NCLEX-PN Test #1

Question 1

A practical nurse is caring for a client who is short of breath and anxious. Which action should the nurse take first?

Accepted Answer

Elevate the head of the bed.

Answer

Elevating the head of the bed (Fowler's position) helps to improve lung expansion and reduce the effort of breathing by allowing gravity to pull the diaphragm down. This immediate physical intervention can significantly alleviate shortness of breath and, consequently, reduce the client's anxiety related to difficulty breathing. It is a priority action for respiratory distress.

Question 2

Before administering digoxin to an adult client, which assessment finding would require the nurse to hold the medication and notify the provider?

Accepted Answer

Apical pulse of 54 beats per minute.

Answer

Digoxin is a cardiac glycoside that slows the heart rate and strengthens myocardial contractions. An apical pulse below 60 beats per minute in an adult is a common contraindication for administering digoxin, as it could lead to severe bradycardia. The nurse must hold the medication and notify the provider to prevent adverse cardiac effects.

Question 3

A client on opioid analgesics reports new constipation. Which instruction by the nurse is most appropriate?

Accepted Answer

Increase fluid and fiber intake and walk daily as tolerated.

Answer

Opioid analgesics commonly cause constipation by slowing gastrointestinal motility. Increasing fluid and fiber intake helps to soften stool and add bulk, while daily walking promotes bowel peristalsis. These non-pharmacological interventions are essential for preventing and managing opioid-induced constipation, promoting regular bowel movements, and improving client comfort.

Question 4

Which action by the practical nurse helps prevent falls in an older adult client who is unsteady when walking?

Accepted Answer

Place the call light within easy reach and respond promptly.

Answer

For an unsteady older adult, placing the call light within easy reach and responding promptly ensures that they can request assistance whenever needed, rather than attempting to get up alone. This direct intervention significantly reduces the risk of falls by providing immediate support and preventing unsupervised ambulation. It is a cornerstone of fall prevention in healthcare settings.

Question 5

A client with a new colostomy asks the nurse how to care for the stoma. Which response is most accurate?

Accepted Answer

The stoma should look moist and pink to red in color.

Answer

A healthy, viable stoma should appear moist and be pink to beefy red in color, similar to the mucous membranes inside the mouth. This indicates adequate blood supply and tissue perfusion. Any significant deviation from this appearance, such as a dry, pale, or dusky stoma, could indicate compromised circulation and requires immediate assessment.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #1