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

Question 1: An interprofessional care conference is scheduled for a patient with complex needs. What is the PN's primary role in this conference?

To provide bedside nursing observations and advocate for the patient's expressed needs (Correct answer)
To lead the meeting and set the agenda
To make all final care decisions on behalf of the team
To defer entirely to the physician's plan without offering input

Correct answer: To provide bedside nursing observations and advocate for the patient's expressed needs

The PN contributes direct bedside observations and serves as a patient advocate within the interprofessional team, ensuring the patient's preferences are heard.

Question 2: A nurse is preparing to administer potassium chloride (KCl) 40 mEq IV. Which safety precaution is essential?

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

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

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

Question 3: A nurse is teaching a client about colon cancer screening. At what age should average-risk adults begin colorectal cancer screening?

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

Correct answer: 45 years

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

Question 4: A nurse is preparing to insert a urinary catheter. Which action is essential to maintain sterile technique?

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

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

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

Question 5: A client presents with confusion, muscle twitching, and a serum sodium of 122 mEq/L. What is the most likely cause of these neurological symptoms?

Cells shrinking due to hyperosmolar state
Increased ADH suppression
Cerebral edema from hypotonic fluid shifting into brain cells (Correct answer)
Hyperchloremia-induced nerve conduction changes

Correct answer: Cerebral edema from hypotonic fluid shifting into brain cells

Severe hyponatremia causes water to shift into brain cells, leading to cerebral edema and neurological symptoms such as confusion and seizures.

Question 6: A patient is receiving IV vancomycin and develops flushing, erythema, and hypotension during the infusion. What is the most likely cause?

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

Correct answer: Red man syndrome

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

Question 7: A PN is coordinating care for a patient being discharged to a skilled nursing facility. Which action is the PN's priority?

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

Correct answer: Ensuring transfer documentation and medication reconciliation are complete

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

Question 8: A nurse has finished providing care for a client on contact and droplet precautions. To minimize the risk of self-contamination, which of the following represents the correct sequence for removing (doffing) personal protective equipment (PPE)?

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

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

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

Question 9: A patient is at risk for falls. Which intervention is most effective for fall prevention?

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

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

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

Question 10: A patient with terminal cancer is enrolled in hospice. Which statement BEST describes the goal of hospice care?

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

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

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

Question 11: Which behavior best demonstrates a client successfully resolving Erikson's stage of 'Industry vs. Inferiority'?

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

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

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

Question 12: A patient in hypovolemic shock has a BP of 80/50 mmHg and HR of 128 bpm. Which physiological response explains the tachycardia?

Baroreceptor-mediated sympathetic activation (Correct answer)
Parasympathetic stimulation of the SA node
Direct effect of lactic acid on cardiac muscle
Increased vagal tone from hypoxia

Correct answer: Baroreceptor-mediated sympathetic activation

Decreased arterial pressure reduces baroreceptor stretch, triggering sympathetic nervous system activation that increases heart rate.

Question 13: A nurse is educating a patient about proper use of a metered-dose inhaler (MDI) without a spacer. Which instruction is correct?

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

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

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

Question 14: A nurse is caring for a client with dysphagia. Which food consistency is MOST appropriate to prevent aspiration?

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

Correct answer: Nectar-thickened liquids

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

Question 15: A nurse is assessing a newborn's Apgar score at 5 minutes. The infant has a heart rate of 110, strong cry, active motion, grimaces with stimulation, and is completely pink. What is the Apgar score?

7
8
10 (Correct answer)
9

Correct answer: 10

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

Question 16: A nurse is administering total parenteral nutrition (TPN) through a central line. Which nursing action is essential?

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

Correct answer: Monitor blood glucose levels regularly

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

Question 17: Which laboratory value requires the nurse to hold the next dose of warfarin and notify the provider?

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

Correct answer: INR of 5.8

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

Question 18: A nurse is providing hygiene care to an unconscious client. Which action is essential to prevent injury?

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

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

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

Question 19: A postoperative client is encouraged to ambulate as soon as possible. Which of the following is the primary rationale for early ambulation?

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

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

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

Question 20: In the event of a fire on a nursing unit, what is the correct sequence of actions?

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

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

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

Question 21: According to Erikson's stages of development, a 25-year-old client who expresses difficulty forming meaningful relationships with others is likely struggling with which psychosocial crisis?

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

Correct answer: Intimacy vs. Isolation

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

Question 22: If an Orthodox Jewish patient won't use the call bell or answer the intercom because they won't use electrical appliances on the Sabbath, shouldn't the nurse?

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

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

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

Question 23: Which primary prevention strategy is most appropriate for a community at high risk for Type 2 diabetes?

Insulin sensitizer prophylaxis for all adults
Early initiation of metformin therapy
Annual fasting glucose screening
Weight management and physical activity programs (Correct answer)

Correct answer: Weight management and physical activity programs

Primary prevention focuses on reducing risk before disease onset; lifestyle modification through diet and exercise is the most effective intervention for Type 2 diabetes prevention.

Question 24: Which action by the nurse BEST promotes sleep hygiene for a hospitalized client?

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

Correct answer: Cluster nursing care activities to minimize nighttime interruptions

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

Question 25: Which position is most appropriate for a patient experiencing difficulty breathing?

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

Correct answer: High Fowler's position

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

Question 26: A PN-RN is assessing a client's readiness to learn about a new low-sodium diet. Which factor most directly affects learning readiness?

The number of family members present
The client's age
The client's educational background
The client's current pain level (Correct answer)

Correct answer: The client's current pain level

Uncontrolled pain significantly impairs concentration and information retention, making it the most direct barrier to learning readiness.

Question 27: The ethical principle of beneficence requires a nurse to take what type of action?

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

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

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

Question 28: A nurse is administering an IV piggyback antibiotic when the client reports burning and swelling at the IV site. Which action should the nurse take first?

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

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

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

Question 29: A nurse is caring for a terminally ill patient who has a valid DNR order. The patient goes into cardiac arrest. The patient's adult son demands that the nurse 'do everything.' What is the appropriate nursing response?

Call the physician to cancel the DNR order before taking any action
Initiate CPR to honor the family's wishes
Defer to the son's request since he is the next of kin
Explain to the son that the patient's documented wishes and DNR order will be followed (Correct answer)

Correct answer: Explain to the son that the patient's documented wishes and DNR order will be followed

A valid DNR order reflects the patient's autonomous decision and must be honored; the nurse should compassionately explain this to the family.

Question 30: A patient with diabetes mellitus has a fasting blood glucose of 52 mg/dL and is conscious. What is the nurse's priority intervention?

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

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

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

Question 31: A patient's durable power of attorney for healthcare (DPAHC) designates a spouse as surrogate decision-maker. The patient is now unconscious. The adult children disagree with the spouse's decision. Who has legal authority?

The spouse designated in the DPAHC (Correct answer)
The majority vote of the adult children
The attending physician
The hospital ethics committee

Correct answer: The spouse designated in the DPAHC

The legally designated healthcare proxy in a DPAHC holds decision-making authority over all family members who are not designated.

Question 32: A nurse is conducting a health history. The client reports smoking 1 pack of cigarettes per day for 20 years. How many pack-years does this represent?

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

Correct answer: 20 pack-years

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

Question 33: Which patient is most at risk for developing hypokalemia?

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

Correct answer: A patient taking hydrochlorothiazide for hypertension

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

Question 34: A nurse is reviewing the lab results for a client with end-stage renal disease. The serum potassium level is 6.2 mEq/L. Which of the following is the priority nursing assessment?

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

Correct answer: Monitoring cardiac rate and rhythm

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

Question 35: A nurse is caring for a client receiving enteral tube feedings. Which assessment finding warrants IMMEDIATE action?

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

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

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

Question 36: A nurse is caring for a terminally ill client who states, 'If I can just live until my daughter's wedding, then I'll be ready to go.' This is an example of which stage of grief?

Acceptance
Depression
Anger
Bargaining (Correct answer)

Correct answer: Bargaining

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

Question 37: A patient with severe burns covering 40% TBSA is in the first 24 hours post-injury. Which physiological change requires the most aggressive fluid resuscitation?

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

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

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

Question 38: A nurse is monitoring a patient receiving a blood transfusion who develops urticaria (hives) without other symptoms. What is the appropriate initial action?

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

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

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

Question 39: When triaging four patients in the emergency department, which patient requires the highest priority of care?

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

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

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

Question 40: A nurse is caring for a client receiving Total Parenteral Nutrition (TPN) via a central venous catheter. Which of the following is a priority nursing intervention to prevent a metabolic complication?

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

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

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

Question 41: Which assessment finding in a patient taking lithium carbonate requires immediate intervention?

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

Correct answer: Serum lithium level of 2.5 mEq/L

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

Question 42: When administering a peripheral IV infusion, the nurse notices the site is cool, pale, and swollen. What is the priority action?

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

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

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

Question 43: During interdisciplinary rounds, a nurse has information about a client's pain management concerns. Which action best reflects the nurse's advocacy role?

Document pain concerns in the chart only
Wait until after rounds to speak privately with the physician
Ask the client's family to bring up the concerns instead
Clearly communicate the client's pain assessment and concerns to the team during rounds (Correct answer)

Correct answer: Clearly communicate the client's pain assessment and concerns to the team during rounds

The nurse is the client's advocate and must directly communicate relevant assessment findings and client concerns to the interdisciplinary team during rounds.

Question 44: Which finding in a patient's health history most increases the risk for developing a pressure injury?

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

Correct answer: Braden Scale score of 12 and urinary incontinence

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

Question 45: A nurse is monitoring a client receiving an IV infusion of 0.9% sodium chloride. The client complains of pain and swelling at the IV site, and the surrounding skin appears cool and blanched. Which action should the nurse take first?

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

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

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

Question 46: Which patient is at HIGHEST risk for developing a healthcare-associated infection (HAI)?

A 20-year-old patient admitted for observation after a minor injury
A 30-year-old ambulatory patient post-appendectomy
A 75-year-old patient with an indwelling urinary catheter on antibiotics (Correct answer)
A 45-year-old patient receiving oral antihypertensives

Correct answer: A 75-year-old patient with an indwelling urinary catheter on antibiotics

Older age, invasive devices (urinary catheter), and antibiotic use are all major risk factors for HAIs.

Question 47: A patient's chart shows a temperature of 38.9°C. What is the equivalent Fahrenheit temperature?

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

Correct answer: 102.0°F

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

Question 48: Drooling is prolonged and swallowing is impeded in stroke patients with right-sided paralysis. What kind of suctioning is recommended?

Nasopharyngeal.
Endotracheal.
Tracheal.
Oropharyngeal. (Correct answer)

Correct answer: Oropharyngeal.

For a patient who has had a stroke, has right-sided paralysis, persistent drooling, and poor swallowing, oropharyngeal suctioning is recommended. This procedure, which uses a Yankauer nozzle to suction mucous secretions from the mouth to prevent the patient from aspirating them, is the least invasive and irritating for the patient. For suctioning, patients should be positioned semi-Fowler's or upright.

Question 49: A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). The nurse notes that the client is breathing very deeply and rapidly. The nurse recognizes this respiratory pattern, Kussmaul respirations, as the body's attempt to compensate for which acid-base imbalance?

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

Correct answer: Metabolic Acidosis

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

Question 50: A nurse receives a verbal order from a physician during an emergency. What is the nurse's priority action after carrying out the order?

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

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

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

Question 51: A nurse is working in a hospital that uses a team nursing model. What is the primary advantage of this care delivery model?

Each nurse manages an equal number of clients independently
Nursing tasks are shared among team members based on skill level and scope (Correct answer)
Unlicensed personnel provide all direct client care
One nurse is solely responsible for all aspects of a client's care

Correct answer: Nursing tasks are shared among team members based on skill level and scope

Team nursing distributes care tasks among team members according to their scope of practice and competency, maximizing efficiency and skill utilization.

Question 52: Which of the following factors raises the chance of pulmonary embolism after surgery?

Age younger than 60.
Thyroid disease.
Prolonged immobilization. (Correct answer)
Hypocoagulability.

Correct answer: Prolonged immobilization.

Since prolonged immobility might result in deep vein thrombosis (DVT), it is one of the main risk factors for the development of pulmonary embolus in the postoperative period. When a piece of the thrombus development separates and enters the bloodstream, it can cause DVT, which in turn can cause pulmonary embolism. Patients are urged to move around in bed and ambulate as soon as possible because of this. Age and blood's hypercoagulability, which renders it prone to clotting, are additional risk factors.

Question 53: Which behavior modification technique is MOST appropriate when counseling a client about smoking cessation?

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

Correct answer: Setting a specific quit date

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

Question 54: A 30-year-old client is recovering from a major surgery that has resulted in a significant change in body image. The client refuses to look at the surgical site. This behavior is an example of which defense mechanism?

Sublimation
Rationalization
Denial (Correct answer)
Projection

Correct answer: Denial

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

Question 55: Long-term usage of corticosteroids or antibiotics raises the risk of?

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

Correct answer: candidiasis.

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

Question 56: A nurse is caring for a patient experiencing status epilepticus. Which intervention takes priority?

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

Correct answer: Maintaining a patent airway and administering IV benzodiazepine

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

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

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

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

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

Question 58: A Jehovah's Witness patient scheduled for elective surgery refuses a blood transfusion even if life-saving. The patient is alert and oriented. Which action is ethically and legally correct?

Discharge the patient because surgery cannot proceed safely
Administer the transfusion anyway during surgery when the patient is unconscious
Document the patient's refusal and ensure informed refusal is signed; explore bloodless alternatives (Correct answer)
Obtain a court order to override the patient's refusal

Correct answer: Document the patient's refusal and ensure informed refusal is signed; explore bloodless alternatives

A competent adult has the legal and ethical right to refuse treatment, including blood transfusions, based on religious beliefs. The nurse must document informed refusal, ensure the patient understands the risks, and collaborate with the team to explore bloodless surgical techniques. Overriding an alert competent patient's decision violates autonomy.

Question 59: Which immunization is recommended for all adults aged 65 and older to prevent pneumococcal disease?

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

Correct answer: PPSV23 (Pneumovax)

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

Question 60: Which principle requires nurses to treat all patients equally regardless of socioeconomic status, race, or personal beliefs?

Autonomy
Fidelity
Veracity
Justice (Correct answer)

Correct answer: Justice

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

Question 61: A nurse is caring for a patient in septic shock. Which set of vital signs is most consistent with early (warm) septic shock?

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

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

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

Question 62: When assessing a surgical incision two days after an operation, which of the following findings indicates a normal physiological response during the inflammatory phase of wound healing?

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

Correct answer: Localized warmth, redness, and swelling

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

Question 63: A nurse uses the SBAR communication technique when calling a physician. Which component is 'A' in SBAR?

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

Correct answer: Assessment of the client's current condition

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

Question 64: The nurse is assessing a client who is 72 hours postoperative following a total hip arthroplasty. Which assessment finding is most indicative of a potential pulmonary embolism and requires immediate notification of the provider?

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

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

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

Question 65: A nurse is teaching a pregnant client about nutrition. Which nutrient is most critical during the first trimester to prevent neural tube defects?

Folic acid (Correct answer)
Calcium
Vitamin D
Iron

Correct answer: Folic acid

Folic acid (400–800 mcg daily) is essential in early pregnancy to prevent neural tube defects such as spina bifida.

Question 66: A nurse is assisting a patient with dysphagia. Which dietary modification is most appropriate to reduce the risk of aspiration?

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

Correct answer: Thickened liquids

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

Question 67: A nurse is caring for a client receiving a blood transfusion who develops hives, itching, and mild urticaria 15 minutes after the infusion begins. What is the priority nursing action?

Stop the transfusion, keep the IV open with normal saline, and notify the physician (Correct answer)
Slow the infusion rate and monitor closely
Administer diphenhydramine and continue the transfusion
Stop the transfusion and notify the physician

Correct answer: Stop the transfusion, keep the IV open with normal saline, and notify the physician

An allergic transfusion reaction requires stopping the transfusion, maintaining IV access with normal saline, and notifying the physician to determine further management.

Question 68: An RN on a medical-surgical unit is planning assignments for the upcoming shift. The team consists of another RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which task is most appropriate for the RN to delegate to the LPN?

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

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

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

Question 69: A new mother two weeks postpartum tells the nurse she has thoughts of harming her baby. What is the priority nursing action?

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

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

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

Question 70: A nurse is caring for a client who is visually impaired. Which approach is MOST appropriate when assisting with ambulation?

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

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

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

Question 71: A nurse is preparing to change a wound dressing for a patient with methicillin-resistant Staphylococcus aureus (MRSA). In addition to standard precautions, which transmission-based precaution category is required?

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

Correct answer: Contact precautions

MRSA is spread through direct or indirect contact with infected wounds or colonized skin; contact precautions, including gloves and gown, are required in addition to standard precautions to prevent transmission.

Question 72: A nurse observes that a hospitalized 4-year-old child is clinging to a blanket and sucking their thumb. How should the nurse interpret this behavior?

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

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

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

Question 73: During a disaster, which triage category receives treatment first?

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

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

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

Question 74: A nurse is inserting an indwelling urinary catheter in a female patient. During insertion, urine is not obtained. What should the nurse do?

Inflate the balloon and wait for urine flow
Remove the catheter and insert it into the correct opening
Leave the catheter in place and insert a new one into the urethral meatus (Correct answer)
Push the catheter in further until urine appears

Correct answer: Leave the catheter in place and insert a new one into the urethral meatus

If no urine returns, the catheter was likely inserted into the vagina. The nurse should leave it as a landmark, insert a new sterile catheter into the urethral meatus, then remove the misplaced catheter.

Question 75: A client is brought to the emergency department following a significant traumatic injury with suspected internal bleeding. Which of the following findings is considered an early compensatory sign of hypovolemic shock?

Bradycardia
Decreased respiratory rate
Tachycardia (Correct answer)
Hypotension

Correct answer: Tachycardia

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

Question 76: A nurse accidentally sustains a needlestick injury from a contaminated needle. What is the priority first action?

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

Correct answer: Wash the site thoroughly with soap and water

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

Question 77: A client who was just informed of a terminal diagnosis begins yelling at the nurse, 'This is your fault! You didn't push for more tests!' The nurse recognizes this response as:

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

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

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

Question 78: A nurse is orienting a new graduate nurse and observes her document an assessment she did not perform. What is the nurse's priority action?

Remind the new nurse to complete all assessments on time
Add a late entry to the chart correcting the record
Counsel the new nurse privately and allow her to self-correct
Report the falsified documentation to the charge nurse or supervisor immediately (Correct answer)

Correct answer: Report the falsified documentation to the charge nurse or supervisor immediately

Falsifying documentation is a serious legal and ethical violation that must be reported immediately to a supervisor.

Question 79: A nurse is performing passive range-of-motion (PROM) exercises on a client's hip. Which movement involves moving the leg away from the midline of the body?

Internal rotation
Flexion
Adduction
Abduction (Correct answer)

Correct answer: Abduction

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

Question 80: A nurse uses a therapeutic communication technique when responding to an anxious client. Which response demonstrates the technique of 'focusing'?

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

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

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

Question 81: A nurse is caring for a client on prolonged bed rest. To reduce the client's risk of developing renal calculi, which intervention is the highest priority?

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

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

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

Question 82: A nurse suspects that a coworker is diverting controlled substances. What is the most appropriate first action?

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

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

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

Question 83: To what temperature should ground beef be cooked to avoid food poisoning?

140° F.
125° F.
180° F.
160° F. (Correct answer)

Correct answer: 160° F.

Ground beef needs to be cooked to 160° F to avoid food poisoning. Because ground beef is more likely to be contaminated than solid pieces of meat due to the grinding process, it should not be served rare because the surface contamination of solid pieces of meat is more quickly eliminated while cooking. In addition, poultry should always be cooked to a least of 165° F and to a well-done state, however many experts advise cooking to 180° F.

Question 84: A nurse must perform hand hygiene after caring for a patient with C. difficile. Which method is preferred?

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

Correct answer: Soap and water for at least 20 seconds

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

Question 85: Which finding is a classic sign of diabetic ketoacidosis (DKA)?

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

Correct answer: Fruity odor to the breath

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

Question 86: A client's morning blood glucose is 52 mg/dL and they are conscious and able to swallow. What is the nurse's first action?

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

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

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

Question 87: What is the best crutch gait to use if a patient is not permitted to put any weight on their left leg?

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

Correct answer: three-point.

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

Question 88: A patient receiving total parenteral nutrition (TPN) develops sudden shortness of breath and chest pain after the central line is repositioned. What should the nurse suspect first?

Hyperglycemia
Fluid overload
Air embolism (Correct answer)
Catheter occlusion

Correct answer: Air embolism

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

Question 89: A nurse is inserting a urinary catheter in a female client. After cleansing the urinary meatus, the catheter accidentally touches the labia. What is the CORRECT action?

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

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

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

Question 90: What is the purpose of performing a 'time out' immediately before a surgical procedure?

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

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

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

Question 91: A nurse is preparing to administer a continuous intravenous infusion of heparin. Which of the following laboratory values is essential for the nurse to review immediately before initiating the infusion?

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

Correct answer: Activated Partial Thromboplastin Time (aPTT)

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

Question 92: A nurse is developing a plan of care for an older adult client at risk for pressure injuries. Which of the following interventions should be included?

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

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

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

Question 93: A nurse prepares to insert a urinary catheter. Which action is most important in reducing the risk of catheter-associated urinary tract infection (CAUTI)?

Irrigating the catheter with normal saline daily
Maintaining a closed drainage system (Correct answer)
Using the smallest catheter size appropriate
Taping the catheter to the inner thigh

Correct answer: Maintaining a closed drainage system

Maintaining a sterile, closed drainage system is the single most effective measure for preventing CAUTI.

Question 94: What is the recommended daily fluid intake for an average healthy adult?

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

Correct answer: 2500-3000 mL

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

Question 95: A nurse is caring for a client with Medicare. Which statement about Medicare Part B is accurate?

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

Correct answer: It covers outpatient physician services and preventive care

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

Question 96: A nurse notices a client has been isolating herself and crying frequently since her husband's death two weeks ago. The nurse's best initial action is to:

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

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

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

Question 97: A nurse witnesses a healthcare provider explaining a surgical procedure to a client who speaks a different language, using the client's 12-year-old grandchild as an interpreter. Which ethical principle is most immediately compromised in this situation?

Nonmaleficence
Justice
Fidelity
Autonomy (Correct answer)

Correct answer: Autonomy

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

Question 98: Which type of isolation precaution is required for a patient diagnosed with tuberculosis?

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

Correct answer: Airborne precautions

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

Question 99: A patient has a nursing diagnosis of 'Risk for Falls.' Which intervention is the priority?

Place a fall-risk identification band on the patient
Educate the patient about fall prevention strategies
Document the fall risk assessment in the medical record
Keep the call light and personal items within reach and ensure the bed is in the lowest position (Correct answer)

Correct answer: Keep the call light and personal items within reach and ensure the bed is in the lowest position

Environmental modifications that reduce the immediate risk of falling—such as lowering the bed and ensuring call light accessibility—are the highest-priority direct safety interventions.

Question 100: Which assessment finding best indicates that a client is at risk for complicated grief?

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

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

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

Question 101: A nurse discovers that the wrong patient received a medication intended for another patient in the same room. After assessing the patient, what documentation is required?

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

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

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

Question 102: Which action by a nurse constitutes assault (as opposed to battery)?

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

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

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

Question 103: A patient is receiving IV amphotericin B. Which assessment finding is most expected and requires ongoing monitoring?

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

Correct answer: Rising serum creatinine

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

Question 104: When performing a head-to-toe physical assessment, in what order should the nurse assess the abdomen?

Palpation, inspection, auscultation, percussion
Auscultation, percussion, palpation, inspection
Inspection, auscultation, percussion, palpation (Correct answer)
Inspection, palpation, percussion, auscultation

Correct answer: Inspection, auscultation, percussion, palpation

The abdomen is assessed by inspection first, then auscultation before percussion and palpation to avoid altering bowel sounds.

Question 105: A nurse is assessing a 3-year-old who insists on doing tasks 'by myself.' According to Erikson, this behavior reflects which developmental stage?

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

Correct answer: Autonomy vs. shame and doubt

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

Question 106: A nurse enters a patient's room and smells a strong gas odor. What is the nurse's first action?

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

Correct answer: Evacuate the patient from the room

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

Question 107: According to Erikson, a 70-year-old who expresses regret about life choices and feels despair is experiencing failure of which developmental stage?

Generativity vs. stagnation
Intimacy vs. isolation
Identity vs. role confusion
Ego integrity vs. despair (Correct answer)

Correct answer: Ego integrity vs. despair

Ego integrity vs. despair is Erikson's stage for late adulthood (65+), where failure results in despair over an unfulfilling life.

Question 108: A nurse is administering potassium chloride 40 mEq IV. Which practice is safest?

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

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

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

Question 109: A nurse is caring for a client who had a stroke and has dysphagia. Which of the following interventions is the priority to ensure the client's safety and comfort during meals?

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

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

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

Question 110: A patient with terminal cancer has a Do-Not-Resuscitate (DNR) order. The patient goes into cardiac arrest. What is the nurse's appropriate action?

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

Correct answer: Provide comfort measures only

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

Question 111: A patient's serum calcium is 12.5 mg/dL. Which priority intervention should the nurse implement for hypercalcemia?

Encourage oral fluid intake and ambulation (Correct answer)
Apply seizure precautions and pad side rails
Prepare the patient for emergency hemodialysis
Administer calcium gluconate IV push

Correct answer: Encourage oral fluid intake and ambulation

Increasing fluid intake promotes renal calcium excretion, and weight-bearing ambulation reduces bone resorption, making these the first-line interventions for mild-to-moderate hypercalcemia.

Question 112: When assisting a patient with a bed bath, in which direction should the nurse wash the extremities?

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

Correct answer: Distal to proximal

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

Question 113: A nurse receives shift report on four patients. Which patient should the nurse assess first?

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

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

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

Question 114: A nurse is admitting a client with suspected active pulmonary tuberculosis (TB). Which of the following environmental controls is essential to implement for airborne precautions?

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

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

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

Question 115: Which nursing action is most important before administering the first dose of an aminoglycoside antibiotic such as gentamicin?

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

Correct answer: Obtain baseline hearing assessment and renal function tests

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

Question 116: A nurse is caring for a patient on contact precautions. In what order should PPE be removed after leaving the room?

Gloves, mask/eye protection, gown, hand hygiene
Gloves, gown, mask/eye protection, hand hygiene (Correct answer)
Mask/eye protection, gown, gloves, hand hygiene
Gown, gloves, mask/eye protection, hand hygiene

Correct answer: Gloves, gown, mask/eye protection, hand hygiene

CDC guidelines specify removing gloves first (most contaminated), then gown, then mask/eye protection, followed by hand hygiene.

Question 117: Which medication requires the nurse to monitor potassium levels closely due to the risk of hyperkalemia?

Mannitol
Hydrochlorothiazide
Furosemide
Spironolactone (Correct answer)

Correct answer: Spironolactone

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

Question 118: A nurse reviews a client's medication list and notes they are taking warfarin. Which laboratory value is most critical to monitor to reduce risk of bleeding complications?

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

Correct answer: International Normalized Ratio (INR)

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

Question 119: A nurse is providing health promotion education to a community group. Which statement best describes secondary prevention?

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

Correct answer: Screening hypertensive clients to detect complications early

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

Question 120: A patient's culture results show Clostridioides difficile (C. diff) infection. Which precaution must the nurse implement?

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

Correct answer: Contact precautions with soap and water hand hygiene

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

Question 121: A patient with cirrhosis develops asterixis, confusion, and elevated ammonia levels. Which physiological process is occurring?

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

Correct answer: Hepatic encephalopathy from impaired ammonia detoxification

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

Question 122: A nurse is caring for a patient in four-point restraints. How frequently must the nurse assess the patient?

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

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

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

Question 123: A nurse is caring for an older adult client who is confused and has repeatedly attempted to pull out their peripheral intravenous (IV) catheter. After assessing the client, which action should the nurse take first to ensure the client's safety?

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

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

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

Question 124: A client who recently lost a limb says, 'I know I'll never be normal again, but I'm learning to adapt.' This statement reflects which phase of Kübler-Ross's grief model?

Anger
Acceptance (Correct answer)
Bargaining
Depression

Correct answer: Acceptance

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

Question 125: A nurse is preparing to administer a medication via a nasogastric tube. Which action ensures patient safety?

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

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

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

Question 126: A nurse is caring for a client receiving furosemide for heart failure. The client reports significant muscle weakness, and the cardiac monitor shows flattened T waves and prominent U waves. The nurse should suspect which electrolyte imbalance?

Hypomagnesemia
Hypokalemia (Correct answer)
Hyponatremia
Hypercalcemia

Correct answer: Hypokalemia

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

Question 127: A client with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department with increased shortness of breath. An arterial blood gas (ABG) analysis reveals the following: pH 7.28, PaCO2 55 mmHg, HCO3 26 mEq/L. How should the nurse interpret these findings?

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

Correct answer: Respiratory Acidosis, Uncompensated

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

Question 128: A patient recently diagnosed with cancer states, 'I want to know all about my treatment options.' According to Kubler-Ross, which stage of grief is the patient most likely experiencing?

Denial
Acceptance (Correct answer)
Depression
Bargaining

Correct answer: Acceptance

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

Question 129: A nurse working on a medical-surgical unit discovers a fire in a client's trash can. What is the nurse's immediate priority action?

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

Correct answer: Rescue any clients in immediate danger.

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

Question 130: A PN is supervising a UAP who reports that a patient's blood pressure is 88/52 mmHg. What is the nurse's best initial action?

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

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

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

Question 131: A client with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which assessment finding requires the nurse's most immediate action?

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

Correct answer: Irregular cardiac rhythm on telemetry

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

Question 132: Florence Nightingale's Environmental Theory of nursing emphasizes that healing is best supported by:

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

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

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

Question 133: When providing oral care to an unconscious client, which position is MOST appropriate?

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

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

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

Question 134: A client states, 'My doctor says I have cancer, but I know the lab results are wrong.' This is an example of which defense mechanism?

Displacement
Projection
Denial (Correct answer)
Rationalization

Correct answer: Denial

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

Question 135: When removing PPE after caring for a patient on contact precautions, which item should be removed FIRST?

Gown
Goggles
Mask
Gloves (Correct answer)

Correct answer: Gloves

Gloves are removed first because they are the most contaminated item and removal prevents contaminating the hands during further doffing.

Question 136: A nurse receives a physician's order that appears to be incorrect. What is the nurse's responsibility?

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

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

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

Question 137: A nurse witnesses another nurse administering a medication without checking the patient's identification. This is an example of which legal concept?

Malpractice
Battery
False imprisonment
Negligence (Correct answer)

Correct answer: Negligence

Negligence occurs when a nurse fails to exercise the standard of care that a reasonable nurse would provide, such as failing to verify patient identification before medication administration.

Question 138: A nurse needs to hand off a patient to the oncoming nurse. Which communication framework is the standard for structured handoff reporting?

RACE
SBAR (Correct answer)
SOAP
ADPIE

Correct answer: SBAR

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

Question 139: A nurse is monitoring a patient after a thyroidectomy. Which complication should the nurse assess for within the first 24 hours?

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

Correct answer: Hypocalcemia

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

Question 140: A nurse is preparing to administer IV medications to two patients simultaneously. Which action BEST prevents medication errors?

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

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

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

Question 141: A patient with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 6. What does this indicate about the patient's neurological status?

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

Correct answer: Severe brain injury

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

Question 142: A nurse is teaching a patient about warfarin therapy. Which food should the patient be instructed to consume consistently rather than avoid entirely?

Alcohol
Green leafy vegetables (Correct answer)
Grapefruit juice
Aged cheese

Correct answer: Green leafy vegetables

Patients on warfarin should keep vitamin K intake (from green leafy vegetables) consistent rather than eliminating it, as abrupt changes alter INR.

Question 143: A patient is ordered 250 mg of amoxicillin. The medication is available as 125 mg/5 mL. How many mL should the nurse administer?

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

Correct answer: 10 mL

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

Question 144: A patient recovering from surgery develops sudden onset dyspnea, chest pain, and tachycardia. Which complication should the nurse suspect?

Atelectasis
Heart failure
Pneumonia
Pulmonary embolism (Correct answer)

Correct answer: Pulmonary embolism

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

Question 145: A nurse is teaching a patient about a newly prescribed medication. Which statement by the patient indicates the need for further teaching?

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

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

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

Question 146: A client taking lithium carbonate reports nausea, vomiting, coarse hand tremors, and confusion. Which nursing action is the priority?

Hold the next lithium dose and notify the physician immediately (Correct answer)
Administer an antiemetic and reassure the client
Obtain a serum lithium level and continue scheduled doses
Encourage increased fluid and sodium intake

Correct answer: Hold the next lithium dose and notify the physician immediately

These signs indicate lithium toxicity; the nurse must hold the medication and notify the physician immediately to prevent serious neurological and cardiac complications.

Question 147: A nurse is planning care for four clients. Which client should the nurse assess first?

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

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

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

Question 148: A nurse is teaching an adult client about colorectal cancer screening. At what age should average-risk individuals begin screening colonoscopy?

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

Correct answer: 45 years

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

Question 149: A nurse is caring for a client who refuses a prescribed blood transfusion for religious reasons. Which action best reflects the ethical principle of autonomy?

Ask the family to convince the client to accept treatment
Administer the transfusion because it is life-saving
Document the refusal and notify the physician without proceeding (Correct answer)
Consult the ethics committee to override the client's decision

Correct answer: Document the refusal and notify the physician without proceeding

Autonomy requires respecting a competent client's right to refuse treatment; the nurse documents the refusal and informs the provider.

Question 150: Which therapeutic communication technique involves restating the patient's message in the nurse's own words to verify understanding?

Reflecting
Paraphrasing (Correct answer)
Clarifying
Summarizing

Correct answer: Paraphrasing

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

Question 151: Which finding during a well-child visit in a 6-month-old warrants further evaluation by the nurse?

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

Correct answer: Absence of babbling

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

Question 152: A nurse is asked by a physician to witness an informed consent signature for a complex surgical procedure the nurse did not observe being explained. The nurse should:

Sign as a witness since the physician is responsible for the explanation
Countersign and note 'explanation given by physician' in the chart
Refuse to sign and inform the physician that the nurse did not witness the explanation (Correct answer)
Ask the patient to summarize what was explained before signing

Correct answer: Refuse to sign and inform the physician that the nurse did not witness the explanation

A witness signature attests that the signer observed the consent process; signing without having witnessed it is legally and ethically fraudulent.

Question 153: A postoperative client reports sudden onset of chest pain and shortness of breath on day 2 after hip replacement surgery. What is the nurse's priority action?

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

Correct answer: Notify the physician immediately

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

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

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

Correct answer: Every 2 hours

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

Question 155: A nurse is assisting a client who uses a cane. On which side should the cane be held?

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

Correct answer: The unaffected (stronger) side

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

Question 156: Which of the following tasks is appropriate for a Registered Nurse (RN) to delegate to a Licensed Practical Nurse (LPN)?

Completing the initial admission assessment for a new patient.
Administering a scheduled oral antibiotic to a stable patient. (Correct answer)
Providing discharge teaching to a patient after major surgery.
Developing the nursing care plan for a patient with complex health needs.

Correct answer: Administering a scheduled oral antibiotic to a stable patient.

The scope of practice for an LPN typically includes administering medications to stable patients with predictable outcomes. Initial assessments, developing the comprehensive nursing care plan, and providing complex patient education (like discharge teaching) are responsibilities of the RN and require a broader scope of knowledge and clinical judgment.

Question 157: A client is prescribed 3% hypertonic saline for severe hyponatremia. Which complication should the nurse monitor for during infusion?

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

Correct answer: Osmotic demyelination syndrome if corrected too rapidly

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

Question 158: A bedridden client has a stage II pressure injury on the coccyx. Which intervention is the PRIORITY?

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

Correct answer: Reposition the client every 2 hours

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

Question 159: A patient post-thyroidectomy develops tingling around the mouth and carpopedal spasms. Which lab value should the nurse check immediately?

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

Correct answer: Serum calcium

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

Question 160: A patient with a pulmonary embolism has sudden onset of hypoxia despite oxygen therapy. Which physiological mechanism best explains this finding?

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

Correct answer: Ventilation-perfusion mismatch

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

Question 161: A nurse is preparing to administer heparin 5,000 units subcutaneously. Which action is correct?

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

Correct answer: Do not rub the injection site after administration

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

Question 162: Which legal doctrine holds hospitals responsible for the negligent acts of their employed nurses?

Contributory negligence
Respondeat superior (Correct answer)
Res ipsa loquitur
Charitable immunity

Correct answer: Respondeat superior

Respondeat superior ('let the master answer') holds employers vicariously liable for employees' negligent acts performed within the scope of employment.

Question 163: A nurse is providing well-child teaching to parents of a 12-month-old. Which food should the nurse instruct parents to avoid until the child is at least 12 months old?

Whole cow's milk (Correct answer)
Pureed vegetables
Soft cooked pasta
Mashed bananas

Correct answer: Whole cow's milk

Whole cow's milk should not be introduced until 12 months of age because it can cause intestinal bleeding and does not provide adequate nutrition for infants.

Question 164: A nurse is caring for a client on bed rest after surgery. Which action BEST prevents venous thromboembolism (VTE)?

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

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

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

Question 165: A patient with type 2 diabetes is prescribed metformin. Which condition is an absolute contraindication to its use?

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

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

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

Question 166: A nurse working the night shift notices a pattern of medication errors occurring on the unit over the past month. What is the most appropriate action?

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

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

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

Question 167: A patient with anxiety tells the nurse, 'I feel like I'm going to die.' What is the most therapeutic response?

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

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

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

Question 168: Which teaching point is most important for a patient prescribed warfarin?

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

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

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

Question 169: A client with a new colostomy expresses embarrassment about odor. Which nurse response is MOST therapeutic?

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

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

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

Question 170: A nurse is caring for a patient with a nasogastric (NG) tube for enteral feeding. Before administering the feeding, what should the nurse verify first?

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

Correct answer: Correct tube placement

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

Question 171: A client's urine output for the past 8 hours totals 200 mL. How should the nurse document this finding?

Anuria
Polyuria
Nocturia
Oliguria (Correct answer)

Correct answer: Oliguria

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

Question 172: A client asks the nurse about sun safety to reduce skin cancer risk. Which statement by the nurse is most accurate?

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

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

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

Question 173: Which type of nursing diagnosis identifies a clinical judgment about a patient's actual health problem?

Syndrome nursing diagnosis
Wellness nursing diagnosis
Risk nursing diagnosis
Actual nursing diagnosis (Correct answer)

Correct answer: Actual nursing diagnosis

An actual nursing diagnosis describes a clinical judgment about a patient's current health condition that has been validated by defining characteristics (signs and symptoms).

Question 174: A nurse is implementing fall prevention for a patient taking multiple medications. Which medication class poses the greatest fall risk?

Benzodiazepines (Correct answer)
Proton pump inhibitors
Antibiotics
Thyroid hormones

Correct answer: Benzodiazepines

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

Question 175: A nurse is teaching a newly licensed nurse about the chain of infection. Which element, if eliminated, would most effectively prevent the spread of infection?

Reservoir
Mode of transmission (Correct answer)
Portal of entry
Susceptible host

Correct answer: Mode of transmission

Breaking the mode of transmission (e.g., hand hygiene, PPE) is the most practical and effective strategy to interrupt the chain of infection.

Question 176: A school nurse notices a 10-year-old with a BMI at the 88th percentile. Which is the most appropriate initial nursing action?

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

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

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

Question 177: Which developmental milestone is expected in a healthy 12-month-old child?

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

Correct answer: Walking with assistance or independently

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

Question 178: When using SBAR for a handoff report, what information is included in the 'Background' component?

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

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

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

Question 179: A patient with diabetes is prescribed NPH insulin and regular insulin. In which order should the nurse draw up the insulins?

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

Correct answer: Regular first, then NPH

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

Question 180: A client is admitted with a stage III pressure injury to the sacrum. Which intervention has the highest priority?

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

Correct answer: Reposition the client every 2 hours

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

Question 181: A nurse is caring for a client experiencing anticipatory grief. Which intervention is most therapeutic?

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

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

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

Question 182: A patient diagnosed with schizophrenia reports hearing voices that tell them to harm themselves. How should the nurse classify this symptom?

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

Correct answer: Command auditory hallucination

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

Question 183: Which client is at highest risk for developing pressure injuries and requires the most intensive skin assessment?

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

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

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

Question 184: A nurse is monitoring a patient who had a cardiac catheterization via the femoral artery 2 hours ago. Which finding requires immediate action?

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

Correct answer: Expanding hematoma at the femoral access site

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

Question 185: A nurse is caring for a client who had a thyroidectomy 12 hours ago. Which finding requires the most immediate intervention?

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

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

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

Question 186: What is the most important nursing consideration when applying a cold pack to a patient's injury?

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

Correct answer: Limit application to 20 minutes at a time

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

Question 187: A patient develops compartment syndrome in the left leg after a tibial fracture. Which assessment finding is most diagnostic?

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

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

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

Question 188: A nurse is preparing to delegate morning care tasks. The UAP states, 'I don't know how to do that.' What is the correct nursing action?

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

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

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

Question 189: A nurse is teaching a client about incentive spirometry after abdominal surgery. Which instruction is CORRECT?

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

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

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

Question 190: Which nursing action BEST reduces the risk of a catheter-associated urinary tract infection (CAUTI)?

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

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

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

Question 191: A nurse is performing oral care for an unconscious patient. What is the priority safety measure?

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

Correct answer: Positioning the patient on their side

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

Question 192: A nurse is assessing a client's nutritional status. Which finding is the BEST indicator of chronic protein-calorie malnutrition?

Complaint of decreased appetite for 2 days
Blood glucose of 110 mg/dL fasting
Serum albumin level of 2.8 g/dL (Correct answer)
Recent weight loss of 2 lb over 1 week

Correct answer: Serum albumin level of 2.8 g/dL

Serum albumin reflects protein stores over 2–3 weeks and a level below 3.5 g/dL indicates chronic malnutrition.

Question 193: Which compensatory mechanism occurs in a patient with metabolic acidosis?

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

Correct answer: Kussmaul respirations to blow off CO2

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

Question 194: A nurse is caring for a dying patient. The patient's family asks the nurse to 'do everything possible' despite the patient's documented wish for comfort measures only. What is the most appropriate response?

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

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

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

Question 195: A client is reporting pain rated at 8 on a 0-10 scale. After administering the prescribed analgesic, which non-pharmacological intervention would be most appropriate for the nurse to implement to provide additional comfort?

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

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

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

Question 196: A nurse is reviewing the laboratory results for a client receiving warfarin therapy. The client's International Normalized Ratio (INR) is 4.5. Which action should the nurse take first?

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

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

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

Question 197: A patient who is immobile is at risk for developing deep vein thrombosis (DVT). Which nursing intervention helps prevent this complication?

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

Correct answer: Applying sequential compression devices

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

Question 198: A client refuses a recommended blood transfusion based on religious beliefs. Which response by the nurse is most appropriate?

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

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

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

Question 199: A nurse administers an incorrect dose of medication to a patient. After assessing the patient and ensuring their immediate safety, what is the nurse's next priority action?

Document the error in the patient's chart.
Ask a colleague for advice on how to handle the situation.
Complete an incident report according to facility policy.
Notify the healthcare provider and the nurse manager. (Correct answer)

Correct answer: Notify the healthcare provider and the nurse manager.

After ensuring patient safety, the immediate priority is to communicate the error to the healthcare provider who can assess the patient and provide any necessary orders to counteract the error. The nurse manager also needs to be informed to follow organizational procedures. While documentation and completing an incident report are crucial, notification must happen first to ensure prompt medical intervention if needed.

Question 200: A client with schizophrenia tells the nurse, 'The FBI is putting thoughts in my head.' The nurse's best response is:

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

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

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

NACE I PN-RN: Foundations of Nursing Exam

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

200

Questions

240 min

Time Limit

75%

To Pass

Checking for saved progress...

Exam Rules

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