NCLEX-RN (National Council Licensure Examination for Registered Nurses) — Questions and Answers

Question 1: A nurse is assessing a client who sustained multiple traumatic injuries and is in the compensatory stage of hypovolemic shock. Which clinical manifestation should the nurse expect?

Cool, clammy skin (Correct answer)
Decreased respiratory rate
Bradycardia
Hypotension

Correct answer: Cool, clammy skin

In the compensatory stage of hypovolemic shock, the sympathetic nervous system is activated to maintain perfusion to vital organs. This causes peripheral vasoconstriction, shunting blood from the skin to the core, which results in cool, clammy skin. The compensatory response also includes tachycardia (increased heart rate) and tachypnea (increased respiratory rate) to improve oxygen delivery. Blood pressure is often maintained during this initial stage and only drops significantly in the later, progressive stage of shock.

Question 2: When prioritizing hypotheses in the NCJMM, the nurse should rank potential patient problems based on which criteria?

Nursing workload and available staffing
Patient preference and cultural background
Physician orders and institutional protocols
Urgency, likelihood, and risk to the patient (Correct answer)

Correct answer: Urgency, likelihood, and risk to the patient

Prioritize Hypotheses requires the nurse to rank problems by their urgency, how likely they are, and the degree of harm they pose to the patient.

Question 3: A registered nurse (RN) is supervising a newly hired unlicensed assistive personnel (UAP). Which action by the UAP requires immediate intervention by the RN?

The UAP documents a client's oral intake and urinary output on the flowsheet.
The UAP ambulates a stable postoperative client in the hallway.
The UAP is observed applying a moisturizing lotion to the feet of a client with peripheral vascular disease. (Correct answer)
The UAP reports a client's blood pressure of 110/70 mmHg to the nurse.

Correct answer: The UAP is observed applying a moisturizing lotion to the feet of a client with peripheral vascular disease.

The RN must intervene immediately if the UAP is applying lotion to the feet of a client with peripheral vascular disease. Clients with PVD or diabetes often have decreased sensation and are at high risk for skin breakdown and infection. Foot care for these clients is complex and should be performed by the RN or LPN, as it requires careful assessment of the skin. Applying lotion between the toes can lead to maceration and fungal infections. This action poses a potential safety risk to the client. The other actions are within the appropriate scope of a UAP's duties.

Question 4: The NCLEX is written by:

nurses (Correct answer)
patients
physicians
administrators

Correct answer: nurses

The NCLEX (National Council Licensure Examination) is written by nurses. The National Council of State Boards of Nursing (NCSBN) develops and administers the NCLEX, which is designed to test the knowledge, skills, and abilities essential for the safe and effective practice of nursing at the entry level.

Question 5: A nurse is planning a health promotion program for a group of older adults at a senior center. To promote musculoskeletal health and reduce the risk of falls, which activity would be most appropriate to include?

Detailed instruction on a low-fat, low-sodium diet.
Balance and weight-bearing exercises. (Correct answer)
High-impact aerobic exercises.
Annual cognitive screening tests.

Correct answer: Balance and weight-bearing exercises.

Balance and weight-bearing exercises, such as tai chi or light weight training, are most effective for improving stability, strengthening bones (reducing osteoporosis risk), and maintaining muscle mass in older adults. This directly addresses the risk of falls, a major health concern in this population. High-impact aerobics can be unsafe, and while diet and cognitive screening are important, they do not directly target musculoskeletal strength and balance.

Question 6: A nurse is generating solutions for a patient with fluid volume deficit. Which step must occur BEFORE the nurse can generate appropriate solutions in the NCJMM framework?

Prioritize Hypotheses (Correct answer)
Recognize Cues
Take Action
Evaluate Outcomes

Correct answer: Prioritize Hypotheses

Hypotheses must be prioritized before solutions are generated so the nurse addresses the most urgent and likely problem first.

Question 7: Assessment Analysis (not RN Dx) Planning Implementation Evaluation

Integrated content areas:
Integrated nursing process areas: (Correct answer)
NCLEX question types:
Answering NCLEX questions:

Correct answer: Integrated nursing process areas:

This refers to the various stages of the nursing process that are integrated into the NCLEX exam questions: Assessment: Collecting data about the patient's health status. Analysis (not RN Dx): Interpreting the collected data to identify potential health issues or needs. Planning: Developing a plan of care based on the identified health needs. Implementation: Carrying out the plan of care and interventions. Evaluation: Assessing the effectiveness of the interventions and modifying the plan as needed.

Question 8: What does the NCLEX stand for?

National Council Licensure Examination (Correct answer)
is a logical, systematic approach to problem-solving and determining nursing care
serve as current regulations and laws set forth by each state and territory in the USA
specific to the practice of nursing

Correct answer: National Council Licensure Examination

The NCLEX stands for National Council Licensure Examination. It is a standardized exam used in the United States and Canada to assess the readiness of nurses for entry-level nursing practice. The NCLEX is required for licensure as a registered nurse (RN) or licensed practical nurse (LPN) in these countries. The NCLEX evaluates the knowledge, skills, and abilities that are essential for safe and effective nursing practice. It tests candidates on various aspects of nursing, including assessment, analysis, planning, implementation, and evaluation. The exam aims to ensure that nurses have the competencies necessary to provide quality care to patients.

Question 9: A client is admitted to the medical-surgical unit for a cholecystectomy. The client has a history of heavy alcohol use and the last drink was 24 hours ago. The nurse should prioritize monitoring for which of the following signs of alcohol withdrawal?

Hypotension and bradypnea
Constricted pupils and euphoria
Bradycardia and somnolence
Tachycardia, tremors, and diaphoresis (Correct answer)

Correct answer: Tachycardia, tremors, and diaphoresis

Signs of early to moderate alcohol withdrawal include autonomic hyperactivity such as tachycardia, tremors, anxiety, and diaphoresis (sweating). These symptoms can begin within hours of the last drink. Bradycardia, somnolence, hypotension, and bradypnea are more indicative of central nervous system depression, not withdrawal. Constricted pupils and euphoria are associated with opioid use, not alcohol withdrawal.

Question 10: During shift handoff, the outgoing nurse fails to communicate a patient's recent drop in blood pressure. This is MOST likely to impair which aspect of clinical judgment for the incoming nurse?

Generating solutions for known problems
Taking action on prioritized hypotheses
Recognizing cues relevant to the patient's condition (Correct answer)
Evaluating outcomes of previous interventions

Correct answer: Recognizing cues relevant to the patient's condition

Incomplete handoff deprives the incoming nurse of critical data, directly impairing the ability to Recognize Cues and detect the significance of the patient's current status.

Question 11: An experienced nurse quickly recognizes a patient's deteriorating status and acts before vital signs confirm the change. This is BEST explained by which concept?

Violation of evidence-based practice guidelines
Failure to follow the nursing process sequentially
Intuition developed through pattern recognition from clinical experience (Correct answer)
Over-reliance on subjective data

Correct answer: Intuition developed through pattern recognition from clinical experience

Expert nurses develop pattern recognition through experience, enabling rapid clinical judgment that anticipates deterioration before all objective data are available.

Question 12: An older adult client is brought to the emergency department from an un-airconditioned home during a heat wave. The client has an altered mental status, a temperature of 105.1°F (40.6°C), and hot, dry skin. The nurse should recognize these findings as characteristic of which condition?

Heat exhaustion
Sepsis
Heat stroke (Correct answer)
Malignant hyperthermia

Correct answer: Heat stroke

Heat stroke is a medical emergency characterized by a core body temperature above 104°F (40°C), central nervous system dysfunction (e.g., altered mental status, confusion), and anhidrosis (the absence of sweating), which leads to hot, dry skin. This indicates a failure of the body's thermoregulatory mechanisms. In contrast, heat exhaustion involves profuse sweating and less severe neurological impairment.

Question 13: A nurse is caring for an older adult client who has been on bed rest for 3 days following hip surgery. The client reports new-onset tenderness and visible swelling in their left calf. What is the nurse's priority action?

Apply a warm, moist compress to the area for 20 minutes.
Keep the client's leg elevated on pillows and notify the healthcare provider. (Correct answer)
Massage the affected leg to promote circulation.
Encourage the client to perform active range-of-motion exercises.

Correct answer: Keep the client's leg elevated on pillows and notify the healthcare provider.

The client's signs and symptoms (unilateral calf tenderness and swelling) are classic indicators of a potential deep vein thrombosis (DVT), a serious complication of immobility. The priority is to maintain the client on bed rest, elevate the affected limb to promote venous return without dislodging a potential clot, and immediately notify the healthcare provider for further diagnostic evaluation and treatment. Massaging the leg is contraindicated as it could dislodge a thrombus, leading to a pulmonary embolism.

Question 14: Which of the following actions is essential for a nurse to perform to prevent a catheter-associated urinary tract infection (CAUTI) for a client with an indwelling urinary catheter?

Disconnecting the catheter from the tubing to obtain a urine sample.
Irrigating the catheter with sterile saline every 12 hours.
Ensuring the drainage bag is kept below the level of the bladder. (Correct answer)
Changing the indwelling catheter every 72 hours.

Correct answer: Ensuring the drainage bag is kept below the level of the bladder.

To prevent CAUTI, it is critical to maintain a closed, sterile drainage system and prevent the backflow of urine. Keeping the drainage bag below the level of the bladder uses gravity to ensure urine flows away from the bladder, which minimizes the risk of infection. Routine irrigation and catheter changes are not recommended as they can introduce bacteria into the system. The system should only be opened when necessary, and samples should be collected from the designated port.

Question 15: Normal Hgb (M/F):

M: 13.2-17.3 g/dL F: 11.7-15.5 g/dL (Correct answer)
0.6-1.3 mg/dl
6-20 mg/dl
M: 39%-50% f: 35%-47%

Correct answer: M: 13.2-17.3 g/dL F: 11.7-15.5 g/dL

Normal Hemoglobin (Hgb) Levels: Males: 13.2-17.3 grams per deciliter (g/dL) Females: 11.7-15.5 grams per deciliter (g/dL) These values represent the typical range of hemoglobin concentrations found in the blood of healthy adult individuals. Hemoglobin is an important protein in red blood cells that carries oxygen from the lungs to tissues throughout the body.

Question 16: The nurse is caring for a client with a C. difficile infection. When exiting the room after providing care, which action is required?

Perform hand hygiene using an alcohol-based sanitizer.
Wash hands with soap and water. (Correct answer)
Remove the gown first, then the gloves.
Keep the same N95 respirator on for the next client.

Correct answer: Wash hands with soap and water.

C. difficile forms spores that are resistant to alcohol-based hand sanitizers. Therefore, it is essential to wash hands with soap and water to physically remove the spores after caring for a client with this infection.

Question 17: A nurse is caring for a client who suddenly develops dyspnea, tachypnea, and uses accessory muscles to breathe. What is the nurse's priority action?

Raise the head of the bed to a high-Fowler's position. (Correct answer)
Obtain a full set of vital signs.
Notify the respiratory therapist.
Administer oxygen via a non-rebreather mask.

Correct answer: Raise the head of the bed to a high-Fowler's position.

The priority action is to raise the head of the bed. This is a quick and non-invasive intervention that can immediately facilitate lung expansion and ease the work of breathing by lowering the diaphragm. This action directly addresses the client's airway and breathing (ABCs) and should be done first. While administering oxygen, obtaining vital signs, and notifying respiratory therapy are all important subsequent actions, repositioning the client is the most immediate intervention to improve their respiratory status.

Question 18: A client with a terminal illness has a valid living will that explicitly refuses the use of mechanical ventilation. The client becomes unconscious and experiences respiratory failure. The client's distraught spouse demands that the healthcare team "do everything possible" to save the client. What is the nurse's primary legal responsibility?

Inform the spouse that only the physician can make the final decision.
Initiate mechanical ventilation and immediately request an ethics consultation.
Follow the spouse's wishes, as they are the next of kin.
Honor the client's wishes as stated in the living will. (Correct answer)

Correct answer: Honor the client's wishes as stated in the living will.

A living will is a legal advance directive that outlines a person's wishes for medical treatment when they are no longer able to communicate. It represents the client's autonomous decision and must be honored by the healthcare team, even if family members disagree.

Question 19: What is the minimum number of questions on the NCLEX?

75 (Correct answer)
specific to the practice of nursing
2005
265

Correct answer: 75

The NCLEX (National Council Licensure Examination) is a standardized test used to assess the readiness of nursing candidates for entry-level nursing practice. The minimum number of questions a candidate can receive on the NCLEX is 75. However, the number of questions may vary for each candidate based on their performance throughout the exam.

Question 20: A nurse is preparing a client for a computed tomography (CT) scan of the abdomen with intravenous contrast. Which of the following findings in the client's record requires the most immediate intervention by the nurse?

A serum creatinine level of 2.5 mg/dL. (Correct answer)
The client is currently prescribed metformin.
A documented history of claustrophobia.
A reported allergy to shellfish.

Correct answer: A serum creatinine level of 2.5 mg/dL.

Intravenous contrast dye is nephrotoxic and can cause acute kidney injury. An elevated serum creatinine level (normal range is typically 0.6-1.3 mg/dL) indicates significant renal impairment. This finding must be reported to the provider immediately as it is a major contraindication to receiving contrast media. While claustrophobia and metformin use are important considerations, severe renal impairment poses the most immediate risk of a serious physiological complication.

Question 21: A nurse is caring for a client who is confused and has been pulling at their intravenous (IV) lines. The nurse has attempted reorientation and distraction techniques without success. Which of the following actions is appropriate when applying wrist restraints?

Secure the restraint straps to the side rails of the bed.
Ensure the restraints are tight enough to prevent any wrist movement.
Attach the restraints to the bed frame using a quick-release knot. (Correct answer)
Use a square knot to ensure the restraints are secure.

Correct answer: Attach the restraints to the bed frame using a quick-release knot.

Restraints must be attached to a part of the bed frame that moves with the client, not the side rails, to prevent injury if the rail is lowered. A quick-release knot must be used for easy removal in an emergency.

Question 22: A nurse identifies that a patient's respiratory rate has increased from 16 to 28 breaths/min over two hours. Which NCJMM cognitive skill is the nurse applying when noting this change?

Take Action
Recognize Cues (Correct answer)
Generate Solutions
Evaluate Outcomes

Correct answer: Recognize Cues

Recognize Cues is the initial skill of noticing and identifying relevant patient information that may require attention, such as a significant change in vital signs.

Question 23: A public health nurse is assessing a 2-year-old child during a home visit. Which developmental finding would be a cause for concern and require further evaluation?

The child engages in parallel play with other toddlers.
The child has a vocabulary of 20 words. (Correct answer)
The child can build a tower of six blocks.
The child can walk up and down stairs with assistance.

Correct answer: The child has a vocabulary of 20 words.

By age 2, a child is expected to have a vocabulary of 50 or more words and be able to speak in two-to-three-word sentences. A vocabulary of only 20 words is a significant delay and warrants further investigation for potential speech or developmental issues. Building a six-block tower, navigating stairs with help, and parallel play are all expected findings for a 2-year-old.

Question 24: A nursing student asks why clinical judgment cannot be replaced by following standardized protocols alone. Which response by the nurse educator is MOST accurate?

Standardized protocols are more accurate than individual judgment
Clinical judgment is only needed when protocols are unavailable
Clinical judgment allows nurses to adapt care to each patient's unique context and unexpected changes (Correct answer)
Protocols eliminate the need for individualized assessment

Correct answer: Clinical judgment allows nurses to adapt care to each patient's unique context and unexpected changes

Clinical judgment is essential because it enables nurses to individualize care, recognize deviations, and respond to dynamic patient situations that protocols may not fully address.

Question 25: A nurse assesses a client receiving morphine via a patient-controlled analgesia (PCA) pump. The client's respiratory rate is 7 breaths/min and they are difficult to arouse. After stopping the PCA infusion, what is the nurse's next priority action?

Document the client's status in the electronic health record.
Notify the healthcare provider of the findings.
Check the client's oxygen saturation level.
Administer naloxone as prescribed by standing order. (Correct answer)

Correct answer: Administer naloxone as prescribed by standing order.

The client is exhibiting signs of severe opioid-induced respiratory depression, which is a life-threatening emergency. After stopping the opioid infusion to prevent further administration, the priority action is to reverse the respiratory depression by administering the opioid antagonist, naloxone. While checking oxygen saturation and notifying the provider are important, they are not the immediate priority over administering the life-saving antidote.

Question 26: A nurse caring for a diabetic patient notices the patient is diaphoretic, trembling, and confused. The nurse checks the blood glucose, which reads 48 mg/dL. Which hypothesis should the nurse PRIORITIZE?

Knowledge deficit regarding insulin administration
Risk for infection related to poor wound healing
Hypoglycemia requiring immediate glucose replacement (Correct answer)
Impaired skin integrity related to neuropathy

Correct answer: Hypoglycemia requiring immediate glucose replacement

Hypoglycemia with neurological symptoms (confusion) is an acute, life-threatening condition that must be prioritized over chronic or lower-acuity concerns.

Question 27: A nurse is providing education to a 22-year-old client newly prescribed fluoxetine, a Selective Serotonin Reuptake Inhibitor (SSRI). Which instruction is most critical for the nurse to include?

"You must avoid eating aged cheese and cured meats while on this medication."
"You can stop taking the medication as soon as you start to feel better."
"It is crucial to immediately report any increase in suicidal thoughts or behaviors." (Correct answer)
"The medication should provide full relief from your symptoms within one week."

Correct answer: "It is crucial to immediately report any increase in suicidal thoughts or behaviors."

All antidepressant medications, including SSRIs, carry a black box warning from the FDA regarding an increased risk of suicidal thinking and behavior, particularly in children, adolescents, and young adults (up to age 24) during the initial weeks of treatment. This is the most critical safety instruction. The dietary restrictions mentioned apply to MAOIs, therapeutic effects take several weeks to develop, and the medication should never be stopped abruptly.

Question 28: A nurse is caring for a client with a new short-leg cast for a fractured tibia. The client reports severe pain in the affected leg that is not relieved by opioid analgesics. The nurse notes the client's toes are pale and cool. What is the nurse's priority action?

Apply a new ice pack over the area of pain.
Elevate the casted leg on two pillows.
Administer the next scheduled dose of pain medication.
Notify the healthcare provider immediately. (Correct answer)

Correct answer: Notify the healthcare provider immediately.

The combination of severe, unrelieved pain (pain out of proportion to the injury), pallor (paleness), and coolness are hallmark signs of acute compartment syndrome. This is a medical emergency caused by swelling and increased pressure within a confined space, which compromises circulation and can lead to permanent limb damage. The nurse's priority is to notify the provider immediately for urgent intervention, such as bivalving the cast or a fasciotomy. Elevating the limb can worsen the condition by further reducing arterial circulation.

Question 29: California Board of Registered Nursing (BRN)

governing body for the committee that prepares the licensure examination; regulate entry into practice in the US; determine application process/deadlines in their state
Read well Think before reading answers Carefully read each answer Eliminate Identify similarities, find one that is different
4 categories of client needs; integrated by 4 processes: nursing process, caring communication & documentation, teaching/learning; integrated by lifespan; integrated in a variety of settings
a state governmental agency established by law to protect the public by regulating the practice of registered nurses. (Correct answer)

Correct answer: a state governmental agency established by law to protect the public by regulating the practice of registered nurses.

The California Board of Registered Nursing (BRN) is a state governmental agency established by law to protect the public by regulating the practice of registered nurses. It oversees the licensure examination process, regulates entry into practice in California, and determines the application process and deadlines for nurses in the state.

Question 30: A registered nurse (RN) is delegating tasks to an unlicensed assistive personnel (UAP). Which of the following tasks is appropriate for the RN to delegate?

Performing a sterile dressing change on a client with a central line.
Assisting a stable client with ambulation to the bathroom. (Correct answer)
Administering a scheduled oral pain medication to a client with chronic pain.
Developing a plan of care for a newly admitted client with diabetes.

Correct answer: Assisting a stable client with ambulation to the bathroom.

Assisting a stable client with ambulation is within the scope of practice for a UAP. Medication administration, sterile procedures, and developing the plan of care are complex tasks that require the assessment and clinical judgment of a registered nurse and cannot be delegated to a UAP.

Question 31: A client who was recently diagnosed with type 2 diabetes mellitus states, 'There's no way I have diabetes. The lab must have made a mistake with my blood work. I feel perfectly fine.' The nurse recognizes the client is using which defense mechanism?

Projection
Sublimation
Denial (Correct answer)
Rationalization

Correct answer: Denial

Denial is the refusal to accept reality or facts to avoid dealing with the emotional impact. The client is refusing to accept the diagnosis despite evidence. Projection is attributing one's own unacceptable thoughts to another person. Rationalization is justifying behavior with logical-sounding reasons. Sublimation is channeling unacceptable impulses into socially acceptable actions.

Question 32: What do registered nurses use the nursing process for?

expectations for professional behavior to protect the nurse, as well as the client and the facility where the client care is practiced
the basis for decision making and actions taken (Correct answer)
specific to the practice of nursing
the standards of nursing practice and the standards of professional performance

Correct answer: the basis for decision making and actions taken

Registered nurses use the nursing process as the basis for decision-making and actions taken in the provision of patient care. This structured approach helps nurses assess patient needs, formulate nursing diagnoses, develop individualized care plans, implement interventions, and evaluate patient responses. The nursing process is specific to the practice of nursing and ensures that care delivery is evidence-based, holistic, and responsive to the patient's physical, emotional, social, and spiritual needs.

Question 33: A nurse is providing prenatal education to a client in her first trimester. Which of the following topics is most crucial to include to prevent congenital neural tube defects?

The need for adequate daily intake of folic acid. (Correct answer)
Strategies for managing morning sickness effectively.
The importance of avoiding unpasteurized dairy products.
The schedule for glucose tolerance testing during pregnancy.

Correct answer: The need for adequate daily intake of folic acid.

Adequate intake of folic acid (at least 400 mcg per day) before and during the early weeks of pregnancy is proven to significantly reduce the risk of neural tube defects like spina bifida. While the other topics are important aspects of prenatal care, folic acid supplementation is directly linked to the prevention of this specific birth defect.

Question 34: Which layer of the NCSBN Clinical Judgment Measurement Model describes the factors that influence a nurse's clinical judgment, such as environment and individual characteristics?

The cognitive skills layer
The clinical judgment layer
The external and internal factors layer (Correct answer)
The outcome layer

Correct answer: The external and internal factors layer

The NCJMM outer layer represents external factors (e.g., time pressure, resources) and internal factors (e.g., nurse's knowledge, experience) that influence clinical judgment.

Question 35: Med-Surg Peds Psych OB Fundamentals

Normal creatinine:
Integrated content areas: (Correct answer)
NCLEX question types:
Integrated nursing process areas:

Correct answer: Integrated content areas:

Integrated content areas in nursing education refer to the incorporation of multiple disciplines or subjects into a comprehensive curriculum. For example, nursing education integrates anatomy, physiology, pharmacology, pathophysiology, and ethics to provide a holistic approach to patient care.

Question 36: A nurse uses the Bow-tie NGN item format. The center of the bow-tie represents which element of clinical judgment?

The patient's primary medical diagnosis
The most likely client condition (Correct answer)
The nursing action or intervention
The expected outcome of care

Correct answer: The most likely client condition

In the Bow-tie item, the center node represents the nurse's determination of the most likely client condition, connecting assessment findings on one side to interventions on the other.

Question 37: Foster the goals of the profession •Membership requirements •Dues •Publications •Research •Continuing Education •Conferences •Advocacy Develop Practice Guidelines •Policy Development ‥ Practice Position Statements ‥ Scope & Standards ‥ Code of Ethics

Professional Performance Standards
Ethical Decision-Making Process 2
Professional Organizations (ANA)- Roles in Practice Guidelines (Correct answer)
Professional Standards of Care

Correct answer: Professional Organizations (ANA)- Roles in Practice Guidelines

Professional organizations such as the ANA contribute significantly to the development of practice guidelines, performance standards, and ethical decision-making processes in nursing. These initiatives help promote safe, effective, and ethical nursing practice.

Question 38: A nurse is preparing to provide oral hygiene to an unconscious client. To minimize the risk of aspiration, the nurse should place the client in which position?

High-Fowler's with the head tilted forward.
Prone with a pillow under the abdomen.
Supine with the head of the bed flat.
Side-lying with the head turned toward the mattress. (Correct answer)

Correct answer: Side-lying with the head turned toward the mattress.

The safest position for providing oral care to an unconscious client is side-lying (lateral) with the head turned to the side. This position allows fluids and secretions to drain out of the mouth by gravity, preventing them from pooling in the back of the throat and being aspirated into the lungs.

Question 39: Specialty Practice Guidelines

-Bioethical Issues -Nursing Care Issues -Ethics - Nursing Profession
Professional Standards of Care -Professional Performance Standards -Specialty Practice Guidelines
- identify role functions in direct care, consultation, and quality assurance
- are protocols of care for specific specialty practice populations (Correct answer)

Correct answer: - are protocols of care for specific specialty practice populations

Specialty Practice Guidelines are protocols or recommendations developed by professional organizations and specialty groups to guide nurses in delivering care to specific patient populations or in specialized areas of practice. These guidelines address unique considerations, evidence-based practices, and interventions tailored to the needs of a particular patient population or clinical setting.

Question 40: A nurse is preparing to enter the room of a client who has active pulmonary tuberculosis. Which of the following pieces of personal protective equipment (PPE) is essential for the nurse to wear?

Face shield
Surgical mask
N95 respirator (Correct answer)
Sterile gloves

Correct answer: N95 respirator

Tuberculosis (TB) is transmitted via airborne particles. Therefore, healthcare workers must wear an N95 respirator, which is designed to filter out these small particles, when entering the room of a client with active TB. A surgical mask is insufficient for airborne precautions.

Question 41: A nurse is caring for a client with schizophrenia who states, 'The aliens are sending me messages through the television and they want to take me away.' Which of the following responses by the nurse is most therapeutic?

"There are no aliens. You are safe here in the hospital and we are not going to let anyone take you away."
"That sounds very frightening. Let's turn off the TV and we can talk about how you're feeling." (Correct answer)
"Why do you think the aliens are trying to send you messages through the television?"
"I don't hear any messages from the television. Let's go play a game of cards."

Correct answer: "That sounds very frightening. Let's turn off the TV and we can talk about how you're feeling."

The most therapeutic response is to acknowledge the client's feelings and fear associated with the delusion without reinforcing or arguing about the delusion itself. This approach validates the client's experience while gently redirecting them to reality and offering support. Challenging the delusion (B) is ineffective and can damage the therapeutic relationship. Asking 'why' (C) can reinforce the delusional thought process. Dismissing the client's experience and changing the subject (D) invalidates their feelings.

Question 42: A nurse is preparing to obtain informed consent from a client for a surgical procedure. Which of the following is a key element of informed consent?

A guarantee of a successful outcome.
The nurse's personal opinion about the procedure.
The cost of the procedure and the client's insurance coverage.
A description of alternative treatments and the risks of no treatment. (Correct answer)

Correct answer: A description of alternative treatments and the risks of no treatment.

Informed consent requires that the client receives a clear explanation of the proposed procedure, including its risks, benefits, alternative treatments, and the potential consequences of refusing treatment. This information allows the client to make an autonomous and informed decision.

Question 43: A client is admitted with a diagnosis of influenza. Which of the following transmission-based precautions should the nurse initiate?

Contact precautions
Protective precautions
Airborne precautions
Droplet precautions (Correct answer)

Correct answer: Droplet precautions

Influenza is transmitted through large respiratory droplets. Therefore, droplet precautions are required. This includes wearing a surgical mask when within 3 to 6 feet of the client and placing the client in a private room or cohorting with a client who has the same infection.

Question 44: A nurse is providing discharge teaching to a client newly prescribed warfarin. Which statement by the client indicates a need for further education?

"I must report any signs of dark, tarry stools to my provider."
"I will use an electric razor for shaving instead of a disposable razor."
"I will start taking ibuprofen for my occasional headaches." (Correct answer)
"I understand I will need to have my blood tested regularly."

Correct answer: "I will start taking ibuprofen for my occasional headaches."

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen increase the risk of bleeding when taken concurrently with warfarin. The nurse must instruct the client to use acetaminophen for pain relief instead. The other statements indicate a correct understanding of bleeding precautions and the required laboratory monitoring (INR/PT).

Question 45: Which NGN item type requires the nurse to select multiple assessment findings that require immediate follow-up from a list of patient data?

Bow-tie item
Extended multiple response (Select All That Apply)
Matrix/Grid item
Highlight item (Correct answer)

Correct answer: Highlight item

Highlight items ask test-takers to identify (highlight) relevant clinical findings within a passage or chart, directly assessing the Recognize Cues skill.

Question 46: A nurse is caring for a client who has just undergone a lumbar puncture. To reduce the risk of a post-dural puncture headache, which intervention should the nurse implement?

Administer a prophylactic sedative medication.
Restrict oral fluid intake for the first 4 hours.
Encourage immediate ambulation to promote circulation.
Instruct the client to remain in a flat or supine position. (Correct answer)

Correct answer: Instruct the client to remain in a flat or supine position.

Positioning the client flat (supine) after a lumbar puncture helps to decrease the leakage of cerebrospinal fluid (CSF) from the puncture site. This reduces the risk of developing a post-dural puncture headache, which is caused by a decrease in intracranial pressure from CSF loss. Ambulation is discouraged, fluids are encouraged to help replace CSF, and sedatives are not a primary preventative measure.

Question 47: An adult client who is a Jehovah's Witness has been in a motor vehicle accident and requires emergency surgery for internal bleeding. The client is alert and oriented and has a signed advance directive refusing all blood products. Which action should the nurse take?

Advocate for the client's wishes and explore bloodless alternative treatments with the healthcare team. (Correct answer)
Contact the hospital's ethics committee to get an order to override the client's refusal.
Explain to the client that a court order will be obtained to administer the necessary blood.
Inform the surgeon to proceed with the transfusion because it is a life-threatening emergency.

Correct answer: Advocate for the client's wishes and explore bloodless alternative treatments with the healthcare team.

A mentally competent adult has the legal and ethical right to refuse medical treatment, including life-saving blood transfusions, based on their religious beliefs. The nurse's primary role is to act as a patient advocate, respecting their autonomy and communicating their wishes to the team. The team should then explore all available bloodless alternatives, such as volume expanders or cell-saver technology. Overriding a competent adult's wishes is a violation of their rights.

Question 48: A client is admitted to the inpatient psychiatric unit with severe anxiety. The client is pacing the hallway and wringing their hands. Which initial action by the nurse is most appropriate?

Acknowledge the behavior and ask about the client's feelings. (Correct answer)
Administer a prescribed PRN anxiolytic medication immediately.
Encourage the client to participate in a quiet group activity.
Tell the client to sit down and try to relax.

Correct answer: Acknowledge the behavior and ask about the client's feelings.

The most therapeutic initial action is to acknowledge the client's nonverbal cues (pacing, wringing hands) and use an open-ended question to encourage the client to verbalize their feelings. This validates the client's experience and opens the door for communication. Telling the client to relax is dismissive. Administering medication may be necessary, but assessment should come first. Encouraging group activity may be too overwhelming for a client with severe anxiety.

Question 49: A client is admitted to the emergency department with suspected diabetic ketoacidosis (DKA). The nurse observes the client's breathing pattern as very deep, rapid, and labored. The nurse correctly identifies this breathing pattern as which of the following?

Cheyne-Stokes respirations
Kussmaul respirations (Correct answer)
Biot's respirations
Apneustic breathing

Correct answer: Kussmaul respirations

Kussmaul respirations are a deep, rapid, and labored breathing pattern that is the body's compensatory mechanism for severe metabolic acidosis, such as that seen in DKA. The body attempts to exhale excess carbon dioxide (an acid) to raise the blood pH back toward a normal level. Cheyne-Stokes, apneustic, and Biot's are other abnormal breathing patterns related to different neurological or physiological conditions.

Question 50: governing body for the committee that prepares the licensure examination; regulate entry into practice in the US; determine application process/deadlines in their state

California Board of Registered Nursing (BRN)
National Council of State Boards of Nursing (NCSBN) (Correct answer)
Do not use these communication answers
Name the priorities in Maslow's hierarchy of needs:

Correct answer: National Council of State Boards of Nursing (NCSBN)

The NCSBN is responsible for overseeing the preparation of the licensure examination (NCLEX) for nursing, regulating entry into nursing practice across the United States, and determining application processes and deadlines in various states.

Question 51: The registered nurse (RN) is creating the daily assignment for a team that includes a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which task is most appropriate to delegate to the UAP?

Assisting a stable client who is 2 days postoperative with personal hygiene and ambulation. (Correct answer)
Developing the plan of care for a newly admitted client.
Performing a sterile dressing change on a client's central line.
Administering a scheduled subcutaneous insulin injection for a client with stable blood glucose levels.

Correct answer: Assisting a stable client who is 2 days postoperative with personal hygiene and ambulation.

The most appropriate task to delegate to the UAP is assisting a stable, postoperative client with activities of daily living (ADLs) such as personal hygiene and ambulation. This task is routine, has a predictable outcome, and does not require nursing judgment. Administering medications (insulin) is within the scope of an LPN or RN. Performing a sterile dressing change requires advanced skill and sterile technique, which is not within the UAP's scope of practice. Developing a plan of care is a core function of the RN and involves assessment and nursing judgment, which cannot be delegated.

Question 52: A client is 12 hours postoperative following abdominal surgery and reports a pain level of 7 on a 0-10 scale. The client received an analgesic 2 hours ago. In addition to assessing the need for further medication, which non-pharmacological comfort measure should the nurse implement first?

Assisting the client to a comfortable position using pillows for support. (Correct answer)
Encouraging the client to ambulate briskly in the hallway.
Vigorously massaging the abdomen near the incision site.
Applying a cold pack directly over the surgical incision.

Correct answer: Assisting the client to a comfortable position using pillows for support.

Proper positioning and the use of pillows to splint the abdomen can significantly reduce muscle tension and pressure on the incision, thereby alleviating pain. This is a safe and effective adjunctive comfort measure. Brisk ambulation may be too strenuous so soon after surgery. Applying a cold pack or massaging near the incision would require a specific provider order and could be contraindicated.

Question 53: When a question asks you "What would you do in this situation?" use this prioritization method:

Nursing Process: Assess, Analyze, Plan, Implement, Evaluate (Correct answer)
Maslow's Hierarchy Of Needs
Client First Equipment Second
Evaluation Assessment Nursing Judgement

Correct answer: Nursing Process: Assess, Analyze, Plan, Implement, Evaluate

When a question asks what you would do in a specific situation, the prioritization method to use is "Nursing Process: Assess, Analyze, Plan, Implement, Evaluate." This approach aligns with the systematic framework of the nursing process, which involves the following steps: Assessment: Gather relevant information about the patient's condition. Analysis: Analyze and interpret the collected data to identify patient needs and problems. Planning: Develop a plan of care based on identified needs and goals. Implementation: Carry out the planned interventions and treatments. Evaluation: Assess the effectiveness of the interventions and outcomes achieved.

Question 54: A nurse is caring for a client with advanced chronic kidney disease (CKD). Which laboratory finding is an expected physiological adaptation to this condition?

Hyperphosphatemia (Correct answer)
Decreased serum creatinine
Hypercalcemia
Hypokalemia

Correct answer: Hyperphosphatemia

In advanced chronic kidney disease, the kidneys' ability to excrete phosphate is impaired, leading to an accumulation of phosphate in the blood, known as hyperphosphatemia. This is often accompanied by hypocalcemia because the excess phosphate binds with calcium. The kidneys also fail to excrete potassium and creatinine, leading to hyperkalemia and elevated serum creatinine, not decreased levels.

Question 55: A nurse is educating a newly diagnosed diabetic client on self-management. The client seems overwhelmed and states, 'I don't think I can do all of this.' Which of the following actions by the nurse best demonstrates an understanding of adult learning principles?

Arranging for a family member to manage the client's care.
Setting mutual goals and prioritizing the most critical learning needs first. (Correct answer)
Advising the client to schedule a follow-up appointment once they feel ready to learn.
Providing the client with several detailed pamphlets to read at home.

Correct answer: Setting mutual goals and prioritizing the most critical learning needs first.

Adult learning is most effective when the learner is involved in the process and the content is perceived as relevant and manageable. By setting mutual goals and prioritizing (e.g., focusing on blood glucose monitoring and hypoglycemia signs first), the nurse breaks down the information into manageable steps and respects the client's autonomy. This approach reduces feelings of being overwhelmed and empowers the client.

Question 56: A surgeon asks a nurse to witness a client's signature on a surgical consent form. The nurse enters the room, and the client states, "I'm not really sure what the doctor is going to do, but I trust him." What is the nurse's most appropriate legal and ethical action?

Notify the surgeon that the client does not have informed consent. (Correct answer)
Sign the form as a witness since the client is willing to proceed.
Provide a detailed explanation of the surgical procedure to the client.
Ask the client's family member to explain the procedure to the client.

Correct answer: Notify the surgeon that the client does not have informed consent.

The nurse's role in witnessing consent is to attest to the authenticity of the signature and the client's competency, not to provide the primary explanation of the procedure. If the client does not understand the procedure, they cannot provide informed consent. The nurse has a duty to act as a patient advocate and must notify the surgeon, who is legally responsible for explaining the procedure and ensuring the client is truly informed.

Question 57: A nurse is reviewing the arterial blood gas (ABG) results for a client with an acute exacerbation of chronic obstructive pulmonary disease (COPD). The results are: pH 7.28, PaCO2 58 mm Hg, PaO2 65 mm Hg, and HCO3 25 mEq/L. Which acid-base imbalance should the nurse identify?

Respiratory acidosis, uncompensated (Correct answer)
Metabolic acidosis, uncompensated
Metabolic alkalosis, uncompensated
Respiratory alkalosis, partially compensated

Correct answer: Respiratory acidosis, uncompensated

The pH of 7.28 is below the normal range (7.35-7.45), indicating acidosis. The PaCO2 of 58 mm Hg is elevated (normal: 35-45 mm Hg), indicating a respiratory cause for the acidosis. The HCO3 of 25 mEq/L is within the normal range (22-26 mEq/L), signifying that the kidneys have not yet started to compensate for the imbalance. Therefore, the client has uncompensated respiratory acidosis, a common finding in COPD exacerbations where CO2 is retained.

Question 58: A client with acute decompensated heart failure is receiving a high-dose intravenous infusion of furosemide, a loop diuretic. Which electrolyte imbalance is the client at the highest risk for developing?

Hypokalemia (Correct answer)
Hypermagnesemia
Hypercalcemia
Hyponatremia

Correct answer: Hypokalemia

Loop diuretics, such as furosemide, work by inhibiting the reabsorption of sodium and chloride in the loop of Henle, which also leads to significant excretion of potassium. This puts the client at a high risk for developing hypokalemia (low potassium). While hyponatremia, hypomagnesemia, and hypocalcemia can also occur, hypokalemia is the most common and concerning imbalance due to its potential to cause life-threatening cardiac dysrhythmias.

Question 59: Which of the following actions by the nurse demonstrates the most effective method for preventing the spread of infection among clients?

Wearing gloves for all client contact.
Administering prophylactic antibiotics to all clients.
Placing all clients on contact precautions.
Performing consistent and thorough hand hygiene. (Correct answer)

Correct answer: Performing consistent and thorough hand hygiene.

The single most effective way to prevent the transmission of infection is through proper and frequent hand hygiene. While other measures are important for specific situations, hand hygiene is a component of standard precautions applied to all patients.

Question 60: Focus on motivation first Evaluate learning by pt verbalization/demonstration Remember that confused patients can not be taught

When a question asks you about safety or when there is no urgent physiological need use this prioritization method:
If a question involves therapeutic communication:
When a question asks you "What does the client need in this situation?" use this prioritization method:
When a question asks about teaching/learning use this prioritization method: (Correct answer)

Correct answer: When a question asks about teaching/learning use this prioritization method:

These prioritization methods and approaches are crucial for nurses preparing for the NCLEX exam, as they emphasize patient-centered care and effective communication.

Question 61: A client who was prescribed lisinopril two weeks ago reports developing a persistent, nonproductive cough. Which of the following is the nurse's best response?

"Stop taking the medication immediately as this indicates a severe allergic reaction."
"This is an expected and common side effect. You should notify your provider to discuss potential medication changes." (Correct answer)
"Increase your fluid intake to help thin the secretions causing the cough."
"You are likely developing a respiratory infection and should see your provider for an antibiotic."

Correct answer: "This is an expected and common side effect. You should notify your provider to discuss potential medication changes."

A persistent, dry, hacking cough is a well-known and common side effect of ACE inhibitors like lisinopril, related to the accumulation of bradykinin. It is not an allergic reaction or a sign of infection. The most appropriate response is to validate the client's experience, identify it as a known side effect, and direct them to consult their provider, who may prescribe an alternative antihypertensive like an ARB.

Question 62: A nurse is preparing to administer an intravenous infusion of vancomycin. To prevent the occurrence of vancomycin flushing syndrome ("Red Man Syndrome"), which nursing action is most appropriate?

Cover the client with a warming blanket during the infusion.
Pre-medicate the client with an antiemetic.
Infuse the medication over at least 60 minutes. (Correct answer)
Administer a rapid IV bolus over 5 minutes.

Correct answer: Infuse the medication over at least 60 minutes.

Vancomycin flushing syndrome is a rate-dependent infusion reaction caused by histamine release, not a true allergic reaction. The primary strategy to prevent it is to infuse the medication slowly, over a period of at least 60 to 90 minutes. Administering it as a rapid bolus would cause the reaction. Pre-medication with antihistamines, not antiemetics, may also be ordered.

Question 63: A nurse is reviewing the laboratory results for a client receiving intravenous furosemide for acute heart failure. Which laboratory value requires the most immediate intervention?

Serum sodium 137 mEq/L
Serum creatinine 1.2 mg/dL
Serum potassium 2.8 mEq/L (Correct answer)
Blood urea nitrogen (BUN) 25 mg/dL

Correct answer: Serum potassium 2.8 mEq/L

Furosemide is a potent loop diuretic that causes the excretion of potassium. A serum potassium level of 2.8 mEq/L is critically low (hypokalemia) and places the client at high risk for life-threatening cardiac dysrhythmias. This finding must be reported to the provider immediately. The other lab values are either within normal limits or not as immediately critical.

Question 64: A nurse discovers a fire in a client's room. After rescuing the client, which of the following actions should the nurse take next?

Extinguish the fire with the nearest fire extinguisher.
Activate the fire alarm. (Correct answer)
Evacuate all other clients from the unit.
Close the door to the client's room.

Correct answer: Activate the fire alarm.

The RACE acronym is a standard protocol for fire safety in healthcare settings: Rescue, Alarm, Contain, Extinguish. After rescuing the immediate client in danger, the next critical step is to activate the alarm to alert other staff and the fire department.

Question 65: A nurse is assessing a client who is three days postoperative from a total knee arthroplasty. The client suddenly reports feeling anxious, short of breath, and has a sense of impending doom. Which additional finding would most strongly suggest the development of a pulmonary embolism?

Swelling, warmth, and redness in the calf.
An acute onset of pleuritic chest pain and tachypnea. (Correct answer)
A productive cough with thick, green sputum.
Bradycardia with a blood pressure of 90/50 mmHg.

Correct answer: An acute onset of pleuritic chest pain and tachypnea.

The classic signs and symptoms of a pulmonary embolism include sudden-onset dyspnea (shortness of breath), pleuritic chest pain (sharp pain on inspiration), anxiety, and tachypnea (rapid breathing). While calf swelling suggests a deep vein thrombosis (DVT), which is a cause of PE, the chest pain and tachypnea are direct signs of the embolism in the lungs. A productive cough suggests infection, and clients with a PE are more likely to be tachycardic.

Question 66: A nurse who consistently provides pain relief, repositions clients for comfort, and advocates for their nutritional needs is primarily demonstrating which ethical principle?

Justice
Beneficence (Correct answer)
Fidelity
Autonomy

Correct answer: Beneficence

Beneficence is the ethical principle of acting for the good and well-being of others. The nurse's actions are all aimed at promoting the client's welfare and doing good, which is the core of beneficence.

Question 67: A nurse on a medical-surgical unit receives the change-of-shift report. Which of the following clients should the nurse assess first?

A client postoperative day 2 following a total knee replacement who is requesting pain medication for pain rated 6 on a 0-10 scale.
A client admitted 2 hours ago with a suspected small bowel obstruction who is now reporting sudden, sharp abdominal pain and has a rigid abdomen. (Correct answer)
A client with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 91% on 2 liters of oxygen via nasal cannula.
A client with type 2 diabetes mellitus who has a fasting blood glucose level of 180 mg/dL and is awaiting a breakfast tray.

Correct answer: A client admitted 2 hours ago with a suspected small bowel obstruction who is now reporting sudden, sharp abdominal pain and has a rigid abdomen.

The nurse should prioritize the client with a suspected small bowel obstruction who is now reporting sudden, sharp pain and has a rigid abdomen. These are hallmark signs of a potential bowel perforation, a life-threatening emergency that requires immediate assessment and intervention. This client's condition is unstable and has changed acutely. The other clients, while requiring care, are more stable: the COPD client's oxygen saturation is at an acceptable baseline, the postoperative client's pain is expected, and the diabetic client's blood glucose is elevated but not critically so.

Question 68: A 55-year-old male client with no significant past medical history asks the nurse what health screenings are recommended for him. Based on current guidelines, which screening should the nurse recommend?

A colonoscopy to screen for colorectal cancer. (Correct answer)
A testicular self-exam to be performed monthly.
A yearly chest X-ray to screen for lung cancer.
A baseline electrocardiogram (ECG) to screen for heart disease.

Correct answer: A colonoscopy to screen for colorectal cancer.

Standard guidelines from organizations like the U.S. Preventive Services Task Force (USPSTF) recommend colorectal cancer screening for average-risk individuals beginning at age 45 or 50. A colonoscopy is a primary screening modality. Baseline ECGs and yearly chest X-rays are not recommended for asymptomatic, average-risk individuals. While testicular self-exams are sometimes discussed, their routine recommendation is less emphasized than colorectal cancer screening.

Question 69: What does the Standards of Professional Practice hold nurses accountable for?

following a code of conduct and upholding ethical values related to the profession (Correct answer)
expectations for professional behavior to protect the nurse, as well as the client and the facility where the client care is practiced
develops plan of care, provide ongoing monitoring, and delegation of tasks ensuring that tasks are within that individuals scope of practice, sets mutual client-specific goals
the standards of nursing practice and the standards of professional performance

Correct answer: following a code of conduct and upholding ethical values related to the profession

The Standards of Professional Practice set the expectations for ethical conduct and professional behavior for nurses. Nurses are expected to uphold the values of the nursing profession, including integrity, compassion, respect, and advocacy. By adhering to these standards, nurses ensure the highest quality of care and maintain trust and confidence in the nursing profession.

Question 70: According to the NCSBN Clinical Judgment Measurement Model (NCJMM), which cognitive skill involves organizing and linking recognized cues to understand the patient's clinical situation?

Prioritize Hypotheses
Analyze Cues (Correct answer)
Recognize Cues
Generate Solutions

Correct answer: Analyze Cues

Analyze Cues is the cognitive skill where the nurse processes and links recognized cues to determine their significance and relationship to the patient's condition.

Question 71: After implementing a nursing intervention, a patient's oxygen saturation improves from 89% to 96%. Which NCJMM cognitive skill is the nurse using when interpreting this finding?

Analyze Cues
Evaluate Outcomes (Correct answer)
Prioritize Hypotheses
Generate Solutions

Correct answer: Evaluate Outcomes

Evaluate Outcomes is the cognitive skill of determining whether nursing actions achieved the desired patient outcomes, such as improved oxygenation.

Question 72: A nurse is caring for a post-operative patient who suddenly becomes tachycardic and hypotensive. Using clinical judgment, which action should the nurse take FIRST?

Notify the surgeon immediately
Administer ordered IV fluids
Document findings in the medical record
Perform a focused assessment to gather more data (Correct answer)

Correct answer: Perform a focused assessment to gather more data

Performing a focused assessment first allows the nurse to gather additional cues to determine the most likely cause before taking action, which is fundamental to sound clinical judgment.

Question 73: Which action demonstrates POOR clinical judgment when a patient's condition changes unexpectedly?

Reassessing the patient with a focused physical exam
Reviewing the patient's recent lab values and history
Continuing the original care plan without reassessment (Correct answer)
Escalating concerns to the charge nurse when worried

Correct answer: Continuing the original care plan without reassessment

Continuing the original care plan without reassessing after an unexpected change fails to apply clinical judgment and may delay recognition of a serious complication.

Question 74: A nurse is providing community education on primary prevention strategies for cardiovascular disease. Which of the following activities should the nurse emphasize as the BEST example of primary prevention?

Completing a health risk assessment at a community fair.
Participating in a cardiac rehabilitation program after a myocardial infarction.
Initiating a regular walking program and smoking cessation. (Correct answer)
Starting a low-dose aspirin regimen after a transient ischemic attack (TIA).

Correct answer: Initiating a regular walking program and smoking cessation.

Primary prevention involves measures to prevent the onset of a disease or injury before the disease process begins. Initiating a walking program and stopping smoking are lifestyle modifications aimed at preventing the development of cardiovascular disease. A health risk assessment is secondary prevention (early detection). Aspirin after a TIA and cardiac rehabilitation are examples of tertiary prevention (managing existing disease).

Question 75: A nurse is reviewing the laboratory results of a client with a potassium level of 2.9 mEq/L. Which of the following assessments is the nurse's priority?

Monitoring for Chvostek's sign
Measuring the client's abdominal girth
Assessing the client's cardiac rhythm (Correct answer)
Checking for pitting edema in the extremities

Correct answer: Assessing the client's cardiac rhythm

Hypokalemia (a low potassium level) can cause life-threatening cardiac dysrhythmias by altering the electrical stability of the myocardium. Therefore, the priority nursing assessment is to monitor the client's heart rate and rhythm. Chvostek's sign is associated with hypocalcemia, pitting edema relates to fluid volume status, and abdominal girth is not a primary assessment for hypokalemia.

Question 76: 135-145 mEq/L

Normal K:
Normal Hgb (m/f):
Normal Na: (Correct answer)
Normal Cl:

Correct answer: Normal Na:

Normal Na (Sodium): 135-145 mEq/L

Question 77: While assessing a 7-year-old child admitted for an asthma exacerbation, the nurse observes multiple circular bruises in various stages of healing on the child's back. The parent states the child is clumsy and falls a lot. Which of the following actions is the nurse's priority legal responsibility?

Ask the parent to provide a more detailed history of the injuries.
Confront the parent about the inconsistencies in their story.
Report the suspicion of abuse to the appropriate authorities. (Correct answer)
Carefully document the findings in the child's medical record only.

Correct answer: Report the suspicion of abuse to the appropriate authorities.

Nurses are mandated reporters. When there is a reasonable suspicion of child abuse (e.g., injuries inconsistent with the explanation, specific patterns of bruising), the nurse has a legal and ethical duty to report these concerns to Child Protective Services or law enforcement, depending on state law and facility policy.

Question 78: A nurse is caring for the family of a client who has just died. The client's spouse states, 'If only I had made him go to the doctor sooner, this wouldn't have happened. Maybe if we pray hard enough, God will give us a second chance.' This statement is characteristic of which stage of grief?

Bargaining (Correct answer)
Depression
Denial
Anger

Correct answer: Bargaining

The spouse's statements, 'If only...' and hoping for a second chance in exchange for prayer, are classic examples of bargaining. In this stage, the individual may try to make deals with a higher power to postpone the inevitable and change the reality of the loss. Denial would be an outright refusal to accept the death. Anger would involve directing frustration at others. Depression is characterized by sadness and hopelessness.

Question 79: When a question asks you about safety or when there is no urgent physiological need use this prioritization method:

3.5-5.0 meq/l
evaluation assessment nursing judgement
Maslow's hierarchy of needs
client first equipment second (Correct answer)

Correct answer: client first equipment second

The prioritization method to use when a question involves safety or when there is no urgent physiological need is "client first, equipment second." This approach emphasizes the importance of ensuring the safety and well-being of the client/patient before considering other factors such as equipment or procedures.

Question 80: A nurse is calculating the total fluid intake for a client during an 8-hour shift. The client consumed 6 oz of juice, 8 oz of water, 4 oz of gelatin, and received 100 mL of intravenous fluids. How many milliliters (mL) should the nurse document as the total intake?

640 mL (Correct answer)
440 mL
540 mL
720 mL

Correct answer: 640 mL

To calculate the total intake in milliliters, the nurse must convert ounces to mL (1 oz = 30 mL) and include all sources of fluid. Juice: 6 oz × 30 mL/oz = 180 mL. Water: 8 oz × 30 mL/oz = 240 mL. Gelatin is a clear liquid and counts as intake: 4 oz × 30 mL/oz = 120 mL. IV fluids: 100 mL. The total intake is the sum of these amounts: 180 + 240 + 120 + 100 = 640 mL.

Question 81: Which of the following actions by a nurse would be a violation of the Health Insurance Portability and Accountability Act (HIPAA)?

Looking up the lab results of a neighbor who is a client on another unit. (Correct answer)
Giving a verbal report on a client's condition to the oncoming shift nurse.
Informing the hospital pharmacist about a client's new medication allergy.
Documenting a client's response to pain medication in the electronic health record.

Correct answer: Looking up the lab results of a neighbor who is a client on another unit.

Accessing a client's protected health information (PHI) without a legitimate, job-related reason ('need to know') is a clear violation of HIPAA's privacy rule. The other options describe permissible disclosures of PHI for the purposes of treatment, payment, or healthcare operations.

Question 82: What are the Standards of Professional Practice?

National Council Licensure Examination
assessment, analysis, planning, implementation, evaluation
the board of nursing
specific to the practice of nursing (Correct answer)

Correct answer: specific to the practice of nursing

The Standards of Professional Practice outline the responsibilities, behaviors, and competencies expected of nurses in their professional roles. They cover areas such as assessment, diagnosis, planning, implementation, and evaluation of patient care. These standards are essential for maintaining the integrity and quality of nursing practice.

Question 83: A nurse evaluates a patient's pain level 30 minutes after administering morphine and finds the pain score unchanged at 8/10. Which NCJMM step does this trigger next?

Discontinue the morphine and document
Recognize new cues and re-analyze the situation (Correct answer)
Defer further assessment to the next shift
Repeat the same dose without assessment

Correct answer: Recognize new cues and re-analyze the situation

When outcomes are not achieved, the nurse must return to earlier cognitive steps — recognizing new cues and re-analyzing — to revise the care plan.

Question 84: A nurse is initiating a transfusion of packed red blood cells (PRBCs) for a client. Which of the following actions is most critical for the nurse to perform within the first 15 minutes of the infusion?

Administer an antihistamine to prevent a reaction.
Document the client's baseline intake and output.
Increase the infusion rate to the prescribed maximum.
Remain with the client and monitor vital signs. (Correct answer)

Correct answer: Remain with the client and monitor vital signs.

The majority of severe, life-threatening transfusion reactions occur within the first 15 minutes or the first 50 mL of the infusion. It is a critical safety standard for the nurse to remain with the client during this period to monitor for signs of a reaction, such as fever, chills, back pain, shortness of breath, or hives, and to monitor vital signs per facility policy.

NCLEX-RN (National Council Licensure Examination for Registered Nurses)

The NCLEX-RN is the standardized licensure exam administered by NCSBN that nursing graduates must pass to obtain RN licensure in the US and Canada. It uses Computerized Adaptive Testing (CAT) with Next Generation NCLEX (NGN) question formats to assess clinical judgment across eight client needs categories.

Questions

300 min

Time Limit

70%

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