NCLEX-PN Test #9

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?

Accepted Answer

Stop the IV infusion immediately.

Answer

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?

Accepted Answer

Sodium increases fluid retention and worsens heart failure.

Answer

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?

Accepted Answer

Check the client’s blood glucose level.

Answer

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?

Accepted Answer

Increase fluid intake to prevent dehydration.

Answer

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?

Accepted Answer

Offer small sips of cool clear liquids.

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #9