom of both hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar), as well as other diabetic complications. Checking the blood glucose level is the immediate priority to determine the cause of the blurred vision and guide appropriate intervention, such as administering insulin or providing a fast-acting carbohydrate.
Question 4: A client prescribed a new antibiotic reports developing mild diarrhea. What should the nurse instruct the client to do?
- Increase fluid intake to prevent dehydration. (Correct answer)
- Stop taking the antibiotic immediately.
- Avoid all food until symptoms stop.
- Take double the next scheduled antibiotic dose.
Correct answer: Increase fluid intake to prevent dehydration.
Mild diarrhea is a common side effect of many antibiotics, as they can disrupt the normal gut flora. While it's important to monitor for severe diarrhea (e.g., C. difficile), mild diarrhea primarily poses a risk of dehydration and electrolyte imbalance. Increasing fluid intake helps to replace lost fluids and prevent dehydration, which is the most appropriate initial nursing instruction.
Question 5: The nurse is caring for a client experiencing nausea. Which intervention is most appropriate?
- Offer small sips of cool clear liquids. (Correct answer)
- Encourage a heavy meal to settle the stomach.
- Have the client lie completely flat.
- Provide warm milk immediately.
Correct answer: Offer small sips of cool clear liquids.
For a client experiencing nausea, offering small sips of cool, clear liquids (like water, ginger ale, or clear broth) is an appropriate intervention. These liquids are generally easier to tolerate, help prevent dehydration, and are less likely to stimulate further nausea or vomiting compared to heavy meals or warm, milky drinks.
Question 6: A client with asthma reports shortness of breath after climbing stairs. What should the nurse do first?
- Administer the client’s prescribed rescue inhaler. (Correct answer)
- Provide a glass of cold water.
- Encourage the client to lie flat.
- Ask the client to take deep, rapid breaths.
Correct answer: Administer the client’s prescribed rescue inhaler.
Shortness of breath in a client with asthma, especially after exertion, indicates an acute asthma exacerbation or bronchospasm. The immediate priority is to administer the client's prescribed rescue inhaler (e.g., a short-acting beta-agonist) to quickly open the airways and relieve respiratory distress. This is a critical, life-saving intervention to restore adequate breathing.
Question 7: The nurse reviews discharge instructions with a client who has a urinary tract infection. Which statement indicates understanding?
- I will finish all of my antibiotics even if I feel better. (Correct answer)
- I can stop the medication as soon as symptoms improve.
- I should avoid drinking water while on antibiotics.
- I will only take the antibiotics on an empty stomach.
Correct answer: I will finish all of my antibiotics even if I feel better.
This statement indicates correct understanding because completing the full course of antibiotics is essential to eradicate the infection completely. Stopping medication early, even if symptoms improve, can lead to antibiotic resistance and a recurrence of the infection, making the treatment less effective in the future.
Question 8: A postoperative client reports feeling very thirsty. What should the nurse assess first?
- Assess the client’s mucous membranes. (Correct answer)
- Provide large amounts of water immediately.
- Ignore the complaint since thirst is normal.
- Restrict all fluids until nausea stops.
Correct answer: Assess the client’s mucous membranes.
Thirst can be a symptom of dehydration, which is common post-surgery due to NPO status, fluid shifts, or blood loss. Assessing the client's mucous membranes provides a quick, non-invasive way to check for objective signs of dehydration before intervening. This allows the nurse to gather essential data to guide appropriate fluid management.
Question 9: A client taking diuretics reports muscle cramps. What should the nurse suspect?
- Possible low potassium level. (Correct answer)
- Improved kidney function.
- Dehydration from drinking too much water.
- Normal adjustment to diuretic therapy.
Correct answer: Possible low potassium level.
Diuretics, especially loop and thiazide diuretics, can cause the body to excrete potassium, leading to hypokalemia. Muscle cramps are a classic symptom of low potassium, making it the most important electrolyte imbalance to suspect and assess for in a client taking diuretics.
NCLEX-PN Test #9
The nurse notices that a client receiving IV fluids has swelling and coolness at the insertion site.
What should the nurse do first?