NCLEX-PN Test #1 — Questions and Answers
Question 1: A practical nurse is caring for a client who is short of breath and anxious. Which action should the nurse take first?
- Elevate the head of the bed. (Correct answer)
- Call the client's family to the bedside.
- Encourage the client to drink fluids.
- Ask the client to rate their anxiety.
Correct answer: Elevate the head of the bed.
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?
- Apical pulse of 54 beats per minute. (Correct answer)
- Blood pressure of 138/82 mm Hg.
- Respiratory rate of 20 breaths per minute.
- Temperature of 37.2 C (99 F).
Correct answer: Apical pulse of 54 beats per minute.
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?
- Increase fluid and fiber intake and walk daily as tolerated. (Correct answer)
- Avoid drinking water after taking the medication.
- Lie in bed as much as possible.
- Double the opioid dose for pain control.
Correct answer: Increase fluid and fiber intake and walk daily as tolerated.
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?
- Place the call light within easy reach and respond promptly. (Correct answer)
- Encourage the client to walk alone to maintain independence.
- Raise all side rails and leave the room.
- Keep the room lights off to promote rest.
Correct answer: Place the call light within easy reach and respond promptly.
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?
- The stoma should look moist and pink to red in color. (Correct answer)
- The stoma should be dry and gray in color.
- You should scrub the stoma firmly each day.
- Any bleeding from the stoma is always normal.
Correct answer: The stoma should look moist and pink to red in color.
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.
Question 6: The nurse is reinforcing teaching about insulin self-administration. Which statement by the client shows a correct understanding?
- I will rotate injection sites within the same area, like my abdomen. (Correct answer)
- I will use the same spot every day so it is less painful.
- I will inject only into my upper arm muscles.
- I can stop my insulin when my blood sugar feels normal.
Correct answer: I will rotate injection sites within the same area, like my abdomen.
Rotating injection sites within the same general area, such as the abdomen, is crucial for preventing lipohypertrophy (fatty lumps) or lipoatrophy (indentations) at the injection sites. These changes can impair insulin absorption and lead to unpredictable blood glucose levels. Consistent rotation ensures optimal absorption and maintains skin integrity.
Question 7: Which finding in a post-operative client should the practical nurse report to the registered nurse or provider immediately?
- A surgical dressing that is suddenly saturated with bright red blood. (Correct answer)
- Mild pain controlled with prescribed analgesics.
- Small amount of dried drainage on the old dressing.
- Temperature of 37.4 C (99.3 F).
Correct answer: A surgical dressing that is suddenly saturated with bright red blood.
A surgical dressing suddenly saturated with bright red blood indicates active hemorrhage, which is a critical and potentially life-threatening complication post-operatively. This requires immediate assessment and intervention to control bleeding and prevent hypovolemic shock. Prompt reporting to the registered nurse or provider is essential for rapid medical management.
Question 8: A client receiving an IV antibiotic develops itching and hives. What is the nurse's priority action?
- Stop the IV infusion immediately. (Correct answer)
- Document the reaction and continue the infusion.
- Tell the client this is an expected side effect.
- Ask the client to drink more fluids.
Correct answer: Stop the IV infusion immediately.
Itching and hives developing during an IV antibiotic infusion are classic signs of an allergic reaction, which can escalate to a severe anaphylactic response. The nurse's priority is to immediately stop the infusion to prevent further exposure to the allergen. This action minimizes the client's reaction and allows for prompt assessment and administration of emergency medications if needed.
Question 9: When providing care for a client in isolation for an airborne infection, which item is essential for the nurse to wear?
- An N95 respirator mask. (Correct answer)
- Only clean gloves.
- A cloth face covering.
- Regular eyeglasses.
Correct answer: An N95 respirator mask.
Airborne precautions are required for infections spread by very small airborne droplets that can remain suspended in the air for extended periods. An N95 respirator mask is specifically designed to filter out these tiny particles, providing essential respiratory protection for the nurse. Standard surgical masks do not offer adequate protection against airborne pathogens.
NCLEX-PN Test #1
A practical nurse is caring for a client who is short of breath and anxious.
Which action should the nurse take first?