NCLEX-RN Exam — Questions and Answers

Question 1: The nurse notes a client receiving oxygen has dry, cracked lips. Which action is most appropriate?

Encourage the client to breathe faster.
Apply petroleum jelly inside the nose.
Add humidification to the oxygen. (Correct answer)
Increase the oxygen flow rate.

Correct answer: Add humidification to the oxygen.

Oxygen therapy, especially at higher flow rates, can be very drying to mucous membranes, leading to dry, cracked lips and nasal passages. Adding humidification to the oxygen system helps to moisten the inspired air, preventing and alleviating dryness and discomfort for the client.

Question 2: Which communication technique demonstrates therapeutic use of silence?

Allowing the client time to reflect before responding (Correct answer)
Giving advice during quiet moments
Changing the subject when uncomfortable
Filling pauses with questions

Correct answer: Allowing the client time to reflect before responding

Therapeutic silence gives the client time to gather thoughts and reflect, signaling the nurse's willingness to listen.

Question 3: A client with preeclampsia is receiving IV magnesium sulfate. Which finding indicates magnesium toxicity?

Blood pressure of 148/92 mmHg
Respiratory rate of 10 breaths per minute (Correct answer)
Urine output of 35 mL/hour
Deep tendon reflexes (DTRs) 2+

Correct answer: Respiratory rate of 10 breaths per minute

Respiratory depression (rate < 12/min) is a sign of magnesium toxicity. Loss of deep tendon reflexes (areflexia) is the earliest sign of toxicity. Normal therapeutic monitoring includes DTRs every hour, urine output ≥25 mL/hr, and respirations ≥12/min. The antidote is calcium gluconate.

Question 4: A competent adult client with a valid advance directive refusing mechanical ventilation goes into respiratory failure. The client's daughter demands intubation. What should the nurse do?

Delay any decision until the daughter agrees with the directive
Follow the advance directive and notify the provider and ethics resources as needed (Correct answer)
Intubate the client because the family member is present and consenting
Ask the daughter to sign a new consent overriding the directive

Correct answer: Follow the advance directive and notify the provider and ethics resources as needed

A valid advance directive reflects the client's autonomous wishes and generally takes priority over family members' requests.

Question 5: Julius stresses the importance of promoting ‘esprit d corps’ among the members of the unit. Which of the following remarks of the staff indicates that they understand what he pointed out?

“We will ensure that all the resources we need are available when needed.”
“We need to put our efforts together in order to raise the bar of excellence in the care we provide to all our patients.”
“Let’s work together in harmony; we need to be supportive of one another” (Correct answer)
“In order that we achieve the same results; we must all follow the directives of Julius and not from other managers.”

Correct answer: “Let’s work together in harmony; we need to be supportive of one another”

'Esprit de corps' is a French phrase meaning 'spirit of the body,' referring to a feeling of pride, fellowship, and common loyalty shared by the members of a particular group. The remark 'Let’s work together in harmony; we need to be supportive of one another' perfectly captures this sentiment of teamwork, mutual support, and group cohesion. This fosters a positive and collaborative work environment.

Question 6: The nurse observes a client with heart failure has 2+ pitting edema in both legs. What should the nurse do first?

Obtain the client’s daily weight. (Correct answer)
Encourage the client to walk more frequently.
Provide salt-rich snacks.
Apply heat packs to both legs.

Correct answer: Obtain the client’s daily weight.

Pitting edema in a client with heart failure indicates fluid retention. Daily weights are the most accurate and objective measure of fluid balance and are crucial for monitoring the effectiveness of diuretic therapy and detecting worsening fluid overload. This assessment helps guide treatment decisions.

Question 7: A client with rheumatoid arthritis reports morning stiffness that lasts 2–3 hours. Which recommendation should the nurse make for morning stiffness management?

Rest completely until stiffness resolves before beginning any activity
Take prescribed anti-inflammatory medications and perform gentle range-of-motion exercises during morning warm-up (Correct answer)
Apply cold packs to inflamed joints before morning activities
Immobilize the affected joints with splints until stiffness resolves

Correct answer: Take prescribed anti-inflammatory medications and perform gentle range-of-motion exercises during morning warm-up

RA morning stiffness is caused by inflammatory fluid accumulation during sleep inactivity. Management includes taking medications (NSAIDs, DMARDs) as prescribed and performing gentle ROM exercises to mobilize joints and decrease stiffness. Warm showers before exercise can also help. Cold therapy and complete rest worsen stiffness.

Question 8: The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client with mania?

Apple
Diet cola
Potato chips
Milkshake (Correct answer)

Correct answer: Milkshake

Clients in a manic phase often have high energy levels, poor concentration, and may not sit long enough for a full meal, leading to inadequate nutritional intake. A milkshake is a high-calorie, nutrient-dense, and easily consumed liquid snack that provides essential energy and hydration. Its portability and minimal effort required for consumption make it ideal for someone with increased psychomotor activity.

Question 9: Which of the following is an example of a physical restraint in a healthcare setting?

A medication to calm the patient
A belt to secure a patient to a chair (Correct answer)
A verbal reminder to stay in bed
A blanket to keep the patient warm

Correct answer: A belt to secure a patient to a chair

A physical restraint is any manual method or physical or mechanical device, material, or equipment that restricts a patient's freedom of movement or access to their body. A belt used to secure a patient to a chair directly limits their ability to move freely. Verbal reminders, blankets for warmth, or medications to calm are not considered physical restraints.

Question 10: A nurse discovers a frayed cord on an IV infusion pump in use. What is the best action?

Continue using it until the shift ends
Unplug it and run the pump on battery indefinitely
Wrap the cord with electrical tape
Replace the pump, tag it as defective, and report to biomedical engineering (Correct answer)

Correct answer: Replace the pump, tag it as defective, and report to biomedical engineering

Faulty electrical equipment must be removed from service, labeled, and reported to prevent shock or fire.

Question 11: When teaching a 20-year-old male client about testicular self-examination, what timing should the nurse recommend?

Monthly, right after exercise
Weekly, first thing in the morning before getting up
Yearly, at the annual physical
Monthly, after a warm shower or bath (Correct answer)

Correct answer: Monthly, after a warm shower or bath

Warm water relaxes the scrotum, which makes it easier to feel for lumps, and the exam is done monthly.

Question 12: The nurse is monitoring a client receiving IV amphotericin B. Which adverse effect requires the most vigilant monitoring?

Peripheral neuropathy
Nephrotoxicity — rising serum creatinine and decreased urine output (Correct answer)
Alopecia
Mild infusion-site discomfort

Correct answer: Nephrotoxicity — rising serum creatinine and decreased urine output

Amphotericin B ("ampho-terrible") is highly nephrotoxic in up to 80% of patients. Monitoring includes: serum creatinine and BUN before each dose, urine output, and electrolytes (hypokalemia and hypomagnesemia are common). Pre-hydration with normal saline and liposomal formulations (AmBisome) reduce but do not eliminate nephrotoxicity.

Question 13: A client with a history of alcohol use disorder is admitted with confusion, ataxia, and ophthalmoplegia. Which intervention should the nurse anticipate?

IV thiamine (vitamin B1) administration (Correct answer)
High-protein diet initiation
Immediate CT scan of the abdomen
Administration of benzodiazepines

Correct answer: IV thiamine (vitamin B1) administration

Confusion, ataxia, and ophthalmoplegia are the classic triad of Wernicke's encephalopathy, which is treated with IV thiamine.

Question 14: A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

Overweight.
Smoking
Family history of heart disease. (Correct answer)
Age

Correct answer: Family history of heart disease.

Hereditary risk factors are those passed down through genes, making a family history of heart disease a key indicator of genetic predisposition to atherosclerosis. While age, overweight, and smoking are significant risk factors, they are considered non-hereditary or modifiable factors. A strong family history suggests an inherited susceptibility to the condition.

Question 15: After a thoracentesis, which finding should the nurse report immediately?

Sudden dyspnea and decreased breath sounds (Correct answer)
Small amount of clear drainage at the site
Relief of pressure symptoms
Mild discomfort at the puncture site

Correct answer: Sudden dyspnea and decreased breath sounds

Sudden dyspnea and diminished breath sounds may indicate a pneumothorax, a serious post-procedure complication.

Question 16: When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.

Reflects atrial muscle depolarization (Correct answer)
Reflects electrical impulse beginning at the SA node (Correct answer)
Indicated electrical impulse beginning at the AV node
Identifies ventricular muscle depolarization
Has duration of normally 0.11 seconds or less (Correct answer)

Correct answer: Reflects atrial muscle depolarization

The P wave on an ECG represents atrial depolarization, which is the electrical activation of the atria. This electrical impulse originates in the sinoatrial (SA) node, the heart's natural pacemaker, and then spreads through the atria, causing them to contract. Therefore, a normal P wave indicates that the electrical activity is starting correctly at the SA node.

Question 17: The physician has ordered a low-potassium diet for a child with acute glomerulonephritis. Which snack is suitable for the child with potassium restrictions?

Bananas
Raisins
Oranges
Apricots (Correct answer)

Correct answer: Apricots

Patients with acute glomerulonephritis often require a low-potassium diet to prevent hyperkalemia, as their kidneys may have impaired potassium excretion. Among the given options, apricots are generally lower in potassium compared to high-potassium fruits like bananas, oranges, and raisins. Therefore, apricots are a more suitable snack choice for a child on potassium restrictions.

Question 18: A patient on a psychiatric unit with bipolar disorder states, 'I am the president of the United States and I need a phone right now to call the Pentagon.' The nurse recognizes this as:

Grandiose delusion consistent with mania (Correct answer)
Confabulation
Dissociation
A hallucination

Correct answer: Grandiose delusion consistent with mania

A grandiose delusion is a fixed, false belief about having special powers, identity, or importance. Believing one is the president when not is a classic grandiose delusion seen in manic episodes.

Question 19: Which finding indicates that a client's hyperosmolar hyperglycemic state (HHS) is improving?

Increasing blood glucose to 800 mg/dL
Serum osmolality rising toward 350 mOsm/kg
Worsening skin turgor
Improving level of consciousness and normalizing serum glucose (Correct answer)

Correct answer: Improving level of consciousness and normalizing serum glucose

Improved mental status and a falling glucose level reflect successful fluid resuscitation and insulin therapy in HHS.

Question 20: Which statement by a parent shows correct understanding of car seat safety for their 18-month-old?

'My child can use a booster seat since they can sit up well.'
'My child can ride in the front seat in a car seat if the airbag is on.'
'Now that my child weighs 20 pounds, I can turn the seat forward-facing.'
'I will keep the car seat rear-facing until my child reaches the seat's maximum height or weight limit.' (Correct answer)

Correct answer: 'I will keep the car seat rear-facing until my child reaches the seat's maximum height or weight limit.'

The AAP recommends keeping children rear-facing as long as possible, until they reach the seat's maximum rear-facing height or weight limit.

Question 21: A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?

Assess the blood pressure for hypertension
Assess the dressing for drainage
Check the calcium level (Correct answer)
Obtain a crash cart

Correct answer: Check the calcium level

A total thyroidectomy removes the thyroid gland, which is anatomically close to the parathyroid glands. Damage to or accidental removal of the parathyroid glands during surgery can lead to hypoparathyroidism, resulting in decreased parathyroid hormone (PTH) production. PTH regulates calcium levels, so a decrease leads to hypocalcemia. Tingling around the mouth and in the fingers and toes (paresthesias) are classic early symptoms of hypocalcemia, making checking the calcium level the priority.

Question 22: A client is diagnosed with disseminated intravascular coagulation (DIC). Which clinical presentation is most characteristic?

Elevated platelet count with normal clotting times
Simultaneous bleeding from multiple sites and thrombosis (Correct answer)
Hypertension with no evidence of bleeding
Isolated DVT in the lower extremity only

Correct answer: Simultaneous bleeding from multiple sites and thrombosis

DIC is a paradoxical coagulopathy: widespread microvascular thrombi form, consuming clotting factors and platelets, leading to simultaneous bleeding from multiple sites (IV sites, gums, GI tract, skin). Lab findings include: low platelets, prolonged PT/aPTT, elevated d-dimer, and low fibrinogen. Treatment addresses the underlying cause.

Question 23: In the NCSBN Clinical Judgment Measurement Model, which of the following lists the cognitive layers in the correct order?

Generate solutions, recognize cues, evaluate outcomes, analyze cues
Prioritize hypotheses, recognize cues, take actions, generate solutions
Recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, evaluate outcomes (Correct answer)
Take action, analyze cues, recognize cues, evaluate outcomes

Correct answer: Recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, evaluate outcomes

The six layers are recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, and evaluate outcomes. They reflect the order in which a nurse notices, interprets, plans, acts, and reassesses.

Question 24: A postoperative client reports nausea after receiving pain medication. What should the nurse do first?

Assess the severity of the nausea. (Correct answer)
Provide a heavy meal.
Immediately stop all pain medication.
Tell the client to ignore the feeling.

Correct answer: Assess the severity of the nausea.

Nausea is a common side effect of opioid pain medications. Before taking any action, the nurse's first step is to assess the severity, onset, and characteristics of the nausea. This assessment provides crucial information to determine the most appropriate intervention, such as administering an antiemetic, adjusting the pain medication, or exploring other causes.

Question 25: The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply:

Determine whether the client has any sudden loss of vision accompanied by pain.
Have the client demonstrate the use of eye drops. (Correct answer)
Assess the client for chronic diseases such as diabetes. (Correct answer)
Discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision.
Instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved.
Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect. (Correct answer)

Correct answer: Have the client demonstrate the use of eye drops.

Certain medications, such as corticosteroids, anticholinergics, and some antidepressants, can increase intraocular pressure (IOP) and exacerbate glaucoma. Therefore, reviewing the client's current medication list is a critical nursing action to identify and potentially modify any medications that could negatively impact their glaucoma management. This helps prevent further vision loss.

Question 26: An RN delegates vital signs to an unlicensed assistive personnel (UAP). Which instruction is most important for the RN to include?

Record the vital signs at the end of the shift
Ask the client how they are feeling
Report any systolic blood pressure below 100 mm Hg right away (Correct answer)
Use the same equipment for every client

Correct answer: Report any systolic blood pressure below 100 mm Hg right away

Good delegation includes clear parameters for which findings the UAP must report right away so the RN can act.

Question 27: A client taking a diuretic reports new dizziness when standing. What should the nurse do first?

Check the client's blood pressure standing and sitting. (Correct answer)
Encourage vigorous exercise.
Provide a salty snack.
Advise drinking less water.

Correct answer: Check the client's blood pressure standing and sitting.

Diuretics can cause fluid loss, which may lead to orthostatic hypotension, characterized by dizziness upon standing due to a sudden drop in blood pressure. Checking the client's blood pressure in both sitting and standing positions helps confirm orthostatic changes. This objective data is crucial for determining if the diuretic dose needs adjustment or if other interventions are required.

Question 28: A charge nurse has a unit with four clients needing care. Which client should be assessed first?

A client with stable COPD requesting assistance to ambulate to the bathroom
A postoperative client who reports incisional pain of 4 out of 10
A client awaiting discharge instructions after an appendectomy yesterday
A client with chest pain radiating to the left arm who is diaphoretic (Correct answer)

Correct answer: A client with chest pain radiating to the left arm who is diaphoretic

Chest pain radiating to the left arm with diaphoresis suggests acute myocardial infarction — a life-threatening emergency that requires immediate assessment and intervention. Prioritization follows the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy.

Question 29: A nurse writes the following nursing diagnosis: 'Impaired physical mobility related to left hip pain as evidenced by inability to bear weight and refusal to ambulate.' Which part of this statement represents the defining characteristics?

Inability to bear weight and refusal to ambulate (Correct answer)
The entire three-part PES statement
Impaired physical mobility
Related to left hip pain

Correct answer: Inability to bear weight and refusal to ambulate

In a three-part nursing diagnosis (PES format), the Problem is the diagnosis label, the Etiology is introduced by 'related to,' and the Signs and Symptoms (defining characteristics) follow 'as evidenced by.' Defining characteristics are the observable data that validate the diagnosis.

Question 30: In which order should the nurse remove personal protective equipment after caring for a client on contact and droplet precautions?

Mask, gown, gloves, goggles
Gloves, goggles, gown, mask (Correct answer)
Gown, gloves, mask, goggles
Goggles, mask, gloves, gown

Correct answer: Gloves, goggles, gown, mask

Remove the most contaminated items first. The usual sequence is gloves, goggles or face shield, gown, then mask or respirator, followed by hand hygiene. Removing the mask before the gown and gloves risks contaminating the face and hands.

Question 31: A client with Clostridioides difficile infection needs hand hygiene performed by staff. Which method is correct after leaving the room?

Soap and water handwashing (Correct answer)
Antimicrobial wipes followed by hand rub
Hand rub only if gloves were torn
Alcohol-based hand rub for 20 seconds

Correct answer: Soap and water handwashing

Alcohol does not reliably kill C. difficile spores, so soap and water friction is required.

Question 32: A client prescribed a corticosteroid reports mood swings. What should the nurse tell the client?

Stop taking the medication immediately.
Avoid all physical activity.
Double the dose to stabilize mood.
Mood changes are a common side effect of this medication. (Correct answer)

Correct answer: Mood changes are a common side effect of this medication.

Corticosteroids are known to have various side effects, including neuropsychiatric effects such as mood swings, irritability, and anxiety. Educating the client that these mood changes are a common and expected side effect helps them understand their experience and manage expectations. This knowledge can reduce anxiety and ensure medication adherence, as abrupt cessation can be dangerous.

Question 33: A nurse is assigned to the pediatric rheumatology clinic and is assessing a child who has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

The child has a poor chance of recovery without joint deformity.
Nonsteroidal anti-inflammatory drugs are the first choice in treatment. (Correct answer)
Most children progress to adult rheumatoid arthritis.
Physical activity should be minimized.

Correct answer: Nonsteroidal anti-inflammatory drugs are the first choice in treatment.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are typically the first-line treatment for juvenile idiopathic arthritis (JIA) to manage pain and inflammation. If NSAIDs are insufficient, other medications like disease-modifying antirheumatic drugs (DMARDs) or biologics may be added. While JIA can be chronic, many children achieve remission, and physical activity is encouraged to maintain joint function, not minimized.

Question 34: What is the role of a nurse in care coordination?

To only follow the physician’s orders without patient input
To provide care to the patient without involving other professionals
To ensure the patient receives timely and appropriate care from all team members (Correct answer)
To limit patient care to only nursing interventions

Correct answer: To ensure the patient receives timely and appropriate care from all team members

Care coordination involves organizing and facilitating all aspects of a patient's care across different providers, settings, and services. The nurse acts as a central point of contact, ensuring seamless transitions, preventing fragmentation of care, and optimizing patient outcomes by integrating all necessary interventions.

Question 35: A home health nurse teaches a family about preventing lead poisoning in a toddler living in a home built in 1965. Which instruction is most important?

Sand painted walls before repainting
Allow the child to play near peeling painted surfaces only when supervised
Wet-mop floors and windowsills frequently (Correct answer)
Use hot tap water for cooking formula

Correct answer: Wet-mop floors and windowsills frequently

Wet-mopping removes lead dust without dispersing it; homes built before 1978 may contain lead paint.

Question 36: The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?

Supplemental oxygen
A tracheostomy set (Correct answer)
Intravenous access supplies
Intravenous fluid administration pump

Correct answer: A tracheostomy set

Epiglottitis is a severe inflammatory condition that can rapidly lead to complete airway obstruction due to swelling of the epiglottis. Given the high risk of sudden and complete airway closure, a tracheostomy set must be immediately available at the bedside. This ensures that an emergency airway can be established if intubation becomes impossible or unsuccessful, preventing respiratory arrest.

Question 37: Which client goal is an example of a long-term goal?

The client will cough and deep breathe every 2 hours during this shift
The client will report pain below 4/10 within 1 hour of analgesia
The client will maintain HbA1c below 7% over the next 6 months (Correct answer)
The client will demonstrate insulin self-injection before discharge tomorrow

Correct answer: The client will maintain HbA1c below 7% over the next 6 months

Long-term goals are reached over weeks to months and often continue after discharge.

Question 38: What is the main goal of the implementation phase in the nursing process?

Setting new patient goals
Carrying out the nursing interventions as planned (Correct answer)
Evaluating patient outcomes
Reassessing patient data

Correct answer: Carrying out the nursing interventions as planned

The implementation phase is the 'doing' phase of the nursing process, where the nurse puts the established care plan into action. The main goal is to carry out the specific nursing interventions that were planned to help the patient achieve their identified health goals. This involves performing direct and indirect care activities, administering medications, and educating the patient and family.

Question 39: Which of the following situations represents a nurse experiencing an ethical dilemma?

A nurse is asked to work a double shift and feels fatigued
A nurse disagrees with a physician's choice of antibiotic but administers it as ordered
A nurse is unsure of the correct dose of a medication and consults a pharmacist
A nurse must choose between honoring a patient's DNR order and responding to family pressure to resuscitate (Correct answer)

Correct answer: A nurse must choose between honoring a patient's DNR order and responding to family pressure to resuscitate

An ethical dilemma occurs when two or more ethical principles conflict, making the right course of action unclear. Choosing between a valid DNR order and family pressure creates a genuine conflict between patient autonomy and family wishes.

Question 40: Which of the following is a risk factor for falls in the elderly population?

High blood pressure
Weakness, poor balance, and environmental hazards (Correct answer)
Being overweight
Age over 50

Correct answer: Weakness, poor balance, and environmental hazards

Falls in the elderly are multifactorial, but key risk factors include physiological changes like muscle weakness and impaired balance, which affect stability and gait. Environmental hazards such as cluttered spaces or poor lighting also significantly increase the likelihood of tripping or losing footing, making these combined factors primary contributors to falls.

Question 41: Which child should NOT receive the varicella vaccine today?

A 5-year-old receiving chemotherapy for leukemia (Correct answer)
A 12-month-old with a history of egg allergy
A 4-year-old taking amoxicillin for otitis media
A 12-month-old with a mild upper respiratory infection

Correct answer: A 5-year-old receiving chemotherapy for leukemia

Varicella is a live attenuated vaccine and is contraindicated in severely immunocompromised children, such as those on chemotherapy.

Question 42: A patient is prescribed metoprolol succinate. Which condition is this medication primarily used to treat?

Pulmonary hypertension
Heart failure and hypertension (Correct answer)
Atrial fibrillation
Deep vein thrombosis

Correct answer: Heart failure and hypertension

Metoprolol succinate is a beta-1 selective blocker used to treat heart failure, hypertension, and angina by reducing heart rate and myocardial oxygen demand.

Question 43: The LPN finds an older adult client on the floor beside the bed. What is the first action?

Call the family
Complete an incident report
Assess the client for injury (Correct answer)
Help the client back into bed

Correct answer: Assess the client for injury

The client must be assessed for injury before being moved, to avoid making a fracture or head injury worse.

Question 44: A client in restraints should be assessed for circulation and skin integrity at least how often according to typical hospital policy?

Only when the client complains
Every 15 minutes to 2 hours depending on policy, with release at least every 2 hours (Correct answer)
Once per shift
Every 8 hours

Correct answer: Every 15 minutes to 2 hours depending on policy, with release at least every 2 hours

Restrained clients need frequent monitoring and restraints released at least every 2 hours for ROM, toileting, and skin care.

Question 45: Which assessment finding is a priority concern when a patient is receiving IV furosemide (Lasix) for heart failure?

Urine output of 200 mL/hour
Serum potassium of 2.8 mEq/L (Correct answer)
Blood pressure of 130/82 mmHg
Weight loss of 1 lb in 24 hours

Correct answer: Serum potassium of 2.8 mEq/L

Furosemide causes potassium loss (hypokalemia). A potassium of 2.8 mEq/L is below normal (3.5–5.0) and can cause life-threatening cardiac dysrhythmias, requiring immediate intervention.

Question 46: A client with Crohn's disease is at risk for deficiency of which vitamin due to terminal ileum involvement?

Vitamin K
Vitamin D
Vitamin B12 (Correct answer)
Vitamin C

Correct answer: Vitamin B12

Vitamin B12 (cobalamin) is absorbed exclusively in the terminal ileum. Crohn's disease commonly involves the terminal ileum, leading to impaired B12 absorption and megaloblastic anemia. Clients with extensive terminal ileum disease or surgical resection require parenteral B12 supplementation.

Question 47: Which client should the nurse place on contact precautions?

A client with Clostridioides difficile infection (Correct answer)
A client with measles
A client with influenza
A client with bacterial meningitis caused by Neisseria meningitidis

Correct answer: A client with Clostridioides difficile infection

C. difficile spreads by direct and indirect contact and its spores survive alcohol-based sanitizers. The client needs contact precautions (gown and gloves) and soap-and-water hand hygiene. Influenza and meningococcal meningitis need droplet precautions, and measles needs airborne precautions.

Question 48: During wound care, the nurse observes a sudden increase in yellow drainage. What should the nurse do first?

Document the findings and notify the provider. (Correct answer)
Ignore the drainage unless odor develops.
Remove the dressing and leave the wound exposed.
Apply ice directly to the wound.

Correct answer: Document the findings and notify the provider.

A sudden increase in yellow drainage from a wound can indicate a worsening infection or other complication. Documenting the observation provides a clear record, and notifying the provider ensures timely assessment and potential intervention, such as wound culture or antibiotic adjustment, to prevent further harm.

Question 49: Why are nonselective beta-blockers used cautiously in patients with asthma?

They cause bronchodilation
They have no respiratory effect
They can cause bronchoconstriction (Correct answer)
They raise blood glucose dangerously

Correct answer: They can cause bronchoconstriction

Beta-2 blockade can trigger bronchoconstriction in asthmatic patients.

Question 50: A patient is admitted with community-acquired pneumonia (CAP). Which findings support this diagnosis?

Clear lung fields on chest X-ray, low-grade fever, and dry cough
Productive cough, fever, pleuritic chest pain, focal infiltrate on CXR, and elevated WBC (Correct answer)
Bilateral wheezing, expiratory prolongation, and low-grade fever
Sudden onset chest pain, dyspnea, and normal chest X-ray

Correct answer: Productive cough, fever, pleuritic chest pain, focal infiltrate on CXR, and elevated WBC

Community-acquired pneumonia presents with productive cough, fever, pleuritic chest pain, lobar or focal infiltrate on chest X-ray, and leukocytosis. Auscultation reveals bronchial breath sounds, crackles, and dullness to percussion over the affected area.

Question 51: A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?

Forcing fluids
Thoroughly cooking all foods
Providing small, frequent meals (Correct answer)
Offering yogurt and buttermilk between meals

Correct answer: Providing small, frequent meals

Clients with AIDS experiencing wasting syndrome often have limited intestinal absorptive capability due to the disease process and opportunistic infections. Providing small, frequent meals helps to maximize nutrient absorption by reducing the volume of food presented to the compromised digestive system at any one time. This approach also helps maintain consistent caloric intake and reduces gastrointestinal distress.

Question 52: A nurse receives a lab result showing a client's INR is 4.8 while on warfarin therapy for atrial fibrillation. Which action is most appropriate?

Administer the next scheduled warfarin dose as ordered
Administer aspirin 81 mg to reduce clotting risk
Encourage the client to increase leafy green vegetable intake
Hold warfarin and notify the provider immediately (Correct answer)

Correct answer: Hold warfarin and notify the provider immediately

The therapeutic INR range for atrial fibrillation is 2.0–3.0. An INR of 4.8 is supratherapeutic and places the client at high risk for serious bleeding complications (intracranial hemorrhage, GI bleed). The nurse must hold the next warfarin dose and notify the provider immediately so the dose can be adjusted or reversed. Vitamin K may be ordered depending on clinical assessment.

Question 53: A nurse's initial interview and evaluation of a patient must include: (Select all that apply.)

weigh the patient using a bed scale.
evaluate the patient's emotional and spiritual needs. (Correct answer)
Take the patient's vital signs.
ensure the coordination of the patient's care (Correct answer)
Analyze the patient's psychomotor status. (Correct answer)

Correct answer: evaluate the patient's emotional and spiritual needs.

A nurse's initial interview and evaluation must encompass a holistic assessment of the patient. This includes ensuring the coordination of the patient's care, which involves planning for their ongoing needs and discharge. Analyzing the patient's psychomotor status helps assess their functional abilities and safety. Additionally, evaluating the patient's emotional and spiritual needs is crucial for providing patient-centered care and addressing all aspects of their well-being.

Question 54: A patient taking a beta-blocker reports fatigue and cold extremities. The nurse explains these are due to what?

Hyperthyroidism
Increased metabolism
Allergic reaction
Reduced cardiac output and peripheral vasoconstriction (Correct answer)

Correct answer: Reduced cardiac output and peripheral vasoconstriction

Beta-blockade reduces cardiac output and can cause cool extremities and fatigue.

Question 55: A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply.

Medication that is antagonistic to antidiuretic hormone (ADH) (Correct answer)
Radiation (Correct answer)
Increased fluid intake
Serum sodium blood levels (Correct answer)
Decreased oral sodium intake
Chemotherapy (Correct answer)

Correct answer: Medication that is antagonistic to antidiuretic hormone (ADH)

SIADH is often a paraneoplastic syndrome, meaning it's caused by the cancer itself, so treating the underlying cancer with radiation or chemotherapy is a primary intervention. Monitoring serum sodium levels is crucial as SIADH causes hyponatremia due to excessive water retention. Medications antagonistic to ADH are used to promote water excretion.

Question 56: A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse most likely observe?

Respirations that are abnormally deep, regular, and increased in rate (Correct answer)
Respirations that are labored and increased in depth and rate
Respirations that cease for several seconds
Respirations that are regular but abnormally slow

Correct answer: Respirations that are abnormally deep, regular, and increased in rate

Kussmaul's respirations are a specific type of hyperventilation characterized by abnormally deep, regular, and increased rate of breathing. This pattern is a compensatory mechanism the body uses to blow off excess carbon dioxide and reduce acidosis, commonly observed in conditions like diabetic ketoacidosis (DKA) where the body is attempting to correct metabolic acidosis.

Question 57: A patient prescribed metformin is scheduled for a CT scan with IV contrast. What is the nurse's priority action?

Double the metformin dose to prevent contrast-induced hyperglycemia
Hold the metformin on the day of the procedure and 48 hours after (Correct answer)
Administer metformin as usual and monitor blood glucose during the scan
Cancel the scan as contrast is absolutely contraindicated with metformin

Correct answer: Hold the metformin on the day of the procedure and 48 hours after

IV contrast can cause acute kidney injury, reducing metformin excretion and increasing the risk of lactic acidosis. Metformin is held before/on the day of contrast and resumed 48 hours after if kidney function is normal.

Question 58: A nurse receives a telephone prescription from a health care provider for a new medication. What is the nurse's priority action?

Write the prescription and have the provider sign it within 72 hours without reading it back
Implement the prescription and document it at the end of the shift
Read back the complete prescription to the provider for verification (Correct answer)
Ask another nurse to listen and transcribe the prescription later

Correct answer: Read back the complete prescription to the provider for verification

Read-back verification of telephone and verbal orders is a Joint Commission safety requirement to prevent errors.

Question 59: Which electrolyte imbalance most increases the risk of digoxin toxicity?

Hypernatremia
Hypermagnesemia
Hypokalemia (Correct answer)
Hypercalcemia

Correct answer: Hypokalemia

Hypokalemia (low potassium) increases the risk of digoxin toxicity because digoxin and potassium compete for the same binding sites on the Na+/K+ ATPase pump.

Question 60: In acid-base balance the normal plasma PCO2 and bicarbonate levels are disturbed. Match the changes in these parameters given below with the disorders in the drop down list. Low plasma PaCO2

Respiratory Acidosis
Respiratory Alkalosis (Correct answer)
Metabolic Acidosis
Metabolic Alkalosis

Correct answer: Respiratory Alkalosis

Low plasma PaCO2 indicates that the body is exhaling too much carbon dioxide. Since CO2 forms carbonic acid in the blood, a decrease in PaCO2 leads to a reduction in acid levels, causing the blood pH to rise. This elevation in pH due to decreased CO2 is the hallmark of respiratory alkalosis.

Question 61: A nurse is counseling a client who asks about the best methods to reduce cardiovascular disease risk. Which lifestyle modification has the strongest evidence for reducing cardiovascular risk?

Eliminating all dietary fat intake
Taking a daily low-dose aspirin
Engaging in regular aerobic exercise (Correct answer)
Consuming red wine in moderation

Correct answer: Engaging in regular aerobic exercise

Regular aerobic exercise has the strongest evidence base for reducing cardiovascular disease risk. It lowers blood pressure, improves lipid profiles, reduces body weight, and improves insulin sensitivity — all major cardiovascular risk factors.

Question 62: Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

Maintain the eye patch or shield. (Correct answer)
Monitor for hemorrhage. (Correct answer)
Educate regarding symptoms of retinal detachment. (Correct answer)
Encourage coughing and deep breathing.
Administer eye medications. (Correct answer)
Assist with activities of daily living.

Correct answer: Maintain the eye patch or shield.

Post-operative care for retinal detachment surgery focuses on protecting the eye and preventing complications. Monitoring for hemorrhage, administering prescribed eye medications, and maintaining the eye patch or shield are crucial for healing and preventing re-detachment. Educating the client on symptoms of re-detachment is also vital for early intervention if it recurs.

Question 63: Which serious adverse effect of ACE inhibitors requires immediate discontinuation and emergency care?

Mild headache
Angioedema (Correct answer)
Constipation
Dry mouth

Correct answer: Angioedema

Angioedema is a life-threatening swelling that requires stopping the drug immediately.

Question 64: During wound care, the nurse notices yellow drainage. What should the nurse do first?

Document the color, odor, and amount of drainage. (Correct answer)
Remove all dressings and leave the wound open.
Stop wound care completely.
Apply ice directly to the wound.

Correct answer: Document the color, odor, and amount of drainage.

Yellow drainage from a wound can indicate the presence of pus or slough, suggesting infection or impaired healing. The nurse's first action is to thoroughly assess and document the characteristics of the drainage, including its color, odor, and amount. This objective data is crucial for the healthcare team to determine the wound's status and guide appropriate treatment decisions.

Question 65: A breastfeeding mother reports cracked, sore nipples. What is the best nursing recommendation?

Ensure proper latch and positioning (Correct answer)
Switch to formula temporarily
Apply alcohol to harden the nipples
Limit feeding to 5 minutes per side

Correct answer: Ensure proper latch and positioning

Improper latch is the most common cause of sore nipples, so correcting positioning resolves the problem.

Question 66: The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?

Apply dressing using sterile technique
Begin proteolytic debridement
Improve the client’s nutritional status (Correct answer)
Initiate limb compression therapy

Correct answer: Improve the client’s nutritional status

Optimal nutritional status is fundamental for effective wound healing. Adequate intake of protein, vitamins (especially C and A), and minerals (like zinc) is crucial for tissue repair, collagen synthesis, and immune function. Without proper nutrition, the body lacks the essential building blocks to repair tissue, making local wound care less effective in promoting healing of a venous stasis ulcer.

Question 67: A client scheduled for surgery tells the nurse, "I'm not sure what the surgeon is going to remove." The consent form is already signed. What is the nurse's best action?

Explain the surgical procedure in detail to the client
Notify the surgeon and hold the procedure until the client's questions are answered (Correct answer)
Reassure the client that the surgeon explained everything already
Witness a new consent form with the client's signature

Correct answer: Notify the surgeon and hold the procedure until the client's questions are answered

Informed consent is the provider's responsibility, so if the client doesn't understand the procedure, the nurse must notify the surgeon before surgery goes ahead.

Question 68: What is the best method for providing comfort to a patient experiencing shortness of breath?

Encourage the patient to lie flat to improve breathing
Position the patient in a semi-Fowler’s position and provide supplemental oxygen (Correct answer)
Tell the patient to take deep breaths while in a standing position
Place the patient in a prone position and avoid oxygen therapy

Correct answer: Position the patient in a semi-Fowler’s position and provide supplemental oxygen

Shortness of breath (dyspnea) is often relieved by positioning that optimizes lung expansion and reduces diaphragmatic pressure. A semi-Fowler's position allows for easier breathing, and supplemental oxygen directly increases oxygen saturation, providing immediate relief and improving respiratory function.

Question 69: A client with a massive GI bleed is receiving multiple units of packed RBCs. Which complication should the nurse monitor for?

Hypoglycemia
Hypernatremia
Metabolic alkalosis only at the first unit
Hypocalcemia from citrate (Correct answer)

Correct answer: Hypocalcemia from citrate

Citrate in stored blood binds calcium, causing hypocalcemia during massive transfusion.

Question 70: A patient at 38 weeks gestation reports decreased fetal movement. Which instruction should the nurse provide?

Increase activity to stimulate fetal movement
Come back in one week for a scheduled visit
This is normal as the baby has less room to move
Perform a kick count; if fewer than 10 movements in 2 hours, contact the provider (Correct answer)

Correct answer: Perform a kick count; if fewer than 10 movements in 2 hours, contact the provider

Decreased fetal movement can indicate fetal distress. Kick counts should be performed: 10 movements in 2 hours is reassuring. Fewer movements warrant immediate provider notification.

Question 71: The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply:

Take ranitidine (Zantac) at hs. (Correct answer)
Increase fluid intake with meals.
Eat a bedtime snack of milk and protein.
Discuss strategies for weight loss if overweight. (Correct answer)
Decrease intake of caffeine. (Correct answer)
Elevate the HOB. (Correct answer)

Correct answer: Take ranitidine (Zantac) at hs.

Elevating the head of the bed (HOB) by 6-8 inches helps to prevent reflux of stomach acid into the esophagus by using gravity. This is a key non-pharmacological intervention for managing GERD symptoms, especially at night. Other important teaching points include dietary modifications, weight loss, and proper medication administration.

Question 72: A nurse finds an unresponsive adult client in the hallway. After confirming unresponsiveness and calling for help, the nurse should next:

Place the client in the recovery position
Check for a pulse and begin CPR if absent (Correct answer)
Begin rescue breathing immediately
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 73: A client with acute kidney injury has potassium of 6.8 mEq/L and peaked T waves. Which medication does the nurse expect to give first to protect the heart?

Calcium gluconate IV (Correct answer)
Furosemide IV
Regular insulin IV with dextrose
Sodium polystyrene sulfonate

Correct answer: Calcium gluconate IV

IV calcium gluconate stabilizes the cardiac membrane right away, though it does not lower potassium.

Question 74: A patient on continuous IV nitroglycerin infusion develops a headache. What is the appropriate nursing response?

Obtain an ECG and notify the provider
Stop the infusion immediately
Administer acetaminophen as ordered and continue monitoring (Correct answer)
Reposition the patient and increase the infusion rate

Correct answer: Administer acetaminophen as ordered and continue monitoring

Headache is the most common side effect of nitroglycerin due to cerebral vasodilation. Acetaminophen can be administered for relief while the infusion continues as prescribed.

Question 75: A nurse receives a call from a person identifying themselves as the client's employer, asking for information about the client's hospitalization. Which response is most appropriate?

Confirm the client is hospitalized but provide no further details
Decline to confirm or deny the client's presence and explain that information is confidential (Correct answer)
Provide a general condition update since the employer likely needs the information for insurance
Ask the employer to contact the client directly for information

Correct answer: Decline to confirm or deny the client's presence and explain that information is confidential

Under HIPAA, the nurse cannot confirm or deny a client's presence in the facility to unauthorized parties. Disclosing that a client is hospitalized, even without clinical details, is a violation of confidentiality.

Question 76: A nurse is assessing a newborn 1 hour after delivery. The infant is cyanotic in the hands and feet but pink in the trunk. Respiratory rate is 46 breaths/min and the infant is crying vigorously. What should the nurse document?

Respiratory distress requiring immediate intervention
Peripheral vascular insufficiency requiring warming
Central cyanosis indicating cardiopulmonary compromise
Acrocyanosis, a normal finding in a newborn (Correct answer)

Correct answer: Acrocyanosis, a normal finding in a newborn

Acrocyanosis (cyanosis of the hands and feet only) is a normal finding in the first 24–48 hours of life due to immature peripheral circulation. The trunk being pink and the newborn crying vigorously indicate adequate central oxygenation. Central cyanosis (blue trunk/lips) would be an abnormal finding requiring intervention.

Question 77: A nurse is caring for a client with schizophrenia who says, 'The television is sending me secret messages.' Which type of thought disturbance is the client experiencing?

Thought broadcasting
Delusion of grandeur
Idea of reference (Correct answer)
Hallucination

Correct answer: Idea of reference

An idea of reference is a type of delusion in which the client believes that ordinary objects, events, or media (such as television broadcasts) are specifically directed at or have special meaning for them. The television sending 'secret messages' is the classic example.

Question 78: The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm (Correct answer)
The client who arrives with a large puncture wound to the abdomen and the client with chest pain
A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis

Correct answer: The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm

In a disaster situation, clients are triaged and assigned rooms based on their acuity and potential for cross-contamination or further harm. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm are both stable enough to share a room without immediate risk of infection or critical deterioration. This pairing prioritizes safety and efficient use of limited resources during an emergency, unlike other options that involve clients with higher acuity, infectious risks, or potential for agitation.

Question 79: A nurse finds a small fire in a client's wastebasket. What is the nurse's first action?

Extinguish the fire with an extinguisher
Close all doors on the unit
Remove the client from the immediate area (Correct answer)
Activate the fire alarm

Correct answer: Remove the client from the immediate area

Using RACE, the first step is Rescue — removing clients from immediate danger.

Question 80: For which of the following research questions would qualitative methods be most appropriate?

Under what conditions does a decubitus ulcer heal most quickly?
How does frequency of medication administration impact the degree of pain experienced following knee replacement surgery?
What is the meaning of health for migrant farm-worker women? (Correct answer)
Which pain medications decrease the need for sleep medication in elderly patients?

Correct answer: What is the meaning of health for migrant farm-worker women?

Qualitative research aims to explore and understand subjective experiences, perceptions, and meanings. The question 'What is the meaning of health for migrant farm-worker women?' directly seeks to uncover the lived experiences and interpretations of a specific group, which is a hallmark of qualitative inquiry. The other options are quantitative, focusing on measurable outcomes or comparisons.

Question 81: Which nursing action reduces the risk of pressure injury in an immobile client?

Limiting fluid intake
Keeping the head of bed at 90 degrees continuously
Massaging reddened bony areas
Repositioning at least every 2 hours (Correct answer)

Correct answer: Repositioning at least every 2 hours

Frequent repositioning relieves prolonged pressure over bony prominences and prevents tissue breakdown.

Question 82: Before giving an antibiotic, which action is most important?

Check the client’s vaccination record.
Administer all other medications first.
Ask the client to fast before the dose.
Collect ordered cultures before administration. (Correct answer)

Correct answer: Collect ordered cultures before administration.

Collecting ordered cultures (e.g., blood, urine, sputum) before administering antibiotics is crucial for accurate diagnosis and effective treatment. Administering antibiotics first can alter the growth of microorganisms in the culture, leading to false-negative results or inaccurate identification of the causative pathogen. This ensures the most appropriate antibiotic is chosen for the specific infection.

Question 83: A pregnant client asks when she will first feel fetal movement (quickening). What is the nurse's best response?

Around 28 to 30 weeks
Around 16 to 20 weeks (Correct answer)
Only in the last week
Around 8 to 10 weeks

Correct answer: Around 16 to 20 weeks

Quickening, the first felt fetal movement, typically occurs between 16 and 20 weeks of gestation.

Question 84: A client receiving chemotherapy has an absolute neutrophil count (ANC) of 400/mm³. Which nursing intervention is the highest priority?

Place the client in strict protective (reverse) isolation
Monitor temperature every 4 hours and report any fever ≥38°C (100.4°F) (Correct answer)
Restrict visitors with fresh flowers and live plants
Administer prescribed prophylactic antibiotics

Correct answer: Monitor temperature every 4 hours and report any fever ≥38°C (100.4°F)

Neutropenic fever (fever ≥38°C with ANC < 500/mm³) is an oncologic emergency with high mortality risk. Fever is often the only sign of serious infection in neutropenic clients because the immune response is blunted. Immediate notification and antibiotic initiation within 1 hour are critical. Temperature monitoring is the key surveillance action.

Question 85: A client with hypertension asks why they must avoid high-sodium foods. What is the nurse’s best explanation?

Sodium reduces the effectiveness of all medications.
Sodium causes your body to retain fluid and increase blood pressure. (Correct answer)
Sodium lowers the heart rate significantly.
Sodium causes dizziness in most people.

Correct answer: Sodium causes your body to retain fluid and increase blood pressure.

Sodium causes the body to retain water, which increases the total blood volume circulating through the blood vessels. This increased volume puts more pressure on the arterial walls, leading to an elevation in blood pressure. Therefore, reducing sodium intake is a key dietary recommendation for managing hypertension.

Question 86: The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

Pink complexion
Respirations 28 shallow (Correct answer)
BP 146/88
Weight gain of 10 pounds in 6 months

Correct answer: Respirations 28 shallow

Anemia reduces the oxygen-carrying capacity of the blood, meaning less oxygen reaches the body's tissues. To compensate for this decreased oxygen delivery, the body increases the respiratory rate to try and take in more oxygen. Therefore, tachypnea (respirations 28 shallow) is a direct clinical manifestation indicative of the body's compensatory response to anemia.

Question 87: A client calls the clinic to report she missed her combined oral contraceptive pill for 2 days. What advice should the nurse provide?

Skip the missed pills and continue taking one pill per day from the current day
Take all missed pills at once and then continue the pack as usual
Take both missed pills today, take today's pill as scheduled, and use backup contraception for 7 days (Correct answer)
Stop the pack and restart when her period begins

Correct answer: Take both missed pills today, take today's pill as scheduled, and use backup contraception for 7 days

For 2 consecutive missed combined oral contraceptive pills: take the most recently missed pill as soon as remembered (even if it means 2 pills in one day), discard the earlier missed pill, continue with the rest of the pack on schedule, and use backup contraception (condom) for 7 days. The risk of ovulation increases significantly with 2+ missed pills.

Question 88: Which assessment finding is consistent with acute respiratory distress syndrome (ARDS)?

Refractory hypoxemia not improved by oxygen (Correct answer)
Hypoxemia easily corrected with low-flow oxygen
Productive cough with green sputum
Slow shallow breathing with high SpO2

Correct answer: Refractory hypoxemia not improved by oxygen

ARDS causes severe hypoxemia that does not respond to supplemental oxygen due to alveolar-capillary damage.

Question 89: After change of shift, you are assigned to care for the following patients. Which patient should you assess first?

A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab
A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
A 50-year old with asthma who complains of shortness of breath after using a bronchodilator (Correct answer)

Correct answer: A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

This patient presents with an acute change in respiratory status and a potential lack of response to a prescribed rescue medication (bronchodilator). Shortness of breath, especially after medication, indicates a worsening condition and potential airway compromise, which is a life-threatening priority. The other patients have stable or less immediately critical conditions, making the asthma patient the highest priority for immediate assessment and intervention.

Question 90: A nurse is asked to float to the pediatric unit. The nurse's usual unit is adult medical-surgical. Which action is most appropriate before beginning care?

Accept the assignment and care for any client without seeking guidance
Inform the charge nurse of the unit about your competency limitations and request appropriate client assignments (Correct answer)
Refuse the float assignment as it is outside the nurse's competency
Administer medications to pediatric clients using adult dosing guidelines

Correct answer: Inform the charge nurse of the unit about your competency limitations and request appropriate client assignments

The nurse should accept the float assignment while transparently communicating specific competency limitations to the receiving unit's charge nurse. This ensures the nurse receives appropriate assignments and support, maintaining patient safety.

Question 91: A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct.

Developmental milestones may be slightly delayed but usually will require no additional intervention.
Regular developmental screening is important to avoid secondary developmental delays. (Correct answer)
Parent support groups are helpful for sharing strategies and managing health care issues. (Correct answer)
Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties. (Correct answer)

Correct answer: Regular developmental screening is important to avoid secondary developmental delays.

Cerebral palsy (CP) results from injury to the developing brain, primarily affecting motor function, but can also lead to ocular and speech difficulties. Regular developmental screening is crucial to identify and address any secondary developmental delays early. Additionally, parent support groups are highly beneficial for sharing strategies and managing the complex healthcare needs associated with CP. Developmental milestones are typically significantly delayed and require intervention, making option C incorrect.

Question 92: You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?

The patient was recently in a motor vehicle accident (Correct answer)
The patient participated in an aerobic exercise program for 6 months
The patient was on bed rest for 6 hours after a diagnostic procedure
The patient gave birth to her youngest child 1 year ago

Correct answer: The patient was recently in a motor vehicle accident

A recent motor vehicle accident is a significant risk factor for developing a pulmonary embolus (PE). Trauma, especially with associated immobility or injury to blood vessels, can lead to the formation of deep vein thrombosis (DVT), which can then dislodge and travel to the lungs, causing a PE. The other options are either not direct risk factors or are less significant in comparison.

Question 93: A client's last menstrual period began on June 10. Using Nägele's rule, what is the estimated date of birth?

April 17
February 17
March 3
March 17 (Correct answer)

Correct answer: March 17

Nägele's rule subtracts 3 months and adds 7 days to the first day of the LMP, so June 10 becomes March 17.

Question 94: A client is prescribed a new medication. Which pair of identifiers is acceptable before administration?

Client name and date of birth (Correct answer)
Diagnosis and date of birth
Room number and client name
Bed number and wristband color

Correct answer: Client name and date of birth

The Joint Commission requires two client-specific identifiers such as name and date of birth; room numbers are never acceptable.

Question 95: A client with suspected myocardial infarction has troponin I drawn at ED arrival. Which finding most supports the diagnosis 6 hours later?

CK-MB alone is elevated with normal troponin
Troponin I has risen to 2.8 ng/mL (significantly elevated) (Correct answer)
D-dimer is elevated, suggesting PE as the alternate diagnosis
Troponin I remains at baseline (< 0.04 ng/mL)

Correct answer: Troponin I has risen to 2.8 ng/mL (significantly elevated)

Troponin I rises 3–6 hours after myocardial injury and peaks at 12–24 hours. An elevated troponin at 6 hours with a normal baseline effectively rules in myocardial infarction (sensitivity approaches 99% with serial troponins). Two serial troponins (0 and 3–6 hours) using high-sensitivity assays can rule in or out NSTEMI rapidly.

Question 96: What is the nurse's role in managing patient care transitions?

Allowing the patient to manage their care independently after discharge
Ensuring clear communication and proper documentation during the transition (Correct answer)
Providing care only until the patient is discharged
Delegating the entire responsibility of transition to the next healthcare team

Correct answer: Ensuring clear communication and proper documentation during the transition

Patient care transitions, such as discharge or transfer, are high-risk periods for adverse events. The nurse's role is crucial in ensuring that all relevant patient information, care plans, and instructions are clearly communicated and thoroughly documented to the receiving care team or the patient/family, promoting continuity and safety.

Question 97: How should a patient store sublingual nitroglycerin tablets to maintain potency?

In a daily pill organizer
In the original dark glass bottle, away from light and heat (Correct answer)
In a plastic bag in a pocket
In the refrigerator door

Correct answer: In the original dark glass bottle, away from light and heat

Nitroglycerin degrades with light and heat, so the dark glass container preserves potency.

Question 98: A nurse is working with a client who has borderline personality disorder (BPD). Which nursing approach is most effective for managing care?

Adapting rules and boundaries when the client becomes upset to prevent escalation
Assigning a different nurse each shift to prevent unhealthy attachment
Maintaining consistent boundaries and clear therapeutic limit-setting (Correct answer)
Providing the client with maximum autonomy to avoid power struggles

Correct answer: Maintaining consistent boundaries and clear therapeutic limit-setting

Consistent boundaries and therapeutic limit-setting are essential in caring for clients with BPD. Inconsistency reinforces splitting behavior and manipulative patterns. Consistency across all staff reduces boundary violations and promotes a therapeutic environment.

Question 99: Which statement reflects appropriate boundaries in the nurse-client therapeutic relationship?

The nurse keeps the focus on the client's needs and goals (Correct answer)
The nurse accepts gifts to build rapport
The nurse discusses personal problems to relate
The nurse shares personal phone numbers for after-hours contact

Correct answer: The nurse keeps the focus on the client's needs and goals

A therapeutic relationship is goal-directed and centered on the client's needs, with clear professional boundaries.

Question 100: A nurse is educating parents of a child diagnosed with type 1 diabetes about sick day management. Which instruction is most important?

Give only half the usual insulin dose during illness
Continue insulin, check blood glucose every 1–2 hours, and check urine/blood ketones (Correct answer)
Hold insulin if the child is not eating to prevent hypoglycemia
Only administer insulin if blood glucose exceeds 400 mg/dL

Correct answer: Continue insulin, check blood glucose every 1–2 hours, and check urine/blood ketones

Illness triggers stress hormones that raise blood glucose and ketone production. Insulin should NEVER be withheld during illness — the child needs insulin plus additional monitoring for hypoglycemia and DKA prevention.

Question 101: A 10-year-old has an order for Demerol (meperidine) 35 mg IM for pain. The medication is available as Demerol 50mg per ml. How much should the nurse administer?

0.6mL
0.7mL (Correct answer)
0.5mL
0.8mL

Correct answer: 0.7mL

To calculate the correct dosage, use the formula: (Desired Dose / Available Dose) x Volume. In this case, (35 mg / 50 mg) x 1 mL = 0.7 mL. Therefore, the nurse should administer 0.7 mL of Demerol.

Question 102: Which of the following interventions is essential in the management of a care team?

Assigning tasks without assessing team capabilities
Delegating tasks without discussing care goals
Fostering open communication and collaboration among team members (Correct answer)
Avoiding discussions about patient care plans

Correct answer: Fostering open communication and collaboration among team members

Effective team management relies on clear and consistent communication to ensure everyone is informed about patient status, care plans, and responsibilities. Collaboration allows team members to work together efficiently, share expertise, and address challenges, ultimately leading to better patient care.

Question 103: A nurse is preparing to administer insulin. The physician order reads: Regular insulin 10 units subcutaneously and NPH insulin 20 units subcutaneously. How should the nurse prepare this combined dose?

Administer each insulin in a separate syringe at separate sites
Draw up NPH first, then regular insulin into the same syringe
Mix both insulins in a vial and draw from the mixed vial
Draw up regular insulin first, then NPH insulin into the same syringe (Correct answer)

Correct answer: Draw up regular insulin first, then NPH insulin into the same syringe

When mixing regular and NPH insulin, the nurse draws regular (clear) insulin first, then NPH (cloudy) insulin. The mnemonic 'Clear before Cloudy' helps remember this sequence. Drawing regular insulin first prevents contamination with NPH.

Question 104: A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

Anticipatory grieving related to terminal illness
Fatigue related to chemotherapy
Sexual dysfunction related to radiation therapy (Correct answer)
Tissue integrity related to prolonged bed rest

Correct answer: Sexual dysfunction related to radiation therapy

For a 21-year-old male who is engaged and planning a future, the potential for sexual dysfunction due to radiation therapy is a significant concern that impacts his future life plans and identity. Radiation can affect fertility and sexual function, making this a priority diagnosis. Addressing these long-term impacts on his reproductive health and relationships is crucial for a young adult facing these life transitions.

Question 105: Which practice by a nursing assistant requires the nurse to intervene regarding fall prevention?

Raising all four side rails on a confused client (Correct answer)
Keeping the call light within the client's reach
Ensuring the client wears nonskid socks
Placing the bed in the lowest position

Correct answer: Raising all four side rails on a confused client

Four raised side rails are considered a restraint and increase fall injury risk when confused clients climb over them.

Question 106: The nurse is caring for a client with stage III Alzheimer’s disease. A characteristic of this stage is:

Failing to recognize familiar objects (Correct answer)
Failing to communicate
Wandering at night
Memory loss

Correct answer: Failing to recognize familiar objects

Stage III (moderate) Alzheimer's disease is characterized by more pronounced cognitive deficits, including agnosia, which is the inability to recognize familiar objects, people, or sounds despite intact sensory function. While memory loss is present in earlier stages and communication difficulties and wandering occur in later stages, agnosia is a hallmark of the moderate stage.

Question 107: What is the therapeutic serum range for digoxin?

0.05–0.1 ng/mL
10–20 ng/mL
0.5–2.0 ng/mL (Correct answer)
5–10 ng/mL

Correct answer: 0.5–2.0 ng/mL

The therapeutic digoxin level is 0.5 to 2.0 ng/mL.

Question 108: A client with heart failure is prescribed furosemide. Which finding should the LPN report promptly?

Weight loss of 1 lb (0.45 kg) since yesterday
Increased urine output
Decreased ankle edema
Serum potassium of 3.1 mEq/L (Correct answer)

Correct answer: Serum potassium of 3.1 mEq/L

Furosemide is a loop diuretic that causes potassium loss, and hypokalemia increases the risk of dysrhythmias.

Question 109: A client with anxiety begins rapid, shallow breathing. What is the nurse’s first action?

Encourage slow, deep breathing. (Correct answer)
Encourage the client to breathe faster.
Place the client completely flat.
Offer caffeinated beverages.

Correct answer: Encourage slow, deep breathing.

Rapid, shallow breathing during anxiety can lead to hyperventilation, causing a decrease in carbon dioxide levels and potentially respiratory alkalosis. Encouraging slow, deep breathing helps to normalize CO2 levels, calm the client, and alleviate symptoms like dizziness or tingling. This intervention directly addresses the physiological response to anxiety.

Question 110: A nurse finds a frayed electrical cord on an IV pump. What is the priority action?

Tape over the frayed area
Remove it from service and report it (Correct answer)
Continue using it carefully
Wait until the shift ends

Correct answer: Remove it from service and report it

Damaged equipment poses a hazard and must be removed from use and reported.

Question 111: In what order should the nurse remove PPE after caring for a client on contact plus droplet precautions?

Gown, gloves, goggles, mask
Mask, goggles, gown, gloves
Gloves, goggles, gown, mask (Correct answer)
Goggles, mask, gloves, gown

Correct answer: Gloves, goggles, gown, mask

CDC sequence for doffing is gloves, goggles/face shield, gown, then mask or respirator, because gloves are the most contaminated.

Question 112: What is a characteristic of metasynthesis?

It synthesizes critical masses of qualitative findings. (Correct answer)
It leads to a higher reliability of research findings.
It cannot be conducted on historical or case study findings.
It is useful for triangulating research.

Correct answer: It synthesizes critical masses of qualitative findings.

Metasynthesis is a systematic and rigorous approach to integrating and interpreting findings from multiple qualitative studies on a particular phenomenon. Its purpose is to create new, broader understandings and interpretations that go beyond the individual findings of each study. This process provides a more comprehensive and nuanced perspective on the topic by synthesizing a critical mass of qualitative evidence.

Question 113: You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?

Hyperoxygenate the patient before suctioning
Maintain the head of the bed at a 30 – to 45-degree angle (Correct answer)
Administer ordered antibiotics as scheduled
Suction the airway when coarse crackles are audible

Correct answer: Maintain the head of the bed at a 30 – to 45-degree angle

Maintaining the head of the bed at a 30- to 45-degree angle is a critical intervention to prevent ventilator-associated pneumonia (VAP). This semi-Fowler's position helps reduce the risk of aspiration of gastric contents and oral secretions into the lungs, which are common pathways for bacterial entry and subsequent infection in mechanically ventilated patients. It is a fundamental component of VAP prevention bundles.

Question 114: A client with a chest tube connected to a water-seal drainage system has continuous bubbling in the water-seal chamber. What does this finding most likely indicate?

Normal functioning of the system
Kinking of the drainage tubing
An air leak in the system (Correct answer)
Resolution of the pneumothorax

Correct answer: An air leak in the system

Continuous bubbling in the water-seal chamber indicates an air leak, while intermittent bubbling with respiration can be expected.

Question 115: A client with hypothyroidism reports feeling unusually cold. Which explanation should the nurse provide?

It indicates dehydration and low fluid intake.
It indicates the thyroid medication is working too quickly.
Cold intolerance is expected due to a slowed metabolism. (Correct answer)
It means the client should stop all medications.

Correct answer: Cold intolerance is expected due to a slowed metabolism.

Hypothyroidism is characterized by an underactive thyroid gland, which leads to a decreased metabolic rate throughout the body. A slowed metabolism results in reduced heat production, making individuals with hypothyroidism more sensitive to cold temperatures and causing cold intolerance. This is a classic and expected symptom of the condition, helping the client understand their experience.

Question 116: A nurse is assessing a client with chronic kidney disease. Which laboratory value would the nurse expect to be elevated?

Glomerular filtration rate
Hemoglobin
Serum creatinine (Correct answer)
Serum albumin

Correct answer: Serum creatinine

In chronic kidney disease, the kidneys lose their ability to filter waste products, causing serum creatinine to accumulate and rise above normal levels. GFR decreases, not increases, and hemoglobin and albumin typically fall.

Question 117: A client newly diagnosed with type 2 diabetes asks about metformin. Which point should the nurse emphasize?

It should be taken on an empty stomach for best effect
It is given by subcutaneous injection
It must be held before contrast dye imaging procedures (Correct answer)
It commonly causes hypoglycemia when taken alone

Correct answer: It must be held before contrast dye imaging procedures

Metformin is held before and after iodinated contrast studies because of the risk of contrast-induced renal impairment and lactic acidosis.

Question 118: A nurse is caring for a client who speaks limited English and requires teaching about a new diagnosis. Which action best promotes safe, effective client education?

Ask the client's family member to interpret during the teaching session
Use a qualified medical interpreter for the teaching session (Correct answer)
Provide written materials in English and have the client review them independently
Speak loudly and slowly and use simple English words

Correct answer: Use a qualified medical interpreter for the teaching session

Using a qualified medical interpreter (in person or via telephone/video) is the standard of care for clients with limited English proficiency. Family members and friends should NOT be used as interpreters because they may omit, change, or misinterpret medical information — compromising client safety and confidentiality. Federal law (Title VI of the Civil Rights Act) requires healthcare facilities to provide language assistance services.

Question 119: A patient prescribed haloperidol (Haldol) develops muscle rigidity, hyperthermia (103°F), diaphoresis, and altered consciousness. What condition does this represent?

Extrapyramidal side effect (EPS)
Neuroleptic malignant syndrome (NMS) (Correct answer)
Serotonin syndrome
Tardive dyskinesia

Correct answer: Neuroleptic malignant syndrome (NMS)

Neuroleptic Malignant Syndrome (NMS) is a rare but potentially fatal reaction to antipsychotics, characterized by the tetrad: hyperthermia, muscle rigidity, altered consciousness, and autonomic instability.

Question 120: A nurse is teaching a group of older adults about fall prevention at home. Which instruction is most important?

Install grab bars in the bathroom and remove loose rugs throughout the home (Correct answer)
Wear socks without shoes indoors to protect floors
Avoid physical activity to prevent exertion-related falls
Limit fluid intake after 6 PM to reduce nighttime bathroom trips

Correct answer: Install grab bars in the bathroom and remove loose rugs throughout the home

Environmental modifications are one of the most effective fall prevention strategies. Grab bars in bathrooms provide stability during transfers, and removing loose rugs eliminates a common tripping hazard. Exercise programs that improve balance and strength are also strongly recommended.

Question 121: A nurse is caring for a client in seclusion who is calm and cooperative. Which statement reflects correct practice regarding restraints?

Restraints are used only when less restrictive measures have failed, and they require a prescriber order with frequent monitoring (Correct answer)
Restraints are acceptable as a substitute for staffing shortages
Restraints can be applied by nursing judgment and a prescriber order is needed only within 24 hours
Restraints can be left on indefinitely if the client is sleeping

Correct answer: Restraints are used only when less restrictive measures have failed, and they require a prescriber order with frequent monitoring

Restraints are a last resort. They require an order, a documented reason, frequent monitoring and assessment of circulation, skin, and needs, and prompt removal once the reason no longer applies. In an emergency the nurse may apply them and obtain the order immediately afterward. Restraints cannot be used for staff convenience.

Question 122: A client in hypovolemic shock is most likely to present with which set of findings?

Bradycardia and warm, flushed skin
Hypertension and bounding pulse
Fever and wide pulse pressure
Tachycardia, hypotension, and cool, pale skin (Correct answer)

Correct answer: Tachycardia, hypotension, and cool, pale skin

Hypovolemia triggers sympathetic compensation with rapid heart rate and vasoconstriction, causing cool, pale skin while blood pressure falls. Warm flushed skin suggests distributive shock.

Question 123: A nurse is assessing a newborn at 5 minutes of life and assigns an Apgar score. Which finding would contribute to a lower score?

Blue hands and feet only
No response to stimulation (Correct answer)
Vigorous cry
Heart rate of 110 beats per minute

Correct answer: No response to stimulation

The Apgar score evaluates heart rate, respiratory effort, muscle tone, reflex irritability, and color. No response to stimulation scores 0 for reflex irritability, which lowers the total score. Blue hands and feet (acrocyanosis) score 1, while a heart rate above 100 and vigorous cry each score 2.

NCLEX-RN Exam

The NCLEX-RN exam certifies entry-level registered nurses, assessing their competency to provide safe and effective patient care.

Questions

300 min

Time Limit

50%

To Pass

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These practice questions were written with AI tools. They are not real exam questions. Exam facts are checked against the official sources listed below. Not reviewed by a subject-matter expert. Editorial policy

Sources & references

Exam facts on this page (fees, format, dates, passing scores) are checked against these official sources; the date is our last check. Editorial policy

nclex.com — Test delivery, score release, passing score, retake fee, score validity, registration deadline, exam format, fees, exam information · verified Oct 2026
ncsbn.zendesk.com — Eligibility, retake policy, test dates · verified Oct 2026