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

Question 1: A nurse receives a change-of-shift report on four clients. Which client should the nurse assess first?

A client admitted with gastritis who is reporting nausea and has not eaten breakfast.
A client postoperative day two following a cholecystectomy who is requesting pain medication.
A client with pneumonia who has a new onset of confusion and an oxygen saturation of 88% on 2L of oxygen. (Correct answer)
An older adult client who is scheduled for discharge and has questions about their new medications.

Correct answer: A client with pneumonia who has a new onset of confusion and an oxygen saturation of 88% on 2L of oxygen.

The client with pneumonia showing a new onset of confusion and low oxygen saturation is the highest priority. These are signs of worsening respiratory status and hypoxia, which is a life-threatening condition requiring immediate assessment and intervention. The other clients are more stable.

Question 2: 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.
Repositioning the client every 4 hours.
Keeping the skin clean and dry and using a moisturizer. (Correct answer)

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

On whichever side feels more comfortable.
Alternating sides with each step.
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 4: Which medication requires the nurse to monitor for ototoxicity as a serious adverse effect?

Metformin
Gentamicin (Correct answer)
Lisinopril
Amoxicillin

Correct answer: Gentamicin

Gentamicin is an aminoglycoside antibiotic with well-documented ototoxic and nephrotoxic effects. Peak and trough levels must be monitored.

Question 5: 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
Administer medications from memory since the nurse knows both patients
Ask a colleague to verify medications verbally

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 6: A nurse is teaching a group of parents about childhood immunizations. Which vaccine is recommended at birth in the US?

MMR
Hepatitis B (Correct answer)
DTaP
Varicella

Correct answer: Hepatitis B

The Hepatitis B vaccine is administered at birth as part of the recommended immunization schedule in the United States.

Question 7: A nurse observes that a fellow nurse consistently fails to perform hand hygiene between patients. What is the most appropriate initial action?

Discuss the observation privately with the colleague (Correct answer)
Report the nurse to the state board of nursing
Ignore it since it is not causing visible harm
Report anonymously to human resources

Correct answer: Discuss the observation privately with the colleague

Addressing the concern directly and privately with the colleague is the appropriate first step in peer accountability.

Question 8: A nurse is prioritizing care for multiple patients. Which framework is most appropriate for organizing tasks based on urgency?

Kohlberg's Moral Development
Piaget's Cognitive Theory
Maslow's Hierarchy of Needs (Correct answer)
Erikson's Developmental Stages

Correct answer: Maslow's Hierarchy of Needs

Maslow's Hierarchy of Needs helps nurses prioritize by addressing physiological and safety needs before higher-level needs.

Question 9: A nurse is counseling a client about primary prevention of type 2 diabetes. Which recommendation is most appropriate?

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

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 10: Which patient is most at risk for developing hypokalemia?

A patient taking hydrochlorothiazide for hypertension (Correct answer)
A patient with Addison's disease on fludrocortisone
A patient with oliguric acute kidney injury
A patient receiving potassium-sparing diuretics

Correct answer: A patient taking hydrochlorothiazide for hypertension

Thiazide diuretics such as hydrochlorothiazide promote renal potassium wasting through enhanced sodium-potassium exchange in the distal tubule, significantly increasing hypokalemia risk.

Question 11: Which finding indicates that a patient with diabetic ketoacidosis (DKA) is responding to treatment?

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

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

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

Correct answer: Near miss

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

Question 13: 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?

Using the TPN line to administer IV push antibiotics.
Monitoring blood glucose levels every 4 to 6 hours. (Correct answer)
Changing the central line dressing every 24 hours.
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 14: 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
Many patients feel this way, it's normal
I'll call the doctor right away
That must feel very frightening. Tell me more about what you're experiencing (Correct answer)

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 15: Which clinical finding is most consistent with hypocalcemia?

Bradycardia
Decreased deep tendon reflexes
Positive Trousseau's sign (Correct answer)
Hypertension

Correct answer: Positive Trousseau's sign

Trousseau's sign (carpal spasm with BP cuff inflation) is a hallmark of hypocalcemia due to increased neuromuscular excitability.

Question 16: A patient with cirrhosis develops asterixis, confusion, and elevated ammonia levels. Which physiological process is occurring?

Hepatic encephalopathy from impaired ammonia detoxification (Correct answer)
Subdural hematoma from coagulopathy
Cerebral infarction from portal hypertension
Wernicke's encephalopathy from thiamine deficiency

Correct answer: Hepatic encephalopathy from impaired ammonia detoxification

Hepatic encephalopathy results from the failing liver's inability to convert ammonia to urea, allowing ammonia to cross the blood-brain barrier and impair neurological function.

Question 17: A competent 80-year-old client with end-stage chronic obstructive pulmonary disease (COPD) has a living will that explicitly states they do not want mechanical ventilation. The client develops acute respiratory failure and becomes lethargic. The client's family insists that 'everything be done' to save them. Which action by the nurse demonstrates proper legal and ethical practice?

Honor the client's advance directive and advocate for comfort care measures. (Correct answer)
Ask the provider to request an ethics committee consultation to mediate the conflict.
Follow the family's wishes, as the client is no longer able to clearly communicate.
Initiate mechanical ventilation as requested by the family until the client is stable.

Correct answer: Honor the client's advance directive and advocate for comfort care measures.

A living will is a legal advance directive that outlines a competent client's wishes for medical treatment at the end of life. The nurse has an ethical and legal obligation to honor these documented wishes. The principle of autonomy dictates that the client's right to self-determination be respected. The nurse's primary role is to advocate for the client's wishes, which in this case involves providing comfort care rather than initiating unwanted life-sustaining treatment.

Question 18: Which electrolyte imbalance is most commonly associated with prolonged loop diuretic therapy such as furosemide?

Hypercalcemia
Hypernatremia
Hypokalemia (Correct answer)
Hypermagnesemia

Correct answer: Hypokalemia

Loop diuretics inhibit potassium reabsorption in the loop of Henle, making hypokalemia the most common electrolyte complication.

Question 19: A nurse is reviewing the lab results for a client with end-stage renal disease. The serum potassium level is 6.2 mEq/L. Which of the following is the priority nursing assessment?

Evaluating skin turgor and mucous membranes
Monitoring bowel sounds
Assessing for peripheral edema
Monitoring cardiac rate and rhythm (Correct answer)

Correct answer: Monitoring cardiac rate and rhythm

Hyperkalemia (an elevated potassium level) is a life-threatening emergency primarily because of its effect on the heart's electrical conduction system. It can lead to dangerous and fatal dysrhythmias, such as ventricular fibrillation and cardiac arrest. Therefore, continuous cardiac monitoring is the highest priority assessment.

Question 20: A patient with type 2 diabetes is prescribed metformin. Which condition is an absolute contraindication to its use?

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

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 21: A nurse is preparing to delegate morning care tasks. The UAP states, 'I don't know how to do that.' What is the correct nursing action?

Accept the statement and assign a different task without further inquiry
Assess the UAP's knowledge gap and provide education or choose not to delegate that task (Correct answer)
Insist the UAP perform the task anyway since it is within their job description
Document the refusal and reassign the patient to another UAP

Correct answer: Assess the UAP's knowledge gap and provide education or choose not to delegate that task

The delegating nurse must verify competency; if the UAP lacks the skill, the nurse must either provide education or retain the task rather than risk patient safety.

Question 22: A new mother two weeks postpartum tells the nurse she has thoughts of harming her baby. What is the priority nursing action?

Suggest she take a nap while someone watches the baby
Reassure her that these feelings are normal for new mothers
Assess for postpartum psychosis and ensure immediate safety of the mother and infant (Correct answer)
Schedule a follow-up appointment in one week

Correct answer: Assess for postpartum psychosis and ensure immediate safety of the mother and infant

Thoughts of harming the baby are a red flag for postpartum psychosis, a psychiatric emergency requiring immediate safety assessment and intervention.

Question 23: A patient is receiving IV amphotericin B. Which assessment finding is most expected and requires ongoing monitoring?

Decreased white blood cell count
Rising serum creatinine (Correct answer)
Prolonged prothrombin time
Elevated blood glucose

Correct answer: Rising serum creatinine

Nephrotoxicity is the most significant dose-limiting adverse effect of amphotericin B, requiring frequent monitoring of renal function.

Question 24: During a disaster, which triage category receives treatment first?

Green tag: minor injuries, can wait
Red tag: immediate, life-threatening conditions (Correct answer)
Black tag: deceased or expected to die
Yellow tag: delayed, serious but not immediately life-threatening

Correct answer: Red tag: immediate, life-threatening conditions

Red-tagged patients have life-threatening but treatable conditions and receive the highest priority for treatment in disaster triage.

Question 25: What is the best crutch gait to use if a patient is not permitted to put any weight on their left leg?

two-point.
three-point. (Correct answer)
four-point.
swing-through.

Correct answer: three-point.

The best crutch gait is three-point if a patient is not allowed to put any weight on their left leg. With this gait, the crutches initially carry all of the weight. The person advances both crutches as the unaffected leg moves forward and then takes all the weight. Normally, the left leg is kept slightly bent, or if that isn't possible, it is stretched slightly in front.

Question 26: A patient diagnosed with schizophrenia reports hearing voices that tell them to harm themselves. How should the nurse classify this symptom?

Illusion
Delusion of persecution
Command auditory hallucination (Correct answer)
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 27: Which action by the nurse BEST promotes sleep hygiene for a hospitalized client?

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

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 28: Which client is at greatest risk for developing hypermagnesemia?

A client with nasogastric suction for 3 days
A 70-year-old with chronic kidney disease taking magnesium-containing antacids (Correct answer)
A postpartum client receiving oxytocin
A 25-year-old with Crohn's disease on TPN

Correct answer: A 70-year-old with chronic kidney disease taking magnesium-containing antacids

Impaired renal excretion combined with magnesium intake from antacids places clients with chronic kidney disease at highest risk for hypermagnesemia.

Question 29: A nurse is teaching a client about incentive spirometry after abdominal surgery. Which instruction is CORRECT?

Inhale slowly and deeply to raise the piston, then hold for 3–5 seconds (Correct answer)
Use the device once each morning after waking
Exhale forcefully into the device to measure lung capacity
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 30: What is the recommended daily fluid intake for an average healthy adult?

3500-4000 mL
2500-3000 mL (Correct answer)
500-1000 mL
1500-2000 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 31: 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
Catheter occlusion
Hyperglycemia
Air embolism (Correct answer)

Correct answer: Air embolism

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

Question 32: A patient taking phenytoin for seizure disorder has a serum level of 25 mcg/mL. Which symptom should the nurse assess for?

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

Correct answer: Nystagmus, ataxia, and confusion

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

Question 33: When administering a peripheral IV infusion, the nurse notices the site is cool, pale, and swollen. What is the priority action?

Apply a warm compress over the site
Elevate the extremity and continue the infusion
Discontinue the IV and restart at a new site (Correct answer)
Slow the infusion rate and reassess in 30 minutes

Correct answer: Discontinue the IV and restart at a new site

Coolness, pallor, and swelling indicate infiltration; the IV must be discontinued immediately and restarted at a new site to prevent tissue damage.

Question 34: Which behavior by a nurse best demonstrates professional accountability?

Acknowledging an error, completing an incident report, and implementing corrective measures (Correct answer)
Blaming a medication error on the pharmacy that dispensed the wrong dose
Asking a colleague to co-sign the incident report to share responsibility
Only reporting errors that resulted in patient harm

Correct answer: Acknowledging an error, completing an incident report, and implementing corrective measures

Professional accountability means accepting responsibility for one's actions, transparently reporting errors, and taking steps to prevent recurrence.

Question 35: A nurse is caring for a patient with a central venous catheter. Which complication should the nurse monitor for during and immediately after insertion?

Pneumothorax (Correct answer)
Peripheral neuropathy
Cellulitis
Phlebitis

Correct answer: Pneumothorax

Pneumothorax is an acute complication of central venous catheter insertion, particularly with subclavian or internal jugular approaches, caused by accidental lung puncture.

Question 36: 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?

Ask the patient's family if they approve of the UAP performing the task
Ensure the UAP has been trained and is competent to perform the task (Correct answer)
Inform the charge nurse of the delegation decision
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 37: A patient on mechanical ventilation has a PaCO2 of 55 mmHg and pH of 7.28. The ventilator rate is 12 breaths/min. What adjustment would correct the respiratory acidosis?

Increase the FiO2
Increase the respiratory rate (Correct answer)
Add PEEP to the circuit
Decrease the tidal volume

Correct answer: Increase the respiratory rate

Increasing the respiratory rate increases minute ventilation, eliminating more CO2 and correcting respiratory acidosis.

Question 38: A nurse is assessing a patient's nutritional status. Which laboratory value is the best indicator of protein status?

Blood glucose
Hemoglobin
Serum albumin (Correct answer)
Serum potassium

Correct answer: Serum albumin

Serum albumin reflects protein status and is commonly used as a marker of nutritional health, though it has a long half-life of approximately 20 days.

Question 39: A charge nurse is reviewing assignments. Which task is MOST appropriate to delegate to an unlicensed assistive personnel (UAP)?

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

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

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

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 41: A client asks the nurse about sun safety to reduce skin cancer risk. Which statement by the nurse is most accurate?

SPF 15 sunscreen is sufficient for all-day outdoor activities
Tanning beds are safer than direct sunlight
Sunscreen should be applied 30 minutes before sun exposure (Correct answer)
A base tan provides adequate UV protection

Correct answer: Sunscreen should be applied 30 minutes before sun exposure

Sunscreen should be applied 15–30 minutes before sun exposure to allow it to bind effectively to the skin.

Question 42: 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:

Manipulative behavior that should be confronted directly
Displacement of anger as part of the grief process (Correct answer)
Rational frustration that requires an apology from the nurse
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 43: A nurse is assessing a client for osteoporosis risk. Which client is at highest risk?

A 60-year-old Asian female with a low BMI who smokes (Correct answer)
A 65-year-old White male with a history of high dairy intake
A 50-year-old Hispanic female who takes calcium supplements
A 55-year-old Black male who exercises regularly

Correct answer: A 60-year-old Asian female with a low BMI who smokes

Risk factors for osteoporosis include female sex, Asian ethnicity, low body weight, smoking, and postmenopausal status — this client has multiple risk factors.

Question 44: A nurse is administering total parenteral nutrition (TPN) through a central line. Which nursing action is essential?

Add medications directly into the TPN bag
Administer TPN through a peripheral IV line for convenience
Run TPN at a rapid rate to complete it within 12 hours
Monitor blood glucose levels regularly (Correct answer)

Correct answer: Monitor blood glucose levels regularly

TPN contains high concentrations of dextrose that can cause hyperglycemia. Blood glucose monitoring every 4-6 hours is essential during TPN administration.

Question 45: 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?

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

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 46: Which nursing intervention best reduces the risk of aspiration in a client receiving continuous enteral tube feedings?

Keep the head of bed elevated at 30–45 degrees (Correct answer)
Check residual volumes once per shift
Flush the tube with 30 mL water every 8 hours
Administer feedings at room temperature

Correct answer: Keep the head of bed elevated at 30–45 degrees

Elevating the head of the bed 30–45 degrees reduces gastroesophageal reflux and the risk of aspiration pneumonia.

Question 47: 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?

Abduction (Correct answer)
Internal rotation
Adduction
Flexion

Correct answer: Abduction

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

Question 48: 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?

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.
Pain at the surgical site rated 4 out of 10.
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 49: A nurse must perform hand hygiene after caring for a patient with C. difficile. Which method is preferred?

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

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

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

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 51: 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)
Depression
Bargaining
Anger

Correct answer: Acceptance

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

Question 52: A patient who had a colectomy for a bowel obstruction is being uncooperative and won't turn over or get out of bed. Which evaluation has precedence?

Emotional status.
Wound
Pain. (Correct answer)
Vital signs.

Correct answer: Pain.

The most frequent cause of inability to move following surgery is pain, thus a patient who has had a colectomy for a bowel blockage and is unwilling to turn, get out of bed, or cooperate should probably first be evaluated for pain. The wound should next be checked, vital signs obtained, and the patient's emotional state should be assessed. The patient could worry that moving will make their discomfort worse or might rip or open their wound.

Question 53: A nurse is teaching a client about colon cancer screening. At what age should average-risk adults begin colorectal cancer screening?

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

Correct answer: 45 years

Current US guidelines recommend colorectal cancer screening beginning at age 45 for average-risk adults.

Question 54: A client with diabetes mellitus is prescribed metformin and is scheduled for a CT scan with contrast dye. Which nursing action is most important prior to the procedure?

Monitor blood glucose every 2 hours post-procedure
Administer an insulin sliding scale before the scan
Hold metformin before and after the procedure as ordered (Correct answer)
Encourage the client to increase fluid intake the day before

Correct answer: Hold metformin before and after the procedure as ordered

Metformin must be held before contrast administration and for 48 hours after because contrast media can impair renal function, causing metformin accumulation and lactic acidosis.

Question 55: Tetanus, diphtheria, and pertussis (Tdap) vaccine is recommended for adults.

one time. (Correct answer)
annually.
every 5 years.
every 10 years.

Correct answer: one time.

Tetanus, diphtheria, and pertussis (Tdap) vaccinations are recommended for adults once only. The Td booster, which serves as a booster for tetanus and diphtheria but not pertussis, should thereafter be given to the patient every ten years. Tdap vaccinations are often administered to children between the ages of 11 and 12, but adults who have not yet had this shot should do so right away. The Tdap vaccine should also be given to expectant mothers in order to protect the unborn child from pertussis.

Question 56: 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
Negligence
Malpractice
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 57: 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
Metabolic Acidosis (Correct answer)
Respiratory Alkalosis
Respiratory Acidosis

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 58: Which action by a nurse constitutes abandonment of a patient?

Requesting reassignment due to a conflict of interest
Leaving the unit at the end of a scheduled shift after giving proper report
Refusing an assignment due to lack of competency in the specialty area
Accepting a patient assignment and then leaving without transferring care to another nurse (Correct answer)

Correct answer: Accepting a patient assignment and then leaving without transferring care to another nurse

Patient abandonment occurs when a nurse accepts responsibility for a patient and then leaves without ensuring continuity of care through proper transfer to another qualified nurse.

Question 59: A patient's culture results show Clostridioides difficile (C. diff) infection. Which precaution must the nurse implement?

Droplet precautions with surgical mask
Airborne precautions with N95 respirator
Standard precautions with alcohol-based hand rub
Contact precautions with soap and water hand hygiene (Correct answer)

Correct answer: Contact precautions with soap and water hand hygiene

C. difficile forms spores that are resistant to alcohol-based hand sanitizers. Contact precautions with soap and water hand washing are required to physically remove spores.

Question 60: A nurse is documenting client care. Which principle of accurate documentation should the nurse follow?

Use approved abbreviations and record only objective findings (Correct answer)
Document care in advance to save time during a busy shift
Correct errors by using correction fluid (white-out)
Leave blank spaces in the chart for later additions

Correct answer: Use approved abbreviations and record only objective findings

Accurate documentation requires use of facility-approved abbreviations, objective language, and timely, factual entries without leaving blank spaces.

Question 61: A patient with heart failure is prescribed furosemide. Which electrolyte imbalance is the priority concern?

Hyperkalemia
Hypercalcemia
Hypokalemia (Correct answer)
Hypernatremia

Correct answer: Hypokalemia

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

Question 62: A nurse is implementing fall prevention for a patient taking multiple medications. Which medication class poses the greatest fall risk?

Benzodiazepines (Correct answer)
Antibiotics
Proton pump inhibitors
Thyroid hormones

Correct answer: Benzodiazepines

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

Question 63: A nurse is creating a plan of care for a client newly diagnosed with an acute deep vein thrombosis (DVT) in the left leg. Which of the following nursing interventions should be included in the plan?

Elevating the affected extremity while the client is in bed. (Correct answer)
Applying sequential compression devices (SCDs) to both legs.
Massaging the affected calf gently to reduce pain.
Encouraging active range-of-motion exercises for the affected leg.

Correct answer: Elevating the affected extremity while the client is in bed.

For a client with an acute DVT, elevating the affected leg is recommended to promote venous return by gravity, which helps decrease edema and pain. Massaging the leg, applying SCDs to the affected limb, and performing active range-of-motion exercises are contraindicated as they can dislodge the thrombus, potentially leading to a life-threatening pulmonary embolism.

Question 64: 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
The expiration date of the formula
Correct tube placement (Correct answer)
The patient's weight

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

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

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

Disturbed body image (Correct answer)
Deficient knowledge
Risk for infection
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 67: When using SBAR communication during a hand-off report, what information belongs in the 'Background' section?

The nurse's assessment of the patient's current status
The patient's current vital signs and chief complaint
The nurse's recommended plan of care for the next shift
Relevant medical history, admitting diagnosis, and current medications (Correct answer)

Correct answer: Relevant medical history, admitting diagnosis, and current medications

Background includes pertinent clinical history such as admitting diagnosis, relevant past medical history, and current medications.

Question 68: A nurse is preparing to administer a medication via a nasogastric tube. Which action ensures patient safety?

Use carbonated beverages to flush the tube after medication administration
Administer medications without stopping the tube feeding
Crush all medications together and mix with the tube feeding formula
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 69: An RN on a medical-surgical unit is planning assignments for the upcoming shift. The team consists of another RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which task is most appropriate for the RN to delegate to the LPN?

Developing the nursing plan of care for a client with a new diagnosis of diabetes.
Administering a dose of intravenous (IV) push furosemide.
Completing the initial admission assessment for a new client.
Performing a sterile dressing change on a client's 10-day old surgical wound. (Correct answer)

Correct answer: Performing a sterile dressing change on a client's 10-day old surgical wound.

The scope of practice for an LPN typically includes performing routine procedures like sterile dressing changes on chronic or stable wounds. Initial assessments, developing the plan of care, and administering IV push medications are complex tasks that require the advanced assessment and clinical judgment of an RN.

Question 70: A nurse finds a patient on the floor next to the bed. After ensuring safety, which action should be taken NEXT?

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

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 71: Which client is at highest risk for developing pressure injuries and requires the most intensive skin assessment?

A 60-year-old client with type 2 diabetes who walks with assistance
A 70-year-old client with mild cognitive impairment who is alert and mobile
A 45-year-old ambulatory client with controlled hypertension
An 80-year-old client who is incontinent, malnourished, and bedridden (Correct answer)

Correct answer: An 80-year-old client who is incontinent, malnourished, and bedridden

Advanced age, immobility, incontinence, and malnutrition are all major independent risk factors that together create the highest risk profile for pressure injury.

Question 72: Which IV solution is classified as isotonic?

0.9% sodium chloride (Correct answer)
3% sodium chloride
0.45% sodium chloride
5% dextrose in 0.45% sodium chloride

Correct answer: 0.9% sodium chloride

0.9% sodium chloride (normal saline) is isotonic with an osmolality of approximately 308 mOsm/L, close to plasma osmolality, so it does not cause fluid shifts into or out of cells.

Question 73: Which of the following best describes the concept of 'continuity of care' in nursing practice?

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)
Assigning the same nurse to a patient every shift to build rapport
Ensuring all nursing documentation is completed before the end of each shift

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 74: A patient says, 'I feel like no one really listens to me.' Which nurse response demonstrates the best therapeutic communication technique?

'Tell me more about what you mean by that.' (Correct answer)
'Don't worry—all the nurses here care about you.'
'I'm sure that's not true. Everyone tries their best.'
'You should speak with the charge nurse about your concerns.'

Correct answer: 'Tell me more about what you mean by that.'

Open-ended statements like 'Tell me more' encourage the patient to elaborate and show genuine interest. Reassuring ('don't worry') or minimizing responses block communication. Redirecting to another nurse dismisses the patient's concern.

Question 75: A patient receiving total parenteral nutrition (TPN) develops tetany and muscle spasms. Which laboratory finding would confirm hypomagnesemia?

Serum magnesium 2.5 mEq/L
Serum magnesium 0.8 mEq/L (Correct answer)
Serum magnesium 1.8 mEq/L
Serum magnesium 3.0 mEq/L

Correct answer: Serum magnesium 0.8 mEq/L

The normal serum magnesium level is 1.5–2.5 mEq/L; a level of 0.8 mEq/L confirms hypomagnesemia, which causes neuromuscular irritability and tetany similar to hypocalcemia.

Question 76: The nurse is preparing to administer insulin glargine (Lantus) to a patient. Which action is correct?

Mix with regular insulin in the same syringe for convenience
Shake the vial vigorously to mix before drawing up
Administer subcutaneously at the same time each day (Correct answer)
Give IV push if the patient is NPO before surgery

Correct answer: Administer subcutaneously at the same time each day

Insulin glargine is a long-acting basal insulin given subcutaneously once daily at the same time; it must never be mixed or given IV.

Question 77: Which situation represents a potential conflict of interest that a nurse must report?

A nurse receiving a referral commission from a home health agency (Correct answer)
A nurse caring for a neighbor who requested her specifically
A nurse accepting a small gift basket from a client's family after discharge
A nurse discussing a client's progress with the client's authorized spouse

Correct answer: A nurse receiving a referral commission from a home health agency

Accepting financial incentives such as referral commissions from agencies creates a conflict of interest and may violate professional and institutional ethics standards.

Question 78: Which assessment tool is most commonly used by nurses to screen for depression in adult patients?

Braden Scale
Patient Health Questionnaire-9 (PHQ-9) (Correct answer)
CAGE Questionnaire
Glasgow Coma Scale

Correct answer: Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 is a validated, widely used screening tool that assesses the nine DSM criteria for major depressive disorder over the past two weeks.

Question 79: A postoperative client is encouraged to ambulate as soon as possible. Which of the following is the primary rationale for early ambulation?

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

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

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

Correct answer: Serum calcium

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

Question 81: A client reports constipation. Which non-pharmacological intervention should the nurse recommend FIRST?

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

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 82: 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)
Acceptance
Depression

Correct answer: Bargaining

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

Question 83: 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?

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
Irrigate the catheter with sterile saline and proceed

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 84: 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 85: According to the ANA Code of Ethics, which statement best describes the nurse's primary commitment?

To the insurance company
To the physician's orders
To the patient (Correct answer)
To the healthcare organization

Correct answer: To the patient

The ANA Code of Ethics Provision 2 states that the nurse's primary commitment is to the patient, whether an individual, family, group, community, or population.

Question 86: 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 87: An older adult patient with mild dementia is being discharged. When obtaining consent for a home health referral, the nurse should:

Skip consent because the patient has a dementia diagnosis
Assess the patient's decision-making capacity for this specific decision (Correct answer)
Refer the matter to the hospital attorney
Obtain consent only from the next of kin

Correct answer: Assess the patient's decision-making capacity for this specific decision

A dementia diagnosis does not automatically negate decision-making capacity; the nurse must assess capacity for each specific decision.

Question 88: Which nursing action best demonstrates the principle of beneficence?

Administering ordered pain medication before a painful procedure (Correct answer)
Allowing a patient to refuse a prescribed treatment
Keeping patient information confidential
Obtaining informed consent before a procedure

Correct answer: Administering ordered pain medication before a painful procedure

Beneficence means acting in the patient's best interest; proactively managing pain before a procedure promotes well-being.

Question 89: A patient is at risk for falls. Which intervention is most effective for fall prevention?

Administering sedation at night to prevent wandering
Ensuring the call light is within reach and the bed is in the lowest position (Correct answer)
Keeping all four side rails raised at all times
Applying a vest restraint during all waking hours

Correct answer: Ensuring the call light is within reach and the bed is in the lowest position

Ensuring the call light is within reach and the bed is in the lowest position are evidence-based fall prevention strategies that maintain patient dignity and independence.

Question 90: Which assessment finding best indicates that a client is at risk for complicated grief?

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

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

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

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

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

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

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

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 94: 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?

Denial (Correct answer)
Rationalization
Projection
Sublimation

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

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

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 96: 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
7
5

Correct answer: 6

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

Question 97: 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?

Self-actualization
Love and belonging
Coping and adaptation (Correct answer)
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 98: A patient is prescribed heparin 5,000 units subcutaneously. The vial contains 10,000 units/mL. How many mL should the nurse administer?

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

Correct answer: 0.5 mL

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

Question 99: A patient's ABG results show: pH 7.30, PaCO2 38 mmHg, HCO3- 18 mEq/L. How should the nurse interpret these results?

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

Correct answer: Metabolic acidosis

A pH of 7.30 (acidosis), normal PaCO2 (38 mmHg), and low HCO3- (18 mEq/L) indicate metabolic acidosis as the primary disorder, with the respiratory system not yet compensating.

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

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

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

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

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

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

Correct answer: PPSV23 (Pneumovax)

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

Question 103: Which nursing intervention is most appropriate for a patient experiencing constipation?

Restrict fluid intake to thicken stool
Administer an enema immediately
Place the patient on bed rest
Encourage a high-fiber diet and increased fluid intake (Correct answer)

Correct answer: Encourage a high-fiber diet and increased fluid intake

A high-fiber diet combined with adequate fluid intake promotes normal bowel function by adding bulk to stool and facilitating peristalsis.

Question 104: A patient with terminal cancer is enrolled in hospice. Which statement BEST describes the goal of hospice care?

Transfer the patient to a skilled nursing facility for 24-hour monitoring
Provide comfort and quality of life when curative treatment is no longer the goal (Correct answer)
Prolong life as long as possible using all available interventions
Cure the underlying disease through aggressive treatment

Correct answer: Provide comfort and quality of life when curative treatment is no longer the goal

Hospice care focuses on comfort, dignity, and quality of life for patients with a terminal prognosis (typically ≤6 months). It is palliative—not curative—and supports both the patient and family through the dying process. Aggressive curative interventions are withdrawn.

Question 105: A charge nurse observes a licensed practical nurse (LPN) performing a task outside their scope of practice. What is the charge nurse's immediate priority?

Immediately stop the task and ensure client safety (Correct answer)
File a formal incident report before speaking to the LPN
Ask the client if they consent to the LPN performing the task
Allow the LPN to complete the task and address it later

Correct answer: Immediately stop the task and ensure client safety

Client safety is the immediate priority; the charge nurse must stop the out-of-scope activity at once, then follow up with documentation and education.

Question 106: A client with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department with increased shortness of breath. An arterial blood gas (ABG) analysis reveals the following: pH 7.28, PaCO2 55 mmHg, HCO3 26 mEq/L. How should the nurse interpret these findings?

Respiratory Alkalosis, Compensated
Respiratory Acidosis, Uncompensated (Correct answer)
Metabolic Acidosis, Uncompensated
Metabolic Alkalosis, Partially Compensated

Correct answer: Respiratory Acidosis, Uncompensated

The pH of 7.28 is below the normal range (7.35-7.45), indicating acidosis. The PaCO2 of 55 mmHg is elevated (normal is 35-45 mmHg), which points to a respiratory cause. The HCO3 of 26 mEq/L is within the normal range (22-26 mEq/L), indicating that the metabolic system has not yet compensated for the respiratory acidosis.

Question 107: When triaging four patients in the emergency department, which patient requires the highest priority of care?

A 45-year-old with a laceration on the forearm requiring sutures
A 72-year-old with a urinary tract infection and low-grade fever
A 60-year-old with chest pain radiating to the left arm and diaphoresis (Correct answer)
A 28-year-old with an ankle sprain and mild swelling

Correct answer: A 60-year-old with chest pain radiating to the left arm and diaphoresis

Chest pain with radiation to the left arm and diaphoresis are classic signs of a myocardial infarction, a life-threatening emergency requiring immediate intervention.

Question 108: A nurse receives shift report on a client with a serum sodium of 122 mEq/L. Which clinical manifestation is most critical to assess for immediately?

Dry mucous membranes and poor skin turgor
Seizure activity and decreased level of consciousness (Correct answer)
Orthostatic hypotension and tachycardia
Muscle cramps and hyperreflexia

Correct answer: Seizure activity and decreased level of consciousness

Severe hyponatremia (sodium <125 mEq/L) causes cerebral edema, leading to seizures and altered consciousness, which are life-threatening.

Question 109: What is the purpose of performing a 'time out' immediately before a surgical procedure?

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

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 110: 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?

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.
Keeping the sterile field at or above waist level.
Reaching over the sterile field to discard a used dressing. (Correct answer)

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 111: A nurse is educating a client about the DASH diet for hypertension management. Which food choice is consistent with DASH diet principles?

Salted pretzels with cream cheese dip
Grilled salmon with steamed broccoli (Correct answer)
Canned soup with 900 mg sodium
White bread with processed cheese

Correct answer: Grilled salmon with steamed broccoli

The DASH diet emphasizes fruits, vegetables, lean proteins, and low-sodium foods; grilled salmon with steamed broccoli aligns with these principles.

Question 112: When teaching a client about a low-sodium diet, which food choice indicates the client needs further instruction?

Canned tomato soup (Correct answer)
Apple slices with peanut butter
Fresh baked chicken breast
Fresh steamed broccoli

Correct answer: Canned tomato soup

Canned soups are typically very high in sodium and are not appropriate for a low-sodium diet.

Question 113: 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
Obtain baseline hearing assessment and renal function tests (Correct answer)
Check the patient's blood glucose level

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 114: 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?

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

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 115: Which IV fluid is considered isotonic and is most appropriate for replacing extracellular fluid losses?

D10W
3% NaCl
0.45% NaCl
0.9% NaCl (Correct answer)

Correct answer: 0.9% NaCl

0.9% NaCl (normal saline) is isotonic and expands extracellular fluid without shifting water into or out of cells.

Question 116: A nurse is providing discharge teaching to a patient with newly diagnosed hypertension. Which lifestyle modification should be emphasized first?

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

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 117: A nurse is providing hygiene care to an unconscious client. Which action is essential to prevent injury?

Having another staff member present to help with turning and positioning. (Correct answer)
Providing perineal care from the rectum toward the urethra.
Soaking the feet in hot water to soften the skin.
Using lemon-glycerin swabs for oral care.

Correct answer: Having another staff member present to help with turning and positioning.

Turning and positioning an unconscious client requires at least two staff members to ensure the client's safety, prevent musculoskeletal injury to both the client and the staff, and maintain proper body alignment. Hot water can cause burns, especially in clients with decreased sensation. Lemon-glycerin swabs can dry out the oral mucosa. Perineal care should be performed from the urethra toward the rectum (front to back) to prevent urinary tract infections.

Question 118: 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?

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

Correct answer: Malignant hyperthermia

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

Question 119: A PN receives a verbal telephone order from a physician for a medication. What is the correct process for handling this order?

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

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 120: 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?

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

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

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

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 122: A nurse suspects a patient is experiencing elder abuse. Under mandatory reporting laws, the nurse must:

Discuss findings only with the attending physician
Wait for the patient to disclose the abuse voluntarily
Confirm the abuse before reporting
Report the suspicion to Adult Protective Services (Correct answer)

Correct answer: Report the suspicion to Adult Protective Services

Mandatory reporting laws require nurses to report suspected elder abuse to Adult Protective Services; confirmation is not required before reporting.

Question 123: A patient develops hypophosphatemia after several days NPO without phosphate supplementation. Which complication is the nurse most concerned about?

Pathological bone fractures from calcification
Peaked T waves and cardiac arrhythmias
Renal calculi formation
Muscle weakness and respiratory failure (Correct answer)

Correct answer: Muscle weakness and respiratory failure

Hypophosphatemia impairs ATP production, leading to profound muscle weakness that can affect the diaphragm and intercostal muscles, causing life-threatening respiratory failure.

Question 124: 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
Anxiety about the surgical procedure
Fear of postoperative pain

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 125: A nurse notices a client has been isolating herself and crying frequently since her husband's death two weeks ago. The nurse's best initial action is to:

Document the behavior and notify the physician
Sit with the client and offer presence without pressure to talk (Correct answer)
Encourage the client to join group therapy immediately
Administer a PRN anxiolytic as ordered

Correct answer: Sit with the client and offer presence without pressure to talk

Offering therapeutic presence acknowledges the client's grief and communicates support without imposing expectations.

Question 126: A nurse is educating a client about testicular self-examination (TSE). When should TSE be performed?

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

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 127: A nurse is caring for a patient who reports chest pain radiating to the left arm. Which action should the nurse take first?

Obtain a 12-lead ECG
Assess the patient's pain characteristics and vital signs (Correct answer)
Apply oxygen via nasal cannula
Administer aspirin as ordered

Correct answer: Assess the patient's pain characteristics and vital signs

Assessment is always the first step in the nursing process. The nurse must gather data about the pain and current vital signs before initiating interventions.

Question 128: A nurse suspects that an elderly patient is being financially exploited by a family member. What is the nurse's legal obligation?

Document the suspicion but take no further action
Report the suspected abuse to Adult Protective Services (Correct answer)
Discuss the concern with the family member first
Wait for definitive proof before reporting

Correct answer: Report the suspected abuse to Adult Protective Services

Nurses are mandated reporters of suspected elder abuse, including financial exploitation. Reasonable suspicion is sufficient to trigger reporting.

Question 129: 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?

Instruct the UAP to place the patient in Trendelenburg position immediately
Call the physician with the reported value right away
Ask the UAP to recheck the blood pressure in 15 minutes
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 130: A nurse is preparing a patient for a lumbar puncture. Which position should the patient be placed in?

Sitting upright leaning forward over a bedside table
Prone with a pillow under the abdomen
Lateral recumbent with knees drawn to chest and chin tucked (Correct answer)
Supine with legs elevated

Correct answer: Lateral recumbent with knees drawn to chest and chin tucked

The lateral recumbent (fetal) position with knees drawn to the chest and chin tucked maximally opens the intervertebral spaces for needle insertion during lumbar puncture.

Question 131: A nurse is educating a patient about proper use of a metered-dose inhaler (MDI) without a spacer. Which instruction is correct?

Use the inhaler while lying flat in bed for maximum effect
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)
Inhale rapidly and deeply when pressing the canister

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 132: A PN is caring for four patients. Which patient should the PN assess FIRST?

A patient with COPD whose oxygen saturation dropped from 94% to 88% (Correct answer)
A post-op cholecystectomy patient on day 1 rating pain as 3/10
A patient waiting for discharge instructions
A patient with type 2 diabetes requesting a snack

Correct answer: A patient with COPD whose oxygen saturation dropped from 94% to 88%

A drop in oxygen saturation in a COPD patient represents a potentially life-threatening change in respiratory status and requires immediate assessment.

Question 133: A nurse observes that a hospitalized 4-year-old child is clinging to a blanket and sucking their thumb. How should the nurse interpret this behavior?

The child has a developmental delay requiring referral
The child is being defiant and needs behavioral correction
This is regression, a normal coping mechanism during stress (Correct answer)
This indicates inadequate parenting at home

Correct answer: This is regression, a normal coping mechanism during stress

Regression, reverting to behaviors of an earlier developmental stage, is a normal coping mechanism in young children experiencing the stress of hospitalization.

Question 134: A nurse is caring for a patient in four-point restraints. How frequently must the nurse assess the patient?

Once per shift
Every 2 hours for medical restraints, every 15 minutes to 1 hour for behavioral restraints (Correct answer)
Only when the patient requests an assessment
Every 4 hours

Correct answer: Every 2 hours for medical restraints, every 15 minutes to 1 hour for behavioral restraints

Behavioral health restraints require assessment every 15 minutes to 1 hour, while medical restraints require checks every 2 hours per CMS and Joint Commission standards.

Question 135: 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?

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

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 136: If an Orthodox Jewish patient won't use the call bell or answer the intercom because they won't use electrical appliances on the Sabbath, shouldn't the nurse?

tell him that exceptions are made for ill patients.
check on him every 15 to 30 minutes.
provide him with a hand bell or alternate means of calling the nurse. (Correct answer)
advise him that he is putting himself at risk.

Correct answer: provide him with a hand bell or alternate means of calling the nurse.

The nurse should give an Orthodox Jewish patient who is refusing to use electrical appliances on the Sabbath a hand bell or another alternative method of calling the nurse if he refuses to use the call bell or reply to the intercom. While checking in on the patient every 15 to 30 minutes may not always be practicable, the nurse shouldn't try to persuade the patient to change his or her religious beliefs.

Question 137: A patient presents with sudden severe headache described as 'the worst headache of my life.' Which condition should the nurse suspect?

Subarachnoid hemorrhage (Correct answer)
Tension headache
Cluster headache
Migraine 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 138: 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)
Normal neurological function
Moderate brain injury

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

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

Correct answer: Nectar-thickened liquids

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

Question 140: A patient recovering from surgery develops sudden onset dyspnea, chest pain, and tachycardia. Which complication should the nurse suspect?

Atelectasis
Pulmonary embolism (Correct answer)
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 141: A nurse observes that a patient's Jackson-Pratt (JP) drain has changed from serosanguineous to bright red output. What should the nurse do?

Remove the drain immediately
Clamp the drain and reposition the patient
Notify the surgeon, as this may indicate active bleeding (Correct answer)
Empty the drain and record the output as expected

Correct answer: Notify the surgeon, as this may indicate active bleeding

A change from serosanguineous to bright red drainage in a JP drain suggests active bleeding at the surgical site and requires immediate physician notification.

Question 142: Which nursing action is the single most effective method for preventing the transmission of healthcare-associated infections?

Wearing sterile gloves for all patient contact
Performing proper hand hygiene before and after client care (Correct answer)
Placing all clients in contact precautions
Using N95 respirators during routine care

Correct answer: Performing proper hand hygiene before and after client care

Hand hygiene is consistently identified as the most effective measure to prevent the spread of healthcare-associated infections.

Question 143: 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 guided imagery and relaxation techniques (Correct answer)
Increase the IV opioid drip rate
Apply a warm compress to the surgical site

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

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

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 145: 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 146: A patient develops compartment syndrome in the left leg after a tibial fracture. Which assessment finding is most diagnostic?

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

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 147: A nurse is assessing a patient's skin turgor. The nurse pinches the skin on the back of the hand and it returns to place in 4 seconds. This finding suggests:

Fluid volume excess
Normal hydration status
Adequate tissue perfusion
Dehydration or decreased skin elasticity (Correct answer)

Correct answer: Dehydration or decreased skin elasticity

Normal skin turgor returns within 2 seconds; a return time of 4 seconds indicates decreased turgor, suggesting dehydration or reduced skin elasticity (common in elderly patients).

Question 148: 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?

Tachycardia (Correct answer)
Bradycardia
Hypotension
Decreased respiratory rate

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

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

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

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

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 151: A nurse is caring for an elderly patient who recently lost a spouse and expresses feelings of loneliness. Which intervention is most appropriate?

Encourage the patient to suppress grief to avoid depression
Advise the patient to stay busy to avoid thinking about the loss
Facilitate participation in a bereavement support group (Correct answer)
Tell the patient they will feel better with time

Correct answer: Facilitate participation in a bereavement support group

A bereavement support group provides peer connection, normalized grief expression, and social support, which directly addresses loneliness and facilitates healthy grieving.

Question 152: Long-term usage of corticosteroids or antibiotics raises the risk of?

constipation.
anaphylaxis.
candidiasis. (Correct answer)
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 153: Which behavior best demonstrates a client successfully resolving Erikson's stage of 'Industry vs. Inferiority'?

A teenager forming a stable personal identity
A school-age child completing projects and feeling competent (Correct answer)
A toddler asserting independence during daily tasks
An adult forming close personal relationships

Correct answer: A school-age child completing projects and feeling competent

Industry vs. Inferiority occurs during school age (6–12 years) and is resolved by developing a sense of competence through completing tasks.

Question 154: 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 155: A 45-year-old female client asks when she should begin routine mammography screening. According to the American Cancer Society, what is the nurse's best response?

Age 55 only if symptomatic
Age 40 with the option to start at 40 (Correct answer)
Age 50 for all women
Age 35 for women with no risk factors

Correct answer: Age 40 with the option to start at 40

The American Cancer Society recommends women have the option to start annual mammography screening at age 40 and should begin by age 45.

Question 156: A PN is coordinating care for a patient being discharged to a skilled nursing facility. Which action is the PN's priority?

Notifying the patient's family of the discharge date
Calling the receiving facility to confirm bed availability
Ensuring transfer documentation and medication reconciliation are complete (Correct answer)
Arranging transportation for the patient

Correct answer: Ensuring transfer documentation and medication reconciliation are complete

Complete and accurate transfer documentation and medication reconciliation are essential to ensure continuity and patient safety during transitions of care.

Question 157: 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?

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

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 158: What would you classify yellow-tinged, occasionally crimson, watery wound discharge under?

serosanguineous.
sanguineous.
purulent.
serosanguineous. (Correct answer)

Correct answer: serosanguineous.

Serosanguineous wound discharge is characterized by a thin, watery consistency that is typically pale red or pink. The description 'yellow-tinged, occasionally crimson, watery' accurately reflects this type of exudate, indicating a mixture of serous fluid (watery, yellow-tinged) and a small amount of blood (crimson).

Question 159: A nurse administers the wrong medication and the patient suffers harm. Which element of negligence establishes the link between the action and the injury?

Breach
Damages
Duty
Causation (Correct answer)

Correct answer: Causation

Causation (proximate cause) is the element that establishes the direct link between the nurse's breach of duty and the patient's resulting harm.

Question 160: 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 161: A patient who is immobile is at risk for developing deep vein thrombosis (DVT). Which nursing intervention helps prevent this complication?

Restricting leg movement
Keeping the patient in a flat supine position
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 162: 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 acidosis (Correct answer)
Respiratory alkalosis
Metabolic alkalosis
Metabolic acidosis

Correct answer: Respiratory acidosis

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

Question 163: A patient with cirrhosis develops ascites and peripheral edema. Which laboratory finding would the nurse expect?

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

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 164: A patient with dumping syndrome following gastrectomy should be taught to:

Consume a high-carbohydrate diet with moderate fluid intake during meals
Increase dietary fiber and eat three large meals per day
Eat small, frequent meals low in simple sugars and lie down after eating (Correct answer)
Drink large amounts of fluid with meals to aid digestion

Correct answer: Eat small, frequent meals low in simple sugars and lie down after eating

Dumping syndrome occurs when hyperosmolar food rapidly enters the small intestine. Management includes small frequent meals, avoiding simple sugars (which draw fluid into the gut), limiting fluids during meals, and lying down 30 minutes after eating to slow gastric emptying.

Question 165: A nurse accidentally sustains a needlestick injury from a contaminated needle. What is the priority first action?

Go to the emergency department for testing
Report to the supervisor immediately
File an incident report
Wash the site thoroughly with soap and water (Correct answer)

Correct answer: Wash the site thoroughly with soap and water

The immediate first action after a needlestick injury is to wash the wound thoroughly with soap and water to reduce the risk of pathogen transmission.

Question 166: A nurse is using the five rights of delegation. Which element is NOT one of the five rights?

Right person
Right documentation (Correct answer)
Right supervision
Right task

Correct answer: Right documentation

The five rights of delegation are: right task, right circumstance, right person, right direction/communication, and right supervision — documentation is not one of the five rights.

Question 167: 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 and gloves only (Correct answer)
Gown, gloves, and surgical mask
N95 respirator and eye protection
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 168: Which teaching point is most important for a patient prescribed warfarin?

Take the medication with a full glass of milk
Maintain consistent intake of vitamin K-containing foods (Correct answer)
Take over-the-counter ibuprofen for headaches
Double the dose if a dose is missed

Correct answer: Maintain consistent intake of vitamin K-containing foods

Patients on warfarin should maintain consistent vitamin K intake rather than eliminating it, as vitamin K directly affects warfarin's anticoagulant activity.

Question 169: A competent adult patient refuses a recommended surgical procedure after being fully informed of the risks and benefits. What should the nurse document?

That the patient is being non-compliant
That the patient was informed and voluntarily refused, including the information provided (Correct answer)
Nothing, as the refusal is the physician's responsibility to document
That the patient lacks understanding of the procedure

Correct answer: That the patient was informed and voluntarily refused, including the information provided

The nurse should document that the patient received information about risks, benefits, and alternatives, and voluntarily refused the procedure, demonstrating informed refusal.

Question 170: A nurse is caring for a client experiencing anticipatory grief. Which intervention is most therapeutic?

Provide a quiet environment and allow the client to express feelings freely (Correct answer)
Reassure the client that their fears may not come true
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 171: 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 172: A 72-year-old client is admitted to a long-term care facility. The client expresses feelings of sadness and states, 'I feel like my life has had no purpose.' According to Erik Erikson's stages of psychosocial development, which of the following is the client experiencing?

Isolation
Stagnation
Despair (Correct answer)
Role Confusion

Correct answer: Despair

According to Erikson's theory, the developmental stage for older adults (65 years to death) is 'Ego Integrity vs. Despair.' A person who feels their life has been useless or has regrets is experiencing despair. Stagnation is part of the middle adulthood stage, Isolation is part of the young adulthood stage, and Role Confusion is part of the adolescent stage.

Question 173: Which laboratory value requires the nurse to hold the next dose of warfarin and notify the provider?

INR of 5.8 (Correct answer)
INR of 2.5
aPTT of 35 seconds
PT of 14 seconds

Correct answer: INR of 5.8

An INR of 5.8 is critically elevated (therapeutic range for most conditions is 2.0-3.0), indicating a high risk for hemorrhage and requiring immediate provider notification.

Question 174: What is the most important nursing consideration when applying a cold pack to a patient's injury?

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

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 175: A postoperative client reports sudden onset of chest pain and shortness of breath on day 2 after hip replacement surgery. What is the nurse's priority action?

Encourage deep breathing exercises
Notify the physician immediately (Correct answer)
Administer prescribed analgesic
Reposition the client to the left side

Correct answer: Notify the physician immediately

Sudden chest pain and dyspnea after orthopedic surgery are classic signs of pulmonary embolism, requiring immediate physician notification.

Question 176: Which situation represents a violation of the five rights of delegation?

Asking a UAP to take vital signs on a stable medical patient
Delegating meal assistance to a UAP for a patient on a regular diet
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)

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 177: A client with chronic kidney disease has a serum phosphate of 6.5 mg/dL. The nurse anticipates which secondary electrolyte imbalance?

Hyperkalemia
Hypernatremia
Hypocalcemia (Correct answer)
Hypercalcemia

Correct answer: Hypocalcemia

Elevated phosphate binds calcium in the bloodstream, causing hypocalcemia in clients with chronic kidney disease.

Question 178: Which intervention is the nurse's highest priority when caring for a postoperative patient in the PACU who has a SpO₂ of 89%?

Notify the surgeon immediately
Apply supplemental oxygen and reposition the airway (Correct answer)
Document the finding and continue monitoring
Encourage the patient to cough and deep breathe

Correct answer: Apply supplemental oxygen and reposition the airway

Applying supplemental oxygen and opening the airway addresses the immediate physiologic threat of hypoxemia before notifying the provider.

Question 179: A nurse is caring for a client who is visually impaired. Which approach is MOST appropriate when assisting with ambulation?

Walk slightly ahead and guide the client by the wrist
Walk beside the client and describe the environment verbally only
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

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 180: A patient reports pain as 8/10 and requests medication. The nurse checks the MAR and finds the PRN analgesic is not due for another 90 minutes. The nurse should first:

Ask the patient to wait until the medication is due
Offer non-pharmacological comfort measures and reassess in 30 minutes (Correct answer)
Contact the provider to request a one-time dose or order modification
Administer the medication early since the patient is in severe pain

Correct answer: Offer non-pharmacological comfort measures and reassess in 30 minutes

While awaiting medication eligibility, offering non-pharmacological measures (repositioning, distraction, heat/cold) is a safe and appropriate first intervention.

Question 181: A nurse documents: 'Patient reports pain of 7/10 in the lower abdomen. Abdomen is rigid and tender on palpation. Nurse suspects possible bowel obstruction and notified physician.' Which component of SOAP documentation is represented by the nurse's clinical interpretation?

Objective
Assessment (Correct answer)
Subjective
Plan

Correct answer: Assessment

The Assessment component of SOAP documentation reflects the nurse's clinical judgment or interpretation of the subjective and objective data gathered, such as suspecting a bowel obstruction based on findings.

Question 182: A nurse is teaching a group of older adults about fall prevention. Which intervention is most effective?

Wearing non-slip footwear indoors (Correct answer)
Removing all furniture from hallways
Limiting physical activity to prevent fatigue
Installing bright lighting only in the bedroom

Correct answer: Wearing non-slip footwear indoors

Wearing non-slip footwear is one of the most effective and practical fall prevention strategies for older adults in the home environment.

Question 183: A nurse is teaching a 45-year-old female client about recommended health screenings. Which screening should the nurse prioritize for this age group?

Annual mammogram (Correct answer)
Pap smear every 2 years
Colonoscopy every 5 years
Bone density scan annually

Correct answer: Annual mammogram

The American Cancer Society recommends annual mammograms for average-risk women beginning at age 45.

Question 184: 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?

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

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

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

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 186: A nurse working on a medical-surgical unit discovers a fire in a client's trash can. What is the nurse's immediate priority action?

Rescue any clients in immediate danger. (Correct answer)
Extinguish the fire with the appropriate extinguisher.
Activate the fire alarm.
Confine the fire by closing the door.

Correct answer: Rescue any clients in immediate danger.

The RACE acronym is the standard protocol for fire safety in healthcare settings: Rescue, Alarm, Confine, and Extinguish/Evacuate. The absolute first priority is to rescue anyone in immediate danger from the fire or smoke.

Question 187: A nurse is caring for a client receiving enteral tube feedings. Which assessment finding warrants IMMEDIATE action?

Client reports mild nausea after feeding rate increase
Residual gastric volume of 100 mL
Abdomen that is firm, distended, and silent (Correct answer)
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 188: Which action by a nursing student demonstrates correct understanding of surgical asepsis?

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

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

3% Hypertonic Saline
D5W 0.45% NaCl
0.45% Half Normal Saline
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 190: A patient is receiving IV vancomycin and develops flushing, erythema, and hypotension during the infusion. What is the most likely cause?

Anaphylactic reaction
Red man syndrome (Correct answer)
Septic shock
Phlebitis

Correct answer: Red man syndrome

Red man syndrome is a rate-related reaction to rapid vancomycin infusion causing histamine release, resulting in flushing, erythema, and hypotension.

Question 191: A post-operative client has a urine output of 20 mL/hr for 2 consecutive hours. What is the nurse's priority action?

Increase the IV flow rate independently
Notify the provider (Correct answer)
Encourage oral fluid intake
Document findings and continue monitoring

Correct answer: Notify the provider

Urine output below 30 mL/hr indicates oliguria and possible renal hypoperfusion; the provider must be notified promptly.

Question 192: A nurse discovers a colleague has been accessing patient records of celebrities out of curiosity. What is the nurse's primary obligation under HIPAA?

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

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

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

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

Epinephrine excess stimulating the renin-angiotensin system
Aldosterone deficiency impairing sodium retention and potassium excretion (Correct answer)
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 195: 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
Increase the oxygen flow rate to 4 L/min
Withhold the next scheduled morphine dose
Administer naloxone (Narcan) per protocol (Correct answer)

Correct answer: Administer naloxone (Narcan) per protocol

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

Question 196: A nurse is performing oral care for an unconscious patient. What is the priority safety measure?

Using a soft-bristle toothbrush
Positioning the patient on their side (Correct answer)
Applying lip moisturizer afterward
Using fluoride-free toothpaste

Correct answer: Positioning the patient on their side

Positioning an unconscious patient on their side (lateral position) prevents aspiration of oral secretions and cleaning solutions during mouth care.

Question 197: According to Erikson's theory, which developmental task is the primary focus for adolescents?

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

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 198: Which behavior modification technique is MOST appropriate when counseling a client about smoking cessation?

Setting a specific quit date (Correct answer)
Switching to a lower-nicotine brand
Gradually reducing cigarettes daily
Avoiding all social situations

Correct answer: Setting a specific quit date

Setting a specific quit date is a proven behavioral strategy that increases commitment and success in smoking cessation programs.

Question 199: A nurse is caring for a patient experiencing status epilepticus. Which intervention takes priority?

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

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

Running without falling
Riding a tricycle
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.

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

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