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

Question 1: A patient with chronic kidney disease (CKD) is at risk for hyperkalemia. Which food should the nurse instruct the patient to avoid?

White rice and pasta
Whole wheat bread
Chicken breast and turkey
Bananas and oranges (Correct answer)

Correct answer: Bananas and oranges

Bananas and oranges are high-potassium foods that can worsen hyperkalemia in CKD patients whose kidneys cannot excrete excess potassium.

Question 2: A nurse is reviewing a patient's medication list before surgery. Which finding requires the most immediate action?

The patient takes warfarin 5 mg daily (Correct answer)
The patient takes lisinopril 10 mg daily
The patient takes a daily multivitamin
The patient takes metformin 500 mg twice daily

Correct answer: The patient takes warfarin 5 mg daily

Warfarin must be discontinued before surgery to reduce the risk of excessive bleeding and is the most critical finding.

Question 3: Which of the following assessment results is in line with a volume deficit of extracellular fluid?

Hypertension
Hyperglycemia
Oliguria (Correct answer)
Bradycardia

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 4: A patient on mechanical ventilation has a sudden decrease in oxygen saturation and increasing peak airway pressures. The nurse's first action should be:

Suction the patient
Call the physician
Disconnect from the ventilator and manually ventilate with a bag-valve mask (Correct answer)
Increase the FiO2 on the ventilator

Correct answer: Disconnect from the ventilator and manually ventilate with a bag-valve mask

DOPE mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure) guides troubleshooting; manual ventilation with a bag-valve mask confirms and bypasses equipment failure immediately.

Question 5: A client's gestational age is determined by the nurse practitioner to be around 9 weeks. The healthcare provider gives the client information on the bodily changes that will occur during the first trimester, such as:

Quickening
Abdominal enlargement
Nausea and vomiting (Correct answer)
A 6-8 weight gain

Correct answer: Nausea and vomiting

Nausea and vomiting, commonly known as 'morning sickness,' are very typical symptoms experienced by pregnant individuals during the first trimester (approximately weeks 6-12). These symptoms are primarily caused by significant hormonal changes, particularly rising levels of human chorionic gonadotropin (hCG). Other options like abdominal enlargement and quickening occur later in pregnancy.

Question 6: A patient arrives to the emergency room with a headache, disorientation, and a blood pressure of 180/130 mmHg. Which other observation supports the diagnosis of a hypertensive emergency?

Jaundice
Bradycardia
Urinary retention
Retinopathy (Correct answer)

Correct answer: Retinopathy

A hypertensive emergency is defined by severe hypertension (blood pressure typically >180/120 mmHg) accompanied by acute target organ damage. Retinopathy, which involves damage to the blood vessels in the retina, is a direct and visible sign of such acute end-organ damage caused by dangerously high blood pressure. This finding confirms the severity of the patient's condition and the need for immediate intervention.

Question 7: A nurse is caring for a client with a chest tube following a pneumothorax. The water-seal chamber shows continuous bubbling. What does this finding indicate?

Excessive fluid drainage from the pleural space
A persistent air leak from the lung or system (Correct answer)
Adequate lung re-expansion
Normal chest tube functioning

Correct answer: A persistent air leak from the lung or system

Continuous bubbling in the water-seal chamber indicates an ongoing air leak, either from the lung itself or from a break in the closed drainage system.

Question 8: A nurse is reviewing a patient's ABG results: pH 7.28, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the nurse interpret these findings?

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

Correct answer: Respiratory acidosis

A low pH with elevated PaCO2 and normal HCO3 indicates respiratory acidosis, caused by CO2 retention from hypoventilation.

Question 9: A nurse caring for a patient in Buck's traction discovers that the weights are resting on the floor. What should the nurse do?

Leave the weights in place to reduce patient discomfort
Remove the traction and notify the orthopedic surgeon
Reposition the patient so the weights hang freely (Correct answer)
Document the finding and reassess in one hour

Correct answer: Reposition the patient so the weights hang freely

Traction is only effective when weights hang freely; resting weights eliminate the therapeutic pull needed to maintain alignment.

Question 10: Which teaching should the nurse provide to a patient who is immunocompromised regarding infection prevention?

Wear a mask only in hospitals
Stop all prescribed medications during illness
Avoid fresh fruits and vegetables entirely
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 11: 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?

10 mL (Correct answer)
2 mL
5 mL
8 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 12: In which situation should a nurse use soap and water for hand hygiene instead of an alcohol-based hand rub?

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

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 13: The nurse checks with the patient to see if there are any drug sensitivities before giving penicillin intramuscularly to a patient with "NKDA" on his medical record. The customer replies, "I'm not certain. One time, when I was ill and received a shot, I might have developed a rash." Which course of action is best for the nurse?

Hold the penicillin and contact the prescribing provider (Correct answer)
Contact the hospital pharmacist for oral penicillin
Ask the client for more details before giving the penicillin
Administer the penicillin and observe for 60 minutes

Correct answer: Hold the penicillin and contact the prescribing provider

Even an uncertain history of a rash after an injection warrants caution, especially with a medication like penicillin, which is a common allergen. To ensure patient safety and adhere to the 'Right Patient, Right Drug, Right Dose, Right Route, Right Time, Right Documentation, Right Reason, Right Response, Right to Refuse, Right Assessment' principles, the nurse must clarify the allergy status with the provider before administering the medication.

Question 14: A nurse is assisting a client with a bedpan. Which action best maintains the client's dignity and comfort?

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

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 15: A nurse is teaching a pregnant patient about folic acid. How much folic acid should a woman consume daily before and during early pregnancy?

200 mcg
1,000 mcg
400 mcg (Correct answer)
100 mcg

Correct answer: 400 mcg

The CDC recommends 400 mcg of folic acid daily for all women of childbearing age to prevent neural tube defects, ideally starting at least one month before conception.

Question 16: A post-operative patient develops redness, warmth, swelling, and purulent drainage at the incision site 5 days after abdominal surgery. This presentation is most consistent with which healthcare-associated infection?

Surgical site infection (SSI) (Correct answer)
Catheter-associated urinary tract infection
Central line-associated bloodstream infection
Ventilator-associated pneumonia

Correct answer: Surgical site infection (SSI)

Surgical site infections present with classic signs of inflammation and purulent drainage localized to the operative wound within 30 days of surgery.

Question 17: When Nurse John arrives for his shift, he observes that Nurse Jane has an alcoholic odor and slurs her speech. What is Nurse John supposed to do?

Report his observation to the charge nurse. (Correct answer)
Tell Nurse Jane she should go home.
Assist Nurse Jane with her patient care.
Document his findings in an incident report.

Correct answer: Report his observation to the charge nurse.

Patient safety is the paramount concern in healthcare. A nurse exhibiting signs of alcohol impairment poses a significant risk to patient care and safety. The appropriate action is to immediately report the observation to the charge nurse or supervisor, who is responsible for addressing such situations, ensuring patient safety, and following institutional policies regarding impaired staff.

Question 18: A patient with deep partial-thickness burns to 30% TBSA is at highest risk for which complication in the first 24–48 hours?

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

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 19: A patient is scheduled for surgery on the left knee but the consent form reads 'right knee.' The nurse's correct action is:

Delay the procedure and notify the surgeon to correct the consent before proceeding (Correct answer)
Cross out 'right' and write 'left' on the consent form
Ask the patient to initial the error on the consent form
Proceed with surgery because the surgeon knows which knee is involved

Correct answer: Delay the procedure and notify the surgeon to correct the consent before proceeding

Surgical site errors are never events; the nurse must halt the procedure, notify the surgeon, and ensure the consent is corrected and resigned before proceeding per the Universal Protocol.

Question 20: A nurse manager observes that a newly licensed nurse frequently hesitates to ask for help and makes decisions independently beyond their current competency. Which management strategy is MOST appropriate?

Transfer the nurse to a less acute unit
Assign the nurse to work solo shifts to build confidence
Document the behavior and issue a formal warning immediately
Implement a structured mentoring program and create a psychologically safe environment for asking questions (Correct answer)

Correct answer: Implement a structured mentoring program and create a psychologically safe environment for asking questions

A mentoring program and a psychologically safe culture encourage new nurses to seek guidance before errors occur.

Question 21: 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
Administer the insulin
Reposition the patient (Correct answer)

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 22: 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?

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

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 23: 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?

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

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 24: A patient newly diagnosed with breast cancer states, 'I can't believe this is happening to me.' The nurse's best therapeutic response is:

'Many people survive breast cancer with treatment.'
'This must be very frightening. Would you like to talk about how you're feeling?' (Correct answer)
'Let me get you some pamphlets about breast cancer.'
'You should stay positive; attitude affects outcomes.'

Correct answer: 'This must be very frightening. Would you like to talk about how you're feeling?'

Acknowledging the patient's fear and inviting open dialogue is the most therapeutic response, demonstrating empathy and patient-centered communication.

Question 25: A patient's serum sodium level is 122 mEq/L. Which clinical finding does the nurse anticipate?

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

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 26: Which budgeting approach requires each department to justify ALL expenditures from zero each fiscal year, regardless of prior year spending?

Incremental budgeting
Capital budgeting
Zero-based budgeting (Correct answer)
Fixed budgeting

Correct answer: Zero-based budgeting

Zero-based budgeting requires justification for every line item from scratch, promoting cost-consciousness and elimination of unnecessary spending.

Question 27: Preeclampsia has been identified in one of the clients. The doctor prescribes magnesium sulfate. Preeclampsia is treated with magnesium sulfate (MgSO4) for:

Prevention of uterine contractions
Sedation
Prevention of seizures (Correct answer)
Fetal lung protection

Correct answer: Prevention of seizures

Magnesium sulfate is the drug of choice for the prevention and treatment of seizures (eclampsia) in women with severe preeclampsia. It acts as a central nervous system depressant, reducing neuromuscular irritability and vasospasm. While it has other effects, its primary therapeutic goal in preeclampsia is to prevent the life-threatening complication of seizures.

Question 28: A nurse is caring for a patient with a chest tube. Which finding requires the most immediate intervention?

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

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

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

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 30: 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?

40 years
50 years
45 years (Correct answer)
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 31: Which assessment finding in a post-thyroidectomy patient requires the nurse to immediately notify the provider?

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

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 32: Which action places a mechanically ventilated patient at highest risk for ventilator-associated pneumonia (VAP)?

Maintaining the head of bed at 0 degrees (supine) (Correct answer)
Performing oral care with chlorhexidine every 12 hours
Maintaining endotracheal cuff pressure at 20-30 cmH2O
Using continuous subglottic secretion drainage

Correct answer: Maintaining the head of bed at 0 degrees (supine)

Flat supine positioning (0 degrees) promotes aspiration of oral and gastric secretions into the lower airway; HOB elevation to 30-45 degrees is a key VAP bundle element.

Question 33: A expectant client makes her first visit to the prenatal clinic. This is the client's third pregnancy, the nurse observes. She gave birth to a healthy boy four years ago at 38 weeks, and a healthy girl two years ago at 35 weeks. The nurse will document the client's obstetrical history using the gravida/para method.

Gravida 3 - Para 2 (Correct answer)
Gravida 2 - Para 2
Gravida 3 - Para 1
Gravida 2 - Para 1

Correct answer: Gravida 3 - Para 2

Gravida refers to the total number of pregnancies, including the current one. This client has had two previous pregnancies and is currently pregnant, making her Gravida 3. Para refers to the number of pregnancies that reached viability (typically 20 weeks gestation) or resulted in live births. She has had two live births (one at 38 weeks, one at 35 weeks), so her Para is 2.

Question 34: A nurse is preparing to hang a peripheral IV solution of dextrose 10% in water (D10W). This solution is classified as:

Colloid
Hypotonic
Isotonic
Hypertonic (Correct answer)

Correct answer: Hypertonic

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

Question 35: Which route of medication administration has the fastest onset of action?

Transdermal
Sublingual
Intramuscular
Intravenous (Correct answer)

Correct answer: Intravenous

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

Question 36: A patient receiving IV morphine shows a respiratory rate of 8 breaths/min and is difficult to arouse. The priority action is:

Reposition the patient and elevate the head of bed
Reassess in 15 minutes
Increase IV fluid rate to flush the medication
Administer naloxone (Narcan) as ordered (Correct answer)

Correct answer: Administer naloxone (Narcan) as ordered

Respiratory depression from opioid overdose requires immediate reversal with naloxone.

Question 37: A nurse is administering a medication via a nasogastric (NG) tube. Which action is most important before instilling the medication?

Clamp the tube for 30 minutes after administration
Verify tube placement by checking gastric pH or x-ray confirmation (Correct answer)
Flush the tube with 30 mL of sterile water
Crush all tablets and dissolve them together in water

Correct answer: Verify tube placement by checking gastric pH or x-ray confirmation

Confirming NG tube placement before any instillation prevents aspiration or medication delivery into the lungs.

Question 38: A patient with major depressive disorder says, 'I've been giving my belongings away and I feel at peace now.' The nurse's priority action is:

Praise the patient for achieving inner peace
Notify social work for discharge planning
Conduct an immediate suicide risk assessment (Correct answer)
Document the finding and continue monitoring

Correct answer: Conduct an immediate suicide risk assessment

Giving away possessions and sudden calmness in a depressed patient are high-risk warning signs of suicidal intent requiring immediate safety assessment.

Question 39: A postoperative client develops a respiratory rate of 6 breaths/min and is difficult to arouse after receiving IV morphine. What is the priority nursing action?

Administer naloxone (Narcan) as ordered (Correct answer)
Notify the physician immediately
Reposition the client to a lateral position
Administer supplemental oxygen via face mask

Correct answer: Administer naloxone (Narcan) as ordered

Naloxone rapidly reverses opioid-induced respiratory depression and is the priority intervention to restore adequate ventilation.

Question 40: A hospital is transitioning from a centralized to a decentralized management structure. What is the PRIMARY advantage for staff nurses?

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

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 41: A nurse is assessing a patient with a suspected pulmonary embolism. Which clinical finding is most consistent with this diagnosis?

Sudden onset of pleuritic chest pain and dyspnea (Correct answer)
Gradual onset of productive cough with low-grade fever
Bilateral wheezing relieved by bronchodilators
Central chest pressure radiating to the left arm

Correct answer: Sudden onset of pleuritic chest pain and dyspnea

Pulmonary embolism classically presents with sudden-onset pleuritic chest pain (worse with inspiration), dyspnea, and tachycardia.

Question 42: Which of the following is true about the legality of medicine?

Student nurses cannot be sued for malpractice while in a clinical setting.
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.
Consent to medical treatment may be given by a minor with a sexually transmitted disease (STD). (Correct answer)

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

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

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

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

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 45: A nurse is educating a patient newly prescribed metformin. Which adverse effect should the patient monitor for and report immediately?

Muscle pain and weakness with dark urine (Correct answer)
Increased appetite
Weight gain
Facial flushing after meals

Correct answer: Muscle pain and weakness with dark urine

Lactic acidosis is a rare but serious metformin complication; muscle pain and dark urine are warning signs.

Question 46: A post-operative patient's SpO2 drops to 88%. After repositioning the patient, the SpO2 remains at 90%. What is the nurse's next action?

Document the finding and continue to monitor
Administer a bronchodilator
Prepare for emergent intubation
Apply supplemental oxygen as ordered (Correct answer)

Correct answer: Apply supplemental oxygen as ordered

An SpO2 of 90% is below the normal threshold and supplemental oxygen should be applied per protocol to prevent further hypoxia.

Question 47: 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 is a vegetarian
The patient with renal failure on hemodialysis (Correct answer)
The patient who has been NPO for 3 days
The patient with Jackson-Pratt drain

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 48: What is the best way to spot breast cancer tumors in the early stages?

Mammograms every 3 years
Yearly checkups performed by physician
Ultrasounds every 3 years
Monthly breast self-examination (Correct answer)

Correct answer: Monthly breast self-examination

While mammograms and clinical breast exams are crucial for screening, monthly breast self-examination (BSE) empowers women to become familiar with their own breasts and detect any changes early. Regular BSE, combined with clinical exams and mammograms as recommended, significantly increases the chances of early detection of breast cancer, which is vital for successful treatment. Early detection is key to improved outcomes.

Question 49: A non-immune nurse must care for a patient with active varicella (chickenpox). Which combination of PPE is required?

Surgical mask and gloves only
N95 respirator, gown, and gloves (Correct answer)
Surgical mask, gown, and gloves
N95 respirator and gown only

Correct answer: N95 respirator, gown, and gloves

Varicella requires both airborne precautions (N95 respirator) and contact precautions (gown and gloves) because it spreads via airborne droplet nuclei and direct contact with lesions.

Question 50: A nurse is caring for a client with chronic kidney disease (CKD) who has a potassium level of 6.2 mEq/L. Which dietary instruction is most important?

Consume high-protein foods to bind potassium
Increase intake of bananas and oranges
Increase fluid intake to dilute serum potassium
Avoid foods high in potassium such as potatoes and tomatoes (Correct answer)

Correct answer: Avoid foods high in potassium such as potatoes and tomatoes

Hyperkalemia in CKD requires restricting high-potassium foods like potatoes, tomatoes, and bananas to prevent life-threatening cardiac arrhythmias.

Question 51: Which electrolyte imbalance is most commonly associated with prolonged vomiting?

Hypokalemia (Correct answer)
Hypernatremia
Hyperkalemia
Hypercalcemia

Correct answer: Hypokalemia

Prolonged vomiting causes loss of hydrochloric acid and potassium, leading to hypokalemia and metabolic alkalosis.

Question 52: A vegetarian client is being instructed by the nurse in the prenatal clinic on how to prevent iron deficiency anemia while pregnant. Which food selection made by the client suggests that more teaching is required?

Lentil stew and strawberries
Black bean burger and tomato juice
Scrambled eggs and wheat toast (Correct answer)
Instant oatmeal and orange juice

Correct answer: Scrambled eggs and wheat toast

For a vegetarian client, scrambled eggs and wheat toast are not the best choices for preventing iron deficiency anemia. While eggs contain some iron, it is non-heme iron, which is less readily absorbed than heme iron from meat. Furthermore, this meal lacks a significant source of vitamin C, which is crucial for enhancing the absorption of non-heme iron from plant-based foods, unlike the other options that pair iron sources with vitamin C-rich foods.

Question 53: An expectant woman in her 38s meets her nurse practitioner for her routine prenatal appointment. She is thirty weeks pregnant. Which condition connected to her age should the nurse be on the lookout for?

Intrauterine growth retardation
Iron-deficiency anemia
Sexually transmitted disease (STD)
Pregnancy-induced hypertension (PIH) (Correct answer)

Correct answer: Pregnancy-induced hypertension (PIH)

Advanced maternal age, typically defined as 35 years or older at the time of delivery, is a significant risk factor for several pregnancy complications. Women in their late 30s are at an increased risk for developing conditions like gestational hypertension and preeclampsia (Pregnancy-Induced Hypertension). The nurse should closely monitor for signs and symptoms of PIH, such as elevated blood pressure, proteinuria, and edema, in this age group.

Question 54: A nurse administers the wrong medication to a client who experiences no adverse effects. What is the nurse's first action after recognizing the error?

Notify the pharmacy to correct the medication record
Assess the client and monitor for adverse effects (Correct answer)
Complete an incident report and notify the supervisor
Document the error in the nurse's notes

Correct answer: Assess the client and monitor for adverse effects

Client safety is always the priority; the nurse must first assess the client for any adverse reactions before reporting or documenting the error.

Question 55: A nurse is preparing to administer a blood transfusion. Which action is the most important safety check before beginning the infusion?

Confirm the patient had a recent CBC
Ensure the IV line is 22-gauge or smaller
Verify the blood product with another licensed nurse at the bedside using two patient identifiers (Correct answer)
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 56: A patient is receiving total parenteral nutrition (TPN) via a central line. The nurse should assess for which complication?

Hyperglycemia and infection at insertion site (Correct answer)
Hypoglycemia from too much insulin
Bradycardia from lipid infusion
Peripheral edema from fluid overload

Correct answer: Hyperglycemia and infection at insertion site

TPN's high dextrose content can cause hyperglycemia, and the central line is a significant infection risk.

Question 57: In Maslow's hierarchy of needs applied to staff management, which action addresses esteem needs?

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

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 58: 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?

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

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

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

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

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

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 61: A patient with anorexia nervosa is admitted with a BMI of 14. Which nursing action takes priority?

Arrange family counseling
Provide education about healthy body image
Encourage the patient to eat three large meals per day
Monitor electrolytes and cardiac rhythm (Correct answer)

Correct answer: Monitor electrolytes and cardiac rhythm

Severe malnutrition in anorexia nervosa causes electrolyte imbalances (especially hypokalemia and hypophosphatemia) and refeeding syndrome risk, making cardiac monitoring the physiological priority.

Question 62: 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?

Stress the importance of splinting when coughing.
Notify the health care provider (HCP). (Correct answer)
Administer a cough suppressant medication STAT.
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 63: The nursing diagnostic of Impaired Physical Mobility associated with Neuromuscular Impairment is given to patients with Parkinson's disease. All of these tasks are being performed by a nursing assistant, as you can see. What need do you have to step in?

The NA sets up the patient’s tray and encourages the patient to feed himself.
The NA reminds the patient not to look at his feet when he is walking.
The NA assists the patient to ambulate to the bathroom and back to bed.
The NA performs the patient’s complete bath and oral care. (Correct answer)

Correct answer: The NA performs the patient’s complete bath and oral care.

For a patient with Parkinson's disease and 'Impaired Physical Mobility,' the goal is to promote independence and maintain function as much as possible. While NAs can assist with personal care, performing a *complete* bath and oral care for a patient who might be able to do some tasks themselves goes against the principle of encouraging self-care. The nurse should intervene to ensure the patient is encouraged to participate in their care to the fullest extent possible, which helps maintain their physical and cognitive abilities.

Question 64: The following are the main goals of a newborn's initial Apgar score:

Obtain a baseline for comparison with the infant’s future adaptation to the environment
Determine gross abnormal motor function
Determine the extent of congenital malformations
Evaluate the infant’s vital functions (Correct answer)

Correct answer: Evaluate the infant’s vital functions

The Apgar score is a rapid assessment tool used at 1 and 5 minutes after birth to evaluate a newborn's physical condition and immediate adaptation to extrauterine life. It assesses five vital signs: Appearance, Pulse, Grimace, Activity, and Respiration. This score helps identify infants who need immediate medical attention or resuscitation, providing a quick snapshot of their vital functions.

Question 65: A nurse is receiving a verbal order from a physician via telephone. Which action reflects safe communication practice?

Read the order back to the physician immediately after writing it down
Repeat the order aloud while writing and ask the physician to confirm (Correct answer)
Document the order and have the physician sign it within 72 hours
Ask another nurse to listen and witness the telephone order

Correct answer: Repeat the order aloud while writing and ask the physician to confirm

Read-back and verbal confirmation of telephone orders is the Joint Commission-recommended practice to prevent transcription errors.

Question 66: A client with a nasogastric tube reports nausea. Before administering an antiemetic, the nurse should first:

Elevate the head of the bed to 90 degrees
Remove the nasogastric tube temporarily
Administer the antiemetic via IV instead
Check the placement of the nasogastric tube (Correct answer)

Correct answer: Check the placement of the nasogastric tube

Verifying NG tube placement rules out tube displacement into the esophagus as a cause of nausea before any intervention.

Question 67: A nurse is caring for a patient who experienced sexual assault. Which statement by the nurse is most therapeutic?

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

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 68: A 18-year-old female is transported to the emergency room after taking 15 maximum dosage acetaminophen tablets 45 minutes earlier. Which directive should the nurse follow first?

Gastric lavage (Correct answer)
Have the patient drink activated charcoal mixed with water
Administer acetylcysteine (mucomyst) orally
Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open

Correct answer: Gastric lavage

For an acetaminophen overdose within 1 hour of ingestion, gastric lavage (stomach pumping) is often the preferred initial intervention to remove unabsorbed medication from the stomach. This procedure aims to quickly reduce the amount of drug absorbed into the bloodstream. Activated charcoal can also be used, but lavage is more effective for large ingestions within a very short timeframe before significant absorption occurs.

Question 69: A patient with chronic kidney disease has a serum potassium of 6.8 mEq/L. The nurse's priority intervention is to:

Administer oral potassium supplements
Encourage increased dietary potassium
Prepare for cardiac monitoring (Correct answer)
Administer a potassium-sparing diuretic

Correct answer: Prepare for cardiac monitoring

Hyperkalemia at 6.8 mEq/L poses a life-threatening cardiac risk; continuous cardiac monitoring must be initiated immediately.

Question 70: The nurse manager is reviewing patient satisfaction scores and notices a downward trend in communication ratings. The BEST next step is to:

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

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 71: 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?

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

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 72: Which condition requires droplet precautions rather than airborne precautions?

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

Correct answer: Meningococcal meningitis

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

Question 73: 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?

Trade the milkshake for soft drink
Remove the tray and order a new meal (Correct answer)
Replace the cheeseburger with shrimp
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 74: A nurse notes a patient on heparin infusion has an aPTT of 180 seconds (therapeutic range 60–100 seconds). What is the priority intervention?

Stop the infusion and notify the provider (Correct answer)
Administer vitamin K as an antidote
Increase IV fluid rate to dilute the heparin
Continue the infusion and recheck in 4 hours

Correct answer: Stop the infusion and notify the provider

An aPTT of 180 seconds indicates supratherapeutic anticoagulation and bleeding risk; the infusion must be stopped and the provider notified for dose adjustment.

Question 75: 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 76: Which health promotion teaching is most appropriate for a patient who has been newly prescribed metformin for type 2 diabetes?

Take metformin with food to reduce GI side effects, monitor blood glucose, and maintain adequate hydration (Correct answer)
Avoid all carbohydrates entirely
Take metformin on an empty stomach for best absorption
Stop metformin if blood glucose reaches normal levels

Correct answer: Take metformin with food to reduce GI side effects, monitor blood glucose, and maintain adequate hydration

Metformin should be taken with food to minimize GI side effects (nausea, diarrhea); patients must monitor glucose, stay hydrated, and understand it is a long-term therapy.

Question 77: When a patient declines medical care, this is an illustration of

common law (Correct answer)
statutory law
civil 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 78: Which finding in a burn patient indicates adequate fluid resuscitation during the first 24 hours?

Serum sodium of 155 mEq/L
Urine output of 0.1 mL/kg/hour
Heart rate of 130 bpm
Urine output of 0.5–1 mL/kg/hour (Correct answer)

Correct answer: Urine output of 0.5–1 mL/kg/hour

The Parkland formula targets urine output of 0.5–1 mL/kg/hour as the primary indicator of adequate tissue perfusion during burn resuscitation.

Question 79: A nurse is preparing to administer a high-alert medication. Which safety measure is most important before administration?

Confirming the medication was prescribed by the provider
Reviewing the patient's allergy list
Asking a colleague to witness the administration
Having a second nurse perform an independent double-check (Correct answer)

Correct answer: Having a second nurse perform an independent double-check

An independent double-check by a second nurse is the key safety strategy for high-alert medications to catch errors before they reach the patient.

Question 80: A nurse manager is conducting performance appraisals. Which practice best promotes fair and objective evaluations?

Base ratings on recent performance events only
Rate all staff slightly above average to maintain morale
Document behavioral examples throughout the review period (Correct answer)
Compare staff members' scores against each other

Correct answer: Document behavioral examples throughout the review period

Ongoing behavioral documentation prevents recency bias and provides objective evidence for all performance ratings.

Question 81: The patient was brought back to the facility after surgery and is now complaining of pain that is at a level of nine out of ten. When the nurse looks through the paperwork, she finds the surgeon's postoperative order for "10 mg MSO4". What should the nurse do first before giving the patient morphine?

Prepare the medication for administration
Call the pharmacy to send the morphine
Set up a piggyback infusion system
Contact the surgeon before proceeding (Correct answer)

Correct answer: Contact the surgeon before proceeding

The order '10 mg MSO4' is incomplete because it lacks crucial information such as the route of administration, the frequency, and potentially the indication. A complete medication order is essential for safe administration. Therefore, the nurse's first action must be to contact the surgeon to clarify the order and obtain all necessary details before administering the morphine.

Question 82: 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
Administer acetaminophen and continue monitoring
Complete the transfusion quickly before symptoms worsen
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 83: A nurse is teaching a patient with type 2 diabetes about foot care. Which instruction is most important?

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

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

Droplet precautions
Airborne 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 85: Which of the following breast cancer risk factors would a nurse rate as being the most important in a client's history?

Menarche after age 13
Nulliparity
Early menopause
Maternal family history of breast cancer (Correct answer)

Correct answer: Maternal family history of breast cancer

A strong family history, particularly a maternal history of breast cancer (mother, sister, daughter), significantly increases an individual's risk due to potential genetic predispositions (e.g., BRCA1/BRCA2 mutations). While other factors contribute, genetic inheritance from a first-degree relative is generally considered a more potent and non-modifiable risk factor. This makes it the most important risk factor to assess in a client's history.

Question 86: A nurse is caring for a client who is 12 hours post-thyroidectomy. The client reports tingling around the mouth and in the fingertips. What should the nurse assess next?

Surgical site for signs of hemorrhage
Blood pressure for hypertensive urgency
Respiratory rate for laryngospasm onset
Trousseau's sign for hypocalcemia (Correct answer)

Correct answer: Trousseau's sign for hypocalcemia

Perioral and digital tingling after thyroidectomy suggest inadvertent parathyroid removal causing hypocalcemia; Trousseau's sign confirms neuromuscular irritability.

Question 87: 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:

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

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

Notify the infection control department in writing
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

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 89: A nurse is caring for a client who is immobile and at risk for pressure injuries. Which intervention has the highest priority?

Reposition the client every 2 hours (Correct answer)
Place a donut-shaped foam ring under the coccyx
Massage reddened bony prominences vigorously
Apply a moisture barrier cream to intact skin

Correct answer: Reposition the client every 2 hours

Repositioning every 2 hours is the primary intervention to relieve sustained pressure on bony prominences and prevent tissue ischemia.

Question 90: A patient's wound culture grows methicillin-resistant Staphylococcus aureus (MRSA). Which antibiotic is typically the drug of choice?

Vancomycin (Correct answer)
Cephalexin
Penicillin
Ampicillin-sulbactam

Correct answer: Vancomycin

Vancomycin is the drug of choice for MRSA because MRSA produces altered penicillin-binding proteins that confer resistance to all beta-lactam antibiotics.

Question 91: Which intervention is most appropriate for a patient experiencing alcohol withdrawal on day 2 of hospitalization?

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
Encourage ambulation and socialization

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

'Yes, crossing at the ankles is acceptable.'
'No, crossing your legs could dislocate your new hip.' (Correct answer)
'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 93: A nurse is teaching postpartum care to a new mother who had a vaginal delivery. Which instruction is most important for perineal wound care?

Avoid all pain medication to prevent transfer through breast milk
Take a full bath immediately after delivery
Use a peri-bottle with warm water after each toileting episode and apply ice packs in the first 24 hours (Correct answer)
Apply heat packs continuously for the first 48 hours

Correct answer: Use a peri-bottle with warm water after each toileting episode and apply ice packs in the first 24 hours

Using a peri-bottle rinses the perineum gently to prevent infection; ice packs in the first 24 hours reduce edema and pain at the episiotomy or laceration site.

Question 94: The nurse is caring for a patient with a serum sodium of 118 mEq/L receiving a hypertonic saline infusion. The nurse should monitor the patient most carefully for which complication?

Osmotic demyelination syndrome (Correct answer)
Hypokalemia
Metabolic alkalosis
Fluid volume deficit

Correct answer: Osmotic demyelination syndrome

Correcting hyponatremia too rapidly with hypertonic saline can cause osmotic demyelination syndrome, leading to permanent neurological damage.

Question 95: A patient in restraints must be reassessed at minimum every:

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

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 96: Which nursing action is most important to prevent central line-associated bloodstream infection (CLABSI)?

Flush the central line with heparin every 4 hours
Use a non-occlusive dressing at the insertion site
Use maximal sterile barrier precautions during CVC insertion (Correct answer)
Change the CVC dressing every 24 hours regardless of condition

Correct answer: Use maximal sterile barrier precautions during CVC insertion

Maximal sterile barrier precautions (cap, mask, sterile gown, sterile gloves, and full-body drape) during insertion are the most effective intervention to prevent CLABSI.

Question 97: The healthcare professional gives NPH insulin to a diabetic patient at 6:00 a.m. How soon might the patient exhibit hypoglycemic symptoms?

10:00 AM (Correct answer)
9:00 AM
7:00 AM
8:00 AM

Correct answer: 10:00 AM

NPH insulin is an intermediate-acting insulin with an onset of action typically 1-2 hours after administration and a peak effect occurring 4-12 hours later. If administered at 6:00 AM, the patient is most likely to experience hypoglycemic symptoms around the peak time, which would be 10:00 AM (4 hours after administration).

Question 98: 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?

Analyze root causes and plan a targeted intervention (Correct answer)
Implement a mandatory double-check policy immediately
Report the trend to the Joint Commission
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 99: A nurse is assisting a client with ambulation when the client says, 'I feel dizzy and my legs are giving out.' What should the nurse do first?

Lower the client gently to the floor using the nurse's body as a guide (Correct answer)
Return the client to the room immediately
Hold the client upright until help arrives
Call for help loudly before doing anything else

Correct answer: Lower the client gently to the floor using the nurse's body as a guide

Guiding the client to the floor controls the descent and prevents injury when a fall cannot be stopped, which is the safest immediate action.

Question 100: A young client with leukemia is having nausea and vomiting as a result of chemotherapy. Which of the following foods will be the BEST at now supplying enough nutrition?

Warm foods with a strong smell
Cold foods with no smell (Correct answer)
Low-calorie, clear liquids
High-protein, high-calories foods

Correct answer: Cold foods with no smell

Patients undergoing chemotherapy often experience nausea and vomiting, and strong food odors can exacerbate these symptoms. Cold foods tend to have less odor than warm foods, making them more palatable and easier to tolerate for patients with chemotherapy-induced nausea. Bland, cold, and odorless options are generally preferred to help maintain some nutritional intake during this challenging time.

Question 101: Which action by a nursing student during perineal care of a female client requires correction?

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

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 102: A nurse is caring for a patient on heparin infusion. The aPTT result is 3 times the control. The nurse should:

Increase the heparin rate per protocol
Hold the infusion and notify the provider (Correct answer)
Administer protamine sulfate immediately without an order
Continue the infusion and recheck in 6 hours

Correct answer: Hold the infusion and notify the provider

An aPTT three times the control indicates excessive anticoagulation; the infusion should be held and the provider notified.

Question 103: 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:

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

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 104: The medical professional is ready to provide a corticosteroid to a patient who has been diagnosed with asthma. What justification exists for giving this medication to this patient?

To promote bronchodilation
To promote expectoration of mucus
To prevent respiratory infections
To decrease airway swelling (Correct answer)

Correct answer: To decrease airway swelling

Corticosteroids are potent anti-inflammatory medications. In asthma, the primary problem is inflammation and swelling of the airways, leading to bronchoconstriction and increased mucus production. By decreasing airway swelling and inflammation, corticosteroids reduce airway hyperresponsiveness and improve airflow, making them crucial for long-term control of asthma symptoms.

Question 105: Which finding in a client receiving enteral tube feeding requires the most immediate nursing action?

Tube feeding rate of 60 mL/hr
Gastric residual of 150 mL
Oxygen saturation of 90% with new onset cough (Correct answer)
Blood glucose of 180 mg/dL

Correct answer: Oxygen saturation of 90% with new onset cough

New-onset cough with decreased oxygen saturation during tube feeding suggests aspiration, an immediate life-threatening complication.

Question 106: A patient with bipolar disorder in a manic episode is intrusive, demanding, and has not slept in 3 days. The nurse's priority intervention is:

Allow the patient to make all care decisions to promote autonomy
Provide a structured, low-stimulation environment and ensure rest and safety (Correct answer)
Encourage group therapy participation
Encourage physical exercise to channel excess energy

Correct answer: Provide a structured, low-stimulation environment and ensure rest and safety

A low-stimulation environment reduces sensory triggers that escalate mania; ensuring safety and rest are the physiological and behavioral priorities during acute mania.

Question 107: Which patient has the highest risk for developing a healthcare-associated infection (HAI)?

A 55-year-old post-operative patient ambulating independently on day 1
A 25-year-old admitted for an appendectomy with no comorbidities
A 45-year-old receiving IV antibiotics for community-acquired pneumonia
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 108: The nurse can request that unlicensed assistive personnel (UAP) perform ALL of the following EXCEPT

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

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 109: A postpartum patient develops a fever of 100.8°F (38.2°C) on day 3 after a vaginal delivery. Which assessment finding is most concerning for endometritis?

Uterine fundus midline and firm at the umbilicus
Lochia rubra with a fleshy odor
Foul-smelling lochia with uterine tenderness on palpation (Correct answer)
Mild breast engorgement with clear colostrum

Correct answer: Foul-smelling lochia with uterine tenderness on palpation

Foul-smelling lochia combined with uterine tenderness and fever after delivery are hallmark signs of endometritis, a uterine infection requiring antibiotic treatment.

Question 110: A patient's healthcare professional issues a Do-Not-Resuscitate (DNR) order following a discussion with the patient's family. When preparing treatment for this patient, what does the nurse comprehend?

DNR orders from a previous hospitalization will be valid and legal.
The patient and family no longer make medical decisions.
Death will take place within the next 72 hours, so the family should prepare.
Nursing care will continue with the treatment orders in place. (Correct answer)

Correct answer: Nursing care will continue with the treatment orders in place.

A Do-Not-Resuscitate (DNR) order means that in the event of cardiac or respiratory arrest, no resuscitative measures will be initiated. However, it does not mean that all medical care ceases. The nurse will continue to provide comfort care, manage symptoms, administer medications, and offer all other treatments aimed at improving the patient's quality of life, consistent with the patient's wishes and the established plan of care.

Question 111: Total parenteral nutrition (TPN) and lipids should be administered to a patient with an acute aggravation of inflammatory bowel disease. Which of these treatments should be given top priority while treating this patient?

Monitor urine specific gravity every shift
Monitor the patient's blood glucose per protocol (Correct answer)
Change the administration set every 72 hours
Infuse the solution in a large peripheral vein

Correct answer: Monitor the patient's blood glucose per protocol

TPN solutions are highly concentrated with dextrose, which can cause significant fluctuations in blood glucose levels, leading to hyperglycemia. Monitoring blood glucose per protocol is crucial to prevent complications like osmotic diuresis, dehydration, and electrolyte imbalances, making it a top priority.

Question 112: 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 113: A nurse is performing a neurological assessment on a patient with a head injury. Which finding indicates a deteriorating neurological status?

Complaint of a mild headache
Pupils that are equal and reactive to light at 3 mm
GCS score decreasing from 14 to 11 over 2 hours (Correct answer)
Blood pressure of 130/82 mmHg

Correct answer: GCS score decreasing from 14 to 11 over 2 hours

A declining GCS score indicates worsening neurological function and requires immediate provider notification.

Question 114: A client is admitted with suspected meningitis. Which assessment finding is most suggestive of bacterial meningitis?

Positive Kernig's sign and nuchal rigidity (Correct answer)
Generalized pruritic rash without fever
Gradual onset of mild headache and low-grade fever
Productive cough with purulent sputum

Correct answer: Positive Kernig's sign and nuchal rigidity

Positive Kernig's sign (inability to extend the knee when the hip is flexed) and nuchal rigidity are classic meningeal irritation signs associated with bacterial meningitis.

Question 115: The client with a tracheostomy is having his or her ties changed by the nurse. The following actions are the safest ways to adjust tracheostomy ties:

Hold the tracheostomy with the nondominant hand while removing the old tie.
Apply the new tie before removing the old one. (Correct answer)
Ask the doctor to suture the tracheostomy in place.
Have a helper present.

Correct answer: Apply the new tie before removing the old one.

When changing tracheostomy ties, it is crucial to apply the new ties *before* removing the old ones. This prevents accidental dislodgement of the tracheostomy tube, which could lead to airway obstruction or loss of the airway, a life-threatening emergency. Maintaining securement of the tube at all times is paramount for patient safety.

Question 116: 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 117: A patient with acute pancreatitis is prescribed nothing by mouth (NPO). The patient asks why they cannot eat. What is the nurse's best response?

'You need to rest your entire digestive system until you feel better.'
'Your labs show your lipase is too high to digest food safely.'
'We need to give your intestines time to recover from the infection.'
'Eating stimulates the pancreas to release enzymes that worsen inflammation.' (Correct answer)

Correct answer: 'Eating stimulates the pancreas to release enzymes that worsen inflammation.'

Oral intake stimulates pancreatic enzyme secretion, which causes autodigestion and worsens pancreatitis; NPO status allows the pancreas to rest.

Question 118: A patient refuses a blood transfusion based on religious beliefs. The nurse should:

Document the refusal and honor the patient's decision after confirming informed consent (Correct answer)
Override the refusal because the transfusion is life-saving
Administer the transfusion while the patient is sleeping
Ask the family to convince the patient to accept the transfusion

Correct answer: Document the refusal and honor the patient's decision after confirming informed consent

Competent adults have the legal and ethical right to refuse treatment regardless of medical consequences; the nurse must document, confirm understanding, and respect the decision.

Question 119: What types of personal medical data are covered by the HIPAA Privacy Rule?

Electronic
All of the above (Correct answer)
Verbal
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 120: A client using a walker is preparing to sit in a chair. What is the correct sequence of actions?

Sit first, then position the walker in front
Turn to face the chair, place the walker beside it, then sit
Back up to the chair, feel for the seat, then lower into the chair while holding the walker
Back up to the chair, place both hands on the armrests, then lower into the chair (Correct answer)

Correct answer: Back up to the chair, place both hands on the armrests, then lower into the chair

The client backs up, confirms contact with the chair, then transfers grip to the armrests for a stable, controlled seated transfer.

Question 121: 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
Progressive height increase of 4 inches each year
Yearly weight gain of about 5.5 pounds per year (Correct answer)

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 122: An RN is asked to float to an unfamiliar unit. Which action demonstrates safe and professional practice?

Refuse the assignment and clock out
Accept the assignment and communicate any limitations in competency to the charge nurse (Correct answer)
Perform all tasks independently to prove competence
Request that all complex patients be reassigned before accepting the float

Correct answer: Accept the assignment and communicate any limitations in competency to the charge nurse

Communicating scope limitations to the charge nurse ensures appropriate patient assignments and demonstrates professional accountability.

Question 123: A nurse is assessing a 6-month-old during a well-baby visit. Which developmental milestone should the infant have achieved?

Sitting with support and rolling over (Correct answer)
Pincer grasp and pulling to stand
Using two-word phrases
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 124: A patient with a penicillin allergy is prescribed cephalexin. The nurse should:

Administer a test dose first and observe for 30 minutes
Administer it without concern as there is no cross-reactivity
Hold the medication and notify the prescriber about the allergy history (Correct answer)
Substitute with azithromycin on nursing judgment

Correct answer: Hold the medication and notify the prescriber about the allergy history

There is a potential cross-reactivity between penicillins and cephalosporins; the prescriber must be notified to reassess.

Question 125: A charge nurse notices two staff members have a recurring interpersonal conflict that is affecting unit morale. What is the most appropriate initial action?

Issue formal disciplinary warnings to both staff members
Reassign one staff member to a different unit permanently
Ignore the conflict unless patient care is directly impacted
Meet privately with each staff member to hear their perspectives (Correct answer)

Correct answer: Meet privately with each staff member to hear their perspectives

Meeting individually with each party allows the charge nurse to gather unbiased perspectives before facilitating resolution.

Question 126: When providing oral hygiene to an unconscious client, what is the most important safety measure?

Position the client in a semi-Fowler's position
Perform mouth care every 4 hours
Place the client in a lateral position with head turned to the side (Correct answer)
Use a soft-bristle toothbrush

Correct answer: Place the client in a lateral position with head turned to the side

A lateral position with the head turned to the side uses gravity to prevent aspiration of fluids in an unconscious client.

Question 127: 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?

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)
Apply more force to complete the full range of motion
Administer the scheduled analgesic and resume exercises immediately

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 128: What is the appropriate way to respond to a patient at the senior living facility who throws his tray to the ground and yells, "This food is terrible! I can't stand this another minute!"

That was rude! Now you've ruined dinner for everyone else.
Let's find something you might like better. Tell me what sounds good. (Correct answer)
I'm sending you to your room. Another dinner will be delivered there.
You agreed to the behavior rules. Please return to your room.

Correct answer: Let's find something you might like better. Tell me what sounds good.

The most appropriate response is to address the patient's immediate need and feelings in a therapeutic and patient-centered manner. Offering to find something they might like better de-escalates the situation, validates their distress without condoning the behavior, and focuses on a practical solution. This approach maintains respect for the patient while ensuring their nutritional needs are met.

Question 129: A patient with heart failure is prescribed furosemide 40 mg IV. Which laboratory value should the nurse assess before and after administration?

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

Correct answer: Serum potassium

Furosemide is a loop diuretic that causes significant potassium wasting; hypokalemia can lead to dangerous cardiac dysrhythmias.

Question 130: A nurse is preparing a patient for a colonoscopy. Which finding in the patient's history requires immediate communication to the provider?

BMI of 32
Allergy to shellfish
Daily aspirin use for cardiac prophylaxis (Correct answer)
History of constipation

Correct answer: Daily aspirin use for cardiac prophylaxis

Antiplatelet agents like aspirin increase bleeding risk during colonoscopy with potential polypectomy; the provider must decide whether to hold the medication.

Question 131: A nurse is caring for a client with dysphagia. Which dietary modification is the priority safety intervention?

Thicken liquids to the consistency prescribed by the speech therapist (Correct answer)
Allow the client to self-feed without supervision
Serve all foods at room temperature
Offer three large meals to ensure adequate nutrition

Correct answer: Thicken liquids to the consistency prescribed by the speech therapist

Thickened liquids slow the flow of food/fluid to allow time for the impaired swallowing reflex to activate, directly reducing aspiration risk in dysphagia.

Question 132: When using motivational interviewing to help a patient with alcohol use disorder, which statement best reflects the technique?

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

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 133: A patient with myasthenia gravis is being treated with pyridostigmine. The nurse understands this drug works by:

Reducing autoantibody production
Blocking acetylcholine receptors at the neuromuscular junction
Inhibiting acetylcholinesterase to increase acetylcholine availability (Correct answer)
Stimulating beta-2 adrenergic receptors in muscle

Correct answer: Inhibiting acetylcholinesterase to increase acetylcholine availability

Pyridostigmine inhibits acetylcholinesterase, increasing available acetylcholine at the neuromuscular junction to improve muscle strength.

Question 134: The nurse should initially check the patient's ________ when evaluating a patient in the post-anesthesia care unit (PACU).

level of consciousness
level of pain
ability to move
respiratory status (Correct answer)

Correct answer: respiratory status

In the Post-Anesthesia Care Unit (PACU), the patient's respiratory status is the most critical initial assessment. Anesthesia can depress the respiratory drive and airway reflexes, making patients vulnerable to airway obstruction, hypoventilation, and hypoxemia. Ensuring a patent airway and adequate breathing is paramount to prevent life-threatening complications before addressing other concerns.

Question 135: Which step is most appropriate when providing postmortem care for a patient who will donate an eye?

Close the eyes and place the patient in a supine position.
Tape the eyes tightly and place the patient in a high Fowler's position.
Apply silver nitrate to the eyes and place the patient in a Trendelenburg position.
Cover the eyes with saline-soaked pads and place the patient in a low Fowler's position. (Correct answer)

Correct answer: Cover the eyes with saline-soaked pads and place the patient in a low Fowler's position.

When providing postmortem care for a patient who will donate an eye, it is crucial to maintain the integrity and moisture of the corneas. Covering the eyes with saline-soaked pads helps prevent drying and damage to the delicate tissues. Placing the patient in a low Fowler's position can help reduce blood pooling in the head, which is generally recommended for postmortem care, without compromising the eyes.

Question 136: Which lifestyle modification has the greatest impact on reducing cardiovascular disease risk in a patient with hypertension?

Taking daily aspirin without physician guidance
Avoiding all forms of exercise
Following the DASH diet and reducing sodium intake to less than 2,300 mg/day (Correct answer)
Eliminating all dietary fat

Correct answer: Following the DASH diet and reducing sodium intake to less than 2,300 mg/day

The DASH diet combined with sodium restriction of less than 2,300 mg/day is the most evidence-based lifestyle intervention for reducing blood pressure and cardiovascular risk.

Question 137: 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 potassium of 3.0 mEq/L (Correct answer)
BUN of 18 mg/dL
Heart rate of 68 beats/min
Serum digoxin level of 1.0 ng/mL

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 138: Monitoring the patient's vital signs is crucial when a healthcare professional is treating a patient with a cardiac dysrhythmia.

PT and INR
hemoglobin and hematocrit
sodium, potassium, and calcium (Correct answer)
BUN and creatinine

Correct answer: sodium, potassium, and calcium

Electrolytes such as sodium, potassium, and calcium play critical roles in cardiac function, particularly in the electrical conduction system and myocardial contractility. Imbalances in these electrolytes can lead to various cardiac dysrhythmias. Therefore, monitoring their levels is crucial when caring for a patient with a cardiac dysrhythmia to guide treatment and prevent further complications.

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

Sources & references

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