NCLEX-RN Exam — Questions and Answers

Question 1: A patient is experiencing a dissociative episode. Which nursing intervention is most appropriate?

Leave the patient alone until the episode resolves spontaneously
Firmly remind the patient that what they are experiencing is not real
Use grounding techniques: encourage the patient to focus on sensory cues in the present environment (Correct answer)
Administer an antipsychotic medication immediately

Correct answer: Use grounding techniques: encourage the patient to focus on sensory cues in the present environment

Grounding techniques (5-4-3-2-1 sensory method, physical sensation focus) bring the patient back to present reality during dissociation. They are evidence-based, non-pharmacological interventions for dissociative episodes.

Question 2: When providing anticipatory guidance to a mother about infant feeding, what should the nurse emphasize about safe formula preparation?

Prepared formula should be refrigerated and used within 24 hours; discard leftovers from a feeding (Correct answer)
Bottles of formula can be reused without washing if the baby didn't finish
Prepared formula can be stored at room temperature for up to 12 hours
Formula powder can be mixed in advance and stored in a sippy cup

Correct answer: Prepared formula should be refrigerated and used within 24 hours; discard leftovers from a feeding

Prepared formula should be refrigerated and used within 24 hours. Any formula left in a bottle after feeding must be discarded within 1–2 hours due to bacterial contamination from the infant's saliva.

Question 3: He checks if his instruments meet the criteria for evaluation. Which of the following criteria refers to the consistency or the ability to yield the same response upon its repeated administration?

Sensitivity
Reliability (Correct answer)
Validity
Objectivity

Correct answer: Reliability

Reliability refers to the consistency and stability of a measurement instrument. An instrument is reliable if it yields the same or highly similar results when administered repeatedly under the same conditions to the same subjects. It indicates the extent to which a measurement is free from random error, ensuring dependable and reproducible results.

Question 4: A fire starts in a client's room. After the nurse rescues the client and activates the alarm, which action should the nurse take next, following RACE?

Extinguish the fire (Correct answer)
Confine the fire by closing doors and windows
Call the operator to report the fire location
Evacuate the remaining clients on the unit

Correct answer: Extinguish the fire

RACE stands for Rescue, Alarm, Contain (confine), and Extinguish/Evacuate. After rescue and alarm, the nurse confines the fire by closing doors and windows to limit its spread and the oxygen supply, and then extinguishes it if it is small and safe to do so. In this item, confinement is the next step.

Question 5: A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?

The tumor extended beyond the kidney but was completely resected (Correct answer)
The tumor is less than 3 cm. in size and requires no chemotherapy
The tumor has spread into the abdominal cavity and cannot be resected
The tumor did not extend beyond the kidney and was completely resected

Correct answer: The tumor extended beyond the kidney but was completely resected

Wilms tumor staging is crucial for determining treatment and prognosis. Stage II Wilms tumor is characterized by the tumor extending beyond the kidney into surrounding tissues, but it has been completely resected during surgery. This means that all visible tumor tissue was removed, distinguishing it from Stage I (confined to the kidney) and higher stages where resection is incomplete or metastasis has occurred.

Question 6: Examples are: guaranteeing the availability of necessary equipment, collaborating with other healthcare professionals, and reporting a change in shift

Referrals
Direct care
Indirect care (Correct answer)
Delegation

Correct answer: Indirect care

Indirect care refers to nursing activities performed away from the client but on their behalf, supporting the effectiveness of direct care. Examples include ensuring the availability of necessary equipment, collaborating with other healthcare professionals, and reporting changes in shift. These actions are crucial for efficient and safe client care, even though they don't involve direct physical interaction with the patient.

Question 7: Which finding indicates a client with heat stroke rather than heat exhaustion?

Muscle cramps with normal mentation
Temperature of 100.4°F with nausea
Heavy sweating and thirst
Altered mental status with a core temperature above 104°F (Correct answer)

Correct answer: Altered mental status with a core temperature above 104°F

Heat stroke involves central nervous system dysfunction and core temperature above 40°C (104°F).

Question 8: A patient has received instructions on how to administer insulin shots on their own. As the patient tries to recap the needle, the nurse notices that more instruction is required. Which nursing critical thinking technique is the nurse using?

Inference
Evaluation
Interpretation
Analysis (Correct answer)

Correct answer: Analysis

Analysis in critical thinking involves breaking down information into its component parts and examining their relationships to identify patterns or problems. The nurse is observing the patient's technique for administering insulin and specifically identifying an error in recapping the needle. This detailed examination of the patient's actions to pinpoint a specific area needing correction is an example of analysis.

Question 9: A nurse is working with a patient who speaks limited English. Which approach is most appropriate for effective communication?

Ask the patient's family member to interpret all clinical information
Use gestures only, since verbal communication may cause confusion
Speak loudly and slowly so the patient can understand
Request a trained medical interpreter for all significant communications (Correct answer)

Correct answer: Request a trained medical interpreter for all significant communications

A trained medical interpreter must be used for significant clinical communications to ensure accuracy and protect patient confidentiality. Family members may omit, misinterpret, or alter information, especially sensitive findings. Speaking loudly does not aid comprehension for language barriers.

Question 10: A nurse is teaching a patient about clonazepam prescribed for panic disorder. Which statement by the patient requires clarification?

I understand this medication can cause drowsiness and to avoid driving
I can take extra doses if I feel a panic attack coming on (Correct answer)
I should not abruptly stop this medication without talking to my doctor
I should avoid alcohol while taking this medication

Correct answer: I can take extra doses if I feel a panic attack coming on

Taking extra benzodiazepine doses without direction from the provider risks physical dependence, tolerance, and overdose. The patient must take only the prescribed dose — this statement indicates a dangerous misunderstanding.

Question 11: A client with schizophrenia is prescribed risperidone (an atypical antipsychotic). Which side effect should the nurse specifically monitor for?

Tardive dyskinesia and extrapyramidal symptoms (EPS) (Correct answer)
Anticholinergic toxicity with urinary retention and dry mouth
Serotonin syndrome
Agranulocytosis requiring weekly CBC

Correct answer: Tardive dyskinesia and extrapyramidal symptoms (EPS)

Although atypical antipsychotics have lower EPS risk than typical antipsychotics, risperidone has a higher EPS profile among atypicals. Tardive dyskinesia (involuntary repetitive movements) and extrapyramidal symptoms (akathisia, parkinsonism, dystonia) require monitoring. Clozapine specifically requires weekly CBC monitoring for agranulocytosis.

Question 12: A patient is starting lisinopril for hypertension. Which side effect should the nurse include in patient teaching?

Increased urination
Dry, persistent cough (Correct answer)
Hypertrichosis
Weight gain

Correct answer: Dry, persistent cough

ACE inhibitors like lisinopril commonly cause a dry, persistent cough due to accumulation of bradykinin. This is a known side effect and may require switching to an ARB.

Question 13: During a well-baby visit, which finding in a 6-month-old infant requires further evaluation?

The infant does not use a pincer grasp
The infant is not yet walking while holding furniture
The infant shows marked head lag when pulled to a sitting position (Correct answer)
The infant does not say 'mama' with meaning

Correct answer: The infant shows marked head lag when pulled to a sitting position

Head lag should disappear by about 4 to 6 months, so persistent head lag suggests a possible neuromuscular or developmental delay.

Question 14: A nurse is providing health education to a 45-year-old female client with no risk factors. Which cancer screening test should the nurse recommend at this time?

Annual Pap smear with HPV co-test
Annual mammogram (Correct answer)
Colonoscopy within the next 5 years
Annual low-dose CT scan of the chest

Correct answer: Annual mammogram

The American Cancer Society recommends that women with average risk begin annual mammograms at age 40-45. At age 45, annual mammography is the appropriate screening recommendation for breast cancer.

Question 15: A client after surgery reports warmth and tightness around the incision. What should the nurse do first?

Apply cold compresses immediately.
Ignore the symptom unless it spreads.
Assess the incision site. (Correct answer)
Remove all dressings.

Correct answer: Assess the incision site.

Warmth and tightness around an incision can indicate inflammation, infection, or a hematoma. The nurse's priority is to assess the incision site directly to gather objective data about its appearance, palpate for tenderness or swelling, and check for any drainage. This assessment guides subsequent interventions and reporting to the provider.

Question 16: A 12-month-old is brought for a well-child visit. Which gross motor finding is expected?

Climbing stairs alone
Jumping with both feet
Running steadily
Walking with one hand held or first independent steps (Correct answer)

Correct answer: Walking with one hand held or first independent steps

Around 12 months most infants take first independent steps or walk while holding a hand.

Question 17: A nurse manager notices that several nurses on the unit consistently bypass the two-patient identifier protocol before administering medications. The most effective management intervention is to:

Assign the charge nurse to watch every medication administration on the floor
Post a reminder memo on the medication room door
Write up each nurse individually and place the documentation in their personnel files
Conduct a staff education session and implement unit-level audits to monitor compliance (Correct answer)

Correct answer: Conduct a staff education session and implement unit-level audits to monitor compliance

Sustained safety behavior change requires both education and accountability. A targeted education session addresses knowledge gaps, while audits create objective data to monitor compliance and identify persistent issues. This systems-level approach is more effective than individual punitive action.

Question 18: The nurse is monitoring a client receiving peritoneal dialysis and nurse notes that a client’s outflow is less than the inflow. Select actions that the nurse should take.

Contact the physician
Check the peritoneal dialysis system for kinks (Correct answer)
Reposition the client to his or her side. (Correct answer)
Place the client in good body alignment (Correct answer)
Check the level of the drainage bag (Correct answer)

Correct answer: Check the peritoneal dialysis system for kinks

If peritoneal dialysis outflow is less than inflow, the nurse should first troubleshoot potential mechanical issues. Placing the client in good body alignment, repositioning them to their side, and checking for kinks in the tubing can help facilitate drainage by moving the catheter or resolving obstructions. Additionally, ensuring the drainage bag is below the client's abdomen utilizes gravity to promote outflow before escalating to physician notification.

Question 19: A child is diagnosed with Kawasaki disease. Which clinical finding is characteristic of this disease?

Vesicular rash that began on the trunk and spread outward
Purpuric rash on the buttocks and legs
Strawberry tongue, bilateral conjunctival injection, and prolonged fever (Correct answer)
Sandpaper-texture rash with circumoral pallor

Correct answer: Strawberry tongue, bilateral conjunctival injection, and prolonged fever

Kawasaki disease is a systemic vasculitis of unknown etiology affecting children under 5. Diagnostic criteria include fever > 5 days plus ≥4 of: bilateral conjunctival injection (without exudate), strawberry tongue/lip changes, polymorphous rash, extremity changes (edema/peeling), and cervical lymphadenopathy. Untreated, it can cause coronary artery aneurysms.

Question 20: Which client is most appropriate to place in the same room as a client with varicella (chickenpox)?

A client with a different strain of varicella
No other client; the client requires a private airborne isolation room (Correct answer)
A client who has had documented varicella immunity and a fractured femur
A client with shingles who is immunocompromised

Correct answer: No other client; the client requires a private airborne isolation room

Varicella requires airborne plus contact precautions in a private negative-pressure room.

Question 21: The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?

The client lives in a house built in 1976
The client’s parents are skilled stained-glass artists. (Correct answer)
The client has traveled out of the country in the last 6 months.
The client has several brothers and sisters.

Correct answer: The client’s parents are skilled stained-glass artists.

Plumbism is lead poisoning, and exposure to lead is a common cause. Stained-glass artistry involves working with lead solder, which can release lead dust or fumes into the environment. Children living in such households are at a high risk of lead exposure through inhalation or ingestion, making this the most likely related factor.

Question 22: A case manager is planning discharge for a client with heart failure who lives alone and has had three readmissions in 2 months. Which referral is most important?

Home health nursing for weight monitoring and medication management (Correct answer)
A social activities group at a community center
Outpatient physical therapy for gait training
A dietitian visit during the current hospital stay only

Correct answer: Home health nursing for weight monitoring and medication management

Home health nursing gives ongoing monitoring of daily weights, symptoms, and medication adherence, which helps prevent heart failure readmissions.

Question 23: A patient is placed on a psychiatric hold under an involuntary commitment order. Which right does the patient retain?

The right to be treated with dignity, to refuse non-emergency treatment, and to communicate with an attorney (Correct answer)
The right to leave the facility at any time
The right to determine their own treatment plan without provider input
The right to access all portions of their medical record immediately

Correct answer: The right to be treated with dignity, to refuse non-emergency treatment, and to communicate with an attorney

Involuntary commitment restricts freedom of movement but does not eliminate all rights. Patients retain rights to dignity, communication with an attorney, and can refuse non-emergency treatments (though this may be overridden by court order).

Question 24: Which antihypertensive class is contraindicated in pregnancy due to risk of fetal renal damage?

Methyldopa
ACE inhibitors (Correct answer)
Calcium channel blockers
Beta-blockers

Correct answer: ACE inhibitors

ACE inhibitors are teratogenic and contraindicated in pregnancy (especially 2nd and 3rd trimesters) due to risk of fetal renal dysplasia, oligohydramnios, and neonatal death.

Question 25: A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?

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

Correct answer: Family history of heart disease.

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

Question 26: The nurse is caring for a confused elderly client who is attempting to remove an IV line. Which intervention is most appropriate and least restrictive?

Apply bilateral wrist restraints to prevent IV removal
Request a one-to-one sitter and place the client in a room with a window
Administer a PRN sedative to keep the client calm
Place a loose long-sleeved garment over the IV site and engage the client in a meaningful activity (Correct answer)

Correct answer: Place a loose long-sleeved garment over the IV site and engage the client in a meaningful activity

The least-restrictive intervention principle requires trying non-restraint alternatives first. Covering the IV with a long sleeve reduces visibility (out of sight, out of mind) while an activity redirects the client. Restraints are a last resort and can worsen agitation, cause injury, and lead to deconditioning. Document all alternatives tried before restraint use.

Question 27: A client asks whether insulin glargine can be drawn up in the same syringe as regular insulin. What is the best response?

Yes, always draw up the glargine first
No, glargine should not be mixed with other insulins (Correct answer)
Only if the provider orders it
Yes, if both are given right away

Correct answer: No, glargine should not be mixed with other insulins

Mixing insulin glargine with other insulins changes its pH and long-acting absorption profile.

Question 28: Ms. Valencia develops the standards to be followed. Among the following standards, which is considered as a structure standard?

All patients shall have their weights taken recorded
Rotation of duty will be done every four weeks for all patient care personnel (Correct answer)
Patients shall answer the evaluation form before discharge
The patients verbalized satisfaction of the nursing care received

Correct answer: Rotation of duty will be done every four weeks for all patient care personnel

Structure standards relate to the physical environment, organizational characteristics, and resources available for patient care. The rotation of duty for personnel is an aspect of how the nursing unit is organized and managed, describing a characteristic of the system in place. It defines an organizational resource allocation rather than a direct patient outcome or a specific nursing action.

Question 29: A patient on a psychiatric unit with bipolar disorder states, 'I am the president of the United States and I need a phone right now to call the Pentagon.' The nurse recognizes this as:

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

Correct answer: Grandiose delusion consistent with mania

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

Question 30: Which finding indicates that a client's hyperosmolar hyperglycemic state (HHS) is improving?

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

Correct answer: Improving level of consciousness and normalizing serum glucose

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

Question 31: A confused client keeps pulling at their oxygen tubing. What should the nurse do first?

Ignore the behavior until tubing is removed.
Secure or cover the oxygen tubing. (Correct answer)
Remove the oxygen entirely.
Restrain the client immediately.

Correct answer: Secure or cover the oxygen tubing.

A confused client pulling at oxygen tubing risks dislodging it, which can compromise their oxygenation and safety. The nurse's first action should be to secure or cover the tubing to prevent removal while maintaining oxygen delivery. This intervention prioritizes client safety and ensures continuity of therapy without immediately resorting to more restrictive measures.

Question 32: What are characteristics of the literature review required for a quantitative research study? Select all that apply.

The review is exhaustive and must include all studies conducted in the area
Computer-accessed materials are acceptable (Correct answer)
Primary sources are not as important as secondary sources
Doctoral dissertations and masters’ theses are excellent sources of information (Correct answer)

Correct answer: Computer-accessed materials are acceptable

For quantitative research, a literature review should be comprehensive, focusing on relevant, high-quality evidence. Doctoral dissertations and master's theses are valuable primary sources of research, often containing detailed methodologies and findings not yet published elsewhere. Computer-accessed materials, such as reputable electronic databases, are essential and acceptable tools for efficient literature searching, providing access to a vast array of scholarly work.

Question 33: What is the nurse's role in patient advocacy?

Only supporting patient decisions when they align with nursing practice
Ensuring the patient’s needs and preferences are met (Correct answer)
Making decisions for the patient without consulting them
Disregarding patient preferences to follow hospital policies

Correct answer: Ensuring the patient’s needs and preferences are met

Patient advocacy involves speaking up for the patient, protecting their rights, and ensuring their voice is heard in healthcare decisions. The nurse's role is to support the patient's autonomy and ensure their values, beliefs, and preferences guide their care, even if they differ from the healthcare team's initial recommendations.

Question 34: A client takes digoxin and furosemide. Before giving digoxin, which lab result is most important for the nurse to review?

Serum calcium
Serum sodium
Serum potassium (Correct answer)
Blood glucose

Correct answer: Serum potassium

Furosemide can cause hypokalemia, and low potassium increases the risk of digoxin toxicity.

Question 35: A child with suspected epiglottitis arrives drooling and sitting upright, leaning forward. Which action should the LPN avoid?

Inspecting the throat with a tongue depressor (Correct answer)
Allowing the child to stay upright
Preparing emergency airway equipment
Keeping the child calm with the parent

Correct answer: Inspecting the throat with a tongue depressor

Using a tongue depressor can trigger laryngospasm and complete airway obstruction in epiglottitis.

Question 36: A nurse is assessing a client with acute compartment syndrome in the right lower leg following a tibial fracture. Which finding requires immediate intervention?

Mild bruising over the fracture site
Pain that is relieved by elevation of the affected limb
A capillary refill time of 2 seconds in the right toes
Pain that is disproportionate to the injury and unrelieved by opioid analgesics (Correct answer)

Correct answer: Pain that is disproportionate to the injury and unrelieved by opioid analgesics

Severe pain disproportionate to the injury that is unresponsive to analgesics is the hallmark early sign of compartment syndrome. This is a surgical emergency requiring fasciotomy to relieve pressure. Pain relief with elevation is not expected — elevation can worsen ischemia in compartment syndrome.

Question 37: A nurse is administering medications and realizes the client's arm band is missing. What should the nurse do?

Check the room number and administer if the name matches the MAR
Ask the client to state their name and administer the medication
Ask a colleague who knows the client to confirm identity verbally
Do not administer medication; replace and verify the arm band first (Correct answer)

Correct answer: Do not administer medication; replace and verify the arm band first

Client identification before medication administration is a fundamental safety requirement (Joint Commission National Patient Safety Goal). Without a readable arm band, the nurse cannot safely verify identity. The nurse must NOT administer medications until the client is properly identified using at least two identifiers (name + date of birth or medical record number). The arm band must be replaced and verified first.

Question 38: What is the normal serum potassium range?

5.0–6.5 mEq/L
1.5–2.5 mEq/L
2.5–3.5 mEq/L
3.5–5.0 mEq/L (Correct answer)

Correct answer: 3.5–5.0 mEq/L

Normal serum potassium is 3.5–5.0 mEq/L; values outside this range cause cardiac and neuromuscular complications.

Question 39: A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?

Oral contraceptives
Diaphragm (Correct answer)
Contraceptive sponge
Intrauterine device

Correct answer: Diaphragm

For clients with diabetes, barrier methods like the diaphragm are often considered suitable because they do not affect blood glucose levels or interact with diabetes medications. Oral contraceptives and intrauterine devices (IUDs) can sometimes influence glucose metabolism or carry higher risks of infection in diabetic clients, making the diaphragm a safer non-hormonal option.

Question 40: A client scheduled for surgery tells the nurse, "I'm not sure what the surgeon is going to remove." The consent form is already signed. What is the nurse's best action?

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

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

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

Question 41: A client is post-operative day 1 after a bowel resection and has a nasogastric tube to low continuous suction. The client's serum potassium is 2.8 mEq/L and sodium is 128 mEq/L. These electrolyte imbalances are most likely caused by:

Continuous NG suction removing potassium and sodium in gastric secretions, combined with restriction of oral intake (Correct answer)
Surgical blood loss leading to electrolyte depletion
Excessive IV fluid administration causing dilutional hyponatremia
Post-operative fluid redistribution into the third space only

Correct answer: Continuous NG suction removing potassium and sodium in gastric secretions, combined with restriction of oral intake

Gastric secretions contain significant amounts of sodium, potassium, hydrochloric acid, and water. Continuous NG suction depletes these electrolytes, causing hyponatremia, hypokalemia, and metabolic alkalosis. Electrolyte replacement (IV KCl for potassium, isotonic fluids for sodium) and monitoring are essential post-operatively with NG suction.

Question 42: A client is admitted with acute pyelonephritis. Which clinical finding best differentiates pyelonephritis from a lower UTI (cystitis)?

Costovertebral angle (CVA) tenderness, fever, and chills (Correct answer)
Foul-smelling urine with sediment
Dysuria and frequency
Urinary urgency with low-grade fever

Correct answer: Costovertebral angle (CVA) tenderness, fever, and chills

Acute pyelonephritis involves upper urinary tract (kidney) infection. CVA tenderness (flank pain at the costovertebral angle, elicited by percussion), high fever (≥38.5°C), and systemic symptoms (chills, nausea, vomiting) distinguish it from lower UTI. Lower UTI (cystitis) causes dysuria, frequency, and urgency without systemic involvement or CVA tenderness.

Question 43: The primary cause of anemia in a client with chronic renal failure is:

Lack of intrinsic factor
Destruction of red blood cells
Insufficient erythropoietin (Correct answer)
Poor iron absorption

Correct answer: Insufficient erythropoietin

The primary cause of anemia in clients with chronic renal failure is the kidneys' inability to produce sufficient erythropoietin. Erythropoietin is a hormone vital for stimulating red blood cell production in the bone marrow. As kidney function declines, erythropoietin levels drop, leading to a decreased red blood cell count and subsequent anemia.

Question 44: A client receiving a blood transfusion develops fever, chills, and low back pain after 15 minutes. What is the nurse's priority action?

Document and continue monitoring
Slow the infusion rate
Stop the transfusion immediately (Correct answer)
Administer acetaminophen

Correct answer: Stop the transfusion immediately

These signs suggest an acute hemolytic reaction, and stopping the transfusion prevents further harm.

Question 45: A nurse receives four client call lights at the same time. Which client should the nurse see first?

A client with osteoarthritis rating knee pain 5/10
A client 2 days post-thyroidectomy reporting tingling around the mouth (Correct answer)
A client with diabetes asking when breakfast will arrive
A client with pneumonia asking for an extra blanket

Correct answer: A client 2 days post-thyroidectomy reporting tingling around the mouth

Perioral tingling after a thyroidectomy can mean hypocalcemia from parathyroid injury, which can progress to tetany and laryngospasm.

Question 46: A client with a spinal cord injury at T4 develops a severe pounding headache, flushing above the injury, and a blood pressure of 210/110 mm Hg. What is the nurse's first action?

Administer an oral laxative
Sit the client upright and check for bladder distention or other triggers (Correct answer)
Place the client flat and give a sedative
Apply a heating pad to the lower extremities

Correct answer: Sit the client upright and check for bladder distention or other triggers

These are signs of autonomic dysreflexia, a medical emergency. Raise the head of the bed or sit the client up to lower blood pressure, then find and remove the trigger, most often a distended bladder or fecal impaction, before giving an antihypertensive if needed.

Question 47: A nurse sees a coworker's elderly relative's name on the unit census and wants to check the diagnosis to tell the coworker. What is the correct action?

Look at the chart since the coworker is family
Do not access the record because the nurse is not involved in the client's care (Correct answer)
Ask the client's assigned nurse for a brief verbal update
Access only the face sheet and not the clinical notes

Correct answer: Do not access the record because the nurse is not involved in the client's care

Under HIPAA, staff may access protected health information only when they need it for their job, and family ties don't count as a need.

Question 48: A client with a seizure disorder has a seizure while in bed. Which action is appropriate?

Turn the client to the side and time the seizure (Correct answer)
Restrain the extremities to prevent injury
Insert a padded tongue blade between the teeth
Give oral fluids immediately after it stops

Correct answer: Turn the client to the side and time the seizure

Side-lying positioning maintains the airway and allows drainage, and timing guides treatment.

Question 49: A patient with atrial fibrillation is prescribed amiodarone. Which finding requires immediate provider notification?

Potassium of 4.2 mEq/L
Blood pressure of 118/76 mmHg
QTc interval of 520 milliseconds (Correct answer)
Heart rate of 72 bpm

Correct answer: QTc interval of 520 milliseconds

Amiodarone prolongs the QT interval. A QTc of 520 ms significantly exceeds the safe threshold (men >450 ms, women >470 ms) and raises risk for torsades de pointes, a life-threatening dysrhythmia.

Question 50: Which intervention is appropriate for a client experiencing acute mania?

Encourage competitive games
Engage in lengthy detailed conversations
Offer finger foods the client can eat while moving (Correct answer)
Provide a stimulating group activity

Correct answer: Offer finger foods the client can eat while moving

Manic clients are too active to sit and eat, so high-calorie finger foods support nutrition while they move about.

Question 51: A nurse administers the wrong dose of a medication; the client shows no adverse effects. What is the priority action after assessing the client?

Do nothing since no harm occurred
Document the error in the client's medical record as an incident report
Inform the client's family before the provider
Notify the provider and complete an incident report (Correct answer)

Correct answer: Notify the provider and complete an incident report

After assessing the client, the nurse notifies the provider and completes an incident report, which is not placed in the medical record.

Question 52: Which finding in a post-operative client should the practical nurse report to the registered nurse or provider immediately?

Mild pain controlled with prescribed analgesics.
Small amount of dried drainage on the old dressing.
A surgical dressing that is suddenly saturated with bright red blood. (Correct answer)
Temperature of 37.4 C (99.3 F).

Correct answer: A surgical dressing that is suddenly saturated with bright red blood.

A surgical dressing suddenly saturated with bright red blood indicates active hemorrhage, which is a critical and potentially life-threatening complication. This finding suggests significant blood loss and requires immediate reporting to the registered nurse or provider for urgent assessment and intervention. Prompt action is essential to prevent further compromise.

Question 53: When applying a nitroglycerin transdermal patch, the nurse should do what to prevent tolerance?

Apply two patches at once
Leave the patch on continuously for a week
Allow a nitrate-free interval of 10–12 hours daily (Correct answer)
Apply only at the same hairy site

Correct answer: Allow a nitrate-free interval of 10–12 hours daily

A daily nitrate-free interval prevents the development of tolerance.

Question 54: A nurse is teaching a client who will be discharged with home oxygen. Which statement shows the client understands oxygen safety?

I will place a no smoking sign on the door and keep the tank at least 5 to 10 feet from open flames (Correct answer)
I will store the tank lying flat under my bed
I will use petroleum-based lip balm to prevent dry lips
I will keep the oxygen tank near the gas stove so it stays warm

Correct answer: I will place a no smoking sign on the door and keep the tank at least 5 to 10 feet from open flames

Oxygen supports combustion, so open flames, smoking, and heat sources must be kept away, and no-smoking signs should be posted. Petroleum-based products are flammable in oxygen-enriched settings, so water-based lubricants should be used. Tanks should be secured upright.

Question 55: A patient taking spironolactone should be monitored for which electrolyte imbalance?

Hypokalemia
Hyperkalemia (Correct answer)
Hypernatremia
Hyponatremia

Correct answer: Hyperkalemia

Spironolactone is a potassium-sparing diuretic that blocks aldosterone, causing sodium and water excretion while retaining potassium, which can lead to hyperkalemia.

Question 56: An unlicensed assistive personnel reports a client on airborne precautions for measles needs transport to radiology. What should the client wear during transport?

No mask if the transport is under 15 minutes
A gown and gloves
A surgical mask (Correct answer)
An N95 respirator

Correct answer: A surgical mask

Clients on airborne precautions wear a surgical mask when outside the room; staff wear N95 respirators.

Question 57: A nurse is assisting a postoperative patient with ambulation for the first time following abdominal surgery. After taking two steps, the patient states, 'I feel dizzy and my legs are weak.' What is the nurse's best action?

Return the patient to bed immediately using a gait belt and calling for assistance
Have the patient sit in the nearest chair and assess vital signs (Correct answer)
Ask the patient to hold onto the wall and rest for a moment
Encourage the patient to continue walking as dizziness is expected

Correct answer: Have the patient sit in the nearest chair and assess vital signs

Orthostatic hypotension is a common postoperative complication. When a patient reports dizziness and weakness during first ambulation, the safest immediate action is to seat the patient in the nearest stable location (chair) and assess vital signs. This is safer than attempting to walk back to bed and allows immediate assessment of the cause.

Question 58: Which "five rights" of medication administration is the nurse checking when scanning the client's armband and medication barcode?

Right time and right route
Right client and right medication (Correct answer)
Right medication and right dose
Right client and right documentation

Correct answer: Right client and right medication

Barcode medication administration (BCMA) systems verify the right client (by matching the armband ID) and the right medication (by scanning the drug barcode). The nurse is responsible for all five rights, but BCMA technology specifically addresses client identification and medication verification.

Question 59: When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.

Verify patency of the line by the presence of a blood return at regular intervals. (Correct answer)
Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
Inspect the insertion site for swelling, erythema, or drainage. (Correct answer)
Contact the health care provider about verifying placement if the status is questionable. (Correct answer)
If unable to aspirate blood, reposition the client and encourage the client to cough. (Correct answer)

Correct answer: Verify patency of the line by the presence of a blood return at regular intervals.

Verifying blood return is a critical safety measure before administering chemotherapy through a central venous line. The presence of blood return confirms the catheter's patency and intraluminal placement, ensuring the medication will be delivered into the bloodstream and not into surrounding tissues. Administering vesicant chemotherapy without confirmed blood return could lead to severe extravasation and tissue damage.

Question 60: During a pneumonia assessment, the client has thick mucus and difficulty expectorating. What should the nurse do?

Advise the client to avoid coughing.
Have the client lie completely flat.
Encourage the client to drink more fluids. (Correct answer)
Limit fluids until coughing decreases.

Correct answer: Encourage the client to drink more fluids.

For clients with pneumonia and thick, difficult-to-expectorate mucus, increased fluid intake is essential. Hydration helps to thin respiratory secretions, making them easier to mobilize and cough up, which improves airway clearance and gas exchange. This is a fundamental nursing intervention.

Question 61: A client on a heparin infusion has an aPTT of 120 seconds (therapeutic range 60-80 seconds). What should the nurse do first?

Increase the infusion rate
Administer vitamin K
Hold the infusion and notify the provider per protocol (Correct answer)
Recheck the aPTT in 24 hours

Correct answer: Hold the infusion and notify the provider per protocol

A supratherapeutic aPTT raises bleeding risk, so the infusion is held and adjusted per protocol.

Question 62: A patient is receiving mechanical ventilation and the nurse notes high-pressure alarms. Which assessment should the nurse perform first?

Immediately disconnect the patient from the ventilator
Assess the patient and ventilator circuit for obstruction — suctioning, kinking, patient biting tube, bronchospasm (Correct answer)
Increase FiO2 to compensate for potential hypoxia
Increase the set tidal volume to overcome the obstruction

Correct answer: Assess the patient and ventilator circuit for obstruction — suctioning, kinking, patient biting tube, bronchospasm

High-pressure alarms indicate increased resistance or obstruction in the circuit or patient airway. Assessment should identify and correct the cause — secretions, tube kinking, bronchospasm, or pneumothorax.

Question 63: A client taking a new blood pressure medication reports feeling lightheaded. What is the nurse’s best initial action?

Stop the medication immediately.
Give the client a salty snack.
Check the client’s blood pressure. (Correct answer)
Encourage vigorous exercise.

Correct answer: Check the client’s blood pressure.

Feeling lightheaded after starting a new blood pressure medication suggests a potential drop in blood pressure, possibly orthostatic hypotension. The nurse's best initial action is to check the client's blood pressure to confirm hypotension. This objective assessment provides crucial data to determine the severity of the issue and guide appropriate interventions, such as notifying the provider or adjusting the medication.

Question 64: A community health nurse is educating clients about primary prevention of type 2 diabetes. Which intervention is an example of primary prevention?

Screening asymptomatic adults with fasting blood glucose
Promoting weight loss and physical activity in at-risk populations (Correct answer)
Teaching foot care to a client with established diabetes
Referring a pre-diabetic client to a diabetes education program

Correct answer: Promoting weight loss and physical activity in at-risk populations

Primary prevention aims to prevent disease before it occurs by reducing risk factors. Promoting weight loss and physical activity in at-risk populations targets modifiable risk factors for type 2 diabetes. Screening is secondary prevention; education for established or pre-diabetic clients is tertiary/secondary prevention.

Question 65: A client taking isoniazid (INH) should be monitored for which serious adverse effect?

Hepatotoxicity (Correct answer)
Optic neuritis
Renal failure
Hearing loss

Correct answer: Hepatotoxicity

INH can cause liver damage, so liver enzymes and signs of hepatitis must be monitored.

Question 66: A child has drooling, a high fever, and is sitting upright and leaning forward. Which action should the nurse avoid?

Examining the throat with a tongue depressor (Correct answer)
Keeping the child calm on the parent's lap
Having emergency airway equipment ready
Letting the child stay in a position of comfort

Correct answer: Examining the throat with a tongue depressor

Suspected epiglottitis can progress to complete airway obstruction if the throat is examined with a tongue depressor.

Question 67: Which assignment should not be performed by the licensed practical nurse?

Discontinuing a nasogastric tube
Starting a blood transfusion (Correct answer)
Obtaining a sputum specimen
Inserting a Foley catheter

Correct answer: Starting a blood transfusion

Starting a blood transfusion is a complex procedure that carries a high risk of adverse reactions and requires advanced assessment and intervention skills. In most jurisdictions, initiating blood transfusions falls within the scope of practice for a Registered Nurse (RN) due to the critical assessment and monitoring required. Licensed Practical Nurses (LPNs) typically assist with monitoring but do not initiate transfusions.

Question 68: A client is prescribed a new medication. Which pair of identifiers is acceptable before administration?

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

Correct answer: Client name and date of birth

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

Question 69: During evaluation of outcomes for a client treated for hypovolemia, which finding best indicates the interventions were effective?

Capillary refill under 3 seconds and urine output 45 mL/hr (Correct answer)
Heart rate 118/min
Urine output 20 mL/hr
Urine specific gravity 1.035

Correct answer: Capillary refill under 3 seconds and urine output 45 mL/hr

Normal capillary refill and urine output of at least 30 mL/hr show restored perfusion.

Question 70: The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:

Client’s pain
Nutritional status
Serum collection (Davol) drain (Correct answer)
Immobilizer

Correct answer: Serum collection (Davol) drain

Immediately following an open reduction internal fixation (ORIF) of a fractured hip, assessing the serum collection drain (e.g., Davol or Hemovac) is a priority. This drain removes excess blood and fluid from the surgical site, preventing hematoma formation and reducing the risk of infection and swelling. Monitoring the amount and type of drainage provides critical information about potential hemorrhage and fluid balance, which is vital in the immediate postoperative period.

Question 71: A nurse assesses a 6-month-old infant. Which gross motor milestone is expected at this age?

Pulling to a stand
Walking with one hand held
Rolling from back to front (Correct answer)
Sitting without support

Correct answer: Rolling from back to front

By 6 months an infant can typically roll from back to front, while sitting unsupported emerges around 7-8 months.

Question 72: A client has a lactate level of 4.6 mmol/L during resuscitation for sepsis. What does this finding indicate?

Respiratory alkalosis
Early liver regeneration
Tissue hypoperfusion with anaerobic metabolism (Correct answer)
Adequate fluid resuscitation

Correct answer: Tissue hypoperfusion with anaerobic metabolism

A lactate above 4 mmol/L reflects anaerobic metabolism from poor tissue perfusion and requires aggressive resuscitation.

Question 73: Paige is a nurse preceptor who is working with a new nurse Joyce. She notes that the Joyce is reluctant to delegate tasks to members of the care team. Paige recognizes that this reluctance is mostly likely due to:

Lack of trust to the members of the healthcare team. (Correct answer)
Role modeling behaviors of the preceptor.
The philosophy of the new nurse’s school of nursing.
The orientation provided to the new nurse.

Correct answer: Lack of trust to the members of the healthcare team.

New nurses often feel reluctant to delegate tasks due to a lack of established trust in the abilities and judgment of other healthcare team members, such as unlicensed assistive personnel (UAPs). This can stem from a desire to maintain control, ensure tasks are done correctly, or a lack of familiarity with the team's competencies. Building trust and understanding the scope of practice for each team member is essential for effective delegation.

Question 74: A nurse working in a medical-surgical unit receives shift report and has four patients. Which patient should the nurse assess first?

A 55-year-old patient with diabetes who reports hunger and asks for a snack
A 62-year-old patient with heart failure who gained 1 lb since yesterday
A 70-year-old patient post-hip replacement who is requesting pain medication rated 6/10
A 48-year-old patient who returned from bronchoscopy 30 minutes ago and has a new oxygen saturation of 89% (Correct answer)

Correct answer: A 48-year-old patient who returned from bronchoscopy 30 minutes ago and has a new oxygen saturation of 89%

An oxygen saturation of 89% in a post-bronchoscopy patient is a potential airway emergency requiring immediate assessment. Bronchoscopy carries risks of laryngospasm, bronchospasm, and bleeding. This is a life-threatening priority (ABCs — airway/breathing first).

Question 75: The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find?

Rieder’s cells
Lymphoblastic cells.
Gaucher’s cells.
Reed-Sternberg cells. (Correct answer)

Correct answer: Reed-Sternberg cells.

Reed-Sternberg cells are large, distinctive abnormal lymphocytes that are considered the pathological hallmark of Hodgkin's lymphoma. Their presence in a lymph node biopsy is essential for a definitive diagnosis of Hodgkin's disease. Pathologists specifically look for these cells to confirm the diagnosis.

Question 76: An adult took a large aspirin overdose. Which acid-base disturbance usually appears first?

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

Correct answer: Respiratory alkalosis

Salicylates directly stimulate the respiratory center, causing early respiratory alkalosis before metabolic acidosis develops.

Question 77: An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client’s confusion by:

Leaving a nightlight on during the evening and night shifts (Correct answer)
Administering a bedtime sedative
Allowing the client to room with another elderly client
Assigning a nursing assistant to sit with him until he falls asleep

Correct answer: Leaving a nightlight on during the evening and night shifts

Nighttime confusion, often referred to as 'sundowning,' in elderly clients can be worsened by disorientation in unfamiliar or dimly lit environments. Leaving a nightlight on provides visual cues, helps the client orient themselves to their surroundings, and reduces anxiety and confusion by making the environment less threatening and more recognizable during the night.

Question 78: The nurse is administering IV vancomycin. The patient develops flushing, erythema, and hypotension during the infusion. What action should the nurse take?

Continue the infusion and document findings
Stop the infusion and administer epinephrine
Discontinue vancomycin and change to a different antibiotic
Slow the infusion rate and administer diphenhydramine (Correct answer)

Correct answer: Slow the infusion rate and administer diphenhydramine

This describes 'Red Man Syndrome,' a non-immune-mediated reaction caused by too-rapid vancomycin infusion. Slowing the rate and giving diphenhydramine typically resolves symptoms.

Question 79: A nurse is teaching a patient with type 2 diabetes about metformin. Which laboratory value requires immediate provider notification before administering metformin?

Triglycerides of 220 mg/dL
HbA1c of 8.2%
Fasting glucose of 185 mg/dL
eGFR of 25 mL/min/1.73m² (Correct answer)

Correct answer: eGFR of 25 mL/min/1.73m²

Metformin is contraindicated with eGFR <30 mL/min/1.73m² due to risk of lactic acidosis from accumulation. An eGFR of 25 is below this threshold — metformin should be withheld and the provider notified.

Question 80: Before a final exam, a student is breathing at 32 breaths/min and reports lightheadedness. Which imbalance is most likely?

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

Correct answer: Respiratory alkalosis

Hyperventilation blows off too much CO2, which lowers PaCO2 and raises pH.

Question 81: What is the nurse's role in managing patient care transitions?

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

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

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

Question 82: The nurse is administering digoxin. Which assessment finding requires holding the medication and notifying the provider?

Blood pressure of 128/80 mmHg
Heart rate of 68 bpm
Heart rate of 54 bpm (Correct answer)
Potassium level of 4.0 mEq/L

Correct answer: Heart rate of 54 bpm

Digoxin should be held if the apical heart rate is less than 60 bpm in adults. A rate of 54 indicates bradycardia and risk for digoxin toxicity.

Question 83: A patient with a sodium level of 118 mEq/L develops confusion and seizures. Which IV fluid is most appropriate?

0.45% NaCl (half normal saline)
Lactated Ringer's solution
D5W (5% dextrose in water)
3% NaCl (hypertonic saline) (Correct answer)

Correct answer: 3% NaCl (hypertonic saline)

Severe symptomatic hyponatremia with neurological symptoms requires hypertonic saline (3% NaCl) to safely correct the sodium deficit.

Question 84: A child has recently been diagnosed with Duchenne’s muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

Duchenne’s is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.
Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease. (Correct answer)
Sons only have a 1 in 4 (25%) chance of developing the disorder.
Each child has a 1 in 4 (25%) chance of developing the disorder.

Correct answer: Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.

Duchenne's muscular dystrophy is an X-linked recessive disorder, meaning the gene responsible is located on the X chromosome. If the mother is a carrier, each son has a 50% chance of inheriting the affected X chromosome and developing the disease. Each daughter has a 50% chance of inheriting the affected X chromosome and becoming a carrier, as they typically need two affected X chromosomes to manifest the disease.

Question 85: A nurse notices a patient who has been agitated and pacing is suddenly very calm and states 'I've made my decision.' What should the nurse interpret this behavioral change as?

Positive response to therapy and medication
Normal behavioral fluctuation in psychiatric patients
Breakthrough of underlying depression requiring dosage adjustment
A possible sign of resolution of suicidal crisis after deciding to act (Correct answer)

Correct answer: A possible sign of resolution of suicidal crisis after deciding to act

A sudden, calm behavioral change in a previously agitated suicidal patient may indicate the patient has made a decision to act on suicidal ideation and feels relief. This requires immediate safety assessment.

Question 86: A client has a new cast for a fractured wrist. Which discharge instruction is most important?

"Elevate the casted arm above heart level and report numbness, tingling, or color changes." (Correct answer)
"Insert a ruler under the cast if itching occurs to scratch inside."
"Wet the cast daily with a damp cloth to keep it from cracking."
"The cast is waterproof — you can shower normally."

Correct answer: "Elevate the casted arm above heart level and report numbness, tingling, or color changes."

Neurovascular assessment is the most critical component of cast care. The 6 P's of compartment syndrome (Pain, Pressure, Pallor, Paralysis, Paresthesia, Pulselessness) must be reported immediately. Elevating the extremity reduces swelling. Inserting objects under the cast can cause wounds and infections. Plaster casts are not waterproof.

Question 87: After a transurethral resection of the prostate (TURP) with continuous bladder irrigation, a client becomes confused and nauseated. Which imbalance should the nurse suspect?

Hypercalcemia
Dilutional hyponatremia (Correct answer)
Hypermagnesemia
Hypokalemia

Correct answer: Dilutional hyponatremia

Absorbing large volumes of hypotonic irrigating fluid can cause TURP syndrome, which is a dilutional hyponatremia.

Question 88: Which client should the nurse identify as at highest risk for a health care–associated urinary tract infection?

A client using intermittent self-catheterization at home
A client who uses a bedside commode
A client with an indwelling urinary catheter for 6 days (Correct answer)
A client who voids independently every 3 hours

Correct answer: A client with an indwelling urinary catheter for 6 days

Indwelling catheter duration is the main risk factor for catheter-associated UTI.

Question 89: Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for complaints of post-surgical pain. The client’s respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli! The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg and HCO3 24 mEq/L. What does this mean?

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

Correct answer: Respiratory Acidosis, Uncompensated

The pH of 7.10 is significantly acidic, indicating acidosis. The very high PaCO2 of 70 mm Hg points to a respiratory cause, specifically hypoventilation due to opioid overdose. The HCO3 of 24 mEq/L is within the normal range, meaning the kidneys have not yet had time to compensate. Therefore, this is an uncompensated respiratory acidosis.

Question 90: A nurse notes a patient in labor has been pushing for 2.5 hours. The fetal head is visible at the perineum during pushing. What term describes this finding?

Restitution
Station +3
Crowning (Correct answer)
Engagement

Correct answer: Crowning

Crowning refers to when the fetal head is visible at the perineal opening and does not retract between contractions, indicating imminent delivery.

Question 91: A nurse is performing a mental status examination and asks the client to interpret the proverb, 'People who live in glass houses should not throw stones.' Which cognitive domain is the nurse assessing?

Short-term memory and recall
Orientation to person, place, and time
Attention span and concentration
Abstract reasoning and thought processes (Correct answer)

Correct answer: Abstract reasoning and thought processes

Interpreting proverbs requires abstract reasoning — the ability to understand concepts beyond their literal meaning. Impaired abstract thinking is seen in schizophrenia, dementia, and other cognitive disorders. Clients with concrete thinking will interpret the proverb literally.

Question 92: The nurse is caring for a patient who overdosed on a calcium channel blocker. Which intervention is most appropriate for severe cardiovascular toxicity?

Administer IV sodium bicarbonate to reverse toxicity
Administer IV magnesium sulfate
Administer IV calcium gluconate and high-dose insulin-euglycemic therapy (Correct answer)
Administer IV atropine as the first-line antidote

Correct answer: Administer IV calcium gluconate and high-dose insulin-euglycemic therapy

Calcium channel blocker overdose is treated with IV calcium (restores channel function) and high-dose insulin therapy (improves myocardial glucose utilization and contractility), alongside vasopressors as needed.

Question 93: Which of the following is a sign of acute emotional distress in a patient?

Improved sleep and appetite
Calm and cooperative demeanor
Increased social interaction and positivity
Withdrawn behavior and avoidance of care (Correct answer)

Correct answer: Withdrawn behavior and avoidance of care

Withdrawn behavior and avoidance of care are common signs of acute emotional distress in a patient. These behaviors indicate that the patient is struggling to cope, may feel overwhelmed, or is experiencing significant psychological discomfort. Recognizing these signs prompts the nurse to provide appropriate psychosocial support and intervention.

Question 94: A patient taking digoxin and furosemide together is at increased risk for which complication?

Fluid overload
Hyperkalemia
Hypernatremia
Hypokalemia-induced digoxin toxicity (Correct answer)

Correct answer: Hypokalemia-induced digoxin toxicity

Furosemide causes potassium loss, raising the risk of digoxin toxicity.

Question 95: The mother of a 6-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:

24 months
18 months
12 months
30 months (Correct answer)

Correct answer: 30 months

Most children typically erupt all 20 primary (baby) teeth by the age of 30 months, or approximately 2.5 years old. While the first teeth usually appear around 6-10 months, the full set is generally complete by this later age. This developmental milestone is important for chewing, speech development, and proper alignment of permanent teeth.

Question 96: A newly hired nurse is floated to a pediatric ICU and has no pediatric critical care experience. What is the most appropriate response?

Accept a full independent assignment to avoid conflict
Accept and use online references to learn during the shift
Refuse the assignment and go home
Tell the charge nurse about the lack of experience and ask for tasks within one's competence (Correct answer)

Correct answer: Tell the charge nurse about the lack of experience and ask for tasks within one's competence

Nurses should accept float assignments but must tell the charge nurse about competency limits so the assignment matches their skills, without abandoning clients.

Question 97: A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client’s breakfast should be served within:

20 minutes
15 minutes
30 minutes (Correct answer)
45 minutes

Correct answer: 30 minutes

Regular insulin is a short-acting insulin that typically begins to lower blood glucose within 30 to 60 minutes after subcutaneous injection. To prevent hypoglycemia, it is crucial for the client to eat a meal within 30 minutes of administration. This timing ensures that food is available to counteract the insulin's peak action and manage post-meal glucose levels effectively.

Question 98: What is the primary focus of management of care in nursing?

Promoting emotional support exclusively
Administering medications only
Providing direct physical treatment
Ensuring that all care is provided to patients, safely and effectively (Correct answer)

Correct answer: Ensuring that all care is provided to patients, safely and effectively

Management of care in nursing encompasses coordinating, organizing, and overseeing all aspects of patient care. This includes ensuring that interventions are safe, evidence-based, and delivered efficiently by the entire healthcare team to achieve optimal patient outcomes.

Question 99: A client taking an opioid reports feeling very drowsy. What should the nurse assess first?

Assess the client’s respiratory rate. (Correct answer)
Encourage the client to stay awake.
Give another opioid dose to promote tolerance.
Give warm fluids to increase alertness.

Correct answer: Assess the client’s respiratory rate.

Drowsiness is a common side effect of opioid medications and can be a precursor to more severe central nervous system depression, including respiratory depression. The nurse's priority is to assess the client's respiratory rate to ensure their breathing is not compromised. This aligns with the principle of prioritizing airway and breathing.

Question 100: A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:

18 pounds
30 pounds
25 pounds
14 pounds (Correct answer)

Correct answer: 14 pounds

A general guideline for infant growth is that birth weight typically doubles by 5-6 months of age. Therefore, an infant weighing 7 pounds at birth would be expected to weigh approximately 14 pounds by 6 months. This indicates healthy growth and development during early infancy.

Question 101: A nurse is planning care for a client admitted with heart failure. Using Maslow's Hierarchy of Needs, which nursing diagnosis has the highest priority?

Impaired gas exchange related to fluid accumulation in the lungs (Correct answer)
Social isolation related to activity restrictions
Anxiety related to uncertain prognosis
Ineffective coping related to chronic illness

Correct answer: Impaired gas exchange related to fluid accumulation in the lungs

Impaired gas exchange is a physiological survival need and takes highest priority according to Maslow's Hierarchy. It represents an immediate threat to oxygenation (airway/breathing), which supersedes all higher-level needs.

Question 102: A client with diabetes insipidus has a serum sodium of 152 mEq/L. Which is the priority concern?

Hypoglycemia
Hyperkalemia
Fluid overload
Dehydration and hypovolemia (Correct answer)

Correct answer: Dehydration and hypovolemia

Excessive dilute urine output leads to dehydration, hypovolemia, and hypernatremia, making fluid balance the priority.

Question 103: A nurse is doing a home safety assessment for an 82-year-old client who lives alone. Which recommendation best reduces the risk of falls?

Wax the floors so they are easier to clean
Use a soft, low recliner for sitting
Remove loose throw rugs and keep pathways clear (Correct answer)
Keep a dim night-light off to improve sleep

Correct answer: Remove loose throw rugs and keep pathways clear

Loose rugs and clutter are leading environmental causes of falls in older adults.

Question 104: A patient with heart failure is prescribed torsemide. How does torsemide differ from hydrochlorothiazide?

Torsemide is a thiazide diuretic; hydrochlorothiazide is a loop diuretic
Torsemide is a loop diuretic with greater efficacy and better oral bioavailability in heart failure (Correct answer)
Torsemide retains potassium while hydrochlorothiazide wastes potassium
Torsemide is used only for hypertension, not fluid overload

Correct answer: Torsemide is a loop diuretic with greater efficacy and better oral bioavailability in heart failure

Torsemide is a loop diuretic that inhibits the Na-K-2Cl cotransporter in the loop of Henle. It has superior oral bioavailability (~80%) compared to furosemide and is more effective in patients with heart failure and gut edema.

Question 105: A nurse is completing an incident report after a client received the wrong dose of a medication. The report should include:

Objective facts: what happened, when, who was involved, and what actions were taken (Correct answer)
The nurse's personal opinion about why the error occurred
Speculation about which staff member was primarily responsible
The incident report number documented in the client's medical record

Correct answer: Objective facts: what happened, when, who was involved, and what actions were taken

Incident reports are objective factual accounts used for quality improvement, not punitive assignment of blame. They should describe what happened, when it occurred, who was involved, and what interventions followed. The incident report itself is never referenced in the medical record.

Question 106: A nurse is caring for four clients. Which client should the nurse assess first?

A post-operative client reporting pain of 6/10 following knee replacement
A client requesting assistance to the bathroom
A client awaiting discharge teaching for diabetes management
A client with COPD whose oxygen saturation has dropped from 94% to 88% (Correct answer)

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

A drop in oxygen saturation to 88% in a COPD client represents an acute change in respiratory status and a potential airway/breathing emergency. This takes priority over the other clients using the ABCs (Airway, Breathing, Circulation) framework.

Question 107: When Henry uses team nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients, which of the following should be a priority?

Each patient as listed on the worksheet
Patients who need the most care (Correct answer)
Medications and treatments required for all patients
Patients who needs least care

Correct answer: Patients who need the most care

In team nursing, when assessing the priority of care for a group of patients, the highest priority should always be given to patients who need the most care. This typically includes patients who are unstable, critically ill, have complex needs, or require immediate interventions to prevent deterioration. This approach ensures that resources are allocated effectively to those with the greatest need.

Question 108: Which nursing action is an example of secondary prevention?

Scheduling a screening mammogram (Correct answer)
Referring a client to cardiac rehabilitation after a heart attack
Teaching teenagers about seat belt use
Giving the influenza vaccine

Correct answer: Scheduling a screening mammogram

Secondary prevention is screening to find disease early, such as with mammography.

Question 109: A patient newly prescribed enalapril asks why the provider chose this medication over another blood pressure drug. The nurse's best response is:

ACE inhibitors are the cheapest available antihypertensives
ACE inhibitors are the only class safe to use in pregnancy
ACE inhibitors provide additional protection against kidney damage in diabetic patients (Correct answer)
ACE inhibitors work best when combined with sodium-rich diets

Correct answer: ACE inhibitors provide additional protection against kidney damage in diabetic patients

ACE inhibitors reduce intraglomerular pressure by dilating the efferent arteriole. This provides renoprotective benefit in diabetic nephropathy by reducing proteinuria and slowing progression of kidney disease.

Question 110: Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

Traveling by airplane for business trips
A family vacation in the Rocky Mountains
A bus trip to the Museum of Natural History (Correct answer)
Chaperoning the local boys club on a snow-skiing trip

Correct answer: A bus trip to the Museum of Natural History

Clients with sickle cell anemia must avoid activities that cause hypoxia and hypoxemia, as these can trigger a sickle cell crisis. High altitudes (Rocky Mountains, airplane travel) and extreme cold (snow-skiing) can lead to decreased oxygen saturation and vasoconstriction, promoting sickling. A bus trip to a museum is a low-stress activity at normal altitude, making it the safest option that avoids these triggers.

Question 111: Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?

Weight gain should be reported to the physician.
If the client misses one or more pills, two pills should be taken per day for 1 week.
An alternate method of birth control is needed when taking antibiotics. (Correct answer)
Changes in the menstrual flow should be reported to the physician.

Correct answer: An alternate method of birth control is needed when taking antibiotics.

Certain antibiotics, particularly broad-spectrum ones like rifampin, can decrease the effectiveness of oral contraceptives by altering gut flora and interfering with hormone reabsorption. This can lead to unintended pregnancy. Therefore, clients taking oral contraceptives should be advised to use an alternative or backup method of birth control while on antibiotics and for a short period afterward to ensure contraceptive efficacy.

Question 112: After a liver biopsy, in which position should the nurse place the client to reduce bleeding risk?

High Fowler's position
Right side-lying with a pillow against the site (Correct answer)
Prone with arms overhead
Left side-lying

Correct answer: Right side-lying with a pillow against the site

Lying on the right side applies pressure to the biopsy site and helps prevent hemorrhage.

Question 113: A nurse is caring for a client who has been placed in restraints per physician order. Which action is required by The Joint Commission standards?

Family consent is required before any restraint is applied
Restraints require a new physician order every 72 hours
The nurse must assess the restrained client and offer release every 2 hours (Correct answer)
Restraints may remain in place continuously as long as the order is valid

Correct answer: The nurse must assess the restrained client and offer release every 2 hours

The Joint Commission and CMS require that restrained clients be assessed at least every 2 hours. This includes checking circulation, skin integrity, repositioning, offering release, toileting, and ROM exercises.

Question 114: A nurse discovers a frayed cord on an IV infusion pump in use. What is the best action?

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

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

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

Question 115: Which antibiotic is contraindicated for the treatment of infections in infants and young children?

Amoxil (amoxicillin)
E-Mycin (erythromycin)
Tetracyn (tetracycline) (Correct answer)
Cefotan (cefotetan)

Correct answer: Tetracyn (tetracycline)

Tetracycline antibiotics are contraindicated in infants and young children, typically under 8 years of age, due to their adverse effects on developing teeth and bones. Tetracycline can cause permanent discoloration (yellow-gray-brown) of tooth enamel and hypoplasia, as well as reversible inhibition of bone growth.

Question 116: A client reports constipation while taking iron supplements. What is the nurse’s best response?

Increase fluids and dietary fiber. (Correct answer)
Take double the supplement dose.
Avoid all fruits and vegetables.
Stop taking iron immediately.

Correct answer: Increase fluids and dietary fiber.

Iron supplements are a common cause of constipation. Increasing fluid intake helps to soften the stool, while increasing dietary fiber adds bulk, both of which promote regular bowel movements. This is the most effective and non-pharmacological approach to manage this common side effect.

Question 117: The patient had a Billroth procedure for a stomach ulcer. After surgery, the client's NGT drainage is thick, the volume of secretions has significantly decreased during the last two hours, and he feels like throwing up. The best nursing course of action is to:

Irrigate the NGT with 50 cc of sterile
Reposition the NGT by advancing it gently NSS
Discontinue the low-intermittent suction
Notify the MD of your findings (Correct answer)

Correct answer: Notify the MD of your findings

The client's experience of nausea and the decrease in the amount of thick NGT discharge are indicators of potential abdominal distention brought on by NGT obstruction. To avoid strain and rupture at the location of the anastomosis brought on by stomach distention, this should be notified right once to the doctor.

Question 118: The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?

Coconut oil (Correct answer)
Canola oil
Sunflower oil
Safflower oil

Correct answer: Coconut oil

Coconut oil is high in saturated fat, which can raise low-density lipoprotein (LDL) cholesterol levels, often referred to as 'bad' cholesterol. For clients with elevated cholesterol, it is recommended to limit saturated fat intake. Safflower, sunflower, and canola oils are generally healthier alternatives as they are higher in monounsaturated and polyunsaturated fats, which can help lower cholesterol.

Question 119: What are the critiquing criteria used to judge the worth of a research study? Select all that apply.

Measures (Correct answer)
Questions (Correct answer)
Effectiveness
Evaluation guides (Correct answer)
Objectives
Standards (Correct answer)

Correct answer: Measures

Critiquing a research study involves a systematic and objective appraisal of its strengths and weaknesses to determine its worth and applicability. This process is guided by established **standards**, **measures**, **evaluation guides**, and specific **questions** that assess various aspects of the study, such as its methodology, ethical considerations, and the validity of its findings.

Question 120: How should a patient store sublingual nitroglycerin tablets to maintain potency?

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

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

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

Question 121: The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:

The tail of the pancreas
The head of the pancreas (Correct answer)
The entire pancreas
The body of the pancreas

Correct answer: The head of the pancreas

The Whipple procedure, also known as a pancreaticoduodenectomy, is a complex surgical operation primarily performed to remove tumors in the head of the pancreas. This procedure also involves removing parts of the duodenum, gallbladder, and bile duct, making it a major surgery for cancers located specifically in this region.

Question 122: A parent asks when their infant should receive the first dose of the hepatitis B vaccine. The nurse should respond:

At 6 months when the immune system matures
Only if the mother tests positive for hepatitis B
At 2 months of age at the first well-baby visit
Within 24 hours of birth (Correct answer)

Correct answer: Within 24 hours of birth

The CDC recommends the first dose of hepatitis B vaccine within 24 hours of birth for all newborns. This is especially important if the mother's hepatitis B status is unknown or positive.

Question 123: A nurse is providing nutrition education to a pregnant client in the first trimester. Which nutrient deficiency is most likely to cause neural tube defects in the developing fetus?

Folic acid (Correct answer)
Iron
Vitamin D
Calcium

Correct answer: Folic acid

Folic acid (folate) deficiency during the periconceptional period and early pregnancy is strongly associated with neural tube defects such as spina bifida and anencephaly. Women of childbearing age should consume 400-800 mcg of folic acid daily.

NCLEX-RN Exam

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

Questions

300 min

Time Limit

50%

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