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

Question 1: Diabetes-afflicted pregnant women frequently experience issues with insulin's capacity to regulate their blood sugar levels throughout the second part of pregnancy. <br> The nurse explains to the customer why this is so:

Increased human placental lactogen levels (Correct answer)
Decreased estrogen levels
Decreased progesterone levels
Decreased glomerular filtration and increased tubular absorption

Correct answer: Increased human placental lactogen levels

During the second half of pregnancy, the placenta produces human placental lactogen (hPL), which acts as an insulin antagonist. This hormone increases maternal insulin resistance, ensuring a continuous supply of glucose to the fetus. This physiological change explains why pregnant women, especially those with diabetes, often experience issues with insulin's effectiveness and may require increased insulin dosages to maintain blood sugar control.

Question 2: A nurse is caring for a patient who experienced sexual assault. Which statement by the nurse is most therapeutic?

'Can you tell me exactly what happened so I can document it accurately?'
'Were you drinking before the assault occurred?'
'You should report this to the police right away.'
'I believe you. What happened was not your fault, and you are safe here.' (Correct answer)

Correct answer: 'I believe you. What happened was not your fault, and you are safe here.'

Validating the patient's experience, assigning no blame, and reassuring safety are foundational trauma-informed care principles for sexual assault survivors.

Question 3: Which medication classification requires the nurse to assess the patient's apical pulse for one full minute before administration?

Thiazide diuretics
Proton pump inhibitors
ACE inhibitors
Cardiac glycosides (digoxin) (Correct answer)

Correct answer: Cardiac glycosides (digoxin)

Digoxin slows conduction through the AV node; it is withheld if the apical pulse is below 60 beats per minute.

Question 4: A patient with deep partial-thickness burns to 30% TBSA is at highest risk for which complication in the first 24–48 hours?

Infection and sepsis
Hypertensive crisis
Pulmonary embolism
Hypovolemic shock (Correct answer)

Correct answer: Hypovolemic shock

Massive fluid shifts from burned tissue into interstitial spaces cause hypovolemic shock as the primary life threat in the first 24–48 hours post-burn.

Question 5: A nurse is teaching a new mother about sudden infant death syndrome (SIDS) prevention. Which instruction is correct?

Share a bed with the infant for easy nighttime feeding
Use soft bedding and pillows for comfort
Place the infant on their back on a firm, flat surface in their own sleep space (Correct answer)
Place the infant on their stomach to sleep

Correct answer: Place the infant on their back on a firm, flat surface in their own sleep space

The 'Back to Sleep' or 'Safe Sleep' campaign consistently recommends supine positioning on a firm, flat surface without soft objects to reduce SIDS risk.

Question 6: A nurse is preparing to administer digoxin. Which finding should prompt the nurse to withhold the dose and notify the provider?

Serum potassium of 3.2 mEq/L (Correct answer)
Heart rate of 58 bpm
Respiratory rate of 16 breaths/min
Blood pressure of 118/72 mmHg

Correct answer: Serum potassium of 3.2 mEq/L

Hypokalemia (K+ < 3.5 mEq/L) potentiates digoxin toxicity by increasing myocardial sensitivity to the drug.

Question 7: A nurse is assessing a patient who has been in a house fire. The patient's lips appear cherry-red. Which condition does the nurse suspect?

Carbon monoxide poisoning (Correct answer)
Thermal airway burn
Methemoglobinemia
Cyanide poisoning

Correct answer: Carbon monoxide poisoning

Cherry-red skin and mucous membranes are a classic sign of carbon monoxide poisoning because carboxyhemoglobin gives blood a bright red color.

Question 8: In order to give the preoperative medication as directed before a patient is sent to surgery, the operating room telephones the unit nurse. The patient did not sign the surgery consent, the unit nurse finds out after administering the drug. What ought the nurse to start with?

Call the OR to cancel the procedures
Notify the nursing supervisor (Correct answer)
Ask the patient to sign the consent before transport
Notify the surgeon

Correct answer: Notify the nursing supervisor

Administering a preoperative medication to a patient who has not signed the surgical consent form is a serious error, as the patient is no longer considered fully capable of giving informed consent due to the medication's effects. The nurse's first action should be to notify the nursing supervisor. The supervisor can then guide the appropriate steps, which would likely involve informing the surgeon and potentially delaying the surgery until valid consent can be obtained.

Question 9: A patient post-thyroidectomy develops tingling around the mouth and muscle cramps. The nurse should check which lab value first?

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

Correct answer: Serum calcium

Parathyroid glands may be inadvertently removed during thyroidectomy, causing hypocalcemia with characteristic perioral tingling and muscle cramps (Chvostek's and Trousseau's signs).

Question 10: A nurse is reviewing laboratory values for a client on digoxin therapy. Which finding should prompt the nurse to hold the medication and contact the provider?

Serum digoxin level of 1.0 ng/mL
Serum potassium of 3.0 mEq/L (Correct answer)
BUN of 18 mg/dL
Heart rate of 68 beats/min

Correct answer: Serum potassium of 3.0 mEq/L

Hypokalemia potentiates digoxin toxicity by competing for the same myocardial binding sites; a potassium of 3.0 mEq/L significantly increases the risk of fatal arrhythmias.

Question 11: A nurse manager is informed that a staff nurse has been witnessed accessing a patient's electronic health record without a clinical reason. The FIRST action should be:

Reassign the nurse to non-patient care duties and take no further action
Conduct a preliminary investigation and place the nurse on administrative leave pending findings (Correct answer)
Report directly to the state board of nursing before investigating
Immediately terminate the employee

Correct answer: Conduct a preliminary investigation and place the nurse on administrative leave pending findings

A fair and thorough investigation is required before disciplinary action to determine intent and gather all facts, consistent with HIPAA breach response protocols.

Question 12: A nurse is preparing to perform hand hygiene. According to the CDC, when is alcohol-based hand rub NOT appropriate?

Before donning gloves for a venipuncture
After removing gloves following routine patient care
When hands are visibly soiled or after caring for a patient with C. difficile (Correct answer)
Before and after touching a patient's environment

Correct answer: When hands are visibly soiled or after caring for a patient with C. difficile

Alcohol-based hand sanitizers are ineffective against C. difficile spores and do not remove visible soiling; soap and water must be used in these situations per CDC guidelines.

Question 13: When a patient declines medical care, this is an illustration of

common law (Correct answer)
civil law
statutory law
medical law

Correct answer: common law

Common law, also known as case law, is derived from judicial decisions and precedents rather than statutes. A patient's right to decline medical care is a fundamental legal and ethical principle that has been affirmed through numerous court cases, establishing it as a common law right based on individual autonomy and self-determination.

Question 14: Hepatitis is the patient's diagnosis upon admission to the medical facility. Which phase of pharmacokinetics is most affected by the patient's diagnosis when the healthcare professional is getting ready to administer intravenous medications?

Excretion
Metabolism (Correct answer)
Absorption
Distribution

Correct answer: Metabolism

The liver is the primary organ responsible for drug metabolism, which is the process of chemically altering drugs into metabolites for excretion or activation. In a patient with hepatitis, liver function is impaired, significantly affecting the body's ability to metabolize medications. This impairment can lead to altered drug levels, increased toxicity, or reduced therapeutic effect, especially with intravenous medications that bypass initial absorption and go directly into systemic circulation.

Question 15: Four patients' care is being planned by a healthcare professional. Which patient is in need of preventative measures for anemia the most?

The patient who has been NPO for 3 days
The patient who is a vegetarian
The patient with Jackson-Pratt drain
The patient with renal failure on hemodialysis (Correct answer)

Correct answer: The patient with renal failure on hemodialysis

Patients with renal failure on hemodialysis are at high risk for anemia due to several reasons, including decreased erythropoietin production by the kidneys, blood loss during dialysis treatments, and reduced iron absorption. Therefore, preventative measures for anemia, such as iron supplementation and erythropoietin-stimulating agents, are crucial for this patient population.

Question 16: A nurse is assessing a patient who has been receiving total parenteral nutrition (TPN) for 5 days. Which laboratory finding indicates the highest risk complication?

Sodium of 139 mEq/L
Albumin of 3.0 g/dL
Phosphorus of 1.2 mg/dL (Correct answer)
Blood glucose of 210 mg/dL

Correct answer: Phosphorus of 1.2 mg/dL

Severe hypophosphatemia in a patient receiving TPN suggests refeeding syndrome, a potentially fatal metabolic complication.

Question 17: A nurse notices a colleague appears intoxicated at work and smells of alcohol. The most appropriate action is:

Report observations to the charge nurse or supervisor immediately (Correct answer)
Cover the colleague's patients for the shift
Confront the colleague privately and ask them to go home
Document the observation and report at the end of the shift

Correct answer: Report observations to the charge nurse or supervisor immediately

Patient safety is the priority; suspected impairment must be reported to a supervisor immediately to remove the impaired nurse from patient care.

Question 18: A 3-pound infant being given adult-strength digitalis (Digoxin, Lanoxin) by a nurse in the neonatal intensive care unit (NICU). The result is irreversible brain and cardiac damage in the infant. The nurse could face charges for

assault
tort
malpractice (Correct answer)
negligence

Correct answer: malpractice

Malpractice occurs when a healthcare professional deviates from the accepted standard of care, resulting in injury or damage to a patient. In this scenario, administering an adult-strength medication to an infant, leading to severe harm, is a clear breach of the standard of care for medication administration in neonates. This action directly caused harm and constitutes malpractice.

Question 19: A nurse is preparing to administer medication through a nasogastric tube. Which action must be performed first?

Clamp the tube for 30 minutes before medication administration
Flush the tube with 60 mL of water
Verify tube placement by checking pH of aspirate and assessing tube markings (Correct answer)
Crush all medications and mix them together

Correct answer: Verify tube placement by checking pH of aspirate and assessing tube markings

Confirming NG tube placement before each use prevents inadvertent pulmonary instillation; checking aspirate pH and tube length markings are the evidence-based methods.

Question 20: A 3-year-old patient with acute otitis media is given the medication amoxicillin suspension 200 mg PO every 8 hours by the pediatrician. The youngster is 38 pounds (17.2 kg). For kids up to 40 kg, the suggested dose range is 20–40 mg/kg/day, divided into eight-hour intervals. What is the nurse's BEST course of action when following the 10 Rights of Medication Administration?

Withhold the dose because it is too low
Refuse to give because it is not the drug of choice
Administer the medication as prescribed (Correct answer)
Contact the pediatrician to clarify the dose

Correct answer: Administer the medication as prescribed

First, calculate the child's weight in kg (38 lbs / 2.2 lbs/kg = 17.2 kg). Then, calculate the recommended daily dose range: 17.2 kg * 20 mg/kg/day = 344 mg/day to 17.2 kg * 40 mg/kg/day = 688 mg/day. The prescribed dose is 200 mg every 8 hours, which totals 600 mg/day (200 mg x 3 doses). Since 600 mg/day falls within the safe range of 344-688 mg/day, the nurse should administer the medication as prescribed.

Question 21: A nurse is preparing to insert a urinary catheter in a female client. After cleansing the urethral meatus and inserting the catheter 2–3 inches, urine does not flow. What is the most likely explanation?

The catheter is kinked in the bladder
The catheter balloon is inflated too soon
The client is dehydrated with low urine output
The catheter is inserted into the vagina (Correct answer)

Correct answer: The catheter is inserted into the vagina

In female clients, the catheter can easily be inadvertently inserted into the vagina rather than the urethra, requiring removal and reinsertion with a sterile catheter.

Question 22: Which patient is at highest risk for developing a pulmonary embolism postoperatively?

A 25-year-old who had a laparoscopic appendectomy and ambulates 4 hours post-op
A 55-year-old who had an inguinal hernia repair and has mild hypertension
A 68-year-old who had a total hip replacement and remains on bed rest (Correct answer)
A 40-year-old who had a cholecystectomy and is receiving IV fluids

Correct answer: A 68-year-old who had a total hip replacement and remains on bed rest

Older age, orthopedic surgery, and immobility are all major risk factors for deep vein thrombosis and subsequent pulmonary embolism.

Question 23: The National Council of State Boards of Nursing developed and distributed the

National League for Nursing
American Medical Association
American Nurses Association (Correct answer)
National Institutes of Health

Correct answer: American Nurses Association

The National Council of State Boards of Nursing (NCSBN) is responsible for developing and administering the NCLEX examination, which is used for licensure. While the American Nurses Association (ANA) is a prominent professional organization that sets standards for nursing practice and advocates for nurses, both organizations are critical to the nursing profession, with NCSBN focusing on regulation and ANA on professional standards and advocacy.

Question 24: The nurse manager is reviewing patient satisfaction scores and notices a downward trend in communication ratings. The BEST next step is to:

Hire additional patient relations staff to manage complaints
Conduct a root-cause analysis using direct observation and staff input (Correct answer)
Post the scores on the unit bulletin board to shame staff
Threaten disciplinary action if scores do not improve next quarter

Correct answer: Conduct a root-cause analysis using direct observation and staff input

Root-cause analysis with frontline staff insight identifies specific communication breakdowns before selecting an intervention.

Question 25: Which lab value is the most sensitive early indicator of acute pancreatitis?

Elevated serum lipase (Correct answer)
Elevated serum amylase
Elevated bilirubin
Elevated ALT

Correct answer: Elevated serum lipase

Serum lipase remains elevated longer than amylase (up to 14 days vs. 2–3 days) and is more specific and sensitive for acute pancreatitis.

Question 26: A nurse notes that a patient's surgical wound has new separation with yellow drainage. What is the most appropriate nursing response?

Place the patient in reverse Trendelenburg position
Apply a sterile dressing and document the finding
Culture the wound and irrigate with hydrogen peroxide
Notify the surgeon and apply a moist sterile dressing (Correct answer)

Correct answer: Notify the surgeon and apply a moist sterile dressing

Wound dehiscence with purulent drainage suggests infection and requires immediate provider notification and appropriate wound care.

Question 27: A nurse observes that a patient with schizophrenia has been isolating themselves in their room and stopped attending group activities. This change in behavior most likely indicates:

Improvement in symptoms
A preference for solitary activities
Side effects of antipsychotic medication causing fatigue
Potential relapse or medication non-adherence (Correct answer)

Correct answer: Potential relapse or medication non-adherence

Social withdrawal and decreased participation are early warning signs of psychiatric relapse or medication non-adherence in patients with schizophrenia and require immediate assessment.

Question 28: A patient with Addison's disease is admitted with hypotension, hyponatremia, and hyperkalemia during a stressful illness. The nurse anticipates:

Fluid restriction
Administration of IV hydrocortisone (Correct answer)
Insulin and glucose infusion
Administration of aldosterone antagonists

Correct answer: Administration of IV hydrocortisone

Addisonian crisis results from adrenocortical insufficiency; IV hydrocortisone rapidly replaces both glucocorticoid and mineralocorticoid activity needed during stress.

Question 29: A nurse is caring for a patient with increased intracranial pressure (ICP). Which nursing position provides the best outcome?

Left lateral decubitus position
Head of bed elevated 30 degrees with head midline (Correct answer)
Supine with head of bed flat
Trendelenburg position

Correct answer: Head of bed elevated 30 degrees with head midline

Elevating the HOB 30 degrees and keeping the head midline promotes venous drainage from the skull, reducing ICP.

Question 30: In which situation should a nurse use soap and water for hand hygiene instead of an alcohol-based hand rub?

After removing gloves following standard care
Before performing a sterile procedure
Before touching a patient
After caring for a patient with Clostridioides difficile (Correct answer)

Correct answer: After caring for a patient with Clostridioides difficile

Alcohol is ineffective against C. difficile spores; the mechanical friction of soap and water is required to physically remove spores from the hands.

Question 31: A unit-based quality improvement team identifies a high rate of catheter-associated urinary tract infections (CAUTIs). Which tool would BEST help map the steps in the current catheter care process?

Fishbone (Ishikawa) diagram
Pareto chart
Control chart
Flowchart (Correct answer)

Correct answer: Flowchart

A flowchart visually maps each step in a process, making it easy to identify where breakdowns or variation occur.

Question 32: Which of the following would a healthcare professional anticipate when analyzing the arterial blood gases (ABGs) of a patient with a 20-year history of chronic bronchitis?

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

Correct answer: Respiratory acidosis, compensated

Chronic bronchitis leads to impaired gas exchange in the lungs, causing the body to retain carbon dioxide (CO2). This CO2 retention results in an elevated PaCO2 and a decreased pH, indicating respiratory acidosis. Over a 20-year history, the kidneys would have compensated by retaining bicarbonate (HCO3-), bringing the pH back towards a normal range, thus classifying it as compensated respiratory acidosis.

Question 33: The nurse brings an Orthodox Jewish customer a dinner tray. A cheeseburger with lettuce and tomato, French fries, a fruit salad, and a vanilla milkshake are all included on the tray. Which of the nurse's actions is BEST?

Replace the cheeseburger with shrimp
Trade the milkshake for soft drink
Remove the tray and order a new meal (Correct answer)
Deliver the food tray to the client

Correct answer: Remove the tray and order a new meal

Orthodox Jewish dietary laws (Kosher) strictly prohibit the consumption of meat and dairy products together in the same meal. A cheeseburger (meat and dairy) and a vanilla milkshake (dairy) violate these laws. Therefore, the nurse must remove the entire tray and order a new meal that adheres to the client's religious dietary restrictions to ensure cultural and religious sensitivity.

Question 34: A patient on warfarin has an INR of 5.8. Which intervention is most appropriate?

Increase the warfarin dose
Administer heparin as a bridge
Apply a warm compress to bleeding sites
Administer vitamin K as ordered (Correct answer)

Correct answer: Administer vitamin K as ordered

An INR of 5.8 is supratherapeutic, indicating excessive anticoagulation; vitamin K reverses warfarin's effect.

Question 35: A new patient can't take care of their oral hygiene. What guidance should the nurse provide the nurse's assistant out of the following list?

"Rinse the patient's mouth with mouthwash a few times during your shift."
"Use a soft foam applicator to swab the tongue, gums, and lips every 2 hours."
"Check the entire mouth each time oral hygiene is done and document your observations."
"Use a soft toothbrush to brush the patient's teeth after every meal." (Correct answer)

Correct answer: "Use a soft toothbrush to brush the patient's teeth after every meal."

For a patient unable to perform their own oral hygiene, regular and thorough cleaning is essential to prevent plaque buildup, cavities, and gum disease. Using a soft toothbrush after every meal effectively removes food particles and bacteria from the teeth and gums. This method provides more comprehensive cleaning than just rinsing or swabbing, promoting better oral health.

Question 36: A school nurse is teaching adolescents about skin cancer prevention. Which statement is most important?

Skin cancer only affects older adults
Apply broad-spectrum SPF 30+ sunscreen and reapply every 2 hours during outdoor exposure (Correct answer)
A base tan provides adequate sun protection
Tanning beds are safer than outdoor sun exposure

Correct answer: Apply broad-spectrum SPF 30+ sunscreen and reapply every 2 hours during outdoor exposure

Broad-spectrum SPF 30+ sunscreen applied and reapplied every 2 hours provides proven protection against UVA and UVB radiation, which cause skin cancer.

Question 37: A patient with post-traumatic stress disorder (PTSD) is startled by a loud noise and begins hyperventilating. The nurse's priority intervention is:

Administer a PRN anxiolytic immediately
Use a calm voice to ground the patient using sensory-based techniques (Correct answer)
Leave the patient alone to self-regulate
Restrain the patient for safety

Correct answer: Use a calm voice to ground the patient using sensory-based techniques

Grounding techniques (e.g., 5-4-3-2-1 sensory method) delivered calmly help anchor a patient experiencing a PTSD flashback or hyperarousal response to the present moment.

Question 38: When performing a focused assessment on a patient with suspected deep vein thrombosis (DVT), which finding is most significant?

Generalized leg fatigue after ambulation
Intermittent bilateral calf cramping at night
Unilateral calf warmth, redness, and tenderness (Correct answer)
Bilateral lower extremity edema

Correct answer: Unilateral calf warmth, redness, and tenderness

Unilateral calf warmth, redness, and tenderness are classic signs of DVT, distinguishing it from bilateral or systemic causes.

Question 39: Which patient teaching point is the priority for a patient newly prescribed lithium carbonate?

Limit fluid intake to 1 liter per day
Avoid foods high in vitamin K
Maintain consistent dietary sodium intake (Correct answer)
Take the medication on an empty stomach only

Correct answer: Maintain consistent dietary sodium intake

Fluctuations in sodium intake alter lithium renal excretion; low sodium causes lithium retention and increases toxicity risk.

Question 40: A patient presents with Kussmaul respirations, fruity breath odor, and blood glucose of 520 mg/dL. Which condition does the nurse suspect?

Respiratory alkalosis
Hypoglycemia
Diabetic ketoacidosis (DKA) (Correct answer)
Hyperosmolar hyperglycemic state

Correct answer: Diabetic ketoacidosis (DKA)

DKA presents with Kussmaul respirations (deep, rapid breathing to compensate for metabolic acidosis), fruity breath from ketones, and markedly elevated blood glucose.

Question 41: Which of the following assessment results is in line with a volume deficit of extracellular fluid?

Bradycardia
Hypertension
Oliguria (Correct answer)
Hyperglycemia

Correct answer: Oliguria

Extracellular fluid volume deficit, or hypovolemia, signifies a reduction in the body's circulating fluid volume. The kidneys respond to this decreased volume by conserving water, leading to reduced urine output, known as oliguria. Other common signs of fluid volume deficit include tachycardia, hypotension, and dry mucous membranes, not bradycardia or hypertension.

Question 42: A charge nurse is preparing the staffing plan for the evening shift and must prioritize which patients require RN-level care. This decision is based on which principle?

Scope of practice and patient acuity (Correct answer)
Seniority of available nursing staff
Patient preference for nurse assignment
Physician recommendation for staffing

Correct answer: Scope of practice and patient acuity

RN-level task assignment is determined by scope of practice and the clinical complexity of individual patients, ensuring safe and appropriate care.

Question 43: Which action by a nursing student during perineal care of a female client requires correction?

Cleaning from the urethral meatus toward the anus
Using a clean section of cloth for each stroke
Using warm water and mild soap
Cleaning from the anus toward the urethral meatus (Correct answer)

Correct answer: Cleaning from the anus toward the urethral meatus

Cleaning from the anus toward the urethra introduces fecal bacteria to the urinary meatus, increasing urinary tract infection risk.

Question 44: A nurse manager identifies that incident report filings have dropped significantly over the past month. This most likely indicates:

Improved patient safety outcomes
Fewer patient admissions
Better staff competency
Under-reporting of adverse events (Correct answer)

Correct answer: Under-reporting of adverse events

A sudden drop in incident reports typically signals a culture of fear or under-reporting, not a genuine safety improvement.

Question 45: A nurse is reviewing a medication order that reads 'morphine sulfate 4 mg IV q4h PRN pain.' The nurse should clarify which missing element?

Frequency of administration
Pain scale threshold or indication for use (Correct answer)
Route of administration
Name of the prescribing provider

Correct answer: Pain scale threshold or indication for use

A complete PRN order requires a specific indication or pain threshold (e.g., 'for pain >5/10') to guide administration.

Question 46: Which laboratory value should the nurse report immediately to the provider before administering digoxin?

Magnesium 1.8 mg/dL
Potassium 2.8 mEq/L (Correct answer)
Calcium 9.2 mg/dL
Sodium 138 mEq/L

Correct answer: Potassium 2.8 mEq/L

Hypokalemia (potassium < 3.5 mEq/L) increases the risk of digoxin toxicity and must be reported before administration.

Question 47: A nurse observes a colleague leaving a contact isolation room while still wearing their isolation gown. What is the most appropriate immediate action?

Inform the colleague of the breach and have them remove the gown (Correct answer)
Report the incident to the charge nurse immediately
Document the observation in the patient's medical record
Notify the infection control department in writing

Correct answer: Inform the colleague of the breach and have them remove the gown

The immediate priority is to stop the ongoing breach by informing the colleague to remove the gown before contamination spreads further into the unit.

Question 48: A nurse is teaching a patient with type 2 diabetes about foot care. Which instruction is most important?

Inspect feet daily and wear well-fitted shoes (Correct answer)
Walk barefoot indoors to toughen the skin
Use a heating pad for foot pain relief
Soak feet in hot water for 30 minutes each day

Correct answer: Inspect feet daily and wear well-fitted shoes

Daily foot inspection and proper footwear prevent undetected injuries and pressure ulcers that can progress to serious infection or amputation in diabetic patients.

Question 49: A nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about energy conservation. Which technique is most appropriate?

Use pursed-lip breathing during exertion and schedule rest periods (Correct answer)
Breathe rapidly through the mouth during activity
Avoid all physical activity to prevent dyspnea
Perform all activities quickly to get them done

Correct answer: Use pursed-lip breathing during exertion and schedule rest periods

Pursed-lip breathing slows respiration, reduces air trapping, and improves oxygenation; rest periods prevent excessive energy expenditure in COPD patients.

Question 50: Which intervention is the nurse's priority when caring for a patient in skeletal traction?

Applying sequential compression devices
Assessing pin sites for signs of infection (Correct answer)
Encouraging ambulation every 2 hours
Providing high-fiber diet education

Correct answer: Assessing pin sites for signs of infection

Pin site infection is a serious complication of skeletal traction and requires routine assessment to detect early signs.

Question 51: A nurse is caring for a client who uses a cane. Which instruction is correct for descending stairs with a cane?

Lead with the weaker leg, then the cane, then the stronger leg
Lead with the cane, then the weaker leg, then the stronger leg (Correct answer)
Lead with the stronger leg only, keeping the cane stationary
Lead with the stronger leg, then bring the cane and weaker leg down

Correct answer: Lead with the cane, then the weaker leg, then the stronger leg

When descending, the cane and weaker leg go first so the stronger leg bears weight while the client lowers the affected side safely.

Question 52: A nurse receives a verbal telephone order from a physician. Which action best ensures patient safety?

Write the order directly in the chart without repeating it
Implement the order immediately and verify later
Read the order back to the physician to confirm accuracy before ending the call (Correct answer)
Ask the physician to text the order

Correct answer: Read the order back to the physician to confirm accuracy before ending the call

Reading back verbal or telephone orders and receiving confirmation from the prescriber is the Joint Commission-required 'read-back' safety standard to prevent medication errors.

Question 53: A nurse is caring for a patient with borderline personality disorder who says, 'You are the best nurse here — all the others are terrible.' The nurse recognizes this as:

Splitting (Correct answer)
Reaction formation
Transference
Projection

Correct answer: Splitting

Splitting is a defense mechanism characteristic of borderline personality disorder in which people are seen as all good or all bad, with no middle ground.

Question 54: A nurse is performing range-of-motion exercises on a client's shoulder. The client grimaces when the arm is abducted. What should the nurse do?

Administer the scheduled analgesic and resume exercises immediately
Apply more force to complete the full range of motion
Continue the exercise as long as the client does not verbally report pain
Stop the exercise, assess the client's pain level, and document the finding (Correct answer)

Correct answer: Stop the exercise, assess the client's pain level, and document the finding

Non-verbal pain cues such as grimacing indicate the client is experiencing pain and the nurse must stop, assess, and document before proceeding.

Question 55: Which of the following best exemplifies the 'just culture' model in nursing management?

Publicly reporting all staff errors to maintain transparency
Disciplining any nurse who makes a medication error regardless of context
Distinguishing between human error, at-risk behavior, and reckless behavior when responding to mistakes (Correct answer)
Exempting senior nurses from disciplinary review when errors occur

Correct answer: Distinguishing between human error, at-risk behavior, and reckless behavior when responding to mistakes

Just culture differentiates unintentional errors (system fixes), risky behaviors (coaching), and reckless actions (accountability) to promote safety reporting.

Question 56: A nurse is inserting a nasogastric tube. After placement, which method best confirms correct placement before beginning a feeding?

Aspirating stomach contents and testing pH (Correct answer)
Measuring the external length of the tube
Observing for respiratory distress
Instilling air and auscultating over the stomach

Correct answer: Aspirating stomach contents and testing pH

Aspirating gastric contents and testing the pH (≤5.5 confirms gastric placement) is the most reliable bedside method before a chest X-ray.

Question 57: A nurse is about to enter a room under airborne precautions. Which room characteristic must be confirmed before entering?

Standard ventilation with door kept closed
Negative pressure with at least 12 air changes per hour (Correct answer)
Positive pressure ventilation
HEPA filtration without pressure differential

Correct answer: Negative pressure with at least 12 air changes per hour

Airborne precaution rooms require negative pressure with ≥12 air changes per hour to direct contaminated air inward and prevent its escape to hallways.

Question 58: An evaluation of a patient who underwent extensive abdominal surgery five days ago is being done by the nurse. When the client coughed, the client claimed to feel a "pop where my operation was." The nurse examines the area and observes that the borders of the wound have split at the point of the incision. What should the nurse start by doing?

Administer a cough suppressant medication STAT.
Notify the health care provider (HCP). (Correct answer)
Stress the importance of splinting when coughing.
Apply an antibiotic ointment and sterile dressing.

Correct answer: Notify the health care provider (HCP).

The patient's description of a 'pop' and the observation of wound dehiscence (separation of wound edges) after extensive abdominal surgery is a serious complication. The nurse's initial action must be to notify the healthcare provider (HCP) immediately, as this condition requires prompt medical evaluation and potential surgical intervention. While supporting the wound and applying a sterile dressing are important, medical notification is the priority.

Question 59: A nurse is caring for a client in active labor whose fetal heart rate (FHR) shows late decelerations with each contraction. What is the priority nursing action?

Prepare for immediate cesarean delivery
Document findings and reassess in 15 minutes
Increase the rate of the oxytocin infusion
Reposition the client to her left side (Correct answer)

Correct answer: Reposition the client to her left side

Repositioning to the left lateral position relieves aortocaval compression, improving uteroplacental blood flow and is the first nursing action for late decelerations.

Question 60: A nurse is caring for a postoperative patient and notes the Jackson-Pratt drain output has suddenly decreased and the site is swelling. What should the nurse do first?

Notify the surgeon immediately
Check that the drain bulb is compressed correctly (Correct answer)
Apply a pressure dressing over the site
Increase the patient's IV fluid rate

Correct answer: Check that the drain bulb is compressed correctly

A sudden decrease in drain output with site swelling often indicates the bulb is not properly compressed, preventing suction; re-establishing suction resolves the issue.

Question 61: Which route of medication administration has the fastest onset of action?

Intravenous (Correct answer)
Intramuscular
Sublingual
Transdermal

Correct answer: Intravenous

Intravenous administration delivers medication directly into the bloodstream, providing the fastest onset.

Question 62: A patient is admitted with a Clostridium difficile (C. diff) infection. Which precautions should be initiated in addition to standard precautions?

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

Correct answer: Contact precautions

C. difficile spreads via the fecal-oral route through contact with spore-contaminated surfaces or hands, requiring contact precautions.

Question 63: The nurse is authorized to provide phenergan (Promethazine) 25mg and valium (Diazepam) 10mg prior to surgery. The appropriate way to give these drugs is to:

Administer the medication separately (Correct answer)
Administer the Valium, wait 5 minutes, and then inject the Phenergan
Question the order because they cannot be given at the same time
Administer the medications together in one syringe

Correct answer: Administer the medication separately

Phenergan (promethazine) and Valium (diazepam) are incompatible when mixed in the same syringe and can cause precipitation. Administering them separately ensures that each medication maintains its integrity and effectiveness, preventing adverse reactions or reduced therapeutic effect. Always check compatibility before mixing medications to ensure patient safety.

Question 64: For several days, your home health patient has been throwing up. She is currently resting in bed when you arrive. Her eyes are lifeless, and she is pale and listless. She is concerned as well. What is the most likely scenario?

Fecal impaction
Congestive heart failure
Multiple sclerosis
Hypovolemic shock (Correct answer)

Correct answer: Hypovolemic shock

The patient's symptoms of prolonged vomiting, paleness, listlessness, lifeless eyes, and concern strongly suggest significant fluid and electrolyte loss. These are classic signs of hypovolemia, which, if severe enough, can lead to hypovolemic shock due to inadequate tissue perfusion. The body is struggling to maintain circulation due to severe fluid depletion.

Question 65: In Maslow's hierarchy of needs applied to staff management, which action addresses esteem needs?

Ensuring adequate break times and restroom access
Providing a safe working environment free from hazards
Assigning staff to committees where their expertise is publicly recognized (Correct answer)
Fostering friendships through team-building social events

Correct answer: Assigning staff to committees where their expertise is publicly recognized

Esteem needs include recognition and respect; committee roles where staff expertise is valued directly meet this need.

Question 66: A patient receiving a unit of packed red blood cells develops fever, chills, and back pain 15 minutes into the transfusion. The nurse's priority action is:

Slow the infusion rate and administer diphenhydramine
Complete the transfusion quickly before symptoms worsen
Administer acetaminophen and continue monitoring
Stop the transfusion, keep the IV line open with normal saline, and notify the physician and blood bank immediately (Correct answer)

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

Fever, chills, and back pain during transfusion are classic signs of an acute hemolytic reaction; the transfusion must be stopped immediately to prevent renal failure and death.

Question 67: The lab and blood bank need a sample of the patient's blood before the patient can receive a transfusion of whole blood. What tests will be conducted?

Blood type and crossmatch (Correct answer)
Blood culture and sensitivity analysis
Blood type and antigen screen
Complete blood count (CBC) and differential

Correct answer: Blood type and crossmatch

Before any blood transfusion, it is absolutely essential to perform a blood type (ABO and Rh factor) and crossmatch. This ensures that the donor blood is compatible with the recipient's blood, preventing potentially life-threatening transfusion reactions caused by antigen-antibody incompatibilities.

Question 68: A client with Addison's disease is admitted in adrenal crisis. Which IV fluid and medication does the nurse anticipate administering?

0.45% NaCl and fludrocortisone
0.9% NaCl and hydrocortisone (Correct answer)
Lactated Ringer's and vasopressin
D5W and insulin

Correct answer: 0.9% NaCl and hydrocortisone

Adrenal crisis is treated with isotonic saline to correct hypotension and dehydration, plus hydrocortisone to replace deficient glucocorticoids.

Question 69: A unit's medication error rate has increased over three consecutive months. Using the Plan-Do-Study-Act (PDSA) cycle, what is the FIRST step the nurse manager should take?

Implement a mandatory double-check policy immediately
Report the trend to the Joint Commission
Analyze root causes and plan a targeted intervention (Correct answer)
Suspend staff pending investigation

Correct answer: Analyze root causes and plan a targeted intervention

The 'Plan' phase of PDSA begins with identifying root causes and designing a specific, testable intervention before acting.

Question 70: A patient in restraints must be reassessed at minimum every:

15 minutes for behavioral restraints (Correct answer)
8 hours for non-violent restraints
4 hours for all types of restraints
2 hours for all types of restraints

Correct answer: 15 minutes for behavioral restraints

CMS and Joint Commission require that patients in behavioral (violent) restraints be assessed every 15 minutes, while non-violent restraints require reassessment every 2 hours.

Question 71: During a sterile dressing change, which action would break sterile technique?

Opening sterile packages away from the sterile field
Using sterile gloves to handle sterile supplies
Reaching over the sterile field to arrange supplies (Correct answer)
Maintaining sterile items above waist level

Correct answer: Reaching over the sterile field to arrange supplies

Reaching over a sterile field contaminates it because unsterile clothing or arms pass directly above the field, allowing microorganism fallout.

Question 72: A patient with COPD is receiving oxygen therapy. The nurse notes the respiratory rate has dropped to 8 breaths/min. What is the most likely explanation?

The patient's condition has improved significantly
The patient is experiencing pulmonary hypertension
Low-flow oxygen caused carbon dioxide retention
High-flow oxygen suppressed the hypoxic drive (Correct answer)

Correct answer: High-flow oxygen suppressed the hypoxic drive

Patients with COPD may rely on hypoxic drive for ventilation; high-flow oxygen can suppress this drive and cause respiratory depression.

Question 73: A nurse is conducting a well-child visit for a 2-month-old. Which vaccines are due at this visit?

DTaP, IPV, Hib, PCV13, rotavirus, hepatitis B (Correct answer)
HPV and Tdap
Influenza and meningococcal only
MMR, varicella, hepatitis A

Correct answer: DTaP, IPV, Hib, PCV13, rotavirus, hepatitis B

The 2-month immunization schedule includes DTaP, IPV, Hib, PCV13, rotavirus, and hepatitis B as the standard CDC-recommended vaccines.

Question 74: A patient with dementia is repeatedly trying to get out of bed and is at high fall risk. The nurse's least restrictive initial intervention is:

Apply physical wrist restraints
Move the patient close to the nurses' station and use bed alarms (Correct answer)
Administer a sedative medication
Raise all four side rails

Correct answer: Move the patient close to the nurses' station and use bed alarms

The least-restrictive approach—proximity to staff and bed alarms—allows observation and rapid response without restraints, which can increase agitation and injury in patients with dementia.

Question 75: Which teaching is most important for a patient prescribed warfarin for atrial fibrillation?

Avoid all physical activity to prevent bleeding
Take double the dose if a dose is missed
Maintain a consistent intake of vitamin K-containing foods and report unusual bleeding (Correct answer)
Avoid all NSAIDs and monitor INR as scheduled

Correct answer: Maintain a consistent intake of vitamin K-containing foods and report unusual bleeding

Consistent vitamin K intake prevents INR fluctuations, and reporting unusual bleeding ensures early detection of hemorrhagic complications from warfarin therapy.

Question 76: A 16-year-old patient is seeking treatment for a sexually transmitted infection and asks the nurse to keep the visit confidential from their parents. The nurse should:

Inform the parents, as the patient is a minor
Provide treatment; minors may consent to STI treatment in most US states (Correct answer)
Refuse to treat the patient without parental consent
Ask the patient to bring a parent before discussing treatment

Correct answer: Provide treatment; minors may consent to STI treatment in most US states

Most US states grant minors the right to consent to diagnosis and treatment of STIs without parental notification to encourage treatment-seeking behavior.

Question 77: A patient in the ICU is found to be colonized with vancomycin-resistant Enterococcus (VRE). Which precautions should be implemented?

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

Correct answer: Contact precautions

VRE is transmitted through direct or indirect contact with contaminated hands or surfaces, requiring contact precautions including gown and gloves for all patient interactions.

Question 78: A nurse is assessing a 6-month-old during a well-baby visit. Which developmental milestone should the infant have achieved?

Using two-word phrases
Pincer grasp and pulling to stand
Sitting with support and rolling over (Correct answer)
Walking with support

Correct answer: Sitting with support and rolling over

By 6 months, infants typically sit with support, roll from front to back and back to front, babble, and reach for objects.

Question 79: A nurse is teaching a 52-year-old woman about breast cancer screening. According to the American Cancer Society, mammograms should begin at what age for average-risk women?

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

Correct answer: 45 years

The American Cancer Society recommends that average-risk women begin annual mammography at age 45, with the option to start at 40.

Question 80: Which assessment finding indicates successful treatment of fluid volume deficit in a dehydrated patient?

Heart rate of 110 bpm
Blood pressure of 110/70 mmHg with moist mucous membranes (Correct answer)
Urine specific gravity of 1.030
Urine output of 15 mL/hour

Correct answer: Blood pressure of 110/70 mmHg with moist mucous membranes

Adequate blood pressure with moist mucous membranes indicates restored fluid volume, whereas low urine output, tachycardia, and high specific gravity suggest ongoing deficit.

Question 81: A nurse is caring for a client prescribed complete bed rest. Which intervention is most important to include in the plan of care to prevent complications?

Keep the head of the bed flat at all times
Restrict fluid intake to reduce the risk of urinary tract infection
Limit visitors to reduce the client's activity
Encourage the client to perform isometric and active range-of-motion exercises (Correct answer)

Correct answer: Encourage the client to perform isometric and active range-of-motion exercises

Isometric and range-of-motion exercises maintain muscle strength, joint mobility, and venous return, preventing the primary complications of immobility.

Question 82: A nurse is helping a client with chronic obstructive pulmonary disease (COPD) choose foods from the menu. Which option best reduces the work of breathing during meals?

Two large, high-protein meals per day
Three large meals with high carbohydrate content
Liquid nutritional supplements only
Five to six small, low-carbohydrate meals (Correct answer)

Correct answer: Five to six small, low-carbohydrate meals

Small frequent meals reduce diaphragm elevation from a full stomach, and low-carbohydrate foods produce less CO₂ during metabolism, reducing respiratory demand in COPD.

Question 83: On your floor is a 50-year-old patient who is blind and deaf. What is your primary duty to this patient as the charge nurse?

Let others know about the patient's deficits.
Continually update the patient on the social environment.
Communicate with your supervisor about your patient safety concerns.
Provide a secure environment for the patient. (Correct answer)

Correct answer: Provide a secure environment for the patient.

For a patient who is both blind and deaf, their ability to perceive and react to their surroundings is severely compromised, making them highly vulnerable to injury. Therefore, the primary duty of the charge nurse is to ensure a secure and safe environment to prevent falls, accidents, and disorientation. While communication and informing others are important, physical safety takes precedence.

Question 84: A nurse is preparing to hang a peripheral IV solution of dextrose 10% in water (D10W). This solution is classified as:

Colloid
Hypotonic
Hypertonic (Correct answer)
Isotonic

Correct answer: Hypertonic

D10W has an osmolarity of approximately 505 mOsm/L, making it hypertonic compared to plasma.

Question 85: When using motivational interviewing to help a patient with alcohol use disorder, which statement best reflects the technique?

'I'll schedule you for an AA meeting tomorrow.'
'You need to stop drinking before it kills you.'
'Your family is very worried about your drinking.'
'What would your life look like if you reduced your alcohol use?' (Correct answer)

Correct answer: 'What would your life look like if you reduced your alcohol use?'

Motivational interviewing uses open-ended questions to help patients explore their own motivation for change, evoking internal ambivalence rather than imposing external pressure.

Question 86: Which assessment finding in a post-thyroidectomy patient requires the nurse to immediately notify the provider?

Mild sore throat and difficulty swallowing
Temperature of 37.8°C (100°F)
Pain rating of 4/10 at the incision site
Positive Chvostek's sign (Correct answer)

Correct answer: Positive Chvostek's sign

A positive Chvostek's sign indicates hypocalcemia from inadvertent parathyroid gland damage, which can lead to life-threatening tetany.

Question 87: The nurse can request that unlicensed assistive personnel (UAP) perform ALL of the following EXCEPT

report signs of skin breakdown
measure intake and output
assist a patient who is chocking
provide patient and family education (Correct answer)

Correct answer: provide patient and family education

Unlicensed assistive personnel (UAP) can perform tasks that are within their scope of practice and do not require nursing judgment, assessment, or teaching. Providing patient and family education requires professional nursing knowledge, assessment of learning needs, and the ability to evaluate understanding, which falls outside the UAP's scope of practice.

Question 88: A patient receiving vancomycin develops flushing and erythema of the face and neck during infusion. The nurse should:

Document as a normal finding and continue
Administer epinephrine immediately
Slow the infusion rate and notify the provider (Correct answer)
Discontinue vancomycin permanently

Correct answer: Slow the infusion rate and notify the provider

Red man syndrome from vancomycin is managed by slowing the infusion rate; it is not a true allergic reaction.

Question 89: A nurse is teaching a 55-year-old male patient about colorectal cancer screening. Which is the recommended screening for an average-risk adult?

Stool DNA test every 3 years starting at age 65
Annual digital rectal exam only
Colonoscopy every 10 years starting at age 45 (Correct answer)
Sigmoidoscopy every 5 years starting at age 60

Correct answer: Colonoscopy every 10 years starting at age 45

The American Cancer Society recommends colorectal cancer screening beginning at age 45 for average-risk adults; colonoscopy every 10 years is a standard option.

Question 90: A patient's serum sodium level is 122 mEq/L. Which clinical finding does the nurse anticipate?

Extreme thirst and dry mucous membranes
Seizures and altered mental status (Correct answer)
Peaked T-waves on ECG
Hypertension and bradycardia

Correct answer: Seizures and altered mental status

Severe hyponatremia causes cerebral edema, manifesting as neurological symptoms including confusion, seizures, and decreased level of consciousness.

Question 91: A nurse is teaching a client newly prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

I will use a soft toothbrush to prevent bleeding gums.
I can take ibuprofen for my arthritis pain. (Correct answer)
I will have my INR checked regularly.
I will avoid large amounts of leafy green vegetables.

Correct answer: I can take ibuprofen for my arthritis pain.

NSAIDs like ibuprofen increase bleeding risk when combined with warfarin and should be avoided; acetaminophen is the safer analgesic choice.

Question 92: A patient is in an awkward position in her bed when the nurse enters the room to inject insulin. What should the nurse start by doing?

Check the patient's ID band
Verify the patient's name
Reposition the patient (Correct answer)
Administer the insulin

Correct answer: Reposition the patient

Before administering any medication, especially an injection, patient safety and comfort are paramount. If the patient is in an awkward position, the nurse should first reposition them to ensure proper body alignment, comfort, and accessibility to the injection site. This step helps prevent injury to both the patient and the nurse during the procedure.

Question 93: A patient prescribed a fentanyl transdermal patch needs to be educated that the patch should be:

Placed over a bony prominence for best absorption
Placed on non-irritated, non-hairy skin and changed every 72 hours (Correct answer)
Heated with a warm blanket to increase absorption
Changed every 24 hours to a new site

Correct answer: Placed on non-irritated, non-hairy skin and changed every 72 hours

Fentanyl patches are applied to intact, non-hairy skin and replaced every 72 hours; heat increases absorption dangerously.

Question 94: Which patient has the highest risk for developing a healthcare-associated infection (HAI)?

A 45-year-old receiving IV antibiotics for community-acquired pneumonia
A 25-year-old admitted for an appendectomy with no comorbidities
A 55-year-old post-operative patient ambulating independently on day 1
A 70-year-old diabetic patient with an indwelling urinary catheter (Correct answer)

Correct answer: A 70-year-old diabetic patient with an indwelling urinary catheter

The elderly diabetic patient with an indwelling catheter has multiple compounding HAI risk factors: advanced age, diabetes-related immunosuppression, and an invasive device.

Question 95: What would a nurse look for when evaluating a child's progress over the school years?

Decreasing amounts of body fat and muscle mass
Little change in body appearance from year to year
Yearly weight gain of about 5.5 pounds per year (Correct answer)
Progressive height increase of 4 inches each year

Correct answer: Yearly weight gain of about 5.5 pounds per year

School-aged children (6-12 years) typically experience a steady, moderate growth rate. A weight gain of approximately 5.5 pounds (2.5 kg) per year is considered a normal and healthy indicator of progress during these years. This consistent growth reflects adequate nutrition and development, unlike the other options which describe abnormal or inconsistent growth patterns.

Question 96: Which teaching should the nurse provide to a patient who is immunocompromised regarding infection prevention?

Avoid fresh fruits and vegetables entirely
Stop all prescribed medications during illness
Wear a mask only in hospitals
Practice hand hygiene frequently, avoid crowds, and report fever above 100.4°F (38°C) immediately (Correct answer)

Correct answer: Practice hand hygiene frequently, avoid crowds, and report fever above 100.4°F (38°C) immediately

Frequent hand hygiene, crowd avoidance, and prompt reporting of fever are the cornerstone protective behaviors for immunocompromised patients to prevent life-threatening infections.

Question 97: What types of personal medical data are covered by the HIPAA Privacy Rule?

Verbal
All of the above (Correct answer)
Electronic
Written

Correct answer: All of the above

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule protects all individually identifiable health information, regardless of the format in which it is created, received, or maintained. This includes information communicated verbally (e.g., conversations), electronically (e.g., electronic health records), and in written form (e.g., paper charts, faxes). Therefore, all types of personal medical data are covered.

Question 98: Which intervention is most effective in preventing catheter-associated urinary tract infections (CAUTI)?

Using the largest appropriate catheter to ensure complete bladder drainage
Changing the indwelling catheter every 48 hours
Removing the urinary catheter as soon as it is no longer clinically indicated (Correct answer)
Irrigating the catheter with normal saline daily

Correct answer: Removing the urinary catheter as soon as it is no longer clinically indicated

Early catheter removal when no longer needed is the most effective CAUTI prevention strategy, as infection risk increases with each additional day of catheterization.

Question 99: Which intervention is most effective in preventing catheter-associated urinary tract infections (CAUTI)?

Irrigating the catheter with antibiotic solution daily
Maintaining a closed urinary drainage system (Correct answer)
Changing the catheter every 72 hours
Administering prophylactic antibiotics while catheterized

Correct answer: Maintaining a closed urinary drainage system

Maintaining a sterile, closed drainage system is the single most effective intervention to prevent CAUTI by preventing bacterial entry.

Question 100: A nurse is counseling a patient who smokes about cessation. Which approach is most evidence-based?

Telling the patient to quit 'cold turkey' without medication
Prescribing bupropion without counseling
Recommending a combination of NRT and behavioral counseling (Correct answer)
Advising the patient to switch to e-cigarettes

Correct answer: Recommending a combination of NRT and behavioral counseling

Evidence consistently shows that combining pharmacotherapy (such as NRT, varenicline, or bupropion) with behavioral counseling yields the highest smoking cessation success rates.

Question 101: The doctor prescribes Zofran 8 mg PO once daily. A 100 mL bottle with the label "4 mg/tsp" is sent by the pharmacy. How many milliliters should each dose contain?

8 mL
10 mL (Correct answer)
2 mL
5 mL

Correct answer: 10 mL

To calculate the correct dose, first determine the concentration in mg/mL. Since 1 tsp equals 5 mL, the concentration is 4 mg/5 mL. The doctor prescribed 8 mg. To find the volume, set up a proportion: (4 mg / 5 mL) = (8 mg / X mL). Solving for X, (8 mg * 5 mL) / 4 mg = 10 mL. Therefore, each dose should contain 10 mL.

Question 102: A nurse is applying antiembolism stockings (TEDs) to a client. Which action is correct?

Apply stockings in the morning before the client gets out of bed (Correct answer)
Apply stockings only to the leg without an IV line
Apply stockings after the client has been up ambulating for 30 minutes
Apply stockings while the client is standing at the bedside

Correct answer: Apply stockings in the morning before the client gets out of bed

Antiembolism stockings should be applied before the client gets out of bed to prevent venous pooling that occurs with dependency, maximizing their effectiveness.

Question 103: A sentinel event occurs on the unit. After immediate patient stabilization, which process does The Joint Commission require the organization to undertake?

A root cause analysis (RCA) to identify system-level contributing factors (Correct answer)
Termination of the nurse directly involved
Immediate public disclosure to all patients on the unit
A peer review by the state nursing board

Correct answer: A root cause analysis (RCA) to identify system-level contributing factors

TJC mandates a root cause analysis following sentinel events to identify systemic failures and implement corrective actions to prevent recurrence.

Question 104: A nurse is caring for a patient receiving IV aminophylline. Which finding indicates toxicity?

Bradycardia and hypotension
Constipation and urinary retention
Peripheral edema and weight gain
Tachycardia, tremors, and seizures (Correct answer)

Correct answer: Tachycardia, tremors, and seizures

Aminophylline (theophylline) toxicity manifests as tachycardia, tremors, seizures, and arrhythmias.

Question 105: A patient receiving broad-spectrum antibiotics develops profuse watery diarrhea and tests positive for Clostridioides difficile toxin. Which treatment is most appropriate?

IV ceftriaxone
IV amoxicillin-clavulanate
Ciprofloxacin orally
Oral vancomycin or oral fidaxomicin (Correct answer)

Correct answer: Oral vancomycin or oral fidaxomicin

Oral vancomycin or fidaxomicin (for mild-to-moderate disease, oral metronidazole is an alternative) are first-line treatments for C. difficile infection; broad-spectrum antibiotics worsen dysbiosis.

Question 106: Which of the following is true about the legality of medicine?

Student nurses cannot be sued for malpractice while in a clinical setting.
Consent to medical treatment may be given by a minor with a sexually transmitted disease (STD). (Correct answer)
A second-trimester abortion may be obtained without state involvement.
A nurse who becomes ill and leaves during a shift is not abandoning patients if the supervisor is notified.

Correct answer: Consent to medical treatment may be given by a minor with a sexually transmitted disease (STD).

In many jurisdictions, minors are granted the right to consent to medical treatment for certain conditions, including sexually transmitted diseases (STDs), without parental consent. This provision aims to encourage minors to seek necessary treatment for sensitive health issues. The other options are generally incorrect regarding legal principles in nursing.

Question 107: A nurse is educating a patient with newly diagnosed hypertension. Which statement by the patient indicates understanding of lifestyle modifications?

'I only need to make changes when my blood pressure is very high.'
'I will exercise for 30 minutes most days of the week and limit sodium to 2,300 mg/day.' (Correct answer)
'I will limit my alcohol to two drinks per night.'
'I will start a high-protein, low-carbohydrate diet immediately.'

Correct answer: 'I will exercise for 30 minutes most days of the week and limit sodium to 2,300 mg/day.'

Regular aerobic exercise and sodium restriction are two of the most evidence-based lifestyle modifications for blood pressure reduction in hypertensive patients.

Question 108: A nurse is assisting a client with a bedpan. Which action best maintains the client's dignity and comfort?

Perform perineal care before placing the bedpan
Leave the call light within reach and close the curtain while the client uses the bedpan (Correct answer)
Raise all four side rails for safety
Stay at the bedside to monitor for complications

Correct answer: Leave the call light within reach and close the curtain while the client uses the bedpan

Providing privacy with a closed curtain and ensuring access to the call light respect dignity while maintaining safety.

Question 109: A nurse is caring for a client receiving total parenteral nutrition (TPN). Which complication requires the most immediate intervention?

Weight gain of 0.5 kg over 24 hours
Temperature of 39.2°C (102.6°F) with chills (Correct answer)
Blood glucose of 180 mg/dL
Mild nausea without vomiting

Correct answer: Temperature of 39.2°C (102.6°F) with chills

Fever and chills in a TPN client suggest catheter-related bloodstream infection, a life-threatening complication requiring immediate assessment and blood cultures.

Question 110: A nurse is performing a newborn assessment and notes the infant's skin is yellow at 10 hours of life. How should the nurse interpret this finding?

Carotenemia from transplacental transfer of maternal vitamins
Normal skin color variation in newborns of certain ethnicities
Pathologic jaundice requiring immediate evaluation (Correct answer)
Physiologic jaundice, which is normal in the first 24 hours

Correct answer: Pathologic jaundice requiring immediate evaluation

Jaundice appearing within the first 24 hours of life is always pathologic and requires immediate evaluation for conditions such as hemolytic disease.

Question 111: The monitor exhibits late decelerations with tachycardia and declining variability while evaluating the status of the fetal heart rate during labor. What steps needs to be taken by the nurse?

Turn client on right side
Report to physician or midwife (Correct answer)
Decrease IV fluids.
Continue monitoring because this is a normal occurrence

Correct answer: Report to physician or midwife

Late decelerations, especially when accompanied by fetal tachycardia and declining variability, are non-reassuring fetal heart rate patterns. These findings indicate uteroplacental insufficiency and potential fetal hypoxia, requiring immediate intervention. The nurse's priority is to report these critical findings to the physician or midwife for prompt medical evaluation and management, as the fetus may be in distress.

Question 112: What is the single most effective method for preventing the spread of healthcare-associated infections?

Wearing a mask during all patient interactions
Using gloves for all patient contact
Hand hygiene with soap and water or alcohol-based hand rub (Correct answer)
Placing all patients in isolation rooms

Correct answer: Hand hygiene with soap and water or alcohol-based hand rub

Hand hygiene is the single most effective measure for preventing transmission of pathogens in healthcare settings, as recommended by the CDC and WHO.

Question 113: When implementing a new evidence-based protocol, which change theory focuses on unfreezing old behaviors, moving to new ones, and refreezing the change?

Lewin's Force Field Analysis (Correct answer)
Rogers' Diffusion of Innovation
Kotter's 8-Step Model
Lippitt's Phases of Change

Correct answer: Lewin's Force Field Analysis

Lewin's three-step model (unfreeze, change, refreeze) is the foundational theory for planned organizational change.

Question 114: A nurse is caring for a patient with a chest tube. Which finding requires the most immediate intervention?

Tidaling in the water-seal chamber with respirations
Intermittent bubbling in the water-seal chamber during exhalation
Approximately 50 mL of blood in the drainage collection chamber
Continuous bubbling in the water-seal chamber (Correct answer)

Correct answer: Continuous bubbling in the water-seal chamber

Continuous bubbling in the water-seal chamber indicates an air leak in the system that must be identified and corrected immediately.

Question 115: Which behavior indicates a patient is in the bargaining stage of Kübler-Ross's stages of grief?

Refusing to discuss the terminal diagnosis
Crying and expressing feelings of hopelessness
Asking questions about hospice care
'If I follow every treatment, maybe I'll see my grandchild born.' (Correct answer)

Correct answer: 'If I follow every treatment, maybe I'll see my grandchild born.'

Bargaining involves making deals or promises in exchange for more time or a change in outcome, as seen in the statement about surviving to witness a grandchild's birth.

Question 116: Which intervention is most appropriate for a patient experiencing alcohol withdrawal on day 2 of hospitalization?

Encourage ambulation and socialization
Restrict IV fluids to prevent fluid overload
Administer scheduled benzodiazepines per protocol and monitor for seizures (Correct answer)
Provide high-stimulation activities to distract the patient

Correct answer: Administer scheduled benzodiazepines per protocol and monitor for seizures

Benzodiazepines are the pharmacological standard for alcohol withdrawal to prevent progression to seizures and delirium tremens; close monitoring is essential during peak risk (24–72 hours).

Question 117: A nurse is caring for a client who reports pain rated 8/10 after repositioning. The nurse has a PRN analgesic order. What should the nurse do first?

Perform a focused assessment to identify the cause and character of pain (Correct answer)
Administer the PRN analgesic immediately
Reassess pain in 30 minutes after non-pharmacological measures
Ask the client to rate their pain again in 15 minutes

Correct answer: Perform a focused assessment to identify the cause and character of pain

A complete pain assessment (location, quality, onset, aggravating factors) before intervention ensures the correct treatment and identifies any new complications.

Question 118: Which position is contraindicated for a client who had a transurethral resection of the prostate (TURP)?

Lithotomy position (Correct answer)
Sims' position
Semi-Fowler's at 45 degrees
Supine with legs extended

Correct answer: Lithotomy position

The lithotomy position increases pressure in the operative area and is contraindicated postoperatively after TURP to avoid bleeding and discomfort.

Question 119: Without first getting the client's informed consent, doing a non-emergency intrusive surgery on them can be seen as

malpractice
fraud
battery (Correct answer)
harassment

Correct answer: battery

Battery is the intentional and unpermitted touching of another person without their consent. Performing a non-emergency invasive surgery without obtaining the client's informed consent constitutes battery, as it involves an unauthorized physical intervention. Even if the procedure is medically indicated, the lack of consent makes it a legal violation.

Question 120: A nurse is caring for a laboring client who receives an epidural. Fifteen minutes later, the client's blood pressure drops from 118/76 to 82/50 mmHg. What is the priority intervention?

Notify the anesthesiologist before taking any action
Turn the client to a lateral position and increase IV fluid rate (Correct answer)
Elevate the client's head to 90 degrees
Administer oxygen at 10 L/min via face mask

Correct answer: Turn the client to a lateral position and increase IV fluid rate

Epidural-induced hypotension is treated by positioning the client laterally to relieve aortocaval compression and increasing IV fluids to restore preload.

Question 121: A nurse delegates wound care to an unlicensed assistive personnel (UAP). Later, the UAP performs the task incorrectly. Who bears ultimate accountability?

The delegating registered nurse (Correct answer)
The UAP who performed the task
The hospital risk management team
The charge nurse on duty

Correct answer: The delegating registered nurse

The delegating RN retains accountability for the outcome of any task delegated to UAP under the five rights of delegation.

Question 122: A patient requests the nurse's advice on a breakfast that can aid with constipation prevention during a normal check-up. Which of the following food options would be the best?

Plain bagel and cream cheese
Donut and orange juice
Oatmeal and a banana (Correct answer)
Fried eggs and bacon

Correct answer: Oatmeal and a banana

Oatmeal and a banana are excellent choices for preventing constipation due to their high fiber content. Oatmeal provides both soluble and insoluble fiber, which adds bulk to stool and promotes regular bowel movements, while bananas also contribute dietary fiber. The other options are generally low in fiber or high in fat, which can exacerbate constipation.

Question 123: A nurse is preparing to administer a blood transfusion. Which action is the most important safety check before beginning the infusion?

Verify the blood product with another licensed nurse at the bedside using two patient identifiers (Correct answer)
Ensure the IV line is 22-gauge or smaller
Confirm the patient had a recent CBC
Check the patient's allergy list

Correct answer: Verify the blood product with another licensed nurse at the bedside using two patient identifiers

Two-nurse verification of blood product compatibility using two patient identifiers (name and date of birth or medical record number) is the critical safety step to prevent transfusion reactions.

Question 124: A customer is six weeks pregnant. She queries the nurse during her first prenatal appointment, "How much alcohol is safe to drink during pregnancy?" and receives the following response:

No alcohol (Correct answer)
up to 1 oz daily
up to 2 oz daily
up to 4 oz daily

Correct answer: No alcohol

There is no known safe amount of alcohol, no safe time to drink, and no safe type of alcohol during pregnancy. Alcohol consumption during pregnancy can lead to Fetal Alcohol Spectrum Disorders (FASDs), which are a range of lifelong physical, behavioral, and intellectual disabilities. Therefore, complete abstinence from alcohol is recommended throughout pregnancy to prevent these irreversible effects on the fetus.

Question 125: A client is ordered a low-residue diet. Which food selection indicates understanding of the diet?

Steamed white rice with baked chicken breast (Correct answer)
Whole wheat bread with peanut butter
Bran cereal with whole milk
Raw broccoli salad with vinaigrette

Correct answer: Steamed white rice with baked chicken breast

White rice and baked chicken are low in fiber and residue, appropriate for a low-residue diet that minimizes bowel stimulation.

Question 126: Which action best reduces the risk of a wrong-site surgical procedure?

Reviewing the operative consent form before the patient is sedated
Confirming the patient's identity using two identifiers
Asking the surgeon to initial the operative site
Performing a time-out immediately before the incision (Correct answer)

Correct answer: Performing a time-out immediately before the incision

The surgical time-out performed immediately before the incision is the last line of defense to confirm correct patient, site, and procedure.

Question 127: Which condition requires droplet precautions rather than airborne precautions?

Measles
Meningococcal meningitis (Correct answer)
Disseminated varicella
Active pulmonary tuberculosis

Correct answer: Meningococcal meningitis

Meningococcal meningitis spreads via large respiratory droplets and requires droplet precautions, while measles, TB, and varicella require airborne precautions.

Question 128: A postoperative client refuses to use the incentive spirometer. Which response by the nurse is most therapeutic?

Perform chest physiotherapy instead
Tell the client it is required before discharge
Explain that using it prevents serious lung complications such as pneumonia (Correct answer)
Document the refusal and notify the provider

Correct answer: Explain that using it prevents serious lung complications such as pneumonia

Educating the client about the rationale (preventing atelectasis and pneumonia) supports informed decision-making and may improve adherence.

Question 129: A patient is scheduled for a contrast CT scan. Which assessment finding is most important to report to the radiologist?

Heart rate of 92 beats/min
Allergy to shellfish
Blood pressure of 148/88 mmHg
Serum creatinine of 2.4 mg/dL (Correct answer)

Correct answer: Serum creatinine of 2.4 mg/dL

An elevated creatinine indicates impaired renal function, which increases the risk of contrast-induced nephropathy.

Question 130: A nurse receives handoff for a patient on heparin infusion. The aPTT result is 120 seconds (therapeutic range 60-100 seconds). What is the nurse's priority action?

Administer protamine sulfate immediately
Stop or reduce the infusion per protocol and notify the provider (Correct answer)
Increase the infusion rate per protocol
Continue the infusion at the current rate

Correct answer: Stop or reduce the infusion per protocol and notify the provider

An aPTT above the therapeutic range indicates supratherapeutic anticoagulation, requiring rate reduction or cessation per protocol and provider notification.

Question 131: A patient on lithium therapy complains of tremors, confusion, and has a serum level of 2.1 mEq/L. The nurse anticipates:

Administering activated charcoal without consulting the provider
Holding the dose and preparing for supportive treatment of toxicity (Correct answer)
Increasing the lithium dose to achieve therapeutic levels
Encouraging high fluid intake to raise the level further

Correct answer: Holding the dose and preparing for supportive treatment of toxicity

The therapeutic lithium range is 0.6–1.2 mEq/L; a level of 2.1 indicates severe toxicity requiring the dose to be held.

Question 132: To avoid perinatal mortality in women with diabetes during pregnancy, glucose levels must be tightly controlled metabolically. The nurse is aware of the recommended range for serum glucose levels during pregnancy, which is:

40 mg/dL and 130 mg/dL
90 mg/dL and 200 mg/dL
100 mg/dL and 200 mg/dL
70 mg/dL and 120 mg/dL (Correct answer)

Correct answer: 70 mg/dL and 120 mg/dL

Tight glycemic control is crucial for women with diabetes during pregnancy to prevent perinatal mortality and morbidity. The recommended target range for serum glucose levels during pregnancy is generally between 70 mg/dL and 120 mg/dL. Maintaining glucose within this narrow range minimizes the risks of both maternal and fetal complications, such as macrosomia, hypoglycemia, and congenital anomalies.

Question 133: A hospital is transitioning from a centralized to a decentralized management structure. What is the PRIMARY advantage for staff nurses?

Reduced personal accountability for decisions
Elimination of the need for charge nurses
Increased autonomy and empowerment in clinical decision-making (Correct answer)
Standardized care plans developed by administration

Correct answer: Increased autonomy and empowerment in clinical decision-making

Decentralized structures push decision-making authority closer to frontline nurses, increasing autonomy and professional satisfaction.

Question 134: Holding a sterile gauze pad over the injection site while removing the needle serves to

decrease the discomfort of the needle pulling on the skin (Correct answer)
prevent pathogens from entering through the puncture
increase the absorption of the medication
seal off the track left by the needle

Correct answer: decrease the discomfort of the needle pulling on the skin

Holding a sterile gauze pad over the injection site while removing the needle helps to stabilize the skin and apply gentle counter-pressure. This action reduces the pulling sensation on the skin as the needle is withdrawn, thereby decreasing the patient's discomfort during the procedure.

Question 135: A client with a hip replacement asks if they can cross their legs when sitting. The nurse's best response is:

'No, crossing your legs could dislocate your new hip.' (Correct answer)
'Yes, crossing at the ankles is acceptable.'
'Yes, crossing is fine as long as you feel comfortable.'
'No, but you may cross your legs after 6 weeks.'

Correct answer: 'No, crossing your legs could dislocate your new hip.'

Hip flexion beyond 90° and adduction, such as crossing legs, risk prosthesis dislocation after total hip replacement.

Question 136: A patient recovering from a total hip arthroplasty (THA) tries to pick up an object from the floor by bending forward at the hip. What should the nurse do?

Assist the patient to complete the movement safely
Document the movement as a sign of good recovery
Encourage the activity as it promotes range of motion
Instruct the patient to stop; hip flexion beyond 90 degrees is restricted (Correct answer)

Correct answer: Instruct the patient to stop; hip flexion beyond 90 degrees is restricted

After THA, hip flexion beyond 90 degrees is contraindicated to prevent prosthetic dislocation; patients must use adaptive equipment like reachers.

Question 137: For a patient with PIH, the doctor advises rapid hospital admission. Which of these techniques by the nurse would likely be best after understanding her feelings when she tells the nurse, "It's not so easy for me to just go right to the hospital like that"?

Explore with the client her perceptions of why she is unable to go to the hospital. (Correct answer)
Stress to the client that her husband would want her to do what is best for her health.
Explain to the client that she is ultimately responsible for her own welfare and that of her baby.
Repeat the physician’s reasons for advising immediate hospitalization.

Correct answer: Explore with the client her perceptions of why she is unable to go to the hospital.

When a client expresses reluctance or difficulty following medical advice, the most therapeutic nursing action is to first explore their concerns and perceptions. Understanding the underlying reasons for her hesitation (e.g., childcare, work, fear, financial concerns) allows the nurse to address those specific barriers and provide tailored support or solutions. Simply repeating instructions or stressing responsibility is less effective than active listening and problem-solving.

Question 138: A nurse is planning care for a client with major depression who is started on fluoxetine (Prozac). Which statement about antidepressant therapy is most important to include in discharge teaching?

Avoid all physical activity while taking this medication.
You should stop the medication once you feel better.
You will feel better within 24 to 48 hours of starting the medication.
Therapeutic effects may take 2 to 4 weeks to appear. (Correct answer)

Correct answer: Therapeutic effects may take 2 to 4 weeks to appear.

SSRIs typically require 2–4 weeks to produce full therapeutic effects; clients must be informed to continue the medication and not expect immediate results.

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

The NCLEX-RN is a standardized exam that every graduate of an accredited nursing program must pass to become a licensed Registered Nurse (RN). It assesses the knowledge, skills, and abilities essential for the safe and effective practice of nursing.

Questions

300 min

Time Limit

50%

To Pass

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