NCLEX-PN Test #1 Flashcards

A nurse is caring for a client with a chest tube connected to a water-seal drainage system. Which observation indicates the system is functioning properly?

Answer: Gentle tidaling in the water-seal chamber with respirations

Gentle tidaling (fluctuation) in the water-seal chamber that corresponds with respirations indicates the system is patent and functioning correctly.

A client with diabetes is experiencing diaphoresis, tremors, and confusion. The blood glucose reading is 52 mg/dL. What is the nurse's priority action?

Answer: Give 15 grams of a fast-acting carbohydrate

For a conscious client with hypoglycemia, the priority is to administer 15 grams of fast-acting carbohydrate following the rule of 15.

A practical nurse is assisting in the care of a client with a tracheostomy. Which action is essential to maintain airway patency?

Answer: Provide tracheostomy care and assess for signs of obstruction regularly

Regular tracheostomy care and assessment for obstruction are essential to maintain a patent airway and prevent complications.

A nurse is reinforcing teaching about proper use of a metered-dose inhaler (MDI) without a spacer. Which instruction is correct?

Answer: Hold the breath for 10 seconds after inhalation

After actuating the MDI and inhaling slowly, the client should hold their breath for approximately 10 seconds to allow medication to deposit in the airways.

A client is receiving total parenteral nutrition (TPN). Which complication should the nurse monitor for most carefully?

Answer: Hyperglycemia

TPN contains high concentrations of dextrose, placing the client at significant risk for hyperglycemia.

A nurse is prioritizing care for four clients at the start of a shift. Which client should the nurse assess first?

Answer: A client with pneumonia whose oxygen saturation dropped from 96% to 88%

A significant drop in oxygen saturation from 96% to 88% indicates worsening respiratory status that requires immediate assessment and intervention.