NCLEX-PN Test #4 1 — Questions and Answers
Question 1: A nurse finds an unresponsive adult client in the hallway. After confirming unresponsiveness and calling for help, the nurse should next:
- Begin rescue breathing immediately
- Check for a pulse and begin CPR if absent (Correct answer)
- Place the client in the recovery position
- Obtain the client's medication record
Correct answer: Check for a pulse and begin CPR if absent
Following the AHA chain of survival, after activating emergency response and ensuring scene safety, the nurse should check for a pulse (no more than 10 seconds). If no pulse is detected, high-quality CPR should begin immediately with 30 compressions followed by 2 breaths.
Question 2: A nurse is caring for a client who is confused and trying to climb out of bed. A wrist restraint is being considered. Which action must the nurse take before applying the restraint?
- Apply the restraint immediately to prevent falls
- Obtain a provider order and attempt less-restrictive alternatives first (Correct answer)
- Notify the charge nurse and wait for shift change
- Ask a family member for permission before consulting the provider
Correct answer: Obtain a provider order and attempt less-restrictive alternatives first
Restraints require a provider order and must only be used after all less-restrictive measures (reorientation, bed alarm, sitter, low bed) have been tried and failed. Restraints can cause injury, increased agitation, and pressure injuries. A family member's permission does not replace a provider order.
Question 3: A nurse is administering a blood transfusion. Fifteen minutes into the infusion, the client develops chills, flank pain, and dark urine. What is the nurse's immediate action?
- Slow the transfusion rate and administer diphenhydramine
- Stop the transfusion, maintain IV access with normal saline, and notify the provider (Correct answer)
- Stop the transfusion and remove the IV catheter
- Continue the transfusion and apply warm blankets for the chills
Correct answer: Stop the transfusion, maintain IV access with normal saline, and notify the provider
These are signs of an acute hemolytic transfusion reaction, the most dangerous type. The nurse must immediately stop the transfusion, keep the IV line open with normal saline (using new tubing), notify the provider and blood bank, and monitor for signs of shock and renal failure. Removing the IV would eliminate access for emergency treatment.
Question 4: A nurse is caring for a client with a chest tube for a pneumothorax. The nurse notes continuous bubbling in the water-seal chamber. Which action should the nurse take?
- Document as expected and continue monitoring
- Clamp the chest tube immediately
- Assess for an air leak by momentarily clamping the tube near the client (Correct answer)
- Increase suction to the drainage system
Correct answer: Assess for an air leak by momentarily clamping the tube near the client
Continuous bubbling in the water-seal chamber (not the suction control chamber) indicates a possible air leak. The nurse should assess the source by momentarily clamping the tube near the client — if bubbling stops, the leak is in the system; if it continues, the leak is at the insertion site or within the lung. Clamping indefinitely can cause tension pneumothorax.
Question 5: A client with a history of seizures is found having a generalized tonic-clonic seizure. Which nursing action has the highest priority?
- Insert an oral airway to prevent the tongue from obstructing the airway
- Restrain the client's arms and legs to prevent injury
- Position the client on their side and protect the head (Correct answer)
- Administer a stat dose of diazepam per standing order
Correct answer: Position the client on their side and protect the head
During a seizure, the priority is safety. The client should be turned to the lateral position (recovery position) to prevent aspiration and protect the airway. Nothing should be inserted into the mouth during an active seizure (aspiration and broken teeth risk). Restraining limbs can cause fractures. Medication is administered per order once safety is established.
Question 6: A nurse receives a SBAR report that a client who had abdominal surgery 6 hours ago has a blood pressure of 88/52 mmHg, heart rate of 122 bpm, and increasing abdominal distension. What is the priority nursing action?
- Reassess vitals in 15 minutes to confirm the trend
- Administer the PRN analgesic for abdominal pain
- Notify the provider immediately with SBAR communication (Correct answer)
- Place the client in a high-Fowler's position and increase O2
Correct answer: Notify the provider immediately with SBAR communication
The client's signs are consistent with hypovolemic shock from possible internal hemorrhage — a surgical emergency. The nurse must notify the provider immediately using SBAR communication. Waiting 15 minutes is dangerous. Pain medication could mask symptoms and worsen hypotension.
NCLEX-PN Test #4 1
A nurse finds an unresponsive adult client in the hallway.
After confirming unresponsiveness and calling for help, the nurse should next: