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

Question 1: Which assessment is most important before administering digoxin?

Temperature
Respiratory rate
Apical heart rate for one full minute (Correct answer)
Blood pressure

Correct answer: Apical heart rate for one full minute

The apical heart rate must be assessed for one full minute before administering digoxin. The medication should be held if the rate is below 60 bpm in adults.

Question 2: Which assessment tool is most commonly used by nurses to screen for depression in adult patients?

Glasgow Coma Scale
CAGE Questionnaire
Patient Health Questionnaire-9 (PHQ-9) (Correct answer)
Braden 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 3: Which situation represents a potential conflict of interest that a nurse must report?

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

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 4: A nurse asks an anxious patient, 'It sounds like you're worried about going home alone after surgery. Can you tell me more about that?' This is an example of which therapeutic communication technique?

Reflection and open-ended questioning (Correct answer)
Providing false reassurance
Closed-ended questioning
Giving advice

Correct answer: Reflection and open-ended questioning

Reflection mirrors the patient's feelings back to them to confirm understanding, while the open-ended question invites the patient to elaborate; together they promote therapeutic dialogue and show empathetic listening.

Question 5: 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?

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

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 6: 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?

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

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

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

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 8: 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 9: Which infection control measure is most effective in preventing catheter-associated urinary tract infections (CAUTI)?

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

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

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

Question 10: What is the purpose of performing a 'time out' immediately before a surgical procedure?

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

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 11: 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?

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

Correct answer: Metabolic Acidosis

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

Question 12: An Orthodox Jewish patient who keeps kosher receives a tray with a beef entrée. Which item on the tray should the nurse replace?

A dinner roll
Steamed carrots
Apple juice
A glass of milk (Correct answer)

Correct answer: A glass of milk

Kosher dietary law prohibits eating meat and dairy at the same meal.

Question 13: Which nursing intervention is most appropriate for a patient experiencing constipation?

Administer an enema immediately
Restrict fluid intake to thicken stool
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 14: A patient who is a member of The Church of Jesus Christ of Latter-day Saints is wearing a sacred undergarment before surgery. What should the nurse do?

Cut the garment off to save time
Discuss removal with the patient and handle the garment respectfully (Correct answer)
Tell the patient religious items are not allowed in the hospital
Discard the garment with the patient's soiled linens

Correct answer: Discuss removal with the patient and handle the garment respectfully

Temple garments are sacred and should be removed only with the patient's consent and handled with respect.

Question 15: 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?

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

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

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

Correct answer: High Fowler's position

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

Question 17: Which of the following interventions by a nurse best promotes the psychosocial well-being of a hospitalized adolescent client?

Encouraging frequent family visits to reduce feelings of loneliness.
Providing detailed medical information to increase their sense of control.
Scheduling structured quiet time for rest and reflection.
Allowing friends to visit and providing access to social media. (Correct answer)

Correct answer: Allowing friends to visit and providing access to social media.

Adolescents are in the 'Identity vs. Role Confusion' stage of development, where peer relationships are extremely important for developing a sense of self. Allowing interaction with friends and access to social media helps maintain these crucial social connections and promotes a sense of normalcy, which is vital for their psychosocial health during hospitalization.

Question 18: When assessing a surgical incision two days after an operation, which of the following findings indicates a normal physiological response during the inflammatory phase of wound healing?

Coolness of the skin surrounding the incision
A foul odor emanating from the wound
Localized warmth, redness, and swelling (Correct answer)
Copious thick, yellow drainage

Correct answer: Localized warmth, redness, and swelling

The inflammatory phase of wound healing, which occurs in the first few days after injury, is characterized by increased blood flow to the area. This results in localized warmth, redness (erythema), and swelling (edema) as white blood cells and other healing factors are delivered to the site. This is a normal and expected physiological response.

Question 19: 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?

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

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

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

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 21: 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?

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

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

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

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

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

Question 23: 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?

8
5
6 (Correct answer)
7

Correct answer: 6

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

Question 24: 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?

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

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 25: 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.
Encouraging the client to eat quickly to prevent fatigue.
Ensuring the client is in a high-Fowler's position. (Correct answer)
Providing thin liquids to make swallowing easier.

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 26: A nurse pages a provider twice about a client's falling blood pressure and gets no response. What should the nurse do next?

Keep monitoring and page again in an hour
Follow the chain of command by notifying the charge nurse or nursing supervisor (Correct answer)
Document that the provider did not respond and wait
Give an IV fluid bolus without an order

Correct answer: Follow the chain of command by notifying the charge nurse or nursing supervisor

When a provider can't be reached about a worsening client, the nurse must escalate through the chain of command to protect the client.

Question 27: A nurse is monitoring a patient after a thyroidectomy. Which complication should the nurse assess for within the first 24 hours?

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

Correct answer: Hypocalcemia

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

Question 28: Which laboratory value indicates that a client receiving heparin therapy is within the therapeutic range?

aPTT 60 seconds (1.5-2.5x control) (Correct answer)
Platelet count 50,000/mm³
aPTT 25 seconds (normal 25-35 sec)
INR 3.5

Correct answer: aPTT 60 seconds (1.5-2.5x control)

Therapeutic heparin effect is reflected by an aPTT of 1.5–2.5 times the control (approximately 60–80 seconds).

Question 29: A patient with terminal cancer has a Do-Not-Resuscitate (DNR) order. The patient goes into cardiac arrest. What is the nurse's appropriate action?

Contact the family for permission to resuscitate
Provide comfort measures only (Correct answer)
Ignore the DNR because the situation is urgent
Begin CPR and call a code

Correct answer: Provide comfort measures only

A valid DNR order means resuscitative efforts should not be initiated. The nurse should provide comfort measures and ensure the patient's dignity.

Question 30: When titrating opioids for a palliative patient, which assessment finding usually appears before opioid-induced respiratory depression?

Increasing sedation (Correct answer)
Pinpoint pupils
Urinary retention
Pruritus

Correct answer: Increasing sedation

Sedation precedes respiratory depression, so monitoring sedation level is the key safety assessment.

Question 31: A client with a terminal illness has a living will and has expressed a desire to refuse further life-prolonging treatments. The client's family, however, insists that the healthcare team do everything possible to keep the client alive. Which ethical principle should primarily guide the nurse's actions in this situation?

Beneficence
Non-maleficence
Justice
Autonomy (Correct answer)

Correct answer: Autonomy

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

Question 32: A patient is scheduled for an MRI. Which item must the nurse ensure is removed before the procedure?

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

Correct answer: Hearing aids

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

Question 33: A registered nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task is appropriate to delegate?

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

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

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

Question 34: 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 40 with the option to start at 40 (Correct answer)
Age 55 only if symptomatic
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 35: A nurse is assisting a patient with dysphagia. Which dietary modification is most appropriate to reduce the risk of aspiration?

Clear liquid diet
NPO status until further evaluation
Thickened liquids (Correct answer)
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 36: A nurse is caring for a client receiving furosemide for heart failure. The client reports significant muscle weakness, and the cardiac monitor shows flattened T waves and prominent U waves. The nurse should suspect which electrolyte imbalance?

Hypomagnesemia
Hyponatremia
Hypokalemia (Correct answer)
Hypercalcemia

Correct answer: Hypokalemia

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

Question 37: What is the most important nursing consideration when applying a cold pack to a patient's injury?

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

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 38: A hospital is transitioning to a new electronic health record (EHR) system. A nurse manager observes a staff nurse who is struggling to use the new system, causing delays in patient care and medication administration. What is the manager's most appropriate initial action?

Arrange for one-on-one training or a 'super-user' to mentor the nurse. (Correct answer)
Assign the staff nurse a lighter patient load until they become more proficient.
Advise the nurse to complete the required online training modules again.
Initiate disciplinary action for failing to adapt to the new system.

Correct answer: Arrange for one-on-one training or a 'super-user' to mentor the nurse.

The most supportive and effective initial action is to provide direct, personalized support. Arranging for one-on-one training with an educator or a 'super-user' (an experienced peer) addresses the specific learning need without being punitive. This approach promotes competency and patient safety, whereas reducing the workload doesn't solve the skill deficit and disciplinary action is premature.

Question 39: Who should bring up organ donation with the family if a patient is confirmed brain dead following a motorbike accident?

Registered nurses only.
The patient’s physician.
Any nurse on duty.
Specially trained personnel. (Correct answer)

Correct answer: Specially trained personnel.

Discussions about organ donation are highly sensitive and require specialized training to ensure they are handled ethically, legally, and with compassion. These conversations are typically conducted by specially trained personnel from an Organ Procurement Organization (OPO) who are experts in the donation process and can provide comprehensive support to grieving families.

Question 40: A nurse is teaching a client about testicular self-examination (TSE). How often should TSE be performed?

Daily
Annually
Weekly
Monthly (Correct answer)

Correct answer: Monthly

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

Question 41: A patient with COPD is receiving oxygen therapy. The nurse notes the oxygen saturation is 96%. What is the nurse's priority concern?

The saturation is too low and oxygen should be increased
The pulse oximeter must be malfunctioning
This is an expected finding requiring no action
The saturation may be too high, potentially suppressing the hypoxic drive (Correct answer)

Correct answer: The saturation may be too high, potentially suppressing the hypoxic drive

COPD patients rely on hypoxic drive for respiratory stimulation. Target SpO2 for COPD patients is typically 88-92%. An SpO2 of 96% may indicate excessive oxygen administration.

Question 42: A nurse needs to hand off a patient to the oncoming nurse. Which communication framework is the standard for structured handoff reporting?

SOAP
ADPIE
RACE
SBAR (Correct answer)

Correct answer: SBAR

SBAR (Situation, Background, Assessment, Recommendation) is the standardized handoff communication tool used to provide concise, organized information during patient transfers and shift changes, reducing communication errors.

Question 43: Which medication requires the nurse to monitor for ototoxicity as a serious adverse effect?

Metformin
Lisinopril
Amoxicillin
Gentamicin (Correct answer)

Correct answer: Gentamicin

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

Question 44: 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.
Repositioning the client every 4 hours.
Keeping the skin clean and dry and using a moisturizer. (Correct answer)
Using donut-shaped cushions for seating.

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

Every 4 hours
Only when the patient requests
Every 8 hours
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 46: 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?

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

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

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)
Suggest she take a nap while someone watches the baby
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 48: A nurse manager notices that a UAP frequently skips reporting changes in patient condition. Which is the MOST appropriate initial action?

Reassign all of the UAP's patients to licensed staff
File a formal disciplinary report immediately
Privately counsel the UAP on reporting expectations and document the conversation (Correct answer)
Ignore the behavior unless a patient outcome is negatively affected

Correct answer: Privately counsel the UAP on reporting expectations and document the conversation

The initial response should be direct, private counseling to clarify expectations and correct the behavior, with documentation for accountability.

Question 49: According to Erikson's stages of development, a 25-year-old client who expresses difficulty forming meaningful relationships with others is likely struggling with which psychosocial crisis?

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

Correct answer: Intimacy vs. Isolation

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

Question 50: A PN is coordinating care for a patient being discharged to a skilled nursing facility. Which action is the PN's priority?

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

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 51: 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)
Applying a vest restraint during all waking hours
Keeping all four side rails raised at all times

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 52: A nurse is caring for a patient in septic shock. Which set of vital signs is most consistent with early (warm) septic shock?

BP 120/80, HR 72, Temp 98.6 degrees F, normal skin
BP 80/40, HR 120, Temp 103 degrees F, warm flushed skin (Correct answer)
BP 80/40, HR 40, Temp 95 degrees F, mottled skin
BP 160/90, HR 60, Temp 97 degrees F, cool pale skin

Correct answer: BP 80/40, HR 120, Temp 103 degrees F, warm flushed skin

Early septic shock (hyperdynamic/warm phase) presents with hypotension, tachycardia, fever, and vasodilation causing warm, flushed skin.

Question 53: When working with a medical interpreter, which technique should the nurse use?

Look at the interpreter and say, "Tell her..."
Speak directly to the patient using short sentences (Correct answer)
Give all the information at once, then pause
Speak loudly so the patient understands

Correct answer: Speak directly to the patient using short sentences

Speaking directly to the patient in short segments keeps the focus on the patient and improves the accuracy of interpretation.

Question 54: What is the correct method for performing surgical hand antisepsis before an operative procedure?

Apply gloves without hand washing if hands appear clean
Scrub hands and arms to 2 inches above the elbows for 2-6 minutes (Correct answer)
Wash hands with regular soap for 30 seconds
Apply alcohol-based hand rub for 15 seconds

Correct answer: Scrub hands and arms to 2 inches above the elbows for 2-6 minutes

Surgical hand antisepsis requires scrubbing hands and forearms to 2 inches above the elbows with an antimicrobial agent for 2-6 minutes to reduce transient and resident flora.

Question 55: A nurse is developing a plan of care for a client who has recently lost their spouse. According to the principles of psychosocial care, which action should the nurse take first?

Provide education on the normal stages of grief and loss.
Encourage the client to focus on positive memories.
Assess the client's personal coping mechanisms and support systems. (Correct answer)
Refer the client to a bereavement support group.

Correct answer: Assess the client's personal coping mechanisms and support systems.

The nursing process always begins with assessment. Before implementing any interventions, the nurse must first assess the client's individual coping style, the strength of their existing support system (family, friends), and their cultural or spiritual beliefs related to loss. This information is essential for creating a personalized and effective plan of care.

Question 56: What is the recommended daily fluid intake for an average healthy adult?

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

Correct answer: 2500-3000 mL

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

Question 57: A nurse makes a medication error that does not harm the patient. What is the nurse's legal and ethical obligation?

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

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

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

Question 58: 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 expiration date of the formula
The patient's weight
The patient's food preferences
Correct tube placement (Correct answer)

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 59: What distinguishes an advance directive from a power of attorney for healthcare?

An advance directive requires a lawyer; a power of attorney does not
A power of attorney is only valid after the patient dies
An advance directive specifies treatment wishes; a healthcare power of attorney designates a decision-maker (Correct answer)
There is no difference between the two documents

Correct answer: An advance directive specifies treatment wishes; a healthcare power of attorney designates a decision-maker

An advance directive documents specific treatment preferences, while a healthcare power of attorney designates a person to make healthcare decisions when the patient cannot.

Question 60: 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 61: 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 62: A nurse is educating a patient about proper use of a metered-dose inhaler (MDI) without a spacer. Which instruction is correct?

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

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 63: A patient is prescribed 1,000 mL of 0.9% NaCl to infuse over 8 hours. The IV tubing has a drop factor of 15 gtt/mL. What is the correct drip rate in gtt/min?

21 gtt/min
125 gtt/min
31 gtt/min (Correct answer)
42 gtt/min

Correct answer: 31 gtt/min

Using the formula (volume × drop factor) ÷ time in minutes: (1000 mL × 15 gtt/mL) ÷ (8 hr × 60 min) = 15,000 ÷ 480 = 31.25, rounded to 31 gtt/min.

Question 64: A nurse is reviewing the laboratory results for a client receiving warfarin therapy. The client's International Normalized Ratio (INR) is 4.5. Which action should the nurse take first?

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

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

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

Question 65: A patient's chart shows a temperature of 38.9°C. What is the equivalent Fahrenheit temperature?

103.2°F
102.0°F (Correct answer)
100.4°F
101.4°F

Correct answer: 102.0°F

Using the formula °F = (°C × 9/5) + 32: (38.9 × 1.8) + 32 = 70.02 + 32 = 102.02°F, which rounds to 102.0°F.

Question 66: Which therapeutic communication technique involves restating the patient's message in the nurse's own words to verify understanding?

Reflecting
Clarifying
Paraphrasing (Correct answer)
Summarizing

Correct answer: Paraphrasing

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

Question 67: A PN receives a verbal telephone order from a physician for a medication. What is the correct process for handling this order?

Administer the medication immediately based on the verbal order alone
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
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 68: A nurse uses the SBAR communication technique when calling a physician. Which component is 'A' in SBAR?

Assessment of the client's current condition (Correct answer)
Allergies the client has reported
Actions already taken by the nurse
Anticipated orders from the physician

Correct answer: Assessment of the client's current condition

In SBAR, 'A' stands for Assessment, which is the nurse's clinical interpretation of the situation.

Question 69: A client is reporting pain rated at 8 on a 0-10 scale. After administering the prescribed analgesic, which non-pharmacological intervention would be most appropriate for the nurse to implement to provide additional comfort?

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

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

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

Correct answer: Regular first, then NPH

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

Question 71: A nurse is planning an advance directive discussion with a traditional Navajo patient. Which approach is most culturally sensitive?

Hold the discussion with the family only, without the patient
Use third-person or hypothetical wording when discussing negative outcomes (Correct answer)
Directly describe the patient's own likely death in detail
Skip advance directives entirely

Correct answer: Use third-person or hypothetical wording when discussing negative outcomes

Some traditional Navajo people believe that speaking about negative events can cause them, so hypothetical or third-person framing is preferred.

Question 72: When assisting a patient with a bed bath, in which direction should the nurse wash the extremities?

Distal to proximal (Correct answer)
Proximal to distal
In a circular motion only
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 73: A client refuses a recommended blood transfusion based on religious beliefs. Which response by the nurse is most appropriate?

Administer the transfusion anyway to preserve life
Contact the client's family to override the refusal
Document the refusal, ensure informed consent was given, and notify the physician (Correct answer)
Discharge the client immediately for non-compliance

Correct answer: Document the refusal, ensure informed consent was given, and notify the physician

Competent adults have the right to refuse treatment; the nurse must document the informed refusal, notify the provider, and ensure the client understands the risks.

Question 74: Which principle requires nurses to treat all patients equally regardless of socioeconomic status, race, or personal beliefs?

Fidelity
Veracity
Autonomy
Justice (Correct answer)

Correct answer: Justice

Justice is the ethical principle of fairness and equal treatment, requiring nurses to distribute care resources impartially and without discrimination.

Question 75: A nurse is preparing to administer the first dose of an ACE inhibitor. Which assessment finding would cause the nurse to hold the medication?

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

Correct answer: Blood pressure of 84/56 mmHg

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

Question 76: A nurse is planning care for four clients. Which client should the nurse assess first?

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

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

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

Question 77: 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?

Hypotension
Decreased respiratory rate
Bradycardia
Tachycardia (Correct answer)

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

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

Correct answer: Peaked T waves

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

Question 79: Which of the following is an example of a nonverbal communication barrier that a nurse should be aware of?

Speaking too quickly during patient education
Standing over a seated patient while delivering bad news (Correct answer)
Asking two questions at the same time
Using medical jargon with a patient

Correct answer: Standing over a seated patient while delivering bad news

Standing over a seated patient creates a power imbalance and communicates dominance rather than partnership—this is a nonverbal barrier. The other options are verbal communication issues. Sitting at eye level with a patient during sensitive conversations conveys respect and openness.

Question 80: 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?

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

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

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

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

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

Question 82: A provider gives a telephone order for a new medication. What is the nurse's priority action?

Have the unit secretary take the order
Write the order down, read it back to the provider, and get confirmation (Correct answer)
Repeat the medication name only
Give the medication and document it at the end of the shift

Correct answer: Write the order down, read it back to the provider, and get confirmation

The write-down/read-back process confirms the order is accurate and is a Joint Commission patient-safety requirement.

Question 83: A nurse discovers that a patient's advance directive specifies no resuscitation, but the physician has entered a full-code order. What is the nurse's BEST action?

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

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

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

Question 84: 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?

Scant serosanguineous drainage on the surgical dressing.
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.

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

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

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 86: The nurse teaches a client with iron-deficiency anemia to take iron with orange juice because vitamin C enhances absorption of:

Vitamin B12
Non-heme iron (Correct answer)
Zinc
Calcium

Correct answer: Non-heme iron

Ascorbic acid converts non-heme iron to a more absorbable form.

Question 87: According to Campinha-Bacote's model, what is the first step a nurse should take toward cultural competence?

Learning a second language
Asking patients to adapt to hospital norms
Memorizing the beliefs of every ethnic group
Examining their own cultural biases and values (Correct answer)

Correct answer: Examining their own cultural biases and values

Cultural awareness, meaning self-examination of one's own biases, is the foundation of cultural competence.

Question 88: A patient in the emergency department is displaying aggressive behavior and threatening staff. Which de-escalation technique should the nurse try first?

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

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 89: A nurse is caring for an older adult client who is confused and has repeatedly attempted to pull out their peripheral intravenous (IV) catheter. After assessing the client, which action should the nurse take first to ensure the client's safety?

Administer a prescribed sedative medication.
Attempt to reorient the client and conceal the IV site with a gauze wrap. (Correct answer)
Apply soft wrist restraints to both arms.
Ask a family member to sit with the client at all times.

Correct answer: Attempt to reorient the client and conceal the IV site with a gauze wrap.

The nursing principle of 'least restrictive' requires trying less invasive interventions before resorting to physical or chemical restraints. Attempting to reorient the client and camouflaging the IV site addresses the immediate safety risk without restricting the client's freedom of movement.

Question 90: Which finding is a classic sign of diabetic ketoacidosis (DKA)?

Fruity odor to the breath (Correct answer)
Bradycardia
Hypertension
Shallow, slow respirations

Correct answer: Fruity odor to the breath

The fruity or acetone breath odor in DKA results from the breakdown of fatty acids into ketone bodies as the body attempts to use fat for energy without insulin.

Question 91: Which vital sign change should the nurse report immediately to the healthcare provider?

Blood pressure of 88/52 mmHg (Correct answer)
Pulse rate of 78 beats per minute
Oral temperature of 99.0 degrees Fahrenheit
Respiratory rate of 16 breaths per minute

Correct answer: Blood pressure of 88/52 mmHg

A blood pressure of 88/52 mmHg indicates hypotension that could signify shock, hemorrhage, or cardiovascular compromise and requires immediate medical attention.

Question 92: A patient with anxiety tells the nurse, 'I feel like I'm going to die.' What is the most therapeutic response?

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

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

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

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

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

Question 94: A nurse is preparing to enter the room of a client with a confirmed Clostridioides difficile infection. In addition to using gloves and a gown, which action is essential for proper infection control?

Keeping the room door closed at all times.
Washing hands with soap and water after providing care. (Correct answer)
Wearing a surgical mask during all client contact.
Using an alcohol-based hand sanitizer before exiting the room.

Correct answer: Washing hands with soap and water after providing care.

C. difficile forms spores that are resistant to alcohol-based hand sanitizers. The mechanical friction from washing with soap and water is required to remove the spores from the hands, which is a critical step in preventing transmission.

Question 95: A nurse is preparing to administer a continuous intravenous infusion of heparin. Which of the following laboratory values is essential for the nurse to review immediately before initiating the infusion?

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

Correct answer: Activated Partial Thromboplastin Time (aPTT)

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

Question 96: A patient receiving IV fluids develops redness, warmth, and swelling at the insertion site. The nurse should first:

Discontinue the IV and remove the catheter (Correct answer)
Notify the physician before taking any action
Apply a warm compress and reassess in one hour
Slow the infusion rate and continue monitoring

Correct answer: Discontinue the IV and remove the catheter

Signs of phlebitis (redness, warmth, swelling) at an IV site require immediate discontinuation of the infusion and removal of the catheter.

Question 97: A patient with cirrhosis develops ascites and peripheral edema. Which laboratory finding would the nurse expect?

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

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

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

Correct answer: Smoking cessation

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

Question 99: The nurse is coordinating care for a client being discharged after a stroke, which resulted in moderate dysphagia. To ensure a safe transition home, which of the following referrals is the nurse's priority?

Physical therapy for gait training.
A speech-language pathologist for a home swallowing therapy plan. (Correct answer)
A social worker to arrange for financial assistance.
Occupational therapy for assistance with activities of daily living.

Correct answer: A speech-language pathologist for a home swallowing therapy plan.

Dysphagia (difficulty swallowing) places the client at high risk for aspiration and pneumonia. The speech-language pathologist is the specialist who assesses swallowing function and creates a safe plan for eating, drinking, and taking medications. While the other referrals are also important for this client's overall recovery, preventing aspiration is a critical safety priority.

Question 100: A nurse is caring for a dying patient. The patient's family asks the nurse to 'do everything possible' despite the patient's documented wish for comfort measures only. What is the most appropriate response?

Avoid the conversation and continue comfort measures without explanation
Honor the family's request since the patient can no longer speak for themselves
Ask the physician to override the patient's advance directive
Gently review the patient's documented wishes and explain the legal and ethical obligation to follow them (Correct answer)

Correct answer: Gently review the patient's documented wishes and explain the legal and ethical obligation to follow them

The nurse should compassionately review the patient's documented wishes with the family while explaining the ethical and legal obligation to honor the patient's advance directive.

Question 101: A nurse is caring for a patient with a nasogastric tube before administering a tube feeding. Which assessment confirms correct tube placement?

Placing the distal end of the tube in water and observing for bubbles
Auscultating for a 'whoosh' sound when injecting air
Asking the patient to speak to confirm the tube is not in the airway
Aspirating gastric contents and checking pH (pH ≤5.5 confirms gastric placement) (Correct answer)

Correct answer: Aspirating gastric contents and checking pH (pH ≤5.5 confirms gastric placement)

Checking the pH of aspirated contents (pH ≤5.5 indicates gastric placement) is the most reliable bedside method to confirm NG tube placement.

Question 102: A nurse is implementing fall prevention for a patient taking multiple medications. Which medication class poses the greatest fall risk?

Thyroid hormones
Proton pump inhibitors
Antibiotics
Benzodiazepines (Correct answer)

Correct answer: Benzodiazepines

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

Question 103: A nurse is teaching a group of older adults about fall prevention. Which intervention is most effective?

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

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 104: A nurse is caring for a client with Medicare. Which statement about Medicare Part B is accurate?

It requires no monthly premium from beneficiaries
It covers outpatient physician services and preventive care (Correct answer)
It is the prescription drug benefit program
It covers inpatient hospital stays

Correct answer: It covers outpatient physician services and preventive care

Medicare Part B covers outpatient services, physician visits, preventive care, and durable medical equipment, and requires a monthly premium.

Question 105: A client preparing for a colonoscopy is consuming the prescribed polyethylene glycol solution and reports feeling nauseated and bloated. The client states, "I don't think I can drink any more of this." Which nursing response is most appropriate to reduce the risk of an incomplete bowel preparation?

"I will bring you some solid food to help settle your stomach."
"Stop drinking the solution immediately and we will notify the doctor to cancel the procedure."
"You can take a short break for about 30-60 minutes, then resume drinking the solution at a slower pace." (Correct answer)
"It's important to finish the prep; try to drink the rest as quickly as possible."

Correct answer: "You can take a short break for about 30-60 minutes, then resume drinking the solution at a slower pace."

Nausea and bloating are common side effects of bowel preparation solutions. The most effective strategy is to temporarily pause for 30-60 minutes, allow the symptoms to subside, and then resume drinking at a slower rate. This approach increases the likelihood of completing the prep, which is essential for adequate visualization during the colonoscopy, thus reducing the risk of a failed or repeated procedure.

Question 106: A nurse receives a physician's order that appears to be incorrect. What is the nurse's responsibility?

Ask another nurse to carry out the order instead
Refuse to administer and document the refusal
Carry out the order as written since the physician is responsible
Clarify the order with the prescribing physician before carrying it out (Correct answer)

Correct answer: Clarify the order with the prescribing physician before carrying it out

Nurses have an independent duty to question orders that appear incorrect or potentially harmful. The nurse should clarify with the physician before proceeding.

Question 107: Which teaching point should a nurse include when instructing a client about breast self-examination (BSE)?

Perform BSE 1 week before the menstrual period
BSE replaces annual clinical breast exams
BSE should be performed only by women over 50
Perform BSE on the same day each month (Correct answer)

Correct answer: Perform BSE on the same day each month

BSE should be performed consistently on the same day each month; for menstruating women, performing it 5–7 days after the period begins is ideal.

Question 108: A patient receiving IV vancomycin develops flushing of the face, neck, and upper body. What is the nurse's priority action?

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

Correct answer: Slow the infusion rate

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

Question 109: A patient who is immobile is at risk for developing deep vein thrombosis (DVT). Which nursing intervention helps prevent this complication?

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

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 110: 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
Migraine headache
Cluster 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 111: A patient's culture results show Clostridioides difficile (C. diff) infection. Which precaution must the nurse implement?

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

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 112: A UAP reports that a patient who was ambulating independently yesterday now refuses to get out of bed and seems confused. What is the PN's best response?

Immediately assess the patient, as this change may indicate a new clinical problem (Correct answer)
Document the UAP's report and reassess at the next scheduled time
Tell the UAP to encourage the patient and try again in one hour
Inform the UAP that patient refusal must be respected

Correct answer: Immediately assess the patient, as this change may indicate a new clinical problem

A sudden change in cognition or functional status may signal an acute clinical deterioration such as infection or delirium, requiring immediate nursing assessment.

Question 113: A nurse suspects that a coworker is diverting controlled substances. What is the most appropriate first action?

Report the concern to the nurse manager or supervisor (Correct answer)
Ignore the situation to avoid conflict
Search the coworker's belongings for evidence
Confront the coworker directly

Correct answer: Report the concern to the nurse manager or supervisor

Suspected drug diversion should be reported to the nurse manager or supervisor who can initiate a proper investigation while protecting patient safety.

Question 114: A patient is admitted following a stroke and is now unable to eat pork due to Islamic dietary law (halal requirements). Which nursing action is most appropriate?

Tell the patient that the medications may also contain pork derivatives and list them all immediately
Ask the family to bring food from home since the hospital cannot provide halal meals
Notify the dietary department and document the patient's halal dietary requirement in the care plan (Correct answer)
Explain that hospital food cannot accommodate religious preferences

Correct answer: Notify the dietary department and document the patient's halal dietary requirement in the care plan

Accommodating religious dietary needs is both a patient right and standard nursing care. The nurse should communicate the requirement to dietary services and document it in the care plan so all team members are aware. Most hospitals have protocols for religious dietary accommodations.

Question 115: A patient with diabetes insipidus has a urine specific gravity of 1.001 and urinary output of 8 L/day. Which medication does the nurse anticipate administering?

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

Correct answer: Desmopressin (DDAVP)

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

Question 116: 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 117: In the event of a fire on a nursing unit, what is the correct sequence of actions?

Rescue, Alarm, Contain, Extinguish (RACE) (Correct answer)
Attempt to extinguish, evacuate, activate alarm, contain
Alarm, Rescue, Extinguish, Contain
Contain, Alarm, Extinguish, Rescue

Correct answer: Rescue, Alarm, Contain, Extinguish (RACE)

The RACE acronym guides fire response: Rescue anyone in immediate danger, Activate the alarm, Contain the fire by closing doors, and Extinguish if safe to do so.

Question 118: A nurse is caring for a patient in four-point restraints. How frequently must the nurse assess the patient?

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

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 119: A nurse is monitoring a patient receiving a blood transfusion who develops urticaria (hives) without other symptoms. What is the appropriate initial action?

Continue the transfusion since hives are a minor reaction
Stop the transfusion and return the blood to the blood bank
Stop the transfusion, administer an antihistamine per protocol, and monitor (Correct answer)
Administer epinephrine and call a code

Correct answer: Stop the transfusion, administer an antihistamine per protocol, and monitor

Mild allergic reactions (urticaria only) are managed by stopping the transfusion, administering an antihistamine as ordered, and monitoring for progression of symptoms.

Question 120: How many kilocalories does 1 gram of fat provide?

4 kcal
9 kcal (Correct answer)
7 kcal
12 kcal

Correct answer: 9 kcal

Fat provides 9 kcal/g, versus 4 kcal/g for carbohydrate and protein.

Question 121: When administering an intramuscular (IM) injection of an irritating medication to an average-sized adult, which of the following actions demonstrates the correct technique?

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

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

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

Question 122: A client's urine output for the past 8 hours totals 200 mL. How should the nurse document this finding?

Nocturia
Polyuria
Oliguria (Correct answer)
Anuria

Correct answer: Oliguria

Oliguria is defined as urine output less than 30 mL/hour or less than 400 mL/day; 200 mL in 8 hours (25 mL/hr) meets this criterion.

Question 123: A nurse is performing oral care for an unconscious patient. What is the priority safety measure?

Using a soft-bristle toothbrush
Applying lip moisturizer afterward
Positioning the patient on their side (Correct answer)
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 124: A nurse is teaching a group of parents about childhood immunizations. Which vaccine is recommended at birth in the US?

Varicella
DTaP
MMR
Hepatitis B (Correct answer)

Correct answer: Hepatitis B

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

Question 125: A patient recently diagnosed with cancer states, 'I want to know all about my treatment options.' According to Kubler-Ross, which stage of grief is the patient most likely experiencing?

Bargaining
Depression
Denial
Acceptance (Correct answer)

Correct answer: Acceptance

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

Question 126: A critically ill Roman Catholic patient asks for the Anointing of the Sick. Which action by the nurse is most appropriate?

Contact a Catholic priest or the hospital chaplain (Correct answer)
Wait until the patient's condition worsens before calling anyone
Tell the patient this sacrament is only for those already deceased
Pray with the patient instead, since that is equivalent

Correct answer: Contact a Catholic priest or the hospital chaplain

The Anointing of the Sick is performed by a priest and may be given to seriously ill, not only dying, patients.

Question 127: A patient with diabetes mellitus has a fasting blood glucose of 52 mg/dL and is conscious. What is the nurse's priority intervention?

Administer glucagon intramuscularly
Administer IV dextrose 50%
Give 15 grams of a fast-acting carbohydrate orally (Correct answer)
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 128: A postoperative client is encouraged to ambulate as soon as possible. Which of the following is the primary rationale for early ambulation?

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

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 129: A facility uses charting by exception (CBE). What does this documentation system require?

Writing a narrative note for every body system each hour
Documenting only medications that are given
Documenting only findings that differ from established normal standards (Correct answer)
Charting only when the provider requests it

Correct answer: Documenting only findings that differ from established normal standards

CBE assumes predefined normal findings and requires detailed notes only for abnormal findings or changes.

Question 130: A nurse is assessing a newborn's Apgar score at 5 minutes. The infant has a heart rate of 110, strong cry, active motion, grimaces with stimulation, and is completely pink. What is the Apgar score?

10 (Correct answer)
9
8
7

Correct answer: 10

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

Question 131: A nurse is preparing a client for a procedure that requires informed consent. The client states they don't understand the risks. What should the nurse do?

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

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

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

Question 132: 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?

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

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

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

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

Notify the surgeon, as this may indicate active bleeding (Correct answer)
Remove the drain immediately
Clamp the drain and reposition the patient
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 135: Which laboratory value best reflects a patient's long-term nutritional status and protein stores?

Serum albumin (Correct answer)
Total cholesterol
Hemoglobin A1c
Blood glucose

Correct answer: Serum albumin

Serum albumin reflects protein stores over approximately 20 days and is used as a marker of chronic nutritional status. Low albumin indicates protein-calorie malnutrition. Prealbumin reflects shorter-term status, but albumin remains the classic long-term marker.

Question 136: 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
8 hours
4 hours (Correct answer)

Correct answer: 4 hours

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

Question 137: What is the purpose of a root cause analysis (RCA) following a sentinel event?

To determine the financial impact of the error
To assign blame to the individual responsible
To identify system-level factors that contributed to the event and prevent recurrence (Correct answer)
To terminate the employment of staff involved

Correct answer: To identify system-level factors that contributed to the event and prevent recurrence

Root cause analysis is a systematic process to identify underlying system factors that contributed to an adverse event, aiming to implement changes that prevent recurrence.

Question 138: 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?

Role Confusion
Isolation
Stagnation
Despair (Correct answer)

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

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

Correct answer: Canned tomato soup

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

Question 140: 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?

Negligence
Assault
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 141: Which practice best supports safe shift-to-shift handoff communication?

Sharing only the information the off-going nurse thinks is important
Using a standardized tool, at the bedside when possible, with time for questions (Correct answer)
Recording a report and leaving before the oncoming nurse arrives
Giving report at the nurses' station in a hallway full of visitors

Correct answer: Using a standardized tool, at the bedside when possible, with time for questions

Standardized, interactive handoffs with a chance to ask questions reduce omissions and errors.

Question 142: A nurse is initiating a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client develops shortness of breath, chills, and lower back pain. What is the nurse's priority action?

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

Correct answer: Stop the transfusion immediately.

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

Question 143: What should the nurse do first if she gives a medication to the wrong patient?

file an incident report.
notify the physician.
assess the patient for an adverse reaction. (Correct answer)
notify the supervisor.

Correct answer: assess the patient for an adverse reaction.

In any medication error, the nurse's absolute first priority is patient safety. Immediately assessing the patient for any adverse reactions or harm caused by the incorrect medication is crucial to mitigate potential negative outcomes and initiate prompt medical intervention if needed. Reporting and notifying others are important subsequent steps, but patient assessment comes first.

Question 144: A nurse is preparing to administer potassium chloride (KCl) 40 mEq IV. Which safety precaution is essential?

Give the full dose over 15 minutes
Administer undiluted through a peripheral line
Dilute and administer via infusion pump at no more than 10 mEq/hour (Correct answer)
Administer by IV push for rapid correction

Correct answer: Dilute and administer via infusion pump at no more than 10 mEq/hour

IV potassium must always be diluted and administered via infusion pump at a controlled rate (typically no more than 10 mEq/hour) to prevent fatal cardiac dysrhythmias.

Question 145: A nurse witnesses a healthcare provider explaining a surgical procedure to a client who speaks a different language, using the client's 12-year-old grandchild as an interpreter. Which ethical principle is most immediately compromised in this situation?

Autonomy (Correct answer)
Fidelity
Nonmaleficence
Justice

Correct answer: Autonomy

The principle of autonomy requires that a client give informed consent, which is predicated on their ability to fully understand the information presented. Using a minor, untrained family member as an interpreter does not guarantee that complex medical information, risks, and alternatives are conveyed accurately. This compromises the client's ability to make a truly informed decision, thus violating their autonomy.

Question 146: 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?

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

Correct answer: 0.9% Sodium Chloride (Normal Saline)

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

Question 147: A patient recovering from surgery develops sudden onset dyspnea, chest pain, and tachycardia. Which complication should the nurse suspect?

Pneumonia
Heart failure
Atelectasis
Pulmonary embolism (Correct answer)

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

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

Correct answer: SBAR format

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

Question 149: A Muslim patient with type 2 diabetes wants to fast during Ramadan. What is the nurse's best action?

Hold all diabetes medications until Ramadan ends
Advise the patient that Islam forbids fasting for anyone with diabetes
Tell the patient fasting is not allowed during hospitalization
Collaborate with the provider to adjust medication timing around pre-dawn and post-sunset meals (Correct answer)

Correct answer: Collaborate with the provider to adjust medication timing around pre-dawn and post-sunset meals

Respecting the choice to fast while adjusting medication timing with the provider supports safety and cultural values, though ill people may be exempt and should be informed.

Question 150: Which clinical presentation is most consistent with third-spacing of fluid?

Peripheral edema with hypertension and bounding pulse
Decreased urine output with low intravascular volume despite visible fluid accumulation (Correct answer)
Jugular vein distension with crackles and weight gain
Increased urine output with elevated blood pressure

Correct answer: Decreased urine output with low intravascular volume despite visible fluid accumulation

Third-spacing occurs when fluid shifts into non-functional compartments (e.g., ascites, burn edema), reducing intravascular volume and urine output while fluid appears to accumulate in the body.

Question 151: A nurse is caring for a patient who speaks limited English. The patient's bilingual child offers to interpret. What is the most appropriate response?

Use simple English words and speak slowly
Accept the child's help since they can communicate with the patient
Decline and arrange for a certified medical interpreter (Correct answer)
Postpone the discussion until the physician arrives

Correct answer: Decline and arrange for a certified medical interpreter

Using family members, especially children, as interpreters can compromise accuracy and violate the patient's privacy. A certified medical interpreter is required.

Question 152: 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?

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

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 153: A patient with limited English proficiency needs discharge teaching. Who is the most appropriate person to interpret?

The patient's 12-year-old child
A bilingual housekeeper
The patient's roommate
A qualified medical interpreter (Correct answer)

Correct answer: A qualified medical interpreter

Qualified medical interpreters ensure accuracy and confidentiality, while using family members, especially children, is discouraged.

Question 154: 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?

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

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 155: 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)
Sublimation
Projection
Rationalization

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 156: A nurse is preparing to perform a sterile dressing change. Which action breaks sterile technique?

Reaching across the sterile field without touching it
Placing sterile items at the edge of the sterile drape (1 inch border) (Correct answer)
Considering any sterile package that is wet as contaminated
Pouring sterile solution from a distance of 6 inches above the container

Correct answer: Placing sterile items at the edge of the sterile drape (1 inch border)

The 1-inch border around a sterile drape is considered contaminated; sterile items must be placed within the interior of the field.

Question 157: What is the correct sequence for donning personal protective equipment (PPE)?

Gloves, gown, mask, eyewear
Mask, gloves, gown, eyewear
Eyewear, mask, gown, gloves
Gown, mask, eyewear, gloves (Correct answer)

Correct answer: Gown, mask, eyewear, gloves

The correct donning sequence is gown, mask or respirator, eyewear, then gloves, ensuring gloves cover the gown cuffs.

Question 158: A nurse is caring for an elderly patient who recently lost a spouse and expresses feelings of loneliness. Which intervention is most appropriate?

Advise the patient to stay busy to avoid thinking about the loss
Encourage the patient to suppress grief to avoid depression
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 159: A nurse enters a patient's room and smells a strong gas odor. What is the nurse's first action?

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

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

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

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

Spironolactone (Correct answer)
Furosemide
Mannitol
Hydrochlorothiazide

Correct answer: Spironolactone

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

Question 162: A nurse is caring for a patient experiencing status epilepticus. Which intervention takes priority?

Obtaining a detailed neurological history from family members
Maintaining a patent airway and administering IV benzodiazepine (Correct answer)
Restraining the patient's extremities to prevent injury
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 163: A nurse is providing hygiene care to an unconscious client. Which action is essential to prevent injury?

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

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 164: A nurse is preparing a patient for a lumbar puncture. Which position should the patient be placed in?

Lateral recumbent with knees drawn to chest and chin tucked (Correct answer)
Prone with a pillow under the abdomen
Sitting upright leaning forward over a bedside table
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 165: In which situation is a nurse legally mandated to report information, even without the patient's consent?

When a patient reports a history of recreational drug use
When a patient requests information about alternative therapies
When a patient confides about marital problems
When a patient presents with injuries consistent with child abuse (Correct answer)

Correct answer: When a patient presents with injuries consistent with child abuse

All healthcare providers are mandated reporters of suspected child abuse and neglect. This legal obligation overrides patient confidentiality.

Question 166: What is the best crutch gait to use if a patient is not permitted to put any weight on their left leg?

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

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 167: The type of crisis that a patient is most likely going through if she is getting close to 65 and is really unhappy is?

traumatic.
life transitional. (Correct answer)
maturational.
situational.

Correct answer: life transitional.

A patient who is distressed because she is getting close to 65 is probably going through a life transitional crisis. Life transitions are predictable changes (such as high school graduation, marriage, aging, divorce, and moving) that the patient may feel they have no control over and may be unsure of how to handle, even if the transition is ultimately positive.

Question 168: A patient with heart failure is prescribed furosemide 40 mg IV. Which electrolyte imbalance should the nurse monitor for most closely?

Hypernatremia
Hypercalcemia
Hypokalemia (Correct answer)
Hypermagnesemia

Correct answer: Hypokalemia

Furosemide is a loop diuretic that causes significant potassium loss through increased urinary excretion, leading to hypokalemia.

Question 169: A nurse is administering total parenteral nutrition (TPN) through a central line. Which nursing action is essential?

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

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

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

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

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

Question 171: Which quality improvement model uses the cycle of Plan, Do, Study, Act?

Six Sigma
Failure Mode and Effects Analysis
Lean methodology
PDSA cycle (Correct answer)

Correct answer: PDSA cycle

The PDSA (Plan-Do-Study-Act) cycle is a quality improvement model that tests changes on a small scale before implementing them broadly.

Question 172: A nurse suspects that an elderly patient is being financially exploited by a family member. What is the nurse's legal obligation?

Discuss the concern with the family member first
Document the suspicion but take no further action
Report the suspected abuse to Adult Protective Services (Correct answer)
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 173: The ethical principle of beneficence requires a nurse to take what type of action?

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

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

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

Question 174: Which position is most appropriate for a patient who is unconscious and breathing spontaneously to prevent aspiration?

Supine with head of bed elevated 30 degrees
Trendelenburg position
Prone position
Lateral (recovery/side-lying) position (Correct answer)

Correct answer: Lateral (recovery/side-lying) position

The lateral (recovery) position allows secretions and vomit to drain from the mouth, reducing aspiration risk in an unconscious patient.

Question 175: A patient diagnosed with schizophrenia reports hearing voices that tell them to harm themselves. How should the nurse classify this symptom?

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

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 176: A nurse is conducting a health history. The client reports smoking 1 pack of cigarettes per day for 20 years. How many pack-years does this represent?

40 pack-years
10 pack-years
30 pack-years
20 pack-years (Correct answer)

Correct answer: 20 pack-years

Pack-years are calculated by multiplying packs smoked per day by years smoked: 1 pack/day × 20 years = 20 pack-years.

Question 177: A nurse identifies a medication error after administration. What is the priority sequence of actions?

Document in the chart, file an incident report, then assess the client
File an incident report, then assess the client, then notify the physician
Notify the physician, then assess the client, then notify the supervisor
Assess the client, notify the physician, then file an incident report (Correct answer)

Correct answer: Assess the client, notify the physician, then file an incident report

Following a medication error, client safety is the immediate priority: assess the client first, then notify the physician, and then complete the incident report.

Question 178: During a health history, a patient pauses for long periods before answering. What should the nurse do?

Move on to the next question
Ask a family member to answer instead
Allow the silence and wait for the patient to respond (Correct answer)
Rephrase the question right away

Correct answer: Allow the silence and wait for the patient to respond

In many cultures, silence shows thoughtfulness and respect, so the nurse should give the patient time to respond.

Question 179: A nurse is preparing to administer a medication via a nasogastric tube. Which action ensures patient safety?

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

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

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

Question 180: Which behavior modification technique is MOST appropriate when counseling a client about smoking cessation?

Setting a specific quit date (Correct answer)
Gradually reducing cigarettes daily
Switching to a lower-nicotine brand
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 181: During the assessment phase of the nursing process, the nurse gathers both subjective and objective data. Which of the following is an example of subjective data?

The client's statement, "I have a pounding headache." (Correct answer)
A heart rate of 92 beats per minute
Blood pressure reading of 120/80 mmHg
Observed grimacing when the client moves

Correct answer: The client's statement, "I have a pounding headache."

Subjective data is information provided by the client from their own perspective, such as their feelings, perceptions, and concerns. It cannot be directly measured by the healthcare provider. The statement "I have a pounding headache" is what the client is reporting. Blood pressure, heart rate, and observed grimacing are all forms of objective data that can be seen, measured, or observed by the nurse.

Question 182: 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?

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

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

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

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

Blood glucose
Serum albumin (Correct answer)
Hemoglobin
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 185: Which federal law requires facilities that receive federal funding to provide language assistance to patients with limited English proficiency?

HIPAA
Title VI of the Civil Rights Act of 1964 (Correct answer)
EMTALA
The Patient Self-Determination Act

Correct answer: Title VI of the Civil Rights Act of 1964

Title VI prohibits discrimination based on national origin, which includes failing to provide meaningful language access.

Question 186: A nurse is teaching a 45-year-old female client about recommended health screenings. Which screening should the nurse prioritize for this age group?

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

Correct answer: Annual mammogram

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

Question 187: 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
Esteem and recognition
Coping and adaptation (Correct answer)
Love and belonging

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 188: Which teaching point is most important for a patient prescribed warfarin?

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

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

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

Correct answer: Expanding hematoma at the femoral access site

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

Question 190: A nurse observes that a fellow nurse consistently fails to perform hand hygiene between patients. What is the most appropriate initial action?

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

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 191: Which statement by the nurse is an example of a nontherapeutic communication technique?

"You seem upset since your visitors left."
"I notice you haven't eaten much today."
"Tell me more about the pain you felt last night."
"Why didn't you take your blood pressure medicine?" (Correct answer)

Correct answer: "Why didn't you take your blood pressure medicine?"

'Why' questions often sound accusatory and make clients defensive.

Question 192: A nurse is monitoring a client receiving an IV infusion of 0.9% sodium chloride. The client complains of pain and swelling at the IV site, and the surrounding skin appears cool and blanched. Which action should the nurse take first?

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

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

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

Question 193: A nurse is caring for a client who refuses a prescribed blood transfusion due to religious beliefs. The client is hemodynamically unstable. Which action best illustrates the nurse's role as a client advocate while upholding ethical principles?

Contacting the hospital's ethics committee to override the client's decision.
Requesting a family member to convince the client to accept the transfusion.
Documenting the refusal and notifying the healthcare provider of the client's decision. (Correct answer)
Administering the blood transfusion because it is a life-saving measure.

Correct answer: Documenting the refusal and notifying the healthcare provider of the client's decision.

A competent adult has the right to refuse medical treatment (autonomy), even if it is life-sustaining. The nurse's role is to respect this right, ensure the client is fully informed, document the decision, and communicate it to the provider so that alternative treatment plans can be explored. Overriding the client's wishes or coercing them violates ethical principles.

Question 194: Which developmental milestone is expected in a healthy 12-month-old child?

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

Correct answer: Walking with assistance or independently

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

Question 195: A patient's serum potassium is 2.9 mEq/L. Which intervention is the priority nursing action?

Place the patient on continuous cardiac monitoring (Correct answer)
Administer IV potassium chloride via rapid IV push
Administer sodium polystyrene sulfonate (Kayexalate)
Restrict dietary potassium intake

Correct answer: Place the patient on continuous cardiac monitoring

Hypokalemia can cause life-threatening dysrhythmias; continuous cardiac monitoring is the priority to detect and respond to arrhythmias early before or during potassium replacement.

Question 196: An RN delegates the task of obtaining routine vital signs on a stable client to an unlicensed assistive personnel (UAP). The UAP later reports to the RN that the client's blood pressure is 188/102 mmHg. What is the RN's most critical next step?

Tell the UAP to retake the blood pressure in 30 minutes.
Instruct the UAP to notify the charge nurse of the finding.
Personally reassess the client's blood pressure and overall condition. (Correct answer)
Document the vital signs as reported by the UAP.

Correct answer: Personally reassess the client's blood pressure and overall condition.

While tasks can be delegated, the RN retains full accountability for the nursing process, which includes assessment, interpretation, and intervention. When an abnormal finding is reported, the RN must personally validate the data, perform a focused assessment on the client, and then decide on the appropriate action, such as notifying the provider. Delegating assessment or clinical judgment is not appropriate.

Question 197: A patient is receiving continuous pulse oximetry. The reading shows SpO2 of 78% but the patient appears comfortable and in no distress. What should the nurse assess first?

Call a rapid response team
Check the probe placement and patient's perfusion status (Correct answer)
Administer high-flow oxygen immediately
Obtain an arterial blood gas immediately

Correct answer: Check the probe placement and patient's perfusion status

When the pulse oximetry reading does not match the clinical picture, the nurse should first troubleshoot the equipment by checking probe placement, perfusion, and potential interfering factors.

Question 198: Which type of isolation precaution is required for a patient diagnosed with tuberculosis?

Standard precautions only
Airborne precautions (Correct answer)
Droplet precautions
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 199: A patient taking warfarin reports drinking a traditional herbal remedy containing ginkgo biloba. What is the nurse's priority concern?

Hyperglycemia
Decreased warfarin absorption causing clots
Hypokalemia
Increased bleeding risk (Correct answer)

Correct answer: Increased bleeding risk

Ginkgo has antiplatelet effects that can increase bleeding risk when combined with warfarin.

Question 200: 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?

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

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.

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

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