NCLEX-PN Test #6 1 — Questions and Answers
Question 1: A nurse is caring for a client who is receiving IV potassium chloride. Which finding requires the nurse to stop the infusion and notify the provider?
- Serum potassium level of 3.8 mEq/L
- Urine output of 35 mL/hr
- Burning sensation at the IV site with surrounding redness (Correct answer)
- Heart rate of 72 beats per minute
Correct answer: Burning sensation at the IV site with surrounding redness
Burning at the IV site with redness indicates phlebitis or extravasation. IV potassium chloride is a vesicant and can cause severe tissue damage if it infiltrates. The infusion must be stopped immediately and the provider notified. The other findings are within normal or acceptable limits.
Question 2: A client with type 1 diabetes mellitus reports feeling shaky and sweaty before lunch. The nurse checks the blood glucose and finds it is 58 mg/dL. What is the priority nursing action?
- Administer the scheduled insulin dose
- Give 15–20 grams of fast-acting carbohydrate orally (Correct answer)
- Notify the provider immediately
- Encourage the client to eat their full lunch right away
Correct answer: Give 15–20 grams of fast-acting carbohydrate orally
A blood glucose of 58 mg/dL indicates hypoglycemia. The priority is to treat it with 15–20 g of fast-acting carbohydrate (e.g., 4 oz juice or glucose tablets) if the client is conscious and able to swallow. Insulin would worsen hypoglycemia. A full meal is not the first step — rapid glucose correction is.
Question 3: The nurse is preparing to administer medications and notes that a client's apical heart rate is 52 beats per minute. The client is prescribed digoxin 0.125 mg PO daily. What should the nurse do?
- Administer the digoxin as ordered
- Hold the digoxin and notify the provider (Correct answer)
- Give half the digoxin dose and reassess in one hour
- Obtain a 12-lead ECG before administering
Correct answer: Hold the digoxin and notify the provider
Digoxin should be held if the apical heart rate is below 60 beats per minute in an adult, and the provider must be notified. Giving the medication could cause further bradycardia or toxicity. Administering a partial dose is never appropriate without a provider order.
Question 4: A nurse is caring for a postoperative client who had abdominal surgery 8 hours ago. The client reports pain rated 7/10 and has not received any analgesics. Which action is most appropriate?
- Encourage the client to use relaxation techniques and reassess in 1 hour
- Assess the client's pain further and administer the prescribed analgesic (Correct answer)
- Notify the surgeon that the client is in pain
- Reposition the client and apply a warm compress to the abdomen
Correct answer: Assess the client's pain further and administer the prescribed analgesic
Postoperative pain management is essential for recovery. The nurse should assess pain characteristics and then administer the prescribed analgesic. Delegating to non-pharmacologic methods alone is insufficient for a 7/10 pain rating. The surgeon only needs notification if pain is uncontrolled after prescribed treatment.
Question 5: A client is admitted with suspected appendicitis. The client suddenly reports that the pain has completely resolved. How should the nurse interpret this finding?
- The appendicitis has resolved without surgery
- The client may have appendix perforation, which is a medical emergency (Correct answer)
- The analgesic administered earlier is working effectively
- The client's symptoms were likely caused by gas pain
Correct answer: The client may have appendix perforation, which is a medical emergency
Sudden relief of pain in appendicitis is a serious warning sign that the appendix may have perforated. Perforation releases pressure temporarily but leads to peritonitis, a life-threatening emergency. The nurse must notify the provider immediately and prepare for urgent intervention.
Question 6: The nurse is caring for a client in Buck's traction for a fractured hip. Which action is essential in caring for this client?
- Remove the traction weights for 1 hour each shift to relieve skin pressure
- Ensure the weights hang freely and do not rest on the floor or bed (Correct answer)
- Keep the affected leg in a position of internal rotation
- Elevate the head of the bed to 90 degrees to improve alignment
Correct answer: Ensure the weights hang freely and do not rest on the floor or bed
In Buck's traction, the weights must hang freely at all times to maintain the therapeutic pulling force. If weights rest on the floor or bed, traction is ineffective. Weights should never be removed without a provider order. The head of bed is usually elevated no more than 30–45 degrees to maintain traction line.
NCLEX-PN Test #6 1
A nurse is caring for a client who is receiving IV potassium chloride.
Which finding requires the nurse to stop the infusion and notify the provider?