NCLEX-RN Exam — Questions and Answers

Question 1: A nurse is screening a 68-year-old male client for depression. Which validated screening tool is most appropriate?

Glasgow Coma Scale (GCS)
Patient Health Questionnaire-9 (PHQ-9) (Correct answer)
Braden Scale
Mini-Mental State Examination (MMSE)

Correct answer: Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 (Patient Health Questionnaire-9) is a validated, widely used screening tool for depression in adults. It assesses nine symptoms of depression and their frequency over the past two weeks.

Question 2: A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:

Is one of a series of injections that protects against dpt and Hib (Correct answer)
Is given to determine whether the child is susceptible to pertussis
Is a one-time injection that protects against MMR and varicella
Will need to be repeated when the child is 4 years of age

Correct answer: Is one of a series of injections that protects against dpt and Hib

Tetramune is a combination vaccine that provides protection against Diphtheria, Tetanus, Acellular Pertussis (DTaP), and Haemophilus influenzae type b (Hib). It is administered as part of a series of injections during infancy to build immunity against these serious childhood diseases.

Question 3: A clinic nurse interviews a parent who is suspected of abusing her child. Which of the following characteristics is the nurse LEAST likely to find in an abusing parent?

Single status.
Self-blame for the injury to the child. (Correct answer)
Low self-esteem.
Unemployment

Correct answer: Self-blame for the injury to the child.

Abusing parents often exhibit characteristics such as low self-esteem, social isolation, and a lack of empathy, frequently externalizing blame for their actions. While they may express regret or remorse, genuine self-blame for the injury to the child is less common, as they often rationalize or deny their behavior. Instead, they might blame the child, other family members, or external stressors.

Question 4: A nurse is providing health education to a 45-year-old female client with no risk factors. Which cancer screening test should the nurse recommend at this time?

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

Correct answer: Annual mammogram

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

Question 5: Which common side effect should the nurse expect with nitroglycerin?

Constipation
Throbbing headache (Correct answer)
Bradycardia
Hyperglycemia

Correct answer: Throbbing headache

Vasodilation from nitroglycerin commonly causes headache.

Question 6: A patient who was recently diagnosed with cancer says, 'I don't know why I should bother with treatment. I'm going to die anyway.' Which response by the nurse is most therapeutic?

'You shouldn't think that way — many people beat cancer.'
'You need to stay positive. A negative attitude won't help your recovery.'
'I understand how you feel. My aunt had cancer too.'
'It sounds like you're feeling hopeless about your diagnosis. Tell me more about what you're thinking.' (Correct answer)

Correct answer: 'It sounds like you're feeling hopeless about your diagnosis. Tell me more about what you're thinking.'

Reflecting the patient's emotions and using an open-ended statement invites the patient to express their feelings more fully — a core therapeutic communication technique. Telling the patient not to think a certain way is dismissive. Sharing a personal story shifts focus from the patient. Demanding positivity minimizes the patient's distress.

Question 7: A patient with post-traumatic stress disorder (PTSD) is being assessed. Which symptom is NOT a diagnostic criterion for PTSD?

Intrusive re-experiencing of the trauma (flashbacks)
Avoidance of stimuli associated with the trauma
Hypervigilance and exaggerated startle response
Persistent elevated mood and euphoria (Correct answer)

Correct answer: Persistent elevated mood and euphoria

PTSD is characterized by intrusion symptoms, avoidance, negative cognitions/mood changes (not elevated mood), and hyperarousal/reactivity. Persistent elevated mood and euphoria are not PTSD criteria.

Question 8: Rhogam is most often used to treat mothers that have a infant.

RH negative, RH positive (Correct answer)
RH positive, RH negative
RH negative, RH negative
RH positive, RH positive

Correct answer: RH negative, RH positive

Rhogam (Rh immune globulin) is administered to Rh-negative mothers who are pregnant with or have delivered an Rh-positive infant. Its purpose is to prevent the mother's immune system from developing antibodies against the Rh-positive fetal red blood cells, which could lead to hemolytic disease in subsequent Rh-positive pregnancies. This intervention is critical for preventing Rh sensitization and protecting future babies.

Question 9: A nurse is conducting a suicide risk assessment using the SAD PERSONS mnemonic. Which factor should the nurse assess?

Sleep patterns and appetite disturbance
Social engagement levels and activity
Self-esteem and daily living functioning
Sex, age, depression, previous attempts, ethanol use, rational thinking loss, social support lacking, organized plan, no spouse, and sickness (Correct answer)

Correct answer: Sex, age, depression, previous attempts, ethanol use, rational thinking loss, social support lacking, organized plan, no spouse, and sickness

SAD PERSONS is a validated suicide risk assessment tool. Each letter represents a risk factor: Sex, Age, Depression, Previous attempt, Ethanol, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness.

Question 10: The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply.

“I can use regular plate and utensils whenever I eat.” (Correct answer)
“I should use paper tissues to cough in and dispose of them properly.” (Correct answer)
“It is important that I isolate myself from family when possible.”
“I will need to dispose of my old clothing when I return home.”
“I should always cover my mouth and nose when sneezing.” (Correct answer)

Correct answer: “I can use regular plate and utensils whenever I eat.”

Tuberculosis is primarily spread through airborne droplets when an infected person coughs, sneezes, or speaks. Therefore, covering the mouth and nose when sneezing and properly disposing of tissues used for coughing are crucial to prevent droplet transmission. TB is not spread through shared eating utensils, so using regular plates and utensils is acceptable, indicating correct understanding of transmission routes.

Question 11: Abrupt discontinuation of a beta-blocker can cause which dangerous rebound effect?

Hypoglycemia
Rebound tachycardia and hypertension (Correct answer)
Respiratory depression
Severe bradycardia

Correct answer: Rebound tachycardia and hypertension

Stopping beta-blockers abruptly can cause rebound hypertension and angina.

Question 12: A client with heart failure is prescribed furosemide (Lasix). Which laboratory value should the nurse monitor most closely?

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

Correct answer: Serum potassium

Furosemide is a loop diuretic that causes the kidneys to excrete potassium along with water. Hypokalemia is the most common and clinically significant electrolyte imbalance associated with furosemide use and can lead to dangerous cardiac dysrhythmias, making serum potassium the priority lab value to monitor.

Question 13: What is the focus of the evaluation phase in the nursing process?

Rewriting the patient’s diagnosis
Providing medication to the patient
Assessing only the patient’s physical health
Determining if patient goals were met and modifying the care plan if needed (Correct answer)

Correct answer: Determining if patient goals were met and modifying the care plan if needed

The evaluation phase is the final, yet continuous, step of the nursing process. Its focus is to determine if the patient's established goals were met as a result of the nursing interventions. If goals are not met or new issues arise, the nurse critically analyzes the care plan and modifies it as necessary, ensuring the nursing process remains dynamic and responsive to the patient's evolving needs.

Question 14: A client with chronic obstructive pulmonary disease (COPD) has an order for morphine 2 mg IV for pain. The nurse is aware of the client's condition but notes the pain is moderate-severe (7/10). What is the most appropriate action?

Request a change to a non-opioid analgesic before any administration
Administer half the dose and increase if needed
Refuse to administer the opioid and document the refusal
Administer the morphine as ordered, monitor respiratory rate and SpO₂ closely, and have naloxone available (Correct answer)

Correct answer: Administer the morphine as ordered, monitor respiratory rate and SpO₂ closely, and have naloxone available

Opioids are not absolutely contraindicated in COPD. Undertreated pain also impairs respiratory effort by limiting deep breathing. The nurse should administer the morphine as ordered while closely monitoring respiratory rate (hold if < 12/min), SpO₂, and level of consciousness. Naloxone should be readily available. The benefit-risk ratio is acceptable in this scenario.

Question 15: How should the nurse respond to a patient who refuses care?

Tell the patient that refusing care may worsen their condition
Ignore the refusal and proceed with care
Force the patient to comply for their own good
Respect the patient's decision and explore their concerns (Correct answer)

Correct answer: Respect the patient's decision and explore their concerns

Patients have the right to self-determination and can refuse medical treatment, even if it is deemed beneficial. The nurse's ethical responsibility is to respect this autonomy, while also exploring the underlying reasons for refusal to ensure the patient is fully informed and to address any misconceptions or fears.

Question 16: A pregnant client asks when she will first feel fetal movement (quickening). What is the nurse's best response?

Around 28 to 30 weeks
Around 16 to 20 weeks (Correct answer)
Around 8 to 10 weeks
Only in the last week

Correct answer: Around 16 to 20 weeks

Quickening, the first felt fetal movement, typically occurs between 16 and 20 weeks of gestation.

Question 17: A client with hypothyroidism is prescribed levothyroxine (Synthroid). Which instruction is most important?

Take the medication with a calcium supplement for better absorption
Take at bedtime to minimize side effects
Take with food to prevent GI upset
Take on an empty stomach 30–60 minutes before breakfast for optimal absorption (Correct answer)

Correct answer: Take on an empty stomach 30–60 minutes before breakfast for optimal absorption

Levothyroxine is best absorbed when taken on an empty stomach, 30–60 minutes before the first meal. Many foods, supplements (calcium, iron, antacids), and medications reduce absorption. Consistent dosing time is important for maintaining stable thyroid hormone levels.

Question 18: A nurse is reviewing an incident report after a client fell in the hallway. Which statement about incident reports is correct?

Incident reports are filed only when client injury results from the event
The incident report is a legal document admissible in court as evidence
The incident report is an internal quality improvement tool and should not be mentioned in the chart (Correct answer)
The incident report should be referenced in the client's medical record

Correct answer: The incident report is an internal quality improvement tool and should not be mentioned in the chart

Incident reports are internal quality improvement documents used to analyze and prevent adverse events. They should not be referenced in the medical record, as this can make them discoverable in litigation. The event itself is charted in the medical record.

Question 19: A nurse is asked to float to the pediatric unit. The nurse's usual unit is adult medical-surgical. Which action is most appropriate before beginning care?

Administer medications to pediatric clients using adult dosing guidelines
Accept the assignment and care for any client without seeking guidance
Refuse the float assignment as it is outside the nurse's competency
Inform the charge nurse of the unit about your competency limitations and request appropriate client assignments (Correct answer)

Correct answer: Inform the charge nurse of the unit about your competency limitations and request appropriate client assignments

The nurse should accept the float assignment while transparently communicating specific competency limitations to the receiving unit's charge nurse. This ensures the nurse receives appropriate assignments and support, maintaining patient safety.

Question 20: A child with sickle cell disease presents to the emergency department with severe bone pain, fever, and swelling in the hands and feet. What condition does this most likely represent?

Hyperhemolytic crisis
Aplastic crisis due to parvovirus B19
Splenic sequestration crisis
Vaso-occlusive (pain) crisis (Correct answer)

Correct answer: Vaso-occlusive (pain) crisis

Vaso-occlusive (pain) crisis is the most common sickle cell complication, caused by sickling of RBCs in small vessels. Dactylitis (swelling of hands/feet) is a classic early presentation in young children.

Question 21: A nurse is caring for a patient on bed rest. Which intervention is most important to prevent deep vein thrombosis (DVT)?

Keep the patient's legs crossed at the ankles while in bed
Encourage the patient to flex and extend the ankles every 1–2 hours (Correct answer)
Apply ice packs to the lower extremities every 4 hours
Position the patient in a prone position for most of the day

Correct answer: Encourage the patient to flex and extend the ankles every 1–2 hours

Active ankle flexion and extension (ankle pumps) promotes venous return from the lower extremities, reducing the risk of DVT in immobile patients. Crossing the legs compresses blood vessels and increases DVT risk. Sequential compression devices and anticoagulants may also be prescribed.

Question 22: A client's ABG results show: pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the nurse interpret these results?

Compensated respiratory acidosis
Uncompensated respiratory alkalosis
Compensated metabolic acidosis
Uncompensated respiratory acidosis (Correct answer)

Correct answer: Uncompensated respiratory acidosis

ABG interpretation: pH 7.30 is acidosis (normal 7.35–7.45). PaCO2 52 mmHg is elevated (normal 35–45), indicating the problem is respiratory (CO2 is an acid — elevated CO2 = more acid). HCO3 24 mEq/L is normal (normal 22–26), meaning the kidneys have not yet compensated. Therefore, this is uncompensated respiratory acidosis, commonly seen in hypoventilation, COPD exacerbation, or sedation.

Question 23: A nurse is caring for a client who has just been told they need an above-knee amputation due to vascular disease. The client refuses to discuss the surgery and asks about the cafeteria hours. Which stage of the Kübler-Ross model does this behavior represent?

Denial (Correct answer)
Anger
Bargaining
Acceptance

Correct answer: Denial

Avoiding discussion of the surgery and redirecting to mundane topics (cafeteria hours) after receiving devastating news is classic avoidant denial — the client is psychologically retreating from the overwhelming reality of the diagnosis.

Question 24: The nurse is administering amlodipine (Norvasc) to a patient. Which food should the nurse advise the patient to avoid?

Grapefruit juice (Correct answer)
Bananas
Leafy green vegetables
Dairy products

Correct answer: Grapefruit juice

Grapefruit juice inhibits CYP3A4 enzymes in the gut, increasing amlodipine blood levels and risk of hypotension and adverse effects.

Question 25: A nurse has identified the nursing diagnosis 'Risk for infection related to impaired skin integrity.' In the planning phase, which outcome is written correctly using SMART criteria?

The client will have a better wound by the end of the week
The client will remain free of signs of wound infection as evidenced by no erythema, edema, or purulent drainage by day 3 (Correct answer)
The nurse will change the wound dressing every day
The client will understand wound care before discharge

Correct answer: The client will remain free of signs of wound infection as evidenced by no erythema, edema, or purulent drainage by day 3

A correctly written SMART nursing outcome is Specific, Measurable, Achievable, Relevant, and Time-bound. 'Free of signs of infection as evidenced by no erythema, edema, or purulent drainage by day 3' includes observable criteria and a timeline. Nurse-focused statements are not appropriate client outcomes.

Question 26: During a care transition, the nurse realizes that a client's medication list from the transferring facility omits a daily blood thinner. What is the nurse's priority action?

Perform medication reconciliation by contacting the transferring provider to verify the complete list (Correct answer)
Administer a standard dose based on the client's weight and diagnosis
Add the medication to the MAR based on the client's verbal report
Hold all medications until the family can bring the original bottles

Correct answer: Perform medication reconciliation by contacting the transferring provider to verify the complete list

Medication reconciliation at transitions of care is a critical safety process. The nurse must verify the complete and accurate medication list with the previous provider before administering anything. Administering unverified medications can cause serious harm.

Question 27: A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?

Report chest pain. (Correct answer)
Take the medication with milk.
Allow 6 weeks for optimal effects.
Remain upright after taking for 30 minutes.

Correct answer: Report chest pain.

Celecoxib (Celebrex) is a COX-2 inhibitor, a type of NSAID, which carries a black box warning due to an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke. Therefore, instructing the client to report chest pain is a critical safety measure. This warning highlights the importance of monitoring for cardiac symptoms.

Question 28: A nurse identifies that a colleague has been administering a medication without checking the client's armband for identification. Which action is most appropriate?

Report the colleague to the nursing board immediately
Approach the colleague privately and address the safety concern (Correct answer)
Ignore the behavior since no harm has occurred yet
Document the observation in the client's medical record

Correct answer: Approach the colleague privately and address the safety concern

The most appropriate initial action is to approach the colleague privately and address the safety concern professionally. This is a patient safety issue that requires peer intervention, which is part of a culture of safety.

Question 29: The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?

“If they don’t use chalk to autograph, it is okay.”
“Because the cast is made of plaster, autographing can weaken the cast.”
“Autographing or writing on the cast in any form will harm the cast.”
“It will be alright for your friends to autograph the cast.” (Correct answer)

Correct answer: “It will be alright for your friends to autograph the cast.”

Fiberglass casts are known for their durability and water-resistant properties, making them quite robust. Writing on a fiberglass cast with markers or pens will not compromise its structural integrity or effectiveness. Unlike plaster casts, which can be weakened by moisture, fiberglass casts can be safely autographed without harm.

Question 30: A nurse is teaching a 45-year-old male client with a family history of colorectal cancer about cancer screening. Which recommendation is most appropriate?

Begin colonoscopy screening at age 50, which is standard for all adults
Start colonoscopy screening at age 40, ten years before the youngest affected relative (Correct answer)
Colorectal cancer screening is only necessary if the client develops rectal bleeding
Obtain a fecal occult blood test annually and defer colonoscopy until symptoms appear

Correct answer: Start colonoscopy screening at age 40, ten years before the youngest affected relative

For individuals with a first-degree relative diagnosed with colorectal cancer, guidelines recommend beginning colonoscopy screening at age 40 or 10 years before the earliest diagnosis in the family, whichever comes first. Early screening detects precancerous polyps.

Question 31: Which of the following is an important part of discharge planning?

To prevent patients from leaving the facility until fully recovered
To provide the patient with minimal instructions about their recovery
To ensure the patient has all necessary prescriptions and follow-up appointments (Correct answer)
To discharge the patient as quickly as possible

Correct answer: To ensure the patient has all necessary prescriptions and follow-up appointments

Discharge planning is a critical process designed to ensure a smooth and safe transition for the patient from the healthcare facility to home or another care setting. A key component is providing comprehensive instructions, including all necessary prescriptions, follow-up appointments, and contact information. This proactive approach helps prevent complications, reduces the risk of readmission, and supports the patient's continued recovery and self-management.

Question 32: A practical nurse is assisting in the care of a client with a tracheostomy. Which action is essential to maintain airway patency?

Provide tracheostomy care and assess for signs of obstruction regularly (Correct answer)
Limit oral fluid intake to reduce secretions
Keep the tracheostomy cuff deflated at all times
Suction the tracheostomy every 30 minutes on a fixed schedule

Correct answer: Provide tracheostomy care and assess for signs of obstruction regularly

Regular tracheostomy care and assessment for obstruction are essential to maintain a patent airway and prevent complications.

Question 33: A nurse is asked to perform a procedure outside their competency. What should the nurse do?

Perform it to avoid delay
Ask the patient to consent verbally
Have a UAP do it instead
Decline and notify the supervisor (Correct answer)

Correct answer: Decline and notify the supervisor

Nurses must decline tasks outside their competence and notify the supervisor for safety.

Question 34: A nurse is caring for four clients. Which client should the nurse assess first?

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

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

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

Question 35: A nurse is providing care for a patient on mechanical ventilation. The high-pressure alarm sounds on the ventilator. What is the nurse's first action?

Manually ventilate the patient with a bag-valve mask while assessing the cause (Correct answer)
Increase the tidal volume setting
Silence the alarm and continue monitoring
Turn off the ventilator and contact respiratory therapy

Correct answer: Manually ventilate the patient with a bag-valve mask while assessing the cause

When a ventilator alarm sounds, the first priority is the patient's safety. If the cause is not immediately apparent, the nurse should disconnect the patient from the ventilator and manually ventilate with a bag-valve mask while assessing for the cause (secretions, kinked tubing, biting the tube, bronchospasm, etc.).

Question 36: A nurse is monitoring a client who has been taking lithium carbonate for bipolar disorder. Which serum lithium level indicates toxicity requiring immediate intervention?

1.4 mEq/L
1.0 mEq/L
2.2 mEq/L (Correct answer)
0.7 mEq/L

Correct answer: 2.2 mEq/L

The therapeutic range for lithium is 0.6–1.2 mEq/L (up to 1.5 mEq/L during acute mania). A level of 2.2 mEq/L falls well above this range and indicates toxicity, which can cause tremors, confusion, seizures, and cardiac dysrhythmias.

Question 37: Which of the following articles would Kevin least consider for his review of literature?

“Turnaround Time in Emergency Rooms” (Correct answer)
“Story-Telling and Anxiety Reduction Among Pediatric Patients”
“Environmental Manipulation and Client Outcomes”
“Outcome Standards in Tertiary Health Care Institutions”

Correct answer: “Turnaround Time in Emergency Rooms”

Kevin's study aims to determine the level of patient satisfaction on the care they received from the hospital. Articles related to 'Story-Telling and Anxiety Reduction,' 'Outcome Standards,' and 'Environmental Manipulation' are relevant to patient care and outcomes, which could influence satisfaction. 'Turnaround Time in Emergency Rooms,' while a hospital operational metric, is less directly related to patient satisfaction with overall care in a general hospital admission context.

Question 38: What is the primary focus of management of care in nursing?

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

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

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

Question 39: A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:

Will need to be repeated when the child is 4 years of age
Is one of a series of injections that protects against dpt and Hib (Correct answer)
Is a one-time injection that protects against MMR and varicella
Is given to determine whether the child is susceptible to pertussis

Correct answer: Is one of a series of injections that protects against dpt and Hib

Tetramune is a combination vaccine that provides protection against Diphtheria, Tetanus, Pertussis (DTaP), and Haemophilus influenzae type b (Hib). It is administered as part of a series of injections during infancy and early childhood. This multi-component vaccine helps protect against several serious childhood diseases with fewer injections.

Question 40: A nurse is caring for a client who had a thyroidectomy 12 hours ago. The client reports tingling around the mouth and in the fingertips. Which complication should the nurse suspect?

Hemorrhage at the surgical site
Hypocalcemia from accidental parathyroid removal (Correct answer)
Thyroid storm
Laryngeal nerve damage

Correct answer: Hypocalcemia from accidental parathyroid removal

Tingling around the mouth and in the extremities (perioral and peripheral paresthesias) are classic early signs of hypocalcemia, which can occur after thyroidectomy if the parathyroid glands are inadvertently removed or damaged. This is a priority assessment finding that requires immediate provider notification and calcium monitoring.

Question 41: A nurse is caring for a post-operative patient who reports pain of 8/10 and has an order for morphine sulfate. Before administering the medication, which assessment is the priority?

Respiratory rate (Correct answer)
Blood pressure
Temperature
Heart rate

Correct answer: Respiratory rate

Morphine is an opioid analgesic that causes central nervous system and respiratory depression. Assessing respiratory rate before administration is the priority because administering morphine to a patient with already compromised respirations can cause respiratory arrest. A respiratory rate below 12 breaths per minute typically contraindicates opioid administration.

Question 42: The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?

Reluctance to swallow
Drooling of blood-tinged saliva
An axillary temperature of 99°F
Respiratory stridor (Correct answer)

Correct answer: Respiratory stridor

Respiratory stridor in a child following a tonsillectomy is a critical finding that indicates airway obstruction. This could be due to swelling, hematoma formation, or laryngospasm, which are life-threatening complications. Immediate reporting is necessary to prevent respiratory distress and potential arrest, making it the most urgent concern among the options.

Question 43: A patient is prescribed sublingual nitroglycerin for angina. What instruction is correct if pain persists?

Take 5 tablets immediately
Swallow the tablet with water
Take up to 3 tablets 5 minutes apart, then call 911 if unrelieved (Correct answer)
Wait 30 minutes between doses

Correct answer: Take up to 3 tablets 5 minutes apart, then call 911 if unrelieved

Up to 3 doses 5 minutes apart are allowed; unrelieved pain requires emergency care.

Question 44: During assessment, a client with diabetes reports excessive thirst and frequent urination. What should the nurse do first?

Restrict the client’s fluid intake.
Encourage the client to lie down and rest.
Give the next scheduled insulin dose early.
Check the client’s blood glucose level. (Correct answer)

Correct answer: Check the client’s blood glucose level.

Excessive thirst (polydipsia) and frequent urination (polyuria) are hallmark symptoms of hyperglycemia, or high blood glucose, in clients with diabetes. The nurse's priority is to check the client's blood glucose level to confirm hyperglycemia and guide immediate treatment, such as insulin administration. This assessment is crucial for managing the client's diabetic condition.

Question 45: A patient who cannot tolerate an ACE inhibitor cough may be switched to which drug ending in '-sartan'?

Amlodipine
Hydrochlorothiazide
Losartan (an ARB) (Correct answer)
Metoprolol

Correct answer: Losartan (an ARB)

ARBs like losartan provide similar effects without the bradykinin cough.

Question 46: A patient prescribed metformin is scheduled for a CT scan with IV contrast. What is the nurse's priority action?

Double the metformin dose to prevent contrast-induced hyperglycemia
Administer metformin as usual and monitor blood glucose during the scan
Hold the metformin on the day of the procedure and 48 hours after (Correct answer)
Cancel the scan as contrast is absolutely contraindicated with metformin

Correct answer: Hold the metformin on the day of the procedure and 48 hours after

IV contrast can cause acute kidney injury, reducing metformin excretion and increasing the risk of lactic acidosis. Metformin is held before/on the day of contrast and resumed 48 hours after if kidney function is normal.

Question 47: A client is receiving warfarin therapy for atrial fibrillation. The INR result returns at 4.8. The client has no signs of bleeding. Which intervention should the nurse anticipate?

Administer vitamin K and hold the next warfarin dose as ordered (Correct answer)
Continue the current warfarin dose and recheck the INR in one week
Increase the warfarin dose to stabilize the INR
Give protamine sulfate to reverse anticoagulation

Correct answer: Administer vitamin K and hold the next warfarin dose as ordered

An INR of 4.8 is supratherapeutic (therapeutic range for atrial fibrillation is 2.0–3.0). With no active bleeding, the expected interventions are holding the warfarin dose and possibly giving vitamin K as ordered. Protamine sulfate reverses heparin, not warfarin. Increasing the dose would be dangerous.

Question 48: The PN is caring for a client receiving continuous oxygen via nasal cannula at 4 L/min. The client's SpO₂ is 96%. Which assessment finding indicates the oxygen therapy is achieving its goal?

The client is drowsy with a respiratory rate of 22 breaths per minute
The client's SpO₂ has decreased to 88% over the past hour
The client has a PaCO₂ of 58 mmHg
The client is alert, oriented, and their lips and nailbeds are pink (Correct answer)

Correct answer: The client is alert, oriented, and their lips and nailbeds are pink

SpO₂ 96% with alert orientation, pink lips and nailbeds, and a comfortable respiratory rate indicates adequate oxygenation is being maintained. Drowsiness can indicate CO₂ retention (especially in COPD). Elevated PaCO₂ indicates CO₂ retention. Decreasing SpO₂ indicates oxygen therapy is insufficient. Clinical assessment of oxygenation combines SpO₂ with neurological and color assessment.

Question 49: A patient who delivered 2 hours ago is noted to have a soft, boggy uterus displaced to the right of the umbilicus. What is the priority nursing action?

Call the provider for surgical consultation
Increase IV fluid rate and apply a compression bandage
Administer oxytocin IV bolus
Have the patient void, then perform uterine massage (Correct answer)

Correct answer: Have the patient void, then perform uterine massage

A displaced uterus is caused by bladder distension. A full bladder displaces the uterus and prevents proper uterine contraction (atony). Voiding is the priority before massage to correct the displacement.

Question 50: A nurse is participating in a root cause analysis (RCA) following a medication error that reached a client. Which statement best describes the purpose of an RCA?

To determine whether the error was intentional or accidental
To provide documentation for the client's legal malpractice claim
To identify systemic factors and process failures that contributed to the error (Correct answer)
To identify and discipline the individual nurse responsible for the error

Correct answer: To identify systemic factors and process failures that contributed to the error

Root cause analysis is a structured quality improvement process that examines the system-level factors, processes, and conditions that contributed to an adverse event — not to assign individual blame, but to prevent recurrence.

Question 51: Which of the following is an example of tertiary prevention in health promotion?

Rehabilitation after a stroke (Correct answer)
Vaccinating against disease
Screening for hypertension
Teaching healthy eating habits

Correct answer: Rehabilitation after a stroke

Tertiary prevention aims to minimize the long-term impact of an existing disease or disability, focusing on rehabilitation and restoring optimal function. Rehabilitation after a stroke is a prime example, as it helps individuals regain lost abilities, manage chronic conditions, and improve their quality of life. Vaccinating (primary) and screening (secondary) are different levels of prevention.

Question 52: A patient with atrial fibrillation is prescribed amiodarone. Which finding requires immediate provider notification?

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

Correct answer: QTc interval of 520 milliseconds

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

Question 53: Which assessment finding in a newborn at 24 hours of life requires the nurse to immediately notify the provider?

Cephalhematoma from vacuum extraction
Milia on the nose and cheeks
Jaundice (yellow discoloration) visible at 24 hours of life (Correct answer)
Epstein pearls on the hard palate

Correct answer: Jaundice (yellow discoloration) visible at 24 hours of life

Jaundice appearing within the first 24 hours of life is pathologic (not physiologic) and requires immediate evaluation. It suggests hemolytic disease (ABO or Rh incompatibility) requiring urgent bilirubin measurement.

Question 54: The nurse is assessing an elderly client for depression. Which screening tool is most appropriate for older adults?

Hamilton Anxiety Rating Scale
Geriatric Depression Scale (GDS) (Correct answer)
PHQ-2 alone without further assessment
Beck Depression Inventory (BDI-II)

Correct answer: Geriatric Depression Scale (GDS)

The Geriatric Depression Scale (GDS) was specifically developed and validated for use in older adults. It uses simple yes/no questions and avoids questions about somatic symptoms (fatigue, appetite, sleep) that are common in the elderly regardless of depression, making it more specific for this population than tools developed for general adults.

Question 55: A nurse is providing nutrition education to a pregnant client in the first trimester. Which nutrient deficiency is most likely to cause neural tube defects in the developing fetus?

Vitamin D
Iron
Folic acid (Correct answer)
Calcium

Correct answer: Folic acid

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

Question 56: A patient is receiving IV dopamine. The nurse notes the infusion infiltrated the IV site. Which action is the priority?

Slow the infusion rate and continue monitoring
Restart the IV with a larger gauge catheter
Stop the infusion and prepare to administer phentolamine locally (Correct answer)
Apply a warm compress to the site

Correct answer: Stop the infusion and prepare to administer phentolamine locally

Dopamine extravasation causes severe vasoconstriction and local tissue necrosis. Phentolamine (an alpha-adrenergic blocker) should be infiltrated locally to counteract vasoconstriction and prevent tissue damage.

Question 57: A nurse realizes that a late entry must be added to the patient's chart for an assessment performed 2 hours ago. What is the correct approach?

Leave it out — late entries are not permitted in medical documentation
Write a new entry with the current date and time, noting it as a late entry for the original time (Correct answer)
Add the note between existing entries and use the current date and time
Insert the note in chronological order by back-dating it to the original time

Correct answer: Write a new entry with the current date and time, noting it as a late entry for the original time

Late entries are permitted and are sometimes necessary. The note should be entered with the current date and time and labeled 'late entry for [original date and time].' Back-dating documentation is fraudulent. Late entries maintain the completeness of the health record.

Question 58: A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?

A client who requires wound irrigation
A client who requires frequent vital signs after a cardiac catheterization
A client who requires frequent ambulation (Correct answer)
A client who is receiving continuous tube feedings

Correct answer: A client who requires frequent ambulation

Following a lumbar puncture, key interventions focus on preventing complications. Maintaining a flat position helps reduce the risk of post-lumbar puncture headache by minimizing CSF leakage. Monitoring the client's ability to void and move extremities assesses for potential nerve damage or spinal cord compression, while inspecting the puncture site checks for infection or CSF leakage, ensuring early detection of adverse events.

Question 59: A nurse is caring for a client with a new diagnosis of terminal cancer who has just been told their prognosis. The client says, 'I think there's been a mistake. The tests must be wrong.' Which stage of the Kübler-Ross grief model does this represent?

Depression
Anger
Bargaining
Denial (Correct answer)

Correct answer: Denial

Denial is the first stage of the Kübler-Ross grief model and involves refusing to accept the reality of a diagnosis or prognosis. Statements such as 'there must be a mistake' or 'the tests are wrong' are classic expressions of denial.

Question 60: The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1.006. The nurse recognizes that:

The client has a normal specific gravity. (Correct answer)
The client has impaired renal function.
The client has diluted urine from fluid overload.
The client has mild to moderate dehydration.

Correct answer: The client has a normal specific gravity.

The normal range for urine specific gravity is typically 1.005 to 1.030. A specific gravity of 1.006 falls within this normal range, indicating that the client's urine concentration is appropriate. This value does not suggest impaired renal function, dehydration, or fluid overload.

Question 61: The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?

The nurse wears gloves to take the client’s vital signs. (Correct answer)
The doctor washes his hands before examining the client.
The nursing assistant wears gloves while giving the client a bath.
The nurse wears goggles while drawing blood from the client.

Correct answer: The nurse wears gloves to take the client’s vital signs.

Routine vital signs, such as temperature, pulse, respirations, and blood pressure, do not typically involve contact with blood, body fluids, or non-intact skin. Therefore, wearing gloves for these routine assessments is generally unnecessary and indicates a misunderstanding of standard precautions and when personal protective equipment is required.

Question 62: What is the purpose of pharmacokinetics in nursing practice?

To administer medication without understanding its action
To determine the drug's effectiveness
To identify side effects of the drug
To understand how the drug is absorbed, distributed, metabolized, and excreted (Correct answer)

Correct answer: To understand how the drug is absorbed, distributed, metabolized, and excreted

Pharmacokinetics describes the movement of drugs within the body, encompassing the processes of absorption, distribution, metabolism, and excretion (ADME). Understanding these processes allows nurses to predict how a drug will behave in a patient, optimize dosing, minimize adverse effects, and ensure therapeutic efficacy. It is fundamental to safe and effective medication administration.

Question 63: A nurse is caring for a client who has been placed in restraints per physician order. Which action is required by The Joint Commission standards?

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

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

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

Question 64: Which individual is at greatest risk for developing hypertension?

40-year-old Caucasian nurse
40-year-old Caucasian nurse
45 year-old African American attorney (Correct answer)
60-year-old Asian American shop owner

Correct answer: 45 year-old African American attorney

The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

Question 65: The nurse is caring for a patient receiving IV heparin. Which lab value is used to monitor heparin therapy?

aPTT (Correct answer)
Bleeding time
PT/INR
Platelet count only

Correct answer: aPTT

The aPTT (activated partial thromboplastin time) is used to monitor unfractionated heparin therapy. Therapeutic range is typically 60–100 seconds (1.5–2.5 times normal).

Question 66: You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?

Assessing for bilateral breath sounds and symmetrical chest movements
Ordering a chest radiograph to verify that tube placement is correct
Auscultating over the stomach to rule out esophageal intubation
Marking the tube 1 cm from where it touches the incisor tooth or nares (Correct answer)

Correct answer: Marking the tube 1 cm from where it touches the incisor tooth or nares

The nurse must intervene immediately if the student marks the endotracheal tube 1 cm from where it touches the incisor tooth or nares. After intubation, the tube should be secured at the appropriate depth, and the measurement at the incisor or nares should be noted and documented to monitor for displacement. Marking it 1 cm away is not a standard practice and could lead to incorrect depth assessment or accidental dislodgement, compromising the patient's airway.

Question 67: A nurse manager notices that several nurses on the unit consistently bypass the two-patient identifier protocol before administering medications. The most effective management intervention is to:

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

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

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

Question 68: A nurse is working with a client who has been experiencing domestic violence. The client is not ready to leave the relationship. Which response by the nurse is most appropriate?

'I understand this is your choice. I am here to support you and provide resources when you are ready.' (Correct answer)
'Have you considered that you may be contributing to the situation?'
'You need to leave immediately — staying puts your life at risk.'
'I will need to report this to the police on your behalf for your safety.'

Correct answer: 'I understand this is your choice. I am here to support you and provide resources when you are ready.'

Respecting client autonomy is essential in domestic violence situations. Research shows that pressuring a victim to leave before they are ready can be dangerous. The nurse's role is to provide safety information, resources, and non-judgmental support without coercing the client.

Question 69: A nurse is caring for a competent adult patient who refuses a blood transfusion for religious reasons. The nurse's best action is to:

Contact the patient's family to obtain consent
Consult the hospital chaplain to change the patient's mind
Administer the transfusion because it is medically necessary
Notify the physician and document the patient's refusal (Correct answer)

Correct answer: Notify the physician and document the patient's refusal

A competent adult has the legal and ethical right to refuse any medical treatment, including life-saving procedures. The nurse must respect this decision, notify the physician, and document the refusal thoroughly to ensure continuity of care and legal protection.

Question 70: When providing care for a client in isolation for an airborne infection, which item is essential for the nurse to wear?

Only clean gloves.
A cloth face covering.
An N95 respirator mask. (Correct answer)
Regular eyeglasses.

Correct answer: An N95 respirator mask.

Airborne precautions are required for infections spread by very small airborne droplets that can remain suspended in the air for extended periods. An N95 respirator mask is specifically designed to filter out these tiny particles, providing essential respiratory protection for the nurse. Standard surgical masks do not offer adequate protection against airborne pathogens.

Question 71: Which of the following is an example of promoting environmental health?

Reducing exposure to pollutants and toxins (Correct answer)
Encouraging use of air conditioning at all times
Increasing the use of pesticides in agriculture
Building more residential complexes

Correct answer: Reducing exposure to pollutants and toxins

Promoting environmental health involves protecting individuals from harmful environmental factors that can impact their well-being. Reducing exposure to pollutants and toxins, such as air pollution, contaminated water, or hazardous chemicals, directly contributes to a healthier living environment. This proactive approach minimizes health risks associated with environmental hazards.

Question 72: A client prescribed a beta blocker reports feeling unusually tired. What should the nurse do first?

Check the client’s apical pulse. (Correct answer)
Stop the medication immediately.
Encourage strenuous exercise.
Tell the client to ignore the fatigue.

Correct answer: Check the client’s apical pulse.

Beta blockers are known to decrease heart rate, and fatigue is a common side effect. Checking the client's apical pulse is crucial to assess their heart rate and rhythm before administering the medication or reporting the symptom. A significantly low pulse rate might indicate the need to hold the medication or notify the healthcare provider, as it could exacerbate fatigue or lead to other adverse effects.

Question 73: A practical nurse is assisting with the care of a neonate born at 34 weeks gestation. Which assessment finding warrants immediate intervention?

Weak but present suck reflex
Respiratory rate of 46 breaths per minute
Nasal flaring and grunting with respirations (Correct answer)
Axillary temperature of 97.6°F (36.4°C)

Correct answer: Nasal flaring and grunting with respirations

Nasal flaring and grunting are signs of respiratory distress in a neonate and require immediate intervention to prevent deterioration.

Question 74: A client with anxiety begins rapid, shallow breathing. What is the nurse’s first action?

Encourage the client to breathe faster.
Offer caffeinated beverages.
Encourage slow, deep breathing. (Correct answer)
Place the client completely flat.

Correct answer: Encourage slow, deep breathing.

Rapid, shallow breathing during anxiety can lead to hyperventilation, causing a decrease in carbon dioxide levels and potentially respiratory alkalosis. Encouraging slow, deep breathing helps to normalize CO2 levels, calm the client, and alleviate symptoms like dizziness or tingling. This intervention directly addresses the physiological response to anxiety.

Question 75: The major effect of acidosis is overexcitement of the central nervous system.

FALSE (Correct answer)
Both Acidosis and Alkalosis result in overexcitement of the central nervous system.
Maybe
TRUE

Correct answer: FALSE

The major effect of acidosis on the central nervous system (CNS) is depression, not overexcitement. Acidosis can lead to symptoms such as lethargy, confusion, and, in severe cases, coma. Conversely, alkalosis is typically associated with CNS overexcitement, manifesting as nervousness, tremors, and potentially seizures.

Question 76: A nurse is planning care for a client admitted with heart failure. Using Maslow's Hierarchy of Needs, which nursing diagnosis has the highest priority?

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

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

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

Question 77: A nurse is caring for a child with croup (laryngotracheobronchitis). The child has a 'barky' cough and inspiratory stridor at rest. Which treatment is most appropriate?

Initiate immediate IV antibiotics for bacterial infection
Perform immediate intubation to secure the airway
Perform a throat culture to identify the pathogen
Administer nebulized racemic epinephrine and oral/IM dexamethasone (Correct answer)

Correct answer: Administer nebulized racemic epinephrine and oral/IM dexamethasone

Moderate-to-severe croup with stridor at rest is treated with nebulized racemic epinephrine (reduces edema) and dexamethasone (corticosteroid reduces inflammation). Croup is viral and does not require antibiotics.

Question 78: A patient receiving alteplase (tPA) for acute ischemic stroke develops sudden severe headache and changes in consciousness. The nurse should prioritize which action?

Administer an analgesic for the headache
Stop the infusion immediately and notify the provider (Correct answer)
Slow the infusion and obtain a blood pressure
Continue the infusion and document the findings

Correct answer: Stop the infusion immediately and notify the provider

Sudden severe headache and altered consciousness during tPA suggest intracranial hemorrhage, a life-threatening complication. The infusion must be stopped immediately and the provider notified.

Question 79: A client is admitted with suspected appendicitis. The client suddenly reports that the pain has completely resolved. How should the nurse interpret this finding?

The client's symptoms were likely caused by gas pain
The analgesic administered earlier is working effectively
The client may have appendix perforation, which is a medical emergency (Correct answer)
The appendicitis has resolved without surgery

Correct answer: The client may have appendix perforation, which is a medical emergency

Sudden relief of pain in appendicitis is a serious warning sign that the appendix may have perforated. Perforation releases pressure temporarily but leads to peritonitis, a life-threatening emergency. The nurse must notify the provider immediately and prepare for urgent intervention.

Question 80: Which of the following principles is affected by a nurse’s cultural or ethnic background?

Code of conduct
Ethics
Morals (Correct answer)
Veracity

Correct answer: Morals

Morals are an individual's personal beliefs about right and wrong, which are deeply shaped by their cultural background, upbringing, and life experiences. While ethics are professional guidelines and a code of conduct outlines expected behaviors, morals are the foundational, culturally-influenced principles that guide a nurse's personal and professional actions and decision-making.

Question 81: A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?

Minimize patient contact.
Change the disposable mask immediately after use.
Minimize conversation with the patient.
Change gloves immediately after use. (Correct answer)

Correct answer: Change gloves immediately after use.

Neutropenic patients have a severely compromised immune system, making them highly susceptible to infections. Changing gloves immediately after use, along with meticulous hand hygiene, is a fundamental infection control practice. This action prevents the transmission of pathogens and minimizes the risk of introducing bacteria or other microorganisms to the vulnerable patient, thereby protecting them from infection.

Question 82: A client develops sudden sharp chest pain and dyspnea after a deep-vein thrombosis. What is the nurse's first suspicion?

Pneumonia
Asthma attack
Pulmonary embolism (Correct answer)
Pleural effusion

Correct answer: Pulmonary embolism

A dislodged DVT clot traveling to the lung causes sudden pleuritic pain and dyspnea, classic for pulmonary embolism.

Question 83: Which of the following is the best practice for handling hazardous materials in a healthcare setting?

Wear appropriate protective equipment (Correct answer)
Place chemicals near food areas
Store chemicals on open shelves
Discard hazardous materials in regular trash

Correct answer: Wear appropriate protective equipment

When handling hazardous materials in a healthcare setting, wearing appropriate personal protective equipment (PPE) is the best practice to ensure safety. PPE, such as gloves, masks, and eye protection, creates a barrier between the worker and the hazardous substance, preventing direct exposure and potential injury. Improper storage, placing chemicals near food, or discarding them in regular trash are unsafe practices that can lead to contamination or harm.

Question 84: A nurse is the charge nurse on a medical-surgical unit. A client's family member complains that they have been waiting 2 hours to speak with the physician. Which action is most appropriate?

Contact the physician to communicate the family's request for an update (Correct answer)
Ask the primary nurse to spend 30 minutes educating the family
Instruct the family member to call the physician's office directly
Tell the family that physicians are very busy and delays are expected

Correct answer: Contact the physician to communicate the family's request for an update

The charge nurse should advocate for the client and family by contacting the physician to relay the request for communication. This is part of the charge nurse's advocacy and coordination role and addresses the family's legitimate concern.

Question 85: A patient is admitted with a diagnosis of major depressive disorder. Which nursing intervention has the highest priority?

Establish a structured activity schedule
Teach the patient about antidepressant medications
Encourage group therapy attendance
Assess for suicidal ideation and means (Correct answer)

Correct answer: Assess for suicidal ideation and means

Safety is the priority in psychiatric nursing. Major depression carries significant suicide risk, making assessment for suicidal ideation, plan, and means the first and highest-priority intervention.

Question 86: Which strategy is effective for reducing health disparities in underserved populations?

Limiting access to healthcare providers
Reducing funding for community health programs
Offering health insurance to all populations
Increasing access to preventive care (Correct answer)

Correct answer: Increasing access to preventive care

Increasing access to preventive care is an effective strategy for reducing health disparities in underserved populations. Many disparities stem from unequal access to essential services like screenings, immunizations, and health education. By making preventive care more accessible, diseases can be detected and managed earlier, improving health outcomes and promoting health equity for all.

Question 87: The ventilator of a patient sounds the high-pressure alarm. The oxygen saturation meter in the patient's room indicates 87% when you walk in to evaluate the ARDS patient, who is also having trouble sitting up. Which move ought to you make next?

Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning
Manually ventilate the patient while assessing possible reasons for the high-pressure alarm (Correct answer)
Reassure the patient that the ventilator will do the work of breathing for him
Insert an oral airway to prevent the patient from biting on the endotracheal tube

Correct answer: Manually ventilate the patient while assessing possible reasons for the high-pressure alarm

A high-pressure alarm on a ventilator, combined with a low oxygen saturation (87%) and patient distress, indicates an acute respiratory emergency. The immediate priority is to ensure adequate oxygenation and ventilation. Manually ventilating the patient with a bag-valve mask allows the nurse to bypass the malfunctioning ventilator, provide immediate respiratory support, and simultaneously assess for the cause of the alarm (e.g., kinked tubing, secretions, pneumothorax) without delay.

Question 88: A patient who is getting oxygen through a nasal cannula at a flow rate of 6 L/min complains of nasal passage irritation, the nursing assistant informs you. What course of action might you recommend to enhance the patient's comfort in light of this issue?

Suggest that the patient sit up in a chair at the bedside
Suggest that a simple face mask be used instead of a nasal cannula
Suggest that the patient be provided with an extra pillow
Suggest that the patient's oxygen be humidified (Correct answer)

Correct answer: Suggest that the patient's oxygen be humidified

High-flow oxygen delivered via nasal cannula, especially at 6 L/min, can be very drying to the nasal mucosa, leading to irritation, dryness, and even epistaxis. Humidifying the oxygen adds moisture, which helps to soothe and protect the nasal passages, significantly improving patient comfort. This is a standard intervention for preventing and alleviating nasal irritation from oxygen therapy.

Question 89: A client taking a diuretic reports leg cramps. What should the nurse suspect first?

Improved muscle tone.
Excessive fluid intake.
Possible low potassium level. (Correct answer)
Normal adaptation to medication.

Correct answer: Possible low potassium level.

Diuretics, particularly loop and thiazide diuretics, can lead to increased excretion of potassium, resulting in hypokalemia. Leg cramps are a common symptom of low potassium, making it the primary concern for a client on diuretic therapy. The nurse should assess for other signs and symptoms of hypokalemia.

Question 90: How should the nurse manage a conflict between team members in a healthcare setting?

Ignoring the conflict and allowing it to resolve on its own
Escalating the issue to higher authorities immediately
Encouraging open communication and facilitating a resolution (Correct answer)
Taking sides to ensure the best outcome for the nurse

Correct answer: Encouraging open communication and facilitating a resolution

Conflict within a healthcare team can negatively impact patient care and team morale. The nurse's role in conflict management is to facilitate a constructive dialogue, encourage team members to express their perspectives, and guide them towards a mutually acceptable resolution, promoting a healthy work environment.

Question 91: What is the nurse's role in documenting patient care?

Recording care provided and patient responses to interventions in a timely manner (Correct answer)
Only documenting when something goes wrong
Documenting only after the patient's discharge
Avoiding detailed notes to keep records brief

Correct answer: Recording care provided and patient responses to interventions in a timely manner

Accurate and timely documentation is a fundamental legal and ethical responsibility for nurses. It provides a comprehensive, chronological record of the care delivered, the patient's condition, and their responses to interventions. Recording this information in a timely manner ensures continuity of care, facilitates effective communication among the healthcare team, and serves as a vital legal record.

Question 92: A nurse is receiving a client from the emergency department who has a history of MRSA. Which transmission-based precaution is required?

Droplet precautions with a surgical mask and private room
Contact precautions with gloves and gown for all client contact (Correct answer)
Standard precautions only, as MRSA is not transmissible in the inpatient setting
Airborne precautions with an N95 respirator and negative pressure room

Correct answer: Contact precautions with gloves and gown for all client contact

MRSA (methicillin-resistant Staphylococcus aureus) is transmitted by direct and indirect contact with infected surfaces, wounds, and skin. Contact precautions — including gloves and gown worn upon entry to the room — are required. Airborne and droplet precautions are used for respiratory pathogens.

Question 93: A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is NOT recommended?

A diet with adequate caloric intake.
A restricted sodium diet. (Correct answer)
A diet high in grains.
A high protein diet.

Correct answer: A restricted sodium diet.

Patients with Addison's disease have adrenal insufficiency, leading to decreased production of aldosterone, a hormone that regulates sodium and potassium balance. This can result in hyponatremia (low sodium) and hyperkalemia (high potassium). Therefore, a restricted sodium diet is contraindicated; instead, a diet with adequate or even increased sodium intake is often recommended to help maintain fluid and electrolyte balance.

Question 94: A client with hypertension reports a persistent dry cough after starting an ACE inhibitor. What should the nurse do?

Encourage drinking carbonated beverages.
Advise the client to double the dose.
Instruct the client to stop the medication immediately.
Report the symptom to the healthcare provider. (Correct answer)

Correct answer: Report the symptom to the healthcare provider.

A persistent dry cough is a common and well-known side effect of ACE inhibitors, occurring in about 5-20% of clients. While not typically life-threatening, it can be very bothersome and affect medication compliance. The nurse should report this symptom to the healthcare provider, who may consider switching the client to an alternative antihypertensive medication, such as an ARB.

Question 95: A postpartum client's fundus is boggy and displaced to the right. What is the most likely cause?

Normal involution
Uterine infection
A full bladder (Correct answer)
Retained placenta

Correct answer: A full bladder

A full bladder displaces the uterus and prevents firm contraction, causing a boggy, deviated fundus.

Question 96: A patient is prescribed metoprolol succinate. Which condition is this medication primarily used to treat?

Deep vein thrombosis
Atrial fibrillation
Heart failure and hypertension (Correct answer)
Pulmonary hypertension

Correct answer: Heart failure and hypertension

Metoprolol succinate is a beta-1 selective blocker used to treat heart failure, hypertension, and angina by reducing heart rate and myocardial oxygen demand.

Question 97: A nurse is preparing a client for discharge. The client will be taking multiple medications at home. Which action best ensures medication safety at discharge?

Conduct teach-back by having the client explain each medication's purpose, dose, and schedule (Correct answer)
Instruct the client to consult their pharmacist if they have questions
Provide the client with a written list of all medications with names and dosages only
Ensure the client signs the discharge medication reconciliation form

Correct answer: Conduct teach-back by having the client explain each medication's purpose, dose, and schedule

Teach-back — having the client explain in their own words the medications' purpose, dose, and schedule — is the gold standard for verifying health literacy and ensuring the client truly understands their discharge regimen.

Question 98: A nurse monitors a client with SIADH for which neurologic complication of severe hyponatremia?

Flaccid paralysis only
Hyperreflexia and tetany
Improved cognition
Seizures and altered mental status (Correct answer)

Correct answer: Seizures and altered mental status

Severe hyponatremia causes cerebral edema, which can manifest as confusion, seizures, and decreased level of consciousness.

Question 99: A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient?

Metabolic alkalosis
Parkinson’s disease type symptoms
Respiratory alkalosis
Onset of pulmonary edema (Correct answer)

Correct answer: Onset of pulmonary edema

Aspirin (salicylate) overdose is a serious condition that can lead to various complications, including direct toxicity to the lungs. This toxicity can cause non-cardiogenic pulmonary edema, which is a life-threatening accumulation of fluid in the lungs. Monitoring for this acute respiratory complication is crucial during the management of aspirin overdose.

Question 100: A patient taking warfarin has an INR of 4.8. Which action should the nurse take first?

Increase the warfarin dose to stabilize the INR
Give vitamin K immediately without an order
Hold the warfarin and notify the provider (Correct answer)
Administer the next scheduled dose

Correct answer: Hold the warfarin and notify the provider

An INR of 4.8 is supratherapeutic (therapeutic range 2–3 for most indications), indicating a high bleeding risk. The nurse should hold warfarin and notify the provider for further instructions.

Question 101: A client with iron-deficiency anemia is prescribed ferrous sulfate (iron supplement). Which food enhances iron absorption?

Whole grain bread with high fiber content
Milk and calcium-rich dairy products
Green tea or coffee with the meal
A glass of orange juice (vitamin C) (Correct answer)

Correct answer: A glass of orange juice (vitamin C)

Vitamin C (ascorbic acid) converts dietary non-heme iron (ferric to ferrous form), significantly enhancing intestinal absorption of iron. It should be taken at the same time as the iron supplement. Calcium, tannins (tea, coffee), and high-fiber foods inhibit iron absorption and should be avoided with iron supplementation.

Question 102: A nurse suspects that a colleague is diverting controlled substances. The nurse's most appropriate first action is to:

Monitor the situation for several more weeks before taking action
Ask other staff members if they have noticed anything unusual
Confront the colleague directly and ask for an explanation
Report the suspicion to the nurse manager or through the facility's chain of command (Correct answer)

Correct answer: Report the suspicion to the nurse manager or through the facility's chain of command

Drug diversion is a patient safety and legal issue. The nurse has a professional and ethical obligation to report the suspicion through the proper chain of command (charge nurse, nurse manager, or risk management). Confronting the colleague or delaying reporting is inappropriate.

Question 103: Which of the following is an important consideration when delegating tasks to unlicensed assistive personnel (UAP)?

Assigning tasks based solely on patient preferences
Delegating the most complex tasks to UAPs to ease the workload
Ensuring the UAP has the necessary skills and training for the task (Correct answer)
Only delegating tasks that do not require patient interaction

Correct answer: Ensuring the UAP has the necessary skills and training for the task

Delegation is a critical nursing skill that requires the nurse to assess the UAP's competence and the complexity of the task. The nurse is accountable for ensuring that the delegated task is within the UAP's scope of practice and that they possess the required skills and training to perform it safely and effectively.

Question 104: A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?

Decreased appetite (Correct answer)
Gastric irritability
Edema of the ankles
Weight gain of 5 pounds

Correct answer: Decreased appetite

Furosemide (Lasix) is a loop diuretic that can cause electrolyte imbalances, particularly hypokalemia. Hypokalemia can manifest as gastrointestinal symptoms like decreased appetite, nausea, vomiting, and muscle weakness. Therefore, a decreased appetite in a client taking furosemide could indicate an electrolyte imbalance requiring further assessment and intervention.

Question 105: A client with SIADH is expected to have which laboratory finding?

Hypernatremia and high serum osmolality
Hyperglycemia and ketosis
Hyperkalemia and dehydration
Hyponatremia and low serum osmolality with concentrated urine (Correct answer)

Correct answer: Hyponatremia and low serum osmolality with concentrated urine

SIADH causes excessive ADH, leading to water retention, dilutional hyponatremia, low serum osmolality, and concentrated urine.

Question 106: A client with chronic liver disease and ascites requires a paracentesis. After the procedure, which complication should the nurse monitor for most closely?

Pulmonary embolism
Hypernatremia
Hypovolemic shock from fluid shift (Correct answer)
Hyperkalemia

Correct answer: Hypovolemic shock from fluid shift

Rapid removal of large volumes of ascitic fluid (large-volume paracentesis) can cause fluid to shift from the vascular compartment into the peritoneal space, leading to hypovolemic shock. Vital signs, urine output, and mental status must be monitored closely after the procedure. Albumin infusion is often given to maintain intravascular volume.

Question 107: A nurse is caring for a child with epiglottitis. Which intervention should the nurse avoid?

Placing the child in a position of comfort (usually upright/sitting)
Examining the throat with a tongue depressor to visualize the epiglottis (Correct answer)
Preparing for possible emergency airway management
Administering humidified oxygen

Correct answer: Examining the throat with a tongue depressor to visualize the epiglottis

Direct inspection of the throat with a tongue depressor can cause laryngospasm and complete airway obstruction in epiglottitis. This is absolutely contraindicated and can be fatal.

Question 108: For which of the following research questions would qualitative methods be most appropriate?

What is the meaning of health for migrant farm-worker women? (Correct answer)
How does frequency of medication administration impact the degree of pain experienced following knee replacement surgery?
Which pain medications decrease the need for sleep medication in elderly patients?
Under what conditions does a decubitus ulcer heal most quickly?

Correct answer: What is the meaning of health for migrant farm-worker women?

Qualitative research aims to explore and understand subjective experiences, perceptions, and meanings. The question 'What is the meaning of health for migrant farm-worker women?' directly seeks to uncover the lived experiences and interpretations of a specific group, which is a hallmark of qualitative inquiry. The other options are quantitative, focusing on measurable outcomes or comparisons.

Question 109: The following notation is made by the nurse on the patient's care plan: "Not achieved. Patient says, "I'm frightened of falling," and refuses to walk." The nurse needs to:

document the patient's unwillingness to continue the plan of care.
ignore the patient's concern in evaluating goal attainment.
continue the plan of care as originally agreed upon.
modify the care plan in response to the patient's condition and wishes. (Correct answer)

Correct answer: modify the care plan in response to the patient's condition and wishes.

The nursing process is dynamic and patient-centered, requiring continuous reassessment and adaptation. When a patient expresses fear or unwillingness to participate in a goal, the nurse must modify the care plan to address these concerns. Ignoring the patient's wishes or continuing with an unachievable plan is not effective; instead, the nurse should identify the underlying reason (fear of falling) and adjust interventions to ensure patient safety and promote cooperation.

Question 110: A client receiving an IV antibiotic develops itching and hives. What is the nurse's priority action?

Ask the client to drink more fluids.
Stop the IV infusion immediately. (Correct answer)
Document the reaction and continue the infusion.
Tell the client this is an expected side effect.

Correct answer: Stop the IV infusion immediately.

Itching and hives developing during an IV antibiotic infusion are classic signs of an allergic reaction, which can escalate to a severe anaphylactic response. The nurse's priority is to immediately stop the infusion to prevent further exposure to the allergen. This action minimizes the client's reaction and allows for prompt assessment and administration of emergency medications if needed.

Question 111: The nurse is reinforcing teaching about insulin self-administration. Which statement by the client shows a correct understanding?

I will rotate injection sites within the same area, like my abdomen. (Correct answer)
I can stop my insulin when my blood sugar feels normal.
I will inject only into my upper arm muscles.
I will use the same spot every day so it is less painful.

Correct answer: I will rotate injection sites within the same area, like my abdomen.

Rotating injection sites within the same general area, such as the abdomen, is crucial for preventing lipohypertrophy (fatty lumps) or lipoatrophy (indentations) at the injection sites. These changes can impair insulin absorption and lead to unpredictable blood glucose levels. Consistent rotation ensures optimal absorption and maintains skin integrity.

Question 112: A client is receiving IV potassium chloride replacement. Which safety precaution is most critical?

Mix potassium with dextrose 5% in water only
Always dilute and administer via infusion pump at a controlled rate (Correct answer)
Potassium can be safely given intramuscularly if IV access is lost
Administer via rapid IV push for faster correction

Correct answer: Always dilute and administer via infusion pump at a controlled rate

IV potassium must always be diluted and administered via infusion pump at a controlled rate because rapid administration can cause fatal cardiac arrest.

Question 113: A nurse evaluates head circumference growth. By what age does the anterior fontanel normally close?

6 months
12-18 months (Correct answer)
2-3 months
3 years

Correct answer: 12-18 months

The anterior fontanel typically closes between 12 and 18 months of age.

Question 114: A client with terminal cancer has a valid do-not-resuscitate (DNR) order. The client's adult child insists the nurse 'do everything possible' if the client stops breathing. The nurse should:

Honor the client's DNR order and explain it reflects the client's own wishes (Correct answer)
Follow the family's wishes, as they are the client's next of kin
Contact the physician to rescind the DNR order based on family request
Initiate CPR to avoid conflict with the family

Correct answer: Honor the client's DNR order and explain it reflects the client's own wishes

A legally executed DNR order reflects the autonomous decision of a competent client and must be honored. Family members cannot override a valid advance directive. The nurse should communicate compassionately with the family while upholding the client's rights.

Question 115: When de-escalating an agitated, potentially aggressive client, the nurse should:

Stand directly in front and maintain intense eye contact
Raise the voice to assert control
Touch the client to show reassurance
Speak calmly and maintain a safe distance with an exit route (Correct answer)

Correct answer: Speak calmly and maintain a safe distance with an exit route

Calm speech, personal space, and keeping an exit available promote safety during de-escalation.

Question 116: A nurse is suctioning a client's endotracheal tube. How long should each suction pass last?

30-45 seconds
As long as secretions are present
No more than 10-15 seconds (Correct answer)
60 seconds

Correct answer: No more than 10-15 seconds

Limiting suction to 10-15 seconds prevents hypoxemia and mucosal trauma.

Question 117: A client diagnosed with heart failure is prescribed furosemide (Lasix). Which assessment finding indicates the medication is effective?

Decreased urine output
Increased heart rate
Reduced peripheral edema (Correct answer)
Elevated blood pressure

Correct answer: Reduced peripheral edema

Furosemide is a loop diuretic that reduces fluid volume. Decreased peripheral edema indicates effective diuresis and reduced fluid overload.

Question 118: What is the nurse's role in managing patient care transitions?

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

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

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

Question 119: What should the nurse do if a patient’s condition changes unexpectedly?

Disregard the change if it seems minor
Monitor the patient and wait for further changes
Wait for the physician to arrive to assess the situation
Assess the situation, notify the healthcare team, and take appropriate action (Correct answer)

Correct answer: Assess the situation, notify the healthcare team, and take appropriate action

An unexpected change in a patient's condition requires immediate and systematic action. The nurse must first assess the patient to gather objective data, then promptly notify the healthcare provider or rapid response team, and initiate appropriate interventions based on the assessment and standing orders to stabilize the patient.

Question 120: A nurse is completing an incident report after a client received the wrong dose of a medication. The report should include:

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

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

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

Question 121: When she presents the nursing procedures to be followed, she refers to what type of standards?

Structure
Process (Correct answer)
Criteria
Outcome

Correct answer: Process

Nursing procedures are step-by-step guidelines that describe the actions and interventions nurses perform when providing care. These procedures define *how* care is delivered, focusing on the activities and behaviors of healthcare providers. Therefore, they are examples of process standards, which evaluate the actual delivery of care.

Question 122: A patient is taking warfarin and reports starting to take herbal St. John's Wort. The nurse understands this interaction will likely cause:

Decreased warfarin levels and increased clotting risk (Correct answer)
Increased warfarin levels and bleeding risk
Increased risk of warfarin-induced hepatotoxicity
No significant change in warfarin levels

Correct answer: Decreased warfarin levels and increased clotting risk

St. John's Wort induces CYP2C9 and P-glycoprotein, which accelerates warfarin metabolism, reducing plasma levels and decreasing anticoagulant effect, increasing clotting risk.

Question 123: Which nursing intervention is appropriate for a client with SIADH?

Encourage increased free water intake
Give a diuretic to retain sodium
Restrict fluids and monitor sodium levels (Correct answer)
Administer IV hypotonic fluids

Correct answer: Restrict fluids and monitor sodium levels

Fluid restriction is central to managing SIADH because the problem is water retention causing dilutional hyponatremia.

NCLEX-RN Exam

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

Questions

300 min

Time Limit

50%

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