NACE I PN-RN: Foundations of Nursing Exam — Questions and Answers

Question 1: A nurse is preparing to assist with a thoracentesis for a client with a large pleural effusion. To reduce the risk of puncturing the lung, which position should the nurse assist the client into?

Lying flat in a supine position.
In Trendelenburg position.
Seated on the edge of the bed, leaning forward over a bedside table. (Correct answer)
In a side-lying position with the affected side up.

Correct answer: Seated on the edge of the bed, leaning forward over a bedside table.

The upright position, with the client seated and leaning forward over a bedside table, widens the intercostal spaces and allows fluid to accumulate at the base of the lung due to gravity. This positioning makes needle insertion easier and safer, moving the lung tissue up and away from the insertion site, thereby reducing the risk of a pneumothorax.

Question 2: A client with a new colostomy refuses to look at the stoma and says, 'I'm disgusting.' Which nursing diagnosis is the priority?

Risk for infection
Disturbed body image (Correct answer)
Deficient knowledge
Impaired skin integrity

Correct answer: Disturbed body image

Refusal to look at the stoma and negative self-statements indicate disturbed body image as the priority psychosocial diagnosis.

Question 3: A client's morning blood glucose is 52 mg/dL and they are conscious and able to swallow. What is the nurse's first action?

Hold the morning insulin and reassess in one hour
Give 15–20 grams of fast-acting carbohydrates orally (Correct answer)
Notify the physician immediately before intervening
Administer 50% dextrose IV push

Correct answer: Give 15–20 grams of fast-acting carbohydrates orally

The '15-15 rule' directs the nurse to give 15–20 g of fast-acting carbohydrates orally to a conscious hypoglycemic client first.

Question 4: A patient who is immobile is at risk for developing deep vein thrombosis (DVT). Which nursing intervention helps prevent this complication?

Keeping the patient in a flat supine position
Restricting leg movement
Elevating the head of the bed to 90 degrees
Applying sequential compression devices (Correct answer)

Correct answer: Applying sequential compression devices

Sequential compression devices (SCDs) promote venous return by intermittently compressing the legs, reducing blood stasis that leads to DVT formation.

Question 5: A nurse uses a therapeutic communication technique when responding to an anxious client. Which response demonstrates the technique of 'focusing'?

'Tell me everything that happened today.'
'Let's talk specifically about what triggered your anxiety this morning.' (Correct answer)
'How does that make you feel?'
'I understand exactly how you feel.'

Correct answer: 'Let's talk specifically about what triggered your anxiety this morning.'

Focusing directs the conversation to a specific topic, helping the client explore a particular concern in depth.

Question 6: A patient in the emergency department is displaying aggressive behavior and threatening staff. Which de-escalation technique should the nurse try first?

Apply physical restraints immediately
Request security to remove the patient from the department
Speak in a calm, low tone and offer the patient choices (Correct answer)
Administer PRN sedation medication

Correct answer: Speak in a calm, low tone and offer the patient choices

Verbal de-escalation using a calm tone, non-threatening body language, and offering choices gives the patient a sense of control and is the least restrictive intervention.

Question 7: Which type of isolation precaution is required for a patient diagnosed with tuberculosis?

Standard precautions only
Contact precautions
Droplet precautions
Airborne precautions (Correct answer)

Correct answer: Airborne precautions

Tuberculosis is transmitted via airborne droplet nuclei that remain suspended in the air, requiring airborne precautions including an N95 respirator and negative pressure room.

Question 8: A nurse is caring for a client who is verbally refusing a prescribed antipsychotic medication. The nurse proceeds to crush the medication, mix it in applesauce, and administer it to the client without their knowledge. This action constitutes which of the following intentional torts?

Assault
Malpractice
Negligence
Battery (Correct answer)

Correct answer: Battery

Battery is the intentional and wrongful physical contact with a person without their consent. Administering medication to a competent client who has refused it, especially through concealment, is a form of unwanted touching and a violation of the client's right to autonomy. Assault is the threat of harmful contact, while negligence and malpractice are unintentional torts related to failing to meet the standard of care.

Question 9: According to Erikson's theory, which developmental task is the primary focus for adolescents?

Trust versus mistrust
Intimacy versus isolation
Industry versus inferiority
Identity versus role confusion (Correct answer)

Correct answer: Identity versus role confusion

Erikson identified identity versus role confusion as the central developmental task of adolescence (ages 12-18), where teens develop a sense of personal identity.

Question 10: A nurse is caring for a patient experiencing status epilepticus. Which intervention takes priority?

Obtaining a detailed neurological history from family members
Restraining the patient's extremities to prevent injury
Placing a padded tongue blade in the mouth
Maintaining a patent airway and administering IV benzodiazepine (Correct answer)

Correct answer: Maintaining a patent airway and administering IV benzodiazepine

Status epilepticus is a medical emergency requiring immediate airway management and IV benzodiazepine (typically lorazepam) to terminate the continuous seizure activity.

Question 11: A client who was just informed of a terminal diagnosis begins yelling at the nurse, 'This is your fault! You didn't push for more tests!' The nurse recognizes this response as:

Rational frustration that requires an apology from the nurse
Manipulative behavior that should be confronted directly
Displacement of anger as part of the grief process (Correct answer)
A sign of acute psychosis requiring immediate intervention

Correct answer: Displacement of anger as part of the grief process

Displacement of anger onto the nurse is a normal and expected part of the anger stage of grief following a devastating diagnosis.

Question 12: A patient receiving IV vancomycin develops flushing of the face, neck, and upper body. What is the nurse's priority action?

Stop the infusion permanently and notify the provider
Administer epinephrine for anaphylaxis
Apply cold compresses to the flushed areas
Slow the infusion rate (Correct answer)

Correct answer: Slow the infusion rate

This presentation is consistent with Red Man Syndrome, a histamine-mediated reaction to rapid vancomycin infusion. Slowing the infusion rate typically resolves the symptoms.

Question 13: A nurse is assessing a 3-year-old who insists on doing tasks 'by myself.' According to Erikson, this behavior reflects which developmental stage?

Trust vs. mistrust
Initiative vs. guilt
Autonomy vs. shame and doubt (Correct answer)
Industry vs. inferiority

Correct answer: Autonomy vs. shame and doubt

Autonomy vs. shame and doubt occurs from ages 1–3 and is characterized by the toddler's drive for independence.

Question 14: A nurse is preparing to administer a continuous intravenous infusion of heparin. Which of the following laboratory values is essential for the nurse to review immediately before initiating the infusion?

Hemoglobin and Hematocrit
International Normalized Ratio (INR)
Activated Partial Thromboplastin Time (aPTT) (Correct answer)
Prothrombin Time (PT)

Correct answer: Activated Partial Thromboplastin Time (aPTT)

The therapeutic effect of a continuous unfractionated heparin (UFH) infusion is monitored by the aPTT. The nurse must know the baseline aPTT and the desired therapeutic range before starting the infusion to ensure patient safety and effective anticoagulation. PT and INR are used to monitor warfarin therapy. While hemoglobin and hematocrit are important to monitor for bleeding, the aPTT is the primary lab value used for titrating the heparin infusion.

Question 15: A nurse is caring for a patient with Clostridioides difficile (C. diff) infection. Which personal protective equipment (PPE) is essential when entering the room?

Gown, gloves, and surgical mask
N95 respirator and eye protection
Gown and gloves only (Correct answer)
Surgical mask and gloves

Correct answer: Gown and gloves only

C. diff is transmitted via contact, so a gown and gloves are required; a mask is not routinely needed unless splashing is anticipated.

Question 16: A PN is supervising a UAP who reports that a patient's blood pressure is 88/52 mmHg. What is the nurse's best initial action?

Ask the UAP to recheck the blood pressure in 15 minutes
Instruct the UAP to place the patient in Trendelenburg position immediately
Call the physician with the reported value right away
Go to the patient's bedside immediately to perform an assessment (Correct answer)

Correct answer: Go to the patient's bedside immediately to perform an assessment

The nurse must personally assess the patient to verify the finding and determine clinical status before notifying the physician or intervening.

Question 17: Which developmental milestone is expected in a healthy 12-month-old child?

Riding a tricycle
Running without falling
Jumping with both feet
Walking with assistance or independently (Correct answer)

Correct answer: Walking with assistance or independently

Most children begin walking with assistance or independently around 12 months of age as a normal gross motor developmental milestone.

Question 18: Which position is most appropriate for a patient experiencing difficulty breathing?

Prone position
Supine with legs elevated
Left lateral recumbent
High Fowler's position (Correct answer)

Correct answer: High Fowler's position

High Fowler's position (60-90 degrees) promotes maximum lung expansion by allowing the diaphragm to descend fully, reducing the work of breathing.

Question 19: A nurse is reviewing the laboratory results for a client receiving warfarin therapy. The client's International Normalized Ratio (INR) is 4.5. Which action should the nurse take first?

Hold the next dose of warfarin and notify the healthcare provider. (Correct answer)
Document the finding as within the therapeutic range.
Administer the next scheduled dose of warfarin.
Prepare to administer protamine sulfate.

Correct answer: Hold the next dose of warfarin and notify the healthcare provider.

An INR of 4.5 is critically high, placing the client at a significant risk for bleeding. The therapeutic range for most conditions is 2.0 to 3.0. The nurse's first priority is to hold the medication to prevent further elevation of the INR and immediately notify the healthcare provider, who will provide orders, which may include administering the antidote, Vitamin K.

Question 20: A patient with limited English proficiency needs to sign a consent form for a procedure. Which action by the nurse is most appropriate?

Obtain consent from the next of kin since the patient cannot fully understand
Use a professional medical interpreter to explain the consent form to the patient (Correct answer)
Proceed with the procedure using simple words and gestures to explain
Have the patient's bilingual family member interpret the consent form

Correct answer: Use a professional medical interpreter to explain the consent form to the patient

A professional medical interpreter must be used to ensure accurate communication and protect the patient's right to informed consent.

Question 21: A nurse is administering a hypotonic IV solution. Which physiologic effect should be anticipated?

Increased serum osmolality
Fluid shifts from the vascular space into cells (Correct answer)
No change in cellular fluid volume
Fluid shifts from cells into the vascular space

Correct answer: Fluid shifts from the vascular space into cells

Hypotonic solutions have lower osmolality than plasma, causing water to move by osmosis from the vascular space into cells, expanding intracellular volume and potentially causing cellular swelling.

Question 22: A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). The nurse notes that the client is breathing very deeply and rapidly. The nurse recognizes this respiratory pattern, Kussmaul respirations, as the body's attempt to compensate for which acid-base imbalance?

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

Correct answer: Metabolic Acidosis

Diabetic ketoacidosis leads to an accumulation of ketones, which are acidic, causing metabolic acidosis. The respiratory system compensates by increasing the rate and depth of breathing (Kussmaul respirations) to exhale more carbon dioxide (an acid), thereby attempting to raise the blood pH back toward normal.

Question 23: A nurse notes that a patient's peripheral oxygen saturation (SpO2) reads 85%. What is the priority nursing intervention?

Remove the pulse oximeter and obtain an arterial blood gas
Apply supplemental oxygen and assess the patient (Correct answer)
Elevate the head of the bed and encourage coughing
Document the finding and recheck in one hour

Correct answer: Apply supplemental oxygen and assess the patient

An SpO2 of 85% indicates significant hypoxemia requiring immediate oxygen supplementation and assessment of the patient's respiratory status.

Question 24: A nurse is caring for a client who is visually impaired. Which approach is MOST appropriate when assisting with ambulation?

Allow the client to hold the nurse's elbow and walk slightly behind (Correct answer)
Walk slightly behind the client and place hands on their shoulders
Walk slightly ahead and guide the client by the wrist
Walk beside the client and describe the environment verbally only

Correct answer: Allow the client to hold the nurse's elbow and walk slightly behind

The sighted-guide technique has the client hold the guide's elbow and walk a half-step behind, providing safe and dignified navigation.

Question 25: A nurse has finished providing care for a client on contact and droplet precautions. To minimize the risk of self-contamination, which of the following represents the correct sequence for removing (doffing) personal protective equipment (PPE)?

Goggles/face shield, gloves, mask/respirator, gown
Gloves, goggles/face shield, gown, mask/respirator (Correct answer)
Gown, mask/respirator, goggles/face shield, gloves
Mask/respirator, gown, gloves, goggles/face shield

Correct answer: Gloves, goggles/face shield, gown, mask/respirator

According to CDC guidelines, the most contaminated items should be removed first. The standard sequence is to remove gloves, followed by goggles or a face shield, then the gown, and finally the mask or respirator. Hand hygiene should be performed after removing all PPE.

Question 26: Which action by the nurse BEST promotes sleep hygiene for a hospitalized client?

Keep room lighting at a low level throughout the night
Cluster nursing care activities to minimize nighttime interruptions (Correct answer)
Administer a sedative hypnotic at bedtime routinely
Encourage the client to nap during the day to rest

Correct answer: Cluster nursing care activities to minimize nighttime interruptions

Clustering care reduces unnecessary awakenings, which is a key non-pharmacological strategy to promote sleep in hospitalized clients.

Question 27: A competent adult patient refuses a blood transfusion on religious grounds despite a life-threatening hemorrhage. The nurse should:

Contact the ethics committee to override the decision
Administer the transfusion to save the patient's life
Respect the refusal and document it, ensuring the patient understands the consequences (Correct answer)
Obtain a court order to proceed with treatment

Correct answer: Respect the refusal and document it, ensuring the patient understands the consequences

Competent adults have the right to refuse any treatment, including life-saving measures; the nurse must respect this autonomy and document the informed refusal.

Question 28: A registered nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is appropriate to delegate?

Evaluating the effectiveness of a pain medication
Initial patient assessment
Teaching a patient about new medications
Measuring and recording vital signs on a stable patient (Correct answer)

Correct answer: Measuring and recording vital signs on a stable patient

Measuring vital signs on a stable patient is within the UAP's scope of practice. Assessment, teaching, and evaluation are nursing responsibilities that cannot be delegated.

Question 29: Which situation represents a violation of the five rights of delegation?

Assigning a UAP to assist a patient with bathing after confirming the UAP's competency
Directing a UAP to perform a focused neurological assessment on a new stroke patient (Correct answer)
Delegating meal assistance to a UAP for a patient on a regular diet
Asking a UAP to take vital signs on a stable medical patient

Correct answer: Directing a UAP to perform a focused neurological assessment on a new stroke patient

A neurological assessment requires clinical judgment and is outside the UAP's scope of practice, violating the 'right task' component of delegation.

Question 30: A nurse is caring for a 45-year-old client who recently received a diagnosis of a chronic illness. The client is withdrawn and has not been adhering to the treatment plan. Which of the following psychosocial needs is the highest priority for the nurse to address?

Coping and adaptation (Correct answer)
Love and belonging
Self-actualization
Esteem and recognition

Correct answer: Coping and adaptation

While all the listed needs are important, the client's withdrawal and non-adherence to treatment indicate a primary struggle with coping and adapting to a major life change. Addressing the client's coping mechanisms is crucial for their physical and emotional well-being and is a prerequisite for addressing higher-level needs like esteem or self-actualization.

Question 31: According to Maslow's Hierarchy of Needs, which patient need should a nurse address first when a patient reports both anxiety about surgery and difficulty breathing?

Difficulty breathing (Correct answer)
Concern about body image changes
Fear of postoperative pain
Anxiety about the surgical procedure

Correct answer: Difficulty breathing

Maslow's hierarchy places physiological needs at the base; oxygenation and breathing are survival needs that must be addressed before psychological needs such as anxiety or fear.

Question 32: Which compensatory mechanism occurs in a patient with metabolic acidosis?

Kussmaul respirations to blow off CO2 (Correct answer)
Increased aldosterone secretion
Decreased respiratory rate
Increased renal bicarbonate excretion

Correct answer: Kussmaul respirations to blow off CO2

Kussmaul respirations (deep, rapid breathing) are the respiratory compensation for metabolic acidosis, eliminating CO2 to raise pH.

Question 33: Patients who are gynoid (pear-shaped) obese are more likely to develop

varicose veins. (Correct answer)
breast cancer.
diabetes mellitus.
heart disease.

Correct answer: varicose veins.

Gynoid (pear-shaped) obese patients are more likely to develop varicose veins, cellulitis, osteoporosis, and elevated triglycerides. However, compared to android (apple-shaped) obesity, which is linked to diabetes, heart disease, breast and endometrial cancer, gynoid obesity is less dangerous to overall health. The upper arms, buttocks, and thighs are where the majority of the extra weight is carried in gynoid obesity.

Question 34: A nurse is monitoring a client receiving an IV infusion of 0.9% sodium chloride. The client complains of pain and swelling at the IV site, and the surrounding skin appears cool and blanched. Which action should the nurse take first?

Slow the infusion rate and apply a warm compress.
Stop the infusion and remove the IV catheter. (Correct answer)
Check for blood return by lowering the IV bag.
Administer the prescribed analgesic for the pain.

Correct answer: Stop the infusion and remove the IV catheter.

The client's signs and symptoms (pain, swelling, coolness, blanching) are classic indicators of IV infiltration, where the IV fluid leaks into the surrounding subcutaneous tissue. The immediate priority is to stop the infusion to prevent further fluid from entering the tissue and causing more damage. After stopping the infusion, the catheter should be removed.

Question 35: Which communication technique is recommended for nurse-to-nurse handoff reports?

Unstructured narrative storytelling
Text message summaries
Written notes left at the bedside
SBAR format (Correct answer)

Correct answer: SBAR format

SBAR (Situation, Background, Assessment, Recommendation) is the standardized communication framework recommended by The Joint Commission for handoff reports.

Question 36: A nurse is inserting a urinary catheter in a female client. After cleansing the urinary meatus, the catheter accidentally touches the labia. What is the CORRECT action?

Irrigate the catheter with sterile saline and proceed
Advance the catheter quickly before contamination spreads
Discard the catheter and obtain a new sterile catheter (Correct answer)
Wipe the catheter tip with a sterile gauze and continue insertion

Correct answer: Discard the catheter and obtain a new sterile catheter

Any contact with a non-sterile surface contaminates the catheter, requiring a new sterile catheter to prevent urinary tract infection.

Question 37: Which assessment finding best indicates that a client is at risk for complicated grief?

Expressing anger toward the deceased
Crying intermittently two weeks after a loss
Inability to function after six months with persistent denial of loss (Correct answer)
Describing feelings of sadness and emptiness

Correct answer: Inability to function after six months with persistent denial of loss

Complicated grief is indicated by prolonged, impairing symptoms (>6 months) including persistent denial and inability to function.

Question 38: A client with a new colostomy expresses embarrassment about odor. Which nurse response is MOST therapeutic?

Suggest the client limit fluid intake to reduce output
Reassure the client that others cannot smell it
Encourage the client to avoid social situations until adjusted
Teach the client about dietary modifications and odor-control pouches (Correct answer)

Correct answer: Teach the client about dietary modifications and odor-control pouches

Educating the client about diet and odor-control products empowers self-management and addresses the concern directly.

Question 39: A patient with diabetes mellitus has a fasting blood glucose of 52 mg/dL and is conscious. What is the nurse's priority intervention?

Recheck the glucose level in 30 minutes
Administer glucagon intramuscularly
Give 15 grams of a fast-acting carbohydrate orally (Correct answer)
Administer IV dextrose 50%

Correct answer: Give 15 grams of a fast-acting carbohydrate orally

For a conscious patient with hypoglycemia, the 15-15 rule applies: give 15 grams of fast-acting carbohydrate, wait 15 minutes, and recheck the blood glucose.

Question 40: A nurse is preparing to insert a urinary catheter. Which action is essential to maintain sterile technique?

Re-touch the catheter tip if it contacts the client's skin
Keep sterile gloved hands above waist level at all times (Correct answer)
Place sterile items on the sterile field before gloving
Open the sterile field after donning non-sterile gloves

Correct answer: Keep sterile gloved hands above waist level at all times

Sterile gloved hands must remain above waist level and within the nurse's field of vision to be considered sterile.

Question 41: A patient with cirrhosis develops ascites and peripheral edema. Which laboratory finding would the nurse expect?

Elevated hemoglobin
Decreased serum albumin (Correct answer)
Elevated serum albumin
Decreased BUN

Correct answer: Decreased serum albumin

The cirrhotic liver cannot produce adequate albumin, leading to decreased oncotic pressure and fluid shifting into the interstitial space and peritoneal cavity.

Question 42: A client with a terminal illness has a living will and has expressed a desire to refuse further life-prolonging treatments. The client's family, however, insists that the healthcare team do everything possible to keep the client alive. Which ethical principle should primarily guide the nurse's actions in this situation?

Autonomy (Correct answer)
Justice
Beneficence
Non-maleficence

Correct answer: Autonomy

The principle of autonomy honors the client's right to make their own decisions about their healthcare, even if those decisions differ from the family's wishes or the healthcare team's recommendations. The nurse's role is to advocate for the client's wishes as expressed in their advance directive. Beneficence (acting for the patient's good), non-maleficence (do no harm), and justice (fairness) are also important, but autonomy is the guiding principle when a competent client has made their wishes known.

Question 43: A client is brought to the emergency department following a significant traumatic injury with suspected internal bleeding. Which of the following findings is considered an early compensatory sign of hypovolemic shock?

Bradycardia
Tachycardia (Correct answer)
Decreased respiratory rate
Hypotension

Correct answer: Tachycardia

In the initial stage of hypovolemic shock, the body attempts to compensate for the decreased blood volume and maintain cardiac output. The sympathetic nervous system is activated, leading to an increased heart rate (tachycardia) to circulate the remaining volume more effectively. Hypotension is a later sign, indicating that compensatory mechanisms are failing.

Question 44: A patient recovering from surgery develops sudden onset dyspnea, chest pain, and tachycardia. Which complication should the nurse suspect?

Pulmonary embolism (Correct answer)
Atelectasis
Pneumonia
Heart failure

Correct answer: Pulmonary embolism

Sudden onset of dyspnea, pleuritic chest pain, and tachycardia in a post-surgical patient are classic signs of pulmonary embolism, a life-threatening emergency.

Question 45: A patient who speaks limited English is scheduled for surgery. The nurse needs to obtain informed consent. What is the most appropriate action?

Use a hospital-approved professional medical interpreter (Correct answer)
Ask the patient's adult family member to translate the consent form
Speak slowly and use hand gestures to explain the procedure
Have the patient sign the consent form after reading it independently

Correct answer: Use a hospital-approved professional medical interpreter

A professional medical interpreter (in person or via phone/video service) must be used for informed consent to ensure accurate communication and protect patient rights. Using family members is discouraged due to potential bias, omissions, or distortion. This is also a legal and accreditation requirement.

Question 46: What is the most important nursing consideration when applying a cold pack to a patient's injury?

Use only on injuries older than 48 hours
Apply directly to the skin for maximum effect
Limit application to 20 minutes at a time (Correct answer)
Apply continuously until swelling resolves

Correct answer: Limit application to 20 minutes at a time

Cold therapy should be limited to 15-20 minutes per application to prevent tissue damage from prolonged cold exposure, including frostbite and impaired circulation.

Question 47: A nurse is preparing to administer IV medications to two patients simultaneously. Which action BEST prevents medication errors?

Label each syringe and verify at the bedside using two patient identifiers (Correct answer)
Prepare both medications at the same time to save time
Ask a colleague to verify medications verbally
Administer medications from memory since the nurse knows both patients

Correct answer: Label each syringe and verify at the bedside using two patient identifiers

Labeling syringes and verifying two patient identifiers at the bedside is the standard practice to prevent medication errors.

Question 48: A nurse finds a patient on the floor next to the bed. After ensuring safety, which action should be taken NEXT?

Help the patient back into bed immediately
Notify the physician and complete an incident report (Correct answer)
Reassess vital signs only
Administer pain medication if ordered

Correct answer: Notify the physician and complete an incident report

After immediate safety is ensured, the nurse must notify the physician and document the fall using an incident report per facility policy.

Question 49: Florence Nightingale's Environmental Theory of nursing emphasizes that healing is best supported by:

Modifying the patient's environment to support natural healing processes (Correct answer)
Teaching patients to perform their own self-care
Administering medications at prescribed intervals
Encouraging patients to express their feelings openly

Correct answer: Modifying the patient's environment to support natural healing processes

Nightingale's theory holds that nurses should manipulate environmental factors — such as ventilation, light, cleanliness, and noise — to create conditions in which the body can heal itself naturally.

Question 50: A nurse is teaching a patient about a newly prescribed medication. Which statement by the patient indicates the need for further teaching?

I should stop taking this when I feel better (Correct answer)
I will report any unusual side effects to my doctor
I understand I need to take this at the same time each day
I will take this medication with food to reduce stomach upset

Correct answer: I should stop taking this when I feel better

Stopping medication when symptoms improve can lead to incomplete treatment or disease recurrence. Patients should complete the full prescribed course unless directed otherwise.

Question 51: A patient with acute pancreatitis reports severe abdominal pain. Which position should the nurse help the patient assume for pain relief?

Supine with legs extended
Side-lying fetal position with knees drawn to the chest (Correct answer)
Right lateral with knees slightly bent
Prone position with a pillow under the abdomen

Correct answer: Side-lying fetal position with knees drawn to the chest

The fetal position with knees drawn to the chest reduces tension on the abdominal muscles and takes pressure off the inflamed pancreas, providing some pain relief.

Question 52: A nurse administers the wrong dose of a medication but the patient experiences no harm. This event is classified as a:

Sentinel event
Adverse event
Never event
Near miss (Correct answer)

Correct answer: Near miss

A near miss (close call) is an error that reaches the patient but causes no harm.

Question 53: A nurse overhears a colleague tell a patient 'You'll be sorry if you keep refusing your medications.' This statement is an example of:

Assault (Correct answer)
Battery
Slander
Libel

Correct answer: Assault

This verbal threat causes the patient to fear imminent harm or unpleasant consequences, constituting assault.

Question 54: A patient with heart failure is prescribed furosemide. Which electrolyte imbalance is the priority concern?

Hypokalemia (Correct answer)
Hypernatremia
Hypercalcemia
Hyperkalemia

Correct answer: Hypokalemia

Loop diuretics like furosemide inhibit sodium-potassium-chloride reabsorption in the loop of Henle, causing significant potassium wasting and hypokalemia.

Question 55: A nurse is educating a patient about proper use of a metered-dose inhaler (MDI) without a spacer. Which instruction is correct?

Inhale rapidly and deeply when pressing the canister
Hold your breath for 2 seconds after inhaling, then exhale quickly
Shake the inhaler, exhale fully, then inhale slowly and deeply while pressing the canister (Correct answer)
Use the inhaler while lying flat in bed for maximum effect

Correct answer: Shake the inhaler, exhale fully, then inhale slowly and deeply while pressing the canister

Proper MDI technique without a spacer requires shaking the inhaler, exhaling completely, then coordinating a slow deep inhalation with canister activation.

Question 56: A nurse is assessing a newborn's APGAR score at 1 minute. The infant has a heart rate of 96, weak cry, some flexion, grimace with stimulation, and pink body with blue extremities. What is the APGAR score?

6 (Correct answer)
8
5
7

Correct answer: 6

APGAR scoring: HR <100 = 1, weak cry = 1, some flexion = 1, grimace = 1, acrocyanosis = 1; total = 6.

Question 57: A patient develops compartment syndrome in the left leg after a tibial fracture. Which assessment finding is most diagnostic?

2+ pitting edema extending to the knee
Skin discoloration and loss of peripheral pulse
Pain out of proportion to injury unrelieved by opioids, worsened with passive stretch (Correct answer)
Decreased sensation in the plantar surface only

Correct answer: Pain out of proportion to injury unrelieved by opioids, worsened with passive stretch

Pain disproportionate to the injury that worsens with passive muscle stretching is the hallmark early sign of compartment syndrome due to elevated intracompartmental pressure.

Question 58: Which nursing intervention is most appropriate for preventing hospital-acquired pressure injuries?

Using donut-shaped cushions for all bed-bound patients
Keeping the skin moist at all times to prevent dryness
Performing regular skin assessments using the Braden Scale (Correct answer)
Massaging reddened bony prominences vigorously

Correct answer: Performing regular skin assessments using the Braden Scale

Regular skin assessment using a validated tool like the Braden Scale identifies at-risk patients early and guides preventive interventions.

Question 59: A patient presents with sudden severe headache described as 'the worst headache of my life.' Which condition should the nurse suspect?

Migraine headache
Subarachnoid hemorrhage (Correct answer)
Cluster headache
Tension headache

Correct answer: Subarachnoid hemorrhage

A sudden, severe 'thunderclap' headache described as the worst of the patient's life is the hallmark presentation of subarachnoid hemorrhage until proven otherwise.

Question 60: A client is admitted with severe dehydration secondary to gastroenteritis. The healthcare provider orders an intravenous fluid to rapidly expand intravascular volume. Which type of IV solution would the nurse anticipate being ordered?

0.45% Sodium Chloride (1/2 NS)
3% Sodium Chloride
Dextrose 5% in water (D5W)
0.9% Sodium Chloride (Normal Saline) (Correct answer)

Correct answer: 0.9% Sodium Chloride (Normal Saline)

0.9% Sodium Chloride (Normal Saline) is an isotonic solution, meaning it has a similar osmolarity to body fluids. It is the fluid of choice for rapid intravascular volume expansion in cases of dehydration or hypovolemia because it primarily stays within the vascular space. 0.45% NaCl is hypotonic and would shift fluid into cells. D5W is isotonic in the bag but becomes hypotonic in the body as dextrose is metabolized. 3% NaCl is a hypertonic solution used for specific electrolyte imbalances like severe hyponatremia, not for general volume expansion.

Question 61: A nurse receives a telephone order from a physician. Which step is most important to ensure accuracy?

Enter the verbal order directly into the electronic health record
Write the order and have the physician sign it within 72 hours
Ask a second nurse to listen on another phone
Read the order back to the physician and receive confirmation (Correct answer)

Correct answer: Read the order back to the physician and receive confirmation

Read-back verification — repeating the order to the prescriber and receiving confirmation — is the required safety step for telephone orders.

Question 62: A patient receiving total parenteral nutrition (TPN) develops sudden shortness of breath and chest pain after the central line is repositioned. What should the nurse suspect first?

Fluid overload
Air embolism (Correct answer)
Catheter occlusion
Hyperglycemia

Correct answer: Air embolism

Sudden dyspnea and chest pain after central line manipulation are classic signs of air embolism, a life-threatening complication.

Question 63: A nurse is preparing to transfuse packed red blood cells. What is the maximum time allowed for a single unit of PRBC to infuse?

1 hour
2 hours
8 hours
4 hours (Correct answer)

Correct answer: 4 hours

Packed red blood cells must be infused within 4 hours of removal from the blood bank refrigerator to minimize the risk of bacterial proliferation.

Question 64: When a patient is about to go into shock, what posture should you put him in?

flat, supine.
reverse Trendelenburg.
semi-Fowler’s.
Trendelenburg. (Correct answer)

Correct answer: Trendelenburg.

The Trendelenburg position involves placing the patient on their back with their feet elevated higher than their head. This posture helps to improve venous return to the heart and increase blood flow to vital organs like the brain, which is critical in managing or preventing shock by enhancing perfusion.

Question 65: A nurse discovers that a patient's advance directive conflicts with the family's wishes regarding end-of-life care. What is the nurse's primary role?

Request an ethics committee consultation as the first action
Follow the family's wishes since they are present
Defer the decision to the attending physician
Advocate for the patient's documented wishes in the advance directive (Correct answer)

Correct answer: Advocate for the patient's documented wishes in the advance directive

The nurse's primary role as patient advocate is to ensure the patient's documented wishes in a valid advance directive are honored, even when family disagrees.

Question 66: A patient is ordered strict intake and output monitoring. Which item should the nurse include in the output measurement?

Food consumed at meals
Emesis (Correct answer)
Intravenous fluid rate
Insensible perspiration

Correct answer: Emesis

Emesis (vomit) is a measurable fluid output that must be recorded in strict I&O monitoring to accurately track fluid balance.

Question 67: A nurse is teaching an adult client about colorectal cancer screening. At what age should average-risk individuals begin screening colonoscopy?

55 years
40 years
50 years
45 years (Correct answer)

Correct answer: 45 years

The American Cancer Society updated its guideline to recommend colorectal cancer screening beginning at age 45 for average-risk adults.

Question 68: A nurse is caring for a client on bed rest after surgery. Which action BEST prevents venous thromboembolism (VTE)?

Encourage the client to remain still to avoid pain
Apply sequential compression devices (SCDs) as ordered (Correct answer)
Massage the calves vigorously twice per shift
Elevate the foot of the bed 30 degrees at all times

Correct answer: Apply sequential compression devices (SCDs) as ordered

Sequential compression devices promote venous return and are a primary mechanical intervention to prevent VTE in immobile clients.

Question 69: A nurse is caring for a client receiving furosemide for heart failure. The client reports significant muscle weakness, and the cardiac monitor shows flattened T waves and prominent U waves. The nurse should suspect which electrolyte imbalance?

Hypomagnesemia
Hyponatremia
Hypercalcemia
Hypokalemia (Correct answer)

Correct answer: Hypokalemia

Furosemide is a loop diuretic that can cause significant potassium loss. Muscle weakness, fatigue, and cardiac dysrhythmias are classic signs of hypokalemia. The characteristic ECG changes associated with hypokalemia include flattened or inverted T waves, prominent U waves, and ST-segment depression.

Question 70: A nurse is counseling a client about primary prevention of type 2 diabetes. Which recommendation is most appropriate?

Monitor blood glucose weekly
Take metformin prophylactically
Maintain a healthy weight and exercise regularly (Correct answer)
Limit fluid intake to 1 liter per day

Correct answer: Maintain a healthy weight and exercise regularly

Primary prevention of type 2 diabetes centers on lifestyle modifications including maintaining a healthy weight and regular physical activity.

Question 71: Which IV solution is considered isotonic and is commonly used for fluid replacement?

0.45% Half Normal Saline
3% Hypertonic Saline
D5W 0.45% NaCl
0.9% Normal Saline (NS) (Correct answer)

Correct answer: 0.9% Normal Saline (NS)

0.9% Normal Saline is an isotonic solution with the same osmolarity as blood plasma, making it ideal for fluid volume replacement without causing fluid shifts.

Question 72: A nurse discovers a colleague has been accessing patient records of celebrities out of curiosity. What is the nurse's primary obligation under HIPAA?

Notify the affected patients directly
Report the breach to the facility privacy officer (Correct answer)
Document the incident in the patient's chart
Warn the colleague privately before escalating

Correct answer: Report the breach to the facility privacy officer

HIPAA requires healthcare organizations to investigate and report breaches; the nurse must notify the privacy officer who initiates the formal response process.

Question 73: When charting a medication error, the nurse should:

Only complete the incident report and not document in the chart
Omit the error from the chart to avoid liability
Write 'medication error — see incident report' in the chart
Document what was given and the patient's response, and file a separate incident report (Correct answer)

Correct answer: Document what was given and the patient's response, and file a separate incident report

The medical record must objectively reflect the care provided and the patient's response; a separate incident report is filed for quality improvement purposes.

Question 74: When administering an intramuscular (IM) injection of an irritating medication to an average-sized adult, which of the following actions demonstrates the correct technique?

Utilizing the Z-track method during the injection. (Correct answer)
Using a 25-gauge, 5/8-inch needle for the injection.
Inserting the needle at a 45-degree angle to the skin.
Selecting the dorsogluteal site as the preferred location.

Correct answer: Utilizing the Z-track method during the injection.

The Z-track method is a technique used to prevent the leakage of irritating and discoloring medications into the subcutaneous tissue. This method involves displacing the skin and subcutaneous tissue laterally before injection, which creates a zigzag path that seals the medication in the muscle upon needle withdrawal. The dorsogluteal site is no longer recommended due to the risk of sciatic nerve injury. A 5/8-inch needle is too short for an adult IM injection (typically 1 to 1.5 inches is needed). IM injections are administered at a 90-degree angle.

Question 75: A nurse is preparing to administer heparin 5,000 units subcutaneously. Which action is correct?

Use a 21-gauge, 1.5-inch needle
Do not rub the injection site after administration (Correct answer)
Inject into the deltoid muscle
Aspirate before injecting to confirm no blood return

Correct answer: Do not rub the injection site after administration

Rubbing a subcutaneous heparin injection site can cause bruising and hematoma formation, so it should be avoided.

Question 76: A nurse is preparing a sterile field to perform a wound dressing change. Which of the following actions would contaminate the sterile field and require the nurse to start over?

Keeping the sterile field at or above waist level.
Reaching over the sterile field to discard a used dressing. (Correct answer)
Pouring sterile solution into a basin from a height of 4-6 inches.
Opening the outermost flap of the sterile package away from the body.

Correct answer: Reaching over the sterile field to discard a used dressing.

A sterile field is contaminated when a non-sterile object passes over it. Reaching over the field introduces microorganisms from the nurse's arm and clothing, violating a core principle of surgical asepsis.

Question 77: According to Kübler-Ross's five stages of grief, a patient who has just been told she has a terminal diagnosis says, 'The lab must have mixed up my results. I'm going to get a second opinion.' This patient is in which stage?

Anger
Bargaining
Denial (Correct answer)
Acceptance

Correct answer: Denial

Denial is the first stage in Kübler-Ross's model and is characterized by disbelief, shock, and rejection of the diagnosis. The patient's statement that results were mixed up and her plan to seek a second opinion are classic denial behaviors. This is a normal protective psychological response.

Question 78: A nurse is preparing to administer the first dose of an ACE inhibitor. Which assessment finding would cause the nurse to hold the medication?

Serum creatinine of 1.0 mg/dL
Potassium level of 4.2 mEq/L
Blood pressure of 84/56 mmHg (Correct answer)
Heart rate of 82 bpm

Correct answer: Blood pressure of 84/56 mmHg

A blood pressure of 84/56 mmHg indicates significant hypotension. ACE inhibitors lower blood pressure and could cause dangerously low readings in this patient.

Question 79: A nurse is caring for a client receiving Total Parenteral Nutrition (TPN) via a central venous catheter. Which of the following is a priority nursing intervention to prevent a metabolic complication?

Monitoring blood glucose levels every 4 to 6 hours. (Correct answer)
Changing the central line dressing every 24 hours.
Using the TPN line to administer IV push antibiotics.
Infusing the TPN solution rapidly if it falls behind schedule.

Correct answer: Monitoring blood glucose levels every 4 to 6 hours.

TPN solutions have a high dextrose concentration, which places the client at high risk for hyperglycemia. Frequent blood glucose monitoring (typically every 4-6 hours) is essential to detect and manage this common and serious metabolic complication. Central line dressings are changed using sterile technique, but typically not every 24 hours (usually every 7 days or per protocol). The TPN line should be dedicated to the TPN infusion to prevent infection. TPN rates should never be increased to 'catch up' as this can cause severe metabolic disturbances like hyperglycemia and fluid overload.

Question 80: A patient with a pulmonary embolism has sudden onset of hypoxia despite oxygen therapy. Which physiological mechanism best explains this finding?

Ventilation-perfusion mismatch (Correct answer)
Increased pulmonary capillary permeability
Decreased alveolar surfactant production
Left ventricular failure causing pulmonary edema

Correct answer: Ventilation-perfusion mismatch

PE causes ventilation-perfusion (V/Q) mismatch because alveoli are ventilated but perfusion is blocked by the clot, preventing gas exchange.

Question 81: Which of the following best describes the concept of 'continuity of care' in nursing practice?

Ensuring all nursing documentation is completed before the end of each shift
Assigning the same nurse to a patient every shift to build rapport
Limiting the number of care providers involved in a patient's treatment plan
Coordinating and communicating patient care across all providers and settings to ensure seamless transitions (Correct answer)

Correct answer: Coordinating and communicating patient care across all providers and settings to ensure seamless transitions

Continuity of care involves coordinating information and services across providers and settings so patient care remains consistent and uninterrupted.

Question 82: A client reports constipation. Which non-pharmacological intervention should the nurse recommend FIRST?

Increase fluid intake to 2–3 liters per day (Correct answer)
Suggest bed rest to conserve energy
Administer a bisacodyl suppository
Recommend a low-fiber diet

Correct answer: Increase fluid intake to 2–3 liters per day

Increasing fluid intake softens stool and is the first-line non-pharmacological intervention for constipation.

Question 83: A patient is prescribed heparin 5,000 units subcutaneously. The vial contains 10,000 units/mL. How many mL should the nurse administer?

1 mL
2 mL
0.25 mL
0.5 mL (Correct answer)

Correct answer: 0.5 mL

Using the formula: 5,000 units divided by 10,000 units/mL = 0.5 mL.

Question 84: A nurse discovers that the wrong patient received a medication intended for another patient in the same room. After assessing the patient, what documentation is required?

Document the event in the patient's medical record and file an incident report (Correct answer)
Do not document the error to avoid legal liability
Document in the medical record only with no additional reporting
Document only in the incident report to protect against litigation

Correct answer: Document the event in the patient's medical record and file an incident report

Both medical record documentation (factual account of what occurred, assessment findings, and interventions) and an incident report (for quality improvement and risk management) are required.

Question 85: Which action by a nursing student demonstrates correct understanding of surgical asepsis?

Considering a sterile item safe to use if it was opened 2 hours ago
Placing sterile items at the edge of the sterile field for easy access
Keeping sterile gloved hands above the waist and in view (Correct answer)
Reaching over a sterile field to pass instruments

Correct answer: Keeping sterile gloved hands above the waist and in view

Sterile gloved hands must remain above waist level and in the nurse's field of vision to maintain sterility.

Question 86: Which medication requires the nurse to monitor potassium levels closely due to the risk of hyperkalemia?

Mannitol
Hydrochlorothiazide
Spironolactone (Correct answer)
Furosemide

Correct answer: Spironolactone

Spironolactone is a potassium-sparing diuretic that blocks aldosterone, leading to potassium retention and risk of hyperkalemia.

Question 87: Which assessment finding in a patient taking lithium carbonate requires immediate intervention?

Mild hand tremor
Serum lithium level of 2.5 mEq/L (Correct answer)
Polyuria
Slight nausea after doses

Correct answer: Serum lithium level of 2.5 mEq/L

A serum lithium level of 2.5 mEq/L indicates severe toxicity (therapeutic range 0.6–1.2 mEq/L) and requires immediate intervention.

Question 88: A patient with Addison's disease presents with severe hypotension, hyponatremia, and hyperkalemia. Which pathophysiological mechanism explains these findings?

Aldosterone deficiency impairing sodium retention and potassium excretion (Correct answer)
Epinephrine excess stimulating the renin-angiotensin system
Excess cortisol causing fluid shifts
ADH excess causing water retention

Correct answer: Aldosterone deficiency impairing sodium retention and potassium excretion

Aldosterone deficiency in Addison's disease prevents sodium reabsorption and potassium excretion in the kidney, leading to hyponatremia, hyperkalemia, and volume depletion.

Question 89: A terminally ill patient is experiencing Cheyne-Stokes respirations. The family asks what this means. The nurse's BEST response is:

'We should call the physician to start mechanical ventilation.'
'This pattern—cycles of rapid breathing followed by pauses—is a normal sign that death is approaching.' (Correct answer)
'This means the patient needs supplemental oxygen immediately.'
'This breathing pattern means the patient is in pain and needs more medication.'

Correct answer: 'This pattern—cycles of rapid breathing followed by pauses—is a normal sign that death is approaching.'

Cheyne-Stokes respirations (irregular cycles of apnea and hyperpnea) are a normal physiological sign of imminent death caused by decreased cerebral perfusion. Educating the family that this is expected and not distressing to the patient provides comfort and reduces panic. It does not indicate a need for aggressive intervention.

Question 90: A client states, 'My doctor says I have cancer, but I know the lab results are wrong.' This is an example of which defense mechanism?

Rationalization
Projection
Displacement
Denial (Correct answer)

Correct answer: Denial

Denial involves refusing to acknowledge a painful reality, such as rejecting a cancer diagnosis.

Question 91: A nurse reviews a client's medication list and notes they are taking warfarin. Which laboratory value is most critical to monitor to reduce risk of bleeding complications?

Platelet count
Bleeding time
International Normalized Ratio (INR) (Correct answer)
Partial thromboplastin time (PTT)

Correct answer: International Normalized Ratio (INR)

INR is the standard test used to monitor warfarin therapy and guide dosing to prevent hemorrhage.

Question 92: A client who underwent general anesthesia 4 hours ago has a temperature of 39.2°C (102.6°F), tachycardia, and muscle rigidity. Which condition does the nurse suspect?

Septic shock
Thyroid storm
Neuroleptic malignant syndrome
Malignant hyperthermia (Correct answer)

Correct answer: Malignant hyperthermia

Malignant hyperthermia is a life-threatening reaction to certain anesthetic agents characterized by hyperthermia, tachycardia, and severe muscle rigidity.

Question 93: A nurse is caring for a client who had a thyroidectomy 12 hours ago. Which finding requires the most immediate intervention?

Mild sore throat and hoarse voice
Surgical site with scant serosanguineous drainage
Serum calcium of 7.2 mg/dL with positive Chvostek's sign (Correct answer)
Pain rated 4/10 relieved by prescribed analgesic

Correct answer: Serum calcium of 7.2 mg/dL with positive Chvostek's sign

Hypocalcemia after thyroidectomy caused by inadvertent parathyroid removal can lead to tetany and laryngospasm, requiring immediate intervention.

Question 94: A patient recently diagnosed with cancer states, 'I want to know all about my treatment options.' According to Kubler-Ross, which stage of grief is the patient most likely experiencing?

Denial
Acceptance (Correct answer)
Bargaining
Depression

Correct answer: Acceptance

Seeking information and actively participating in treatment decisions suggests the patient has moved toward acceptance of the diagnosis.

Question 95: Which finding during a well-child visit in a 6-month-old warrants further evaluation by the nurse?

Weight doubled from birth weight
Absence of babbling (Correct answer)
Inability to sit without support
Presence of Moro reflex

Correct answer: Absence of babbling

Babbling is an expected developmental milestone by 6 months; its absence may indicate hearing loss or developmental delay requiring further evaluation.

Question 96: A nurse notices that a colleague is consistently charting care that was not performed. What is the nurse's most appropriate action?

Ignore the behavior to avoid conflict
Alter the records to reflect accurate care
Confront the colleague publicly at the nurses' station
Report the behavior to the nurse manager or through the chain of command (Correct answer)

Correct answer: Report the behavior to the nurse manager or through the chain of command

Falsification of documentation is fraud and a serious safety issue; the nurse has an ethical and professional obligation to report it through proper channels.

Question 97: A patient with diabetes insipidus has a urine specific gravity of 1.001 and urinary output of 8 L/day. Which medication does the nurse anticipate administering?

Desmopressin (DDAVP) (Correct answer)
Furosemide (Lasix)
Hydrochlorothiazide
Spironolactone

Correct answer: Desmopressin (DDAVP)

Diabetes insipidus results from ADH deficiency or insensitivity, producing large volumes of very dilute urine; desmopressin (synthetic ADH) is administered to reduce excessive water loss.

Question 98: A nurse is administering potassium chloride 40 mEq IV. Which practice is safest?

Mix with normal saline in a 1 mEq/mL concentration and push slowly
Add to a 50 mL minibag and infuse over 15 minutes
Administer as an IV push over 5 minutes
Dilute in at least 100 mL and infuse no faster than 10 mEq/hour (Correct answer)

Correct answer: Dilute in at least 100 mL and infuse no faster than 10 mEq/hour

IV potassium must be diluted and infused slowly (≤10 mEq/hr peripherally) to prevent cardiac dysrhythmias; IV push is never acceptable.

Question 99: A nurse is caring for a client who had a stroke and has dysphagia. Which of the following interventions is the priority to ensure the client's safety and comfort during meals?

Placing food on the affected side of the mouth.
Providing thin liquids to make swallowing easier.
Ensuring the client is in a high-Fowler's position. (Correct answer)
Encouraging the client to eat quickly to prevent fatigue.

Correct answer: Ensuring the client is in a high-Fowler's position.

Positioning the client in a high-Fowler's position (sitting upright at 90 degrees) uses gravity to aid in swallowing and is the most critical intervention to prevent aspiration in a client with dysphagia. Thin liquids are difficult to control and increase aspiration risk. The client should eat slowly and take small bites. Food should be placed on the unaffected, stronger side of the mouth to facilitate better control.

Question 100: According to Maslow's hierarchy, which client need must be addressed before focusing on self-esteem needs?

Self-actualization needs
Cognitive needs
Belonging and love needs
Safety and security needs (Correct answer)

Correct answer: Safety and security needs

Maslow's hierarchy requires physiological and safety needs to be met before higher-level needs such as belonging and self-esteem.

Question 101: A patient with severe burns covering 40% TBSA is in the first 24 hours post-injury. Which physiological change requires the most aggressive fluid resuscitation?

Increased insensible water loss through eschar
Massive fluid shift from intravascular to interstitial space due to increased capillary permeability (Correct answer)
Hemolysis of red blood cells causing anemia
Decreased cardiac output from pain-induced vasoconstriction

Correct answer: Massive fluid shift from intravascular to interstitial space due to increased capillary permeability

Burn injury causes massive capillary leak syndrome, shifting large volumes from the intravascular to interstitial compartment, causing hypovolemic shock within hours.

Question 102: A nurse is coordinating discharge planning for an elderly client with heart failure. Which team member should the nurse consult first?

The clinical pharmacist
The dietary consultant
The social worker (Correct answer)
The hospital chaplain

Correct answer: The social worker

The social worker is the key team member for discharge planning, assessing community resources, home support, financial assistance, and placement needs.

Question 103: A patient taking phenytoin for seizure disorder has a serum level of 25 mcg/mL. Which symptom should the nurse assess for?

Peripheral edema and weight gain
Polyuria and polydipsia
Nystagmus, ataxia, and confusion (Correct answer)
Hypertension and tachycardia

Correct answer: Nystagmus, ataxia, and confusion

Phenytoin toxicity (therapeutic range 10–20 mcg/mL) commonly manifests as nystagmus, ataxia, and mental status changes.

Question 104: A patient is ordered 250 mg of amoxicillin. The medication is available as 125 mg/5 mL. How many mL should the nurse administer?

5 mL
15 mL
20 mL
10 mL (Correct answer)

Correct answer: 10 mL

Using the formula: (Desired / Have) × Volume = (250 / 125) × 5 mL = 2 × 5 = 10 mL.

Question 105: Which nursing action is most important before administering the first dose of an aminoglycoside antibiotic such as gentamicin?

Ensure the patient has taken a loading dose of a penicillin
Administer a test dose to check for hypersensitivity
Check the patient's blood glucose level
Obtain baseline hearing assessment and renal function tests (Correct answer)

Correct answer: Obtain baseline hearing assessment and renal function tests

Aminoglycosides are ototoxic and nephrotoxic; baseline hearing and renal function must be established before initiating therapy.

Question 106: A nurse is providing discharge teaching to a patient with newly diagnosed hypertension. Which lifestyle modification should be emphasized first?

Begin a high-intensity exercise program immediately
Reduce sodium intake to less than 2,300 mg per day (Correct answer)
Increase caffeine intake to boost metabolism
Take herbal supplements for blood pressure control

Correct answer: Reduce sodium intake to less than 2,300 mg per day

Sodium restriction is a primary lifestyle modification for hypertension management, as excess sodium promotes fluid retention and increases blood pressure.

Question 107: A nurse is developing a plan of care for an older adult client at risk for pressure injuries. Which of the following interventions should be included?

Massaging bony prominences to increase circulation.
Using donut-shaped cushions for seating.
Keeping the skin clean and dry and using a moisturizer. (Correct answer)
Repositioning the client every 4 hours.

Correct answer: Keeping the skin clean and dry and using a moisturizer.

Maintaining skin integrity by keeping it clean, dry, and well-moisturized is a fundamental aspect of pressure injury prevention. Massaging bony prominences is contraindicated as it can cause tissue damage. At-risk clients should be repositioned more frequently, typically every 2 hours. Donut-shaped cushions are avoided because they can impair blood flow.

Question 108: A nurse is conducting a health fair for adults over 65. Which intervention represents secondary prevention?

Referral to a smoking cessation program
Flu vaccination
Teaching fall prevention strategies
Blood pressure screening (Correct answer)

Correct answer: Blood pressure screening

Secondary prevention involves early detection of disease; blood pressure screening identifies hypertension before complications arise.

Question 109: A patient with diabetes is prescribed NPH insulin and regular insulin. In which order should the nurse draw up the insulins?

NPH first, then regular
Either order is acceptable
They must be given in separate syringes
Regular first, then NPH (Correct answer)

Correct answer: Regular first, then NPH

The clear (regular) insulin is always drawn up first to prevent contamination of the regular insulin vial with the cloudy (NPH) insulin.

Question 110: A nurse receives shift report on four patients. Which patient should the nurse assess first?

A patient with a urinary tract infection running a temperature of 100.4 degrees Fahrenheit
A patient 1 day post-appendectomy requesting pain medication
A patient with COPD whose oxygen saturation dropped from 92% to 84% (Correct answer)
A patient scheduled for discharge awaiting medication teaching

Correct answer: A patient with COPD whose oxygen saturation dropped from 92% to 84%

The COPD patient with rapidly declining oxygen saturation represents the most acute change in condition requiring immediate assessment using the ABCs of prioritization.

Question 111: A nurse is teaching a client about testicular self-examination (TSE). How often should TSE be performed?

Daily
Monthly (Correct answer)
Annually
Weekly

Correct answer: Monthly

Testicular self-examination should be performed once a month, ideally after a warm shower when scrotal tissue is relaxed.

Question 112: A nurse is planning care for four clients. Which client should the nurse assess first?

A client requesting pain medication rated 4/10 who had surgery 2 days ago
A client scheduled for discharge who needs medication teaching
A client awaiting a dietary consult for a new diabetic diet
A client with new-onset confusion and oxygen saturation of 88% (Correct answer)

Correct answer: A client with new-onset confusion and oxygen saturation of 88%

New-onset confusion with an oxygen saturation of 88% indicates acute hypoxia, which is a life-threatening emergency requiring immediate assessment.

Question 113: The ethical principle of beneficence requires a nurse to take what type of action?

Taking positive actions to help others and promote the well-being of clients. (Correct answer)
Telling the truth to a client about their diagnosis, even if it is distressing.
Ensuring all clients have equal access to available resources.
Respecting a client's decision to refuse a necessary medical procedure.

Correct answer: Taking positive actions to help others and promote the well-being of clients.

Beneficence is the ethical principle of acting for the good and welfare of others. It involves taking positive, proactive steps to help clients, such as providing effective pain management, offering emotional support, or educating them to promote health. Ensuring equal access relates to justice, respecting a client's decision relates to autonomy, and truth-telling relates to veracity.

Question 114: According to Erikson's stages of development, a 25-year-old client who expresses difficulty forming meaningful relationships with others is likely struggling with which psychosocial crisis?

Intimacy vs. Isolation (Correct answer)
Identity vs. Role Confusion
Initiative vs. Guilt
Trust vs. Mistrust

Correct answer: Intimacy vs. Isolation

The young adulthood stage (approximately 19 to 40 years) is characterized by the psychosocial crisis of 'Intimacy vs. Isolation.' During this time, individuals focus on forming close, committed relationships with other people. Difficulty in this stage can lead to feelings of loneliness and isolation.

Question 115: A nurse is caring for a client with dysphagia. Which food consistency is MOST appropriate to prevent aspiration?

Clear broth served hot
Nectar-thickened liquids (Correct answer)
Thin liquids with a straw
Regular solid foods cut into small pieces

Correct answer: Nectar-thickened liquids

Nectar-thickened liquids slow the flow of fluid, reducing aspiration risk in clients with dysphagia.

Question 116: A patient with anxiety tells the nurse, 'I feel like I'm going to die.' What is the most therapeutic response?

Don't worry, you're going to be fine
I'll call the doctor right away
That must feel very frightening. Tell me more about what you're experiencing (Correct answer)
Many patients feel this way, it's normal

Correct answer: That must feel very frightening. Tell me more about what you're experiencing

Acknowledging the patient's feelings and inviting further expression validates their experience and promotes therapeutic communication.

Question 117: A nurse is monitoring a patient after a thyroidectomy. Which complication should the nurse assess for within the first 24 hours?

Myxedema coma
Graves' disease recurrence
Thyroid storm
Hypocalcemia (Correct answer)

Correct answer: Hypocalcemia

Accidental removal or damage to the parathyroid glands during thyroidectomy can cause hypocalcemia, which may present as tetany, tingling, or muscle spasms.

Question 118: A nurse is preparing a client for a procedure that requires informed consent. The client states they don't understand the risks. What should the nurse do?

Have the client sign the consent form and add a note about confusion
Notify the physician to re-explain the procedure to the client (Correct answer)
Proceed with the procedure since consent was previously discussed
Explain the risks in detail and obtain the signature

Correct answer: Notify the physician to re-explain the procedure to the client

Obtaining informed consent is the physician's responsibility; when a client lacks understanding, the nurse must notify the provider to re-explain risks and obtain true informed consent.

Question 119: A bedridden client has a stage II pressure injury on the coccyx. Which intervention is the PRIORITY?

Place a donut-shaped cushion under the coccyx
Reposition the client every 2 hours (Correct answer)
Apply a heat lamp for 20 minutes twice daily
Massage the area to increase circulation

Correct answer: Reposition the client every 2 hours

Repositioning every 2 hours relieves pressure and is the cornerstone of pressure injury prevention and treatment.

Question 120: A patient receiving morphine for post-operative pain has a respiratory rate of 8 breaths/min and is difficult to arouse. What is the priority intervention?

Reposition the patient to improve airway patency
Administer naloxone (Narcan) per protocol (Correct answer)
Increase the oxygen flow rate to 4 L/min
Withhold the next scheduled morphine dose

Correct answer: Administer naloxone (Narcan) per protocol

Respiratory depression with altered consciousness is opioid toxicity requiring immediate naloxone administration to reverse the effect.

Question 121: A nurse enters a patient's room and smells a strong gas odor. What is the nurse's first action?

Open the windows for ventilation
Investigate the source of the odor
Evacuate the patient from the room (Correct answer)
Turn off all electrical equipment in the room

Correct answer: Evacuate the patient from the room

Patient safety is the priority. The nurse should immediately evacuate the patient from potential danger before investigating the source or taking other actions.

Question 122: A client with schizophrenia tells the nurse, 'The FBI is putting thoughts in my head.' The nurse's best response is:

'I'll call your family so they can reassure you.'
'That sounds frightening. Tell me more about what you're experiencing.' (Correct answer)
'Those thoughts aren't real; the FBI is not involved in your care.'
'You need to focus on what's happening in reality.'

Correct answer: 'That sounds frightening. Tell me more about what you're experiencing.'

Acknowledging the client's feelings and exploring the experience is therapeutic; arguing about the delusion reinforces it or damages trust.

Question 123: A nurse is caring for a patient who speaks a different language. What is the most appropriate action to ensure effective communication?

Arrange for a certified medical interpreter (Correct answer)
Use hand gestures exclusively
Speak louder and slower
Ask a family member to translate

Correct answer: Arrange for a certified medical interpreter

A certified medical interpreter ensures accurate translation of medical terminology and protects patient confidentiality, which family members may not provide.

Question 124: A PN receives a verbal telephone order from a physician for a medication. What is the correct process for handling this order?

Have a UAP transcribe the order to free up the nurse's time
Write down the order, read it back to the physician for verification, and document it per facility policy (Correct answer)
Refuse all verbal orders and insist on written orders only
Administer the medication immediately based on the verbal order alone

Correct answer: Write down the order, read it back to the physician for verification, and document it per facility policy

The read-back process for verbal orders is a Joint Commission-required safety practice to verify accuracy before implementation.

Question 125: Which action by a nurse constitutes assault (as opposed to battery)?

Touching a patient without consent
Threatening to restrain a patient if they do not comply with treatment (Correct answer)
Administering medication the patient refused
Performing a procedure after the patient says 'stop'

Correct answer: Threatening to restrain a patient if they do not comply with treatment

Assault is the threat or act that causes a person to fear imminent harmful contact; battery is the actual unauthorized contact.

Question 126: A patient with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 6. What does this indicate about the patient's neurological status?

Mild brain injury
Severe brain injury (Correct answer)
Moderate brain injury
Normal neurological function

Correct answer: Severe brain injury

A GCS score of 3-8 indicates severe brain injury. The patient likely requires intubation and intensive neurological monitoring.

Question 127: A postoperative client is encouraged to ambulate as soon as possible. Which of the following is the primary rationale for early ambulation?

To improve the client's social interaction.
To increase the client's appetite.
To prevent postoperative complications like deep vein thrombosis (DVT). (Correct answer)
To decrease the need for pain medication.

Correct answer: To prevent postoperative complications like deep vein thrombosis (DVT).

Early ambulation is crucial for preventing serious postoperative complications. It stimulates circulation, which helps prevent the formation of blood clots (deep vein thrombosis) in the legs. While it may indirectly affect appetite, pain, and social interaction, the primary medical reason is to prevent complications such as DVT, atelectasis, and pneumonia.

Question 128: A nurse is providing health promotion education to a community group. Which statement best describes secondary prevention?

Providing rehabilitation after a stroke
Teaching handwashing to prevent infection
Screening hypertensive clients to detect complications early (Correct answer)
Administering vaccines before disease exposure

Correct answer: Screening hypertensive clients to detect complications early

Secondary prevention involves early detection of existing disease to prevent progression, such as monitoring hypertensive clients for target organ damage.

Question 129: A nurse discovers that a patient's advance directive specifies no resuscitation, but the physician has entered a full-code order. What is the nurse's BEST action?

Notify the physician of the discrepancy and escalate to the charge nurse or supervisor if unresolved (Correct answer)
Administer care based on whichever order seems most reasonable
Ignore the advance directive since it was created before admission
Follow the physician's order because it is the most recent

Correct answer: Notify the physician of the discrepancy and escalate to the charge nurse or supervisor if unresolved

A conflict between an advance directive and a physician order requires immediate clarification through the chain of command to protect the patient's legal rights.

Question 130: A client is prescribed 3% hypertonic saline for severe hyponatremia. Which complication should the nurse monitor for during infusion?

Hyperkalemia
Acute respiratory alkalosis
Osmotic demyelination syndrome if corrected too rapidly (Correct answer)
Hypoglycemia

Correct answer: Osmotic demyelination syndrome if corrected too rapidly

Correcting chronic hyponatremia too quickly with hypertonic saline can cause osmotic demyelination syndrome (central pontine myelinolysis), a severe neurological complication.

Question 131: A nurse is implementing fall prevention for a patient taking multiple medications. Which medication class poses the greatest fall risk?

Proton pump inhibitors
Antibiotics
Benzodiazepines (Correct answer)
Thyroid hormones

Correct answer: Benzodiazepines

Benzodiazepines cause sedation, impaired balance, dizziness, and muscle relaxation, significantly increasing fall risk, especially in elderly patients.

Question 132: When using SBAR for a handoff report, what information is included in the 'Background' component?

Relevant medical history, admitting diagnosis, and pertinent lab values (Correct answer)
Current vital signs and immediate concerns
The nurse's recommended action or request
A brief description of the current situation

Correct answer: Relevant medical history, admitting diagnosis, and pertinent lab values

The Background section of SBAR includes the patient's relevant medical history, diagnosis, and pertinent clinical data that provide context for the current situation.

Question 133: A client is admitted with a stage III pressure injury to the sacrum. Which intervention has the highest priority?

Massage the reddened area to improve circulation
Restrict the client's fluid intake
Reposition the client every 2 hours (Correct answer)
Apply a dry gauze dressing to the wound

Correct answer: Reposition the client every 2 hours

Turning and repositioning every 2 hours is the primary prevention and treatment intervention to relieve pressure and promote healing.

Question 134: Which immunization is recommended for all adults aged 65 and older to prevent pneumococcal disease?

Hepatitis B series
MMR booster
PPSV23 (Pneumovax) (Correct answer)
Varicella vaccine

Correct answer: PPSV23 (Pneumovax)

PPSV23 is recommended for all adults aged 65 and older to protect against pneumococcal pneumonia and bacteremia.

Question 135: A patient with SIADH has a serum sodium of 118 mEq/L. Which symptom is most concerning?

Seizures and altered consciousness (Correct answer)
Pitting edema in lower extremities
Dry mucous membranes
Increased urine output

Correct answer: Seizures and altered consciousness

Severe hyponatremia causes cerebral edema, leading to seizures and altered consciousness, which are life-threatening neurological complications.

Question 136: Which therapeutic communication technique involves restating the patient's message in the nurse's own words to verify understanding?

Reflecting
Summarizing
Paraphrasing (Correct answer)
Clarifying

Correct answer: Paraphrasing

Paraphrasing restates the patient's message using the nurse's own words, demonstrating active listening and allowing the patient to confirm or correct the nurse's understanding.

Question 137: Which finding indicates that a patient with diabetic ketoacidosis (DKA) is responding to treatment?

Blood pressure normalizing with persistent abdominal pain
Urine output increasing from 20 mL/hr to 60 mL/hr with persistent Kussmaul breathing
Serum glucose decreasing from 450 to 280 mg/dL with continued ketonuria
Arterial pH rising from 7.10 to 7.32 with decreasing serum ketones (Correct answer)

Correct answer: Arterial pH rising from 7.10 to 7.32 with decreasing serum ketones

Resolution of acidosis (rising pH) and decreasing ketones indicate that insulin therapy is correcting the underlying metabolic derangement in DKA.

Question 138: A nurse is caring for a patient receiving a blood transfusion who suddenly develops chills, fever, and back pain 15 minutes after the transfusion begins. What is the PRIORITY nursing action?

Increase the IV fluid rate to dilute the blood product
Administer prescribed antihistamine and continue the transfusion
Slow the transfusion rate and reassess in 30 minutes
Stop the transfusion immediately and keep the IV line open with normal saline (Correct answer)

Correct answer: Stop the transfusion immediately and keep the IV line open with normal saline

Signs of an acute hemolytic transfusion reaction require immediately stopping the transfusion and maintaining IV access with normal saline while notifying the provider.

Question 139: A nurse is performing passive range-of-motion (PROM) exercises on a client's hip. Which movement involves moving the leg away from the midline of the body?

Flexion
Internal rotation
Abduction (Correct answer)
Adduction

Correct answer: Abduction

Abduction is the movement of a limb away from the midline of the body.

Question 140: A nurse is providing discharge teaching to a client after a myocardial infarction. Which lifestyle modification is the highest priority?

Begin high-intensity exercise immediately
Smoking cessation (Correct answer)
Increase dietary fiber
Moderate alcohol consumption

Correct answer: Smoking cessation

Smoking cessation is the single most important modifiable risk factor for reducing recurrent cardiac events after a myocardial infarction.

Question 141: A nurse is initiating a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client develops shortness of breath, chills, and lower back pain. What is the nurse's priority action?

Administer an antihistamine as ordered.
Stop the transfusion immediately. (Correct answer)
Notify the healthcare provider.
Slow the rate of the transfusion.

Correct answer: Stop the transfusion immediately.

The client's symptoms of chills, shortness of breath, and lower back pain are classic signs of an acute hemolytic transfusion reaction, a life-threatening emergency. The absolute first and most critical action is to stop the transfusion immediately to prevent any more incompatible blood from entering the client's system. After stopping the transfusion, the nurse would then notify the provider and perform other supportive interventions, such as maintaining IV access with normal saline.

Question 142: A nurse is preparing a plan of care for a client. Which step of the nursing process involves setting measurable and achievable short- and long-term goals?

Implementation
Planning (Correct answer)
Diagnosis
Assessment

Correct answer: Planning

The planning phase of the nursing process is where the nurse establishes priorities, sets client-centered goals and expected outcomes, and selects nursing interventions to achieve these goals. This involves creating a roadmap for the client's care with specific, measurable, achievable, realistic, and time-bound (SMART) goals.

Question 143: When using the SBAR communication tool, which information is included in the 'Background' section?

Pertinent medical history, current diagnosis, and recent treatments (Correct answer)
The nurse's assessment of what is wrong with the patient
The patient's name, room number, and current vital signs
The specific action or order the nurse is requesting

Correct answer: Pertinent medical history, current diagnosis, and recent treatments

Background in SBAR includes relevant clinical history, diagnosis, and recent treatments that provide context for the situation.

Question 144: A client with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which assessment finding requires the nurse's most immediate action?

Urine output of 25 mL/hour
Blood pressure of 148/90 mmHg
Mild bilateral ankle edema
Irregular cardiac rhythm on telemetry (Correct answer)

Correct answer: Irregular cardiac rhythm on telemetry

Hyperkalemia causes cardiac dysrhythmias, which can be life-threatening and require immediate intervention.

Question 145: A nurse must perform hand hygiene after caring for a patient with C. difficile. Which method is preferred?

Alcohol-based hand rub for 15 seconds
Soap and water for at least 20 seconds (Correct answer)
Alcohol-based hand rub for 30 seconds
Waterless antimicrobial foam

Correct answer: Soap and water for at least 20 seconds

Soap and water physically removes C. diff spores; alcohol-based hand rubs are not effective against spores.

Question 146: A patient with chronic kidney disease has a potassium level of 6.2 mEq/L. Which cardiac rhythm change should the nurse anticipate?

Prolonged QT interval
Absent P waves with regular rhythm
Peaked T waves (Correct answer)
ST elevation

Correct answer: Peaked T waves

Hyperkalemia characteristically produces tall, peaked T waves on ECG as one of the earliest changes, followed by widened QRS and eventual sine wave pattern.

Question 147: When measuring a patient's blood pressure, the nurse obtains a reading during the first Korotkoff sound. This represents which value?

Pulse pressure
Mean arterial pressure
Systolic pressure (Correct answer)
Diastolic pressure

Correct answer: Systolic pressure

The first Korotkoff sound, heard as a clear tapping, represents the systolic blood pressure, the pressure when the heart ventricles contract.

Question 148: Which patient is at greatest risk for developing hypernatremia?

A 70-year-old with advanced dementia who cannot request fluids independently (Correct answer)
A 30-year-old diagnosed with SIADH
A 60-year-old with fluid overload from cirrhosis
A 45-year-old receiving furosemide therapy for heart failure

Correct answer: A 70-year-old with advanced dementia who cannot request fluids independently

Patients with dementia who cannot communicate thirst or independently access water are at high risk for hypernatremia due to inadequate free water intake relative to sodium.

Question 149: A nurse is caring for a client on prolonged bed rest. To reduce the client's risk of developing renal calculi, which intervention is the highest priority?

Ensuring a fluid intake of 2,500 to 3,000 mL per day. (Correct answer)
Assisting the client to a high-Fowler's position for all meals.
Administering prophylactic antibiotics.
Providing a low-calcium diet.

Correct answer: Ensuring a fluid intake of 2,500 to 3,000 mL per day.

Immobility leads to urinary stasis and bone demineralization, which increases the concentration of calcium and other minerals in the urine, predisposing the client to stone formation. The most effective and highest priority nursing intervention to prevent renal calculi is to ensure adequate hydration (2-3 L/day). A high fluid intake keeps urine dilute and flowing, which prevents mineral precipitation.

Question 150: A nurse receives a verbal order from a physician during an emergency. What is the nurse's priority action after carrying out the order?

Have the physician co-sign the order as soon as possible (Correct answer)
Notify the charge nurse immediately
Refuse the order until it is written
Document the order at the end of the shift

Correct answer: Have the physician co-sign the order as soon as possible

Verbal orders should be read back for confirmation and then signed by the prescribing provider as soon as possible, typically within 24 hours per facility policy.

Question 151: Long-term usage of corticosteroids or antibiotics raises the risk of?

candidiasis. (Correct answer)
constipation.
anaphylaxis.
gingivitis.

Correct answer: candidiasis.

Long-term use of antibiotics or corticosteroids raises the likelihood of developing candidiasis, which is most frequently brought on by Candida albicans. Candida infections can develop in the vagina (yeast infection), on the skin (thrush), or in the mouth (cutaneous). Candida can also enter the circulation and cause systemic infections or infections of other organs. Typically, oral solutions or buccal pills of nystatin or amphotericin B are used to treat oral infections. The type of treatment depends on where the infection is located anatomically.

Question 152: A nurse is reviewing arterial blood gas results: pH 7.30, PaCO2 50 mmHg, HCO3 24 mEq/L. Which acid-base imbalance does this represent?

Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis (Correct answer)

Correct answer: Respiratory acidosis

The low pH (acidotic), elevated PaCO2 (respiratory cause), and normal HCO3 (no metabolic compensation) indicate uncompensated respiratory acidosis.

Question 153: Which situation represents a breach of patient confidentiality under HIPAA?

Reporting a communicable disease to the health department
Discussing patient status with the treatment team during rounds
Sharing patient information with the patient's designated healthcare proxy
Discussing a patient's diagnosis in the hospital elevator with a colleague (Correct answer)

Correct answer: Discussing a patient's diagnosis in the hospital elevator with a colleague

Discussing patient information in a public area like an elevator where unauthorized individuals may overhear is a HIPAA violation.

Question 154: When repositioning a patient to prevent pressure injuries, how frequently should the nurse turn the patient?

Every 8 hours
Every 4 hours
Only when the patient requests
Every 2 hours (Correct answer)

Correct answer: Every 2 hours

Evidence-based guidelines recommend repositioning patients at least every 2 hours to redistribute pressure and prevent tissue breakdown.

Question 155: A patient post-thyroidectomy develops tingling around the mouth and carpopedal spasms. Which lab value should the nurse check immediately?

Serum calcium (Correct answer)
Serum magnesium
Serum potassium
Serum sodium

Correct answer: Serum calcium

Hypocalcemia due to inadvertent parathyroid removal causes tetany symptoms including perioral tingling and carpopedal spasms.

Question 156: A PN is caring for four patients. Which patient should be assessed first?

A patient with a stable wound dressing that needs to be changed
A patient requesting a pain medication refill rated 4/10
A patient who became suddenly confused and restless one hour post-surgery (Correct answer)
A patient awaiting discharge instructions for diabetes management

Correct answer: A patient who became suddenly confused and restless one hour post-surgery

Acute onset confusion and restlessness post-surgery may indicate hemorrhage, hypoxia, or other life-threatening complications requiring immediate assessment.

Question 157: A client who recently lost a limb says, 'I know I'll never be normal again, but I'm learning to adapt.' This statement reflects which phase of Kübler-Ross's grief model?

Acceptance (Correct answer)
Anger
Depression
Bargaining

Correct answer: Acceptance

Acceptance is characterized by acknowledging the loss and beginning to adapt to a new reality.

Question 158: A patient reports pain at a level of 7 on a 0-10 scale following surgery. Which non-pharmacological intervention can the nurse implement independently?

Administer a PRN analgesic
Apply a warm compress to the surgical site
Increase the IV opioid drip rate
Apply guided imagery and relaxation techniques (Correct answer)

Correct answer: Apply guided imagery and relaxation techniques

Guided imagery and relaxation techniques are independent nursing interventions that can complement pharmacological pain management without requiring a physician order.

Question 159: A patient with type 2 diabetes is prescribed metformin. Which condition is an absolute contraindication to its use?

Mild obesity
Hypertension controlled with ACE inhibitors
Stage 3b chronic kidney disease (GFR < 45 mL/min) (Correct answer)
History of urinary tract infections

Correct answer: Stage 3b chronic kidney disease (GFR < 45 mL/min)

Metformin is contraindicated in significant renal impairment (GFR < 30 mL/min and used cautiously below 45) due to risk of lactic acidosis.

Question 160: Which infection control measure is most effective in preventing catheter-associated urinary tract infections (CAUTI)?

Applying antibiotic ointment to the catheter insertion site daily
Routinely changing the catheter every 3 days
Removing the catheter as soon as it is no longer medically necessary (Correct answer)
Irrigating the catheter with sterile saline every 8 hours

Correct answer: Removing the catheter as soon as it is no longer medically necessary

The single most effective CAUTI prevention strategy is removing the urinary catheter as soon as possible, as infection risk increases significantly with each day of catheterization.

Question 161: A nurse is assisting a client who uses a cane. On which side should the cane be held?

Alternating sides with each step
The affected (weaker) side
Either side based on client preference
The unaffected (stronger) side (Correct answer)

Correct answer: The unaffected (stronger) side

The cane is held on the unaffected side so it bears weight simultaneously with the weaker leg, improving stability.

Question 162: A nurse is teaching a client about incentive spirometry after abdominal surgery. Which instruction is CORRECT?

Exhale forcefully into the device to measure lung capacity
Inhale slowly and deeply to raise the piston, then hold for 3–5 seconds (Correct answer)
Use the device once each morning after waking
Breathe rapidly and shallowly to increase respiratory rate

Correct answer: Inhale slowly and deeply to raise the piston, then hold for 3–5 seconds

Slow, deep inhalation followed by a brief breath-hold maximizes alveolar expansion and prevents atelectasis.

Question 163: A patient receiving total parenteral nutrition (TPN) develops sudden onset of chest pain, dyspnea, and decreased breath sounds on the left. The nurse should first suspect:

Air embolism from a disconnected tubing
Pneumothorax from central line insertion (Correct answer)
Catheter-related bloodstream infection
Hypoglycemia from incorrect TPN formulation

Correct answer: Pneumothorax from central line insertion

Pneumothorax is a known complication of central venous catheter insertion (required for TPN). Sudden chest pain, dyspnea, and unilateral absent breath sounds after line placement are classic signs. This is a medical emergency requiring immediate intervention.

Question 164: A charge nurse is reviewing assignments. Which task is MOST appropriate to delegate to an unlicensed assistive personnel (UAP)?

Changing a sterile wound dressing on a surgical incision
Assessing a patient's response to a new pain medication
Ambulating a stable post-op patient on day 2 (Correct answer)
Teaching a diabetic patient about foot care

Correct answer: Ambulating a stable post-op patient on day 2

Ambulating a stable post-operative patient is within the UAP's scope as it does not require assessment or clinical judgment.

Question 165: Which finding in a patient's health history most increases the risk for developing a pressure injury?

Ambulation with a cane and mild cognitive impairment
Controlled type 2 diabetes with HbA1c of 6.8%
BMI of 28 and history of hypertension
Braden Scale score of 12 and urinary incontinence (Correct answer)

Correct answer: Braden Scale score of 12 and urinary incontinence

A Braden Scale score of 12 indicates high pressure injury risk, and incontinence exposes skin to moisture, further increasing breakdown risk.

Question 166: A PN-RN is providing anticipatory guidance to parents of a 2-year-old. Which developmental milestone should the nurse expect the child to have achieved?

Tying shoelaces
Riding a tricycle independently
Speaking in complete sentences
Using a spoon with some spilling (Correct answer)

Correct answer: Using a spoon with some spilling

By age 2, children typically can use a spoon and fork, though some spilling is expected as fine motor skills are still developing.

Question 167: A nurse is preparing a patient for surgery and realizes the informed consent form is unsigned. The patient states they are ready to proceed. What should the nurse do?

Have the patient sign the form immediately and proceed
Document the verbal consent and continue with preparations
Proceed with preoperative preparation since the patient verbally consented
Notify the surgeon and delay the procedure until written informed consent is obtained (Correct answer)

Correct answer: Notify the surgeon and delay the procedure until written informed consent is obtained

A signed informed consent form is legally required before surgery; the nurse must notify the surgeon and halt the procedure until it is properly obtained.

Question 168: A patient diagnosed with schizophrenia reports hearing voices that tell them to harm themselves. How should the nurse classify this symptom?

Command auditory hallucination (Correct answer)
Illusion
Delusion of persecution
Visual hallucination

Correct answer: Command auditory hallucination

Command auditory hallucinations are voices that direct the patient to perform specific actions, including self-harm. These require immediate safety assessment and intervention.

Question 169: A nurse is caring for a patient with a nasogastric (NG) tube for enteral feeding. Before administering the feeding, what should the nurse verify first?

The patient's food preferences
Correct tube placement (Correct answer)
The patient's weight
The expiration date of the formula

Correct answer: Correct tube placement

Verifying correct NG tube placement before each feeding is essential to prevent pulmonary aspiration of feeding formula into the lungs.

Question 170: A postpartum client develops sudden severe headache, blurred vision, and a blood pressure of 158/104 mmHg on day 2 after delivery. Which is the nurse's priority action?

Administer prescribed PRN analgesic for headache relief
Notify the physician immediately and prepare for magnesium sulfate administration (Correct answer)
Encourage oral hydration and reassess blood pressure in 30 minutes
Position the client in left lateral recumbent position and document findings

Correct answer: Notify the physician immediately and prepare for magnesium sulfate administration

These findings indicate postpartum preeclampsia, a medical emergency requiring immediate physician notification and magnesium sulfate to prevent eclamptic seizures.

Question 171: A nurse is caring for a client experiencing anticipatory grief. Which intervention is most therapeutic?

Reassure the client that their fears may not come true
Provide a quiet environment and allow the client to express feelings freely (Correct answer)
Refer the client immediately to a psychiatrist
Encourage the client to stay positive and avoid dwelling on loss

Correct answer: Provide a quiet environment and allow the client to express feelings freely

Allowing free expression of feelings in a supportive environment is the most therapeutic approach to anticipatory grief.

Question 172: A patient's serum sodium is 128 mEq/L. Which symptom would the nurse most likely assess?

Hypertension and flushed skin
Extreme thirst and dry mucous membranes
Decreased deep tendon reflexes and bradycardia
Muscle cramps and irritability (Correct answer)

Correct answer: Muscle cramps and irritability

Hyponatremia (sodium <135 mEq/L) causes neurological symptoms including confusion, headache, muscle cramps, and irritability due to osmotic fluid shifts into brain cells.

Question 173: A nurse working the night shift notices a pattern of medication errors occurring on the unit over the past month. What is the most appropriate action?

Avoid reporting to prevent staff from getting in trouble
Speak only to the nurses involved about being more careful
Report individual nurses directly to the state board of nursing
Bring the concern to the nurse manager and submit a formal quality improvement report (Correct answer)

Correct answer: Bring the concern to the nurse manager and submit a formal quality improvement report

Identifying a pattern of errors requires a systems-level response; the nurse should escalate to management and engage the quality improvement process.

Question 174: A nurse is admitting a client with suspected active pulmonary tuberculosis (TB). Which of the following environmental controls is essential to implement for airborne precautions?

Wear a sterile gown and gloves for all client contact.
Place the client in a negative-pressure airflow room. (Correct answer)
Cohort the client with another client who has a respiratory infection.
Ensure the client wears a standard surgical mask at all times in the room.

Correct answer: Place the client in a negative-pressure airflow room.

Airborne precautions require placing the client in an airborne infection isolation room (AIIR), which is a negative-pressure room that prevents infectious particles from flowing out into adjacent areas. Staff must also wear a fitted N95 respirator when entering the room.

Question 175: A nurse is administering an IV piggyback antibiotic when the client reports burning and swelling at the IV site. Which action should the nurse take first?

Stop the infusion and remove the IV catheter
Stop the infusion and assess the site for infiltration or phlebitis (Correct answer)
Slow the infusion rate and apply a warm compress
Flush the line with normal saline and continue the infusion

Correct answer: Stop the infusion and assess the site for infiltration or phlebitis

The nurse must first stop the infusion and assess whether burning and swelling indicate infiltration, phlebitis, or extravasation before determining next steps.

Question 176: A nurse is preparing to administer a medication via a nasogastric tube. Which action ensures patient safety?

Crush all medications together and mix with the tube feeding formula
Administer medications without stopping the tube feeding
Use carbonated beverages to flush the tube after medication administration
Verify NG tube placement, flush with water before and after each medication, and administer medications separately (Correct answer)

Correct answer: Verify NG tube placement, flush with water before and after each medication, and administer medications separately

Proper NG tube medication administration requires verifying placement, flushing with water before and after, and giving each medication separately to prevent interactions and clogging.

Question 177: When providing oral care to an unconscious client, which position is MOST appropriate?

Prone with head to one side
High Fowler's (90 degrees)
Supine with head flat
Side-lying with head turned to the side (Correct answer)

Correct answer: Side-lying with head turned to the side

Side-lying with the head turned prevents aspiration of secretions during oral care in unconscious clients.

Question 178: A patient is scheduled for an MRI. Which item must the nurse ensure is removed before the procedure?

Cotton hospital gown
Non-metallic hair tie
Plastic identification bracelet
Hearing aids (Correct answer)

Correct answer: Hearing aids

Hearing aids contain metal components and batteries that can be damaged by or become projectiles in the strong magnetic field of an MRI, and they must be removed before the scan.

Question 179: Which principle BEST describes the nurse's legal accountability when delegating a task to a UAP?

The nurse is fully relieved of responsibility once the task is delegated
Accountability transfers to the charge nurse when delegation occurs
The UAP assumes full legal liability for any errors made during the task
The nurse retains accountability for appropriate delegation and must supervise outcomes (Correct answer)

Correct answer: The nurse retains accountability for appropriate delegation and must supervise outcomes

Delegation transfers the task but not the nurse's accountability; the delegating nurse remains responsible for appropriate delegation and oversight.

Question 180: A client is reporting pain rated at 8 on a 0-10 scale. After administering the prescribed analgesic, which non-pharmacological intervention would be most appropriate for the nurse to implement to provide additional comfort?

Encouraging the client to take a long walk.
Starting a rigorous physical therapy session.
Suggesting the client watch television as a distraction. (Correct answer)
Applying a cold pack to the surgical site from 4 hours ago.

Correct answer: Suggesting the client watch television as a distraction.

Distraction techniques, such as watching television or listening to music, can be effective non-pharmacological methods to help manage pain by shifting the client's focus away from the discomfort. Vigorous activity like a long walk or physical therapy would likely exacerbate acute pain. Applying a cold pack may be appropriate, but distraction is a versatile comfort measure that can be implemented easily.

Question 181: A nurse is preparing to delegate the task of ambulating a post-operative patient to an unlicensed assistive personnel (UAP). Which action is most important before delegation?

Ensure the UAP has been trained and is competent to perform the task (Correct answer)
Inform the charge nurse of the delegation decision
Ask the patient's family if they approve of the UAP performing the task
Document the delegation in the patient's chart first

Correct answer: Ensure the UAP has been trained and is competent to perform the task

Before delegating, the nurse must verify that the UAP has the training and competency to safely perform the specific task.

Question 182: A nurse is teaching a pregnant client about neural tube defect prevention. Which nutrient is most important to emphasize?

Vitamin D
Folic acid (Correct answer)
Calcium
Iron

Correct answer: Folic acid

Adequate folic acid intake (400–800 mcg/day) before and during early pregnancy significantly reduces the risk of neural tube defects such as spina bifida.

Question 183: A nurse is caring for a terminally ill client who states, 'If I can just live until my daughter's wedding, then I'll be ready to go.' This is an example of which stage of grief?

Anger
Bargaining (Correct answer)
Depression
Acceptance

Correct answer: Bargaining

Bargaining involves making deals or conditions in hopes of postponing death or loss.

Question 184: A nurse makes a medication error that does not harm the patient. What is the nurse's legal and ethical obligation?

Document the error only if asked by a supervisor
Wait to see if the patient develops symptoms before reporting
Keep the information confidential to avoid liability
Report the error through the facility's incident reporting system (Correct answer)

Correct answer: Report the error through the facility's incident reporting system

All medication errors, regardless of whether harm occurred, must be reported through the facility's incident reporting system to improve safety and prevent future errors.

Question 185: When assisting a patient with a bed bath, in which direction should the nurse wash the extremities?

Direction does not matter
In a circular motion only
Proximal to distal
Distal to proximal (Correct answer)

Correct answer: Distal to proximal

Washing from distal to proximal (from hands/feet toward the trunk) promotes venous return and follows the direction of blood flow back to the heart.

Question 186: The nurse is assessing a client who is 72 hours postoperative following a total hip arthroplasty. Which assessment finding is most indicative of a potential pulmonary embolism and requires immediate notification of the provider?

Pain at the surgical site rated 4 out of 10.
Sudden onset of shortness of breath and pleuritic chest pain. (Correct answer)
Temperature of 99.8°F (37.7°C) and diminished breath sounds in the lung bases.
Scant serosanguineous drainage on the surgical dressing.

Correct answer: Sudden onset of shortness of breath and pleuritic chest pain.

Sudden onset of dyspnea and pleuritic chest pain are hallmark signs of a pulmonary embolism (PE), a life-threatening complication of immobility and major surgery, especially orthopedic surgery. This finding constitutes a medical emergency requiring immediate intervention. While diminished breath sounds and a low-grade fever can indicate atelectasis, it is not as acutely life-threatening as a PE.

Question 187: When teaching a client how to use a standard cane, the nurse should instruct the client to hold the cane on which side?

Alternating sides with each step.
On whichever side feels more comfortable.
On the unaffected (stronger) side. (Correct answer)
On the affected (weaker) side.

Correct answer: On the unaffected (stronger) side.

The cane should be held on the client's stronger (unaffected) side to provide the best support and stability. The cane then moves forward with the weaker leg, creating a wide base of support and allowing the client to lean on the stronger side.

Question 188: Which nursing action BEST reduces the risk of a catheter-associated urinary tract infection (CAUTI)?

Irrigating the catheter every shift
Changing the catheter every 48 hours
Securing the catheter to the thigh and keeping the drainage bag below bladder level (Correct answer)
Cleaning the perineum with antiseptic solution three times daily

Correct answer: Securing the catheter to the thigh and keeping the drainage bag below bladder level

Securing the catheter and maintaining the drainage bag below bladder level prevents backflow and reduces CAUTI risk.

Question 189: A school nurse notices a 10-year-old with a BMI at the 88th percentile. Which is the most appropriate initial nursing action?

Assess the child's dietary habits and physical activity level (Correct answer)
Immediately refer the child to a dietitian
Notify the parents that the child is obese
Recommend a 1,200-calorie diet

Correct answer: Assess the child's dietary habits and physical activity level

A comprehensive assessment of diet and activity is the first step before planning any intervention for a child with an elevated BMI.

Question 190: A nurse is monitoring a patient who had a cardiac catheterization via the femoral artery 2 hours ago. Which finding requires immediate action?

Small bruise at the insertion site
Blood pressure of 128/78 mmHg
Expanding hematoma at the femoral access site (Correct answer)
Patient reports mild soreness at the groin

Correct answer: Expanding hematoma at the femoral access site

An expanding hematoma at the femoral access site indicates ongoing bleeding that requires immediate intervention including direct pressure and physician notification.

Question 191: A nurse is educating a client about testicular self-examination (TSE). When should TSE be performed?

Monthly after a warm shower (Correct answer)
Weekly before going to bed
Annually during a physical exam only
Monthly before a shower

Correct answer: Monthly after a warm shower

TSE should be performed monthly after a warm shower when scrotal skin is relaxed, making abnormalities easier to detect.

Question 192: What is the purpose of performing a 'time out' immediately before a surgical procedure?

To allow time for the anesthesia to take full effect
To give the patient time to reconsider the surgery
To allow the surgical team to rest before a long operation
To verify correct patient, procedure, and surgical site as a final safety check (Correct answer)

Correct answer: To verify correct patient, procedure, and surgical site as a final safety check

A surgical time out is a final verification pause to confirm correct patient identity, correct procedure, correct surgical site, and other safety elements before the first incision.

Question 193: A nurse is preparing to transfer a patient from bed to wheelchair. The patient can bear partial weight. Which action by the nurse is most important for safe transfer?

Instructing the patient to place both arms around the nurse's neck for support
Locking the wheelchair brakes and raising the footrests before the transfer (Correct answer)
Using a wide stance and bending at the waist to maintain balance during the lift
Placing the wheelchair at a 90-degree angle to the bed on the patient's weaker side

Correct answer: Locking the wheelchair brakes and raising the footrests before the transfer

Locking wheelchair brakes and raising footrests prevents the chair from rolling and eliminates a tripping hazard, which are essential safety steps before any transfer.

Question 194: A patient is receiving a blood transfusion and develops chills, fever, and back pain 15 minutes into the infusion. What should the nurse do first?

Continue the transfusion and monitor closely
Increase the IV flow rate to dilute the blood product
Slow the infusion rate and administer acetaminophen
Stop the transfusion immediately (Correct answer)

Correct answer: Stop the transfusion immediately

These symptoms suggest a hemolytic transfusion reaction. The nurse must stop the transfusion immediately to prevent further antigen-antibody reaction and potential organ damage.

Question 195: What is the recommended daily fluid intake for an average healthy adult?

1500-2000 mL
2500-3000 mL (Correct answer)
500-1000 mL
3500-4000 mL

Correct answer: 2500-3000 mL

The general recommendation for healthy adults is approximately 2500-3000 mL of fluid daily, though individual needs vary based on activity level, climate, and health status.

Question 196: A nurse is caring for a client receiving enteral tube feedings. Which assessment finding warrants IMMEDIATE action?

Abdomen that is firm, distended, and silent (Correct answer)
Client reports mild nausea after feeding rate increase
Residual gastric volume of 100 mL
Bowel sounds present in all four quadrants

Correct answer: Abdomen that is firm, distended, and silent

A firm, distended, silent abdomen suggests ileus or obstruction, which can cause aspiration or perforation and requires immediate intervention.

Question 197: A nurse is assessing a newborn's Apgar score at 5 minutes. The infant has a heart rate of 110, strong cry, active motion, grimaces with stimulation, and is completely pink. What is the Apgar score?

8
10 (Correct answer)
9
7

Correct answer: 10

Each of the five criteria (heart rate, respiratory effort, muscle tone, reflex, color) scores 2, giving a total Apgar score of 10.

Question 198: A nurse is assisting a patient with dysphagia. Which dietary modification is most appropriate to reduce the risk of aspiration?

NPO status until further evaluation
Regular diet with small bites
Thickened liquids (Correct answer)
Clear liquid diet

Correct answer: Thickened liquids

Thickened liquids slow the flow of liquid, giving the patient more time to control swallowing and reducing aspiration risk in patients with dysphagia.

Question 199: A 30-year-old client is recovering from a major surgery that has resulted in a significant change in body image. The client refuses to look at the surgical site. This behavior is an example of which defense mechanism?

Rationalization
Projection
Sublimation
Denial (Correct answer)

Correct answer: Denial

Denial is the refusal to accept reality or fact, acting as if a painful event, thought, or feeling did not exist. By refusing to look at the surgical site, the client is avoiding the reality of their changed body image. This is a common early coping mechanism following a traumatic event.

Question 200: A nurse discovers a medication error was made by a previous nurse. Which documentation action is correct?

File only an incident report and omit it from the patient's chart
Notify the supervisor verbally and make no written record until instructed
Correct the previous nurse's charting and add a note
Document the error in the patient's chart and file an incident report (Correct answer)

Correct answer: Document the error in the patient's chart and file an incident report

Medication errors must be documented in the patient's chart (objective facts only—what happened and patient's response) and reported via an incident/occurrence report. Altering another's documentation is falsification; omitting it from the chart is incomplete documentation.

NACE I PN-RN: Foundations of Nursing Exam

The Nursing Acceleration Challenge Exam (NACE I) PN-RN is administered by the National League for Nursing (NLN) to evaluate LPN/LVN candidates seeking advanced placement into RN programs, covering foundational nursing knowledge across clinical and professional domains.

200

Questions

240 min

Time Limit

75%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds