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

Question 1: A nurse is caring for a terminally ill client who states, 'If I can just live until my daughter's wedding, then I'll be ready to go.' This is an example of which stage of grief?

Acceptance
Bargaining (Correct answer)
Anger
Depression

Correct answer: Bargaining

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

Question 2: A nurse is preparing to delegate the task of ambulating a post-operative patient to an unlicensed assistive personnel (UAP). Which action is most important before delegation?

Ensure the UAP has been trained and is competent to perform the task (Correct answer)
Inform the charge nurse of the delegation decision
Ask the patient's family if they approve of the UAP performing the task
Document the delegation in the patient's chart first

Correct answer: Ensure the UAP has been trained and is competent to perform the task

Before delegating, the nurse must verify that the UAP has the training and competency to safely perform the specific task.

Question 3: A competent adult patient refuses a blood transfusion on religious grounds despite a life-threatening hemorrhage. The nurse should:

Contact the ethics committee to override the decision
Obtain a court order to proceed with treatment
Respect the refusal and document it, ensuring the patient understands the consequences (Correct answer)
Administer the transfusion to save the patient's life

Correct answer: Respect the refusal and document it, ensuring the patient understands the consequences

Competent adults have the right to refuse any treatment, including life-saving measures; the nurse must respect this autonomy and document the informed refusal.

Question 4: A nurse receives shift report on a client with a serum sodium of 122 mEq/L. Which clinical manifestation is most critical to assess for immediately?

Muscle cramps and hyperreflexia
Seizure activity and decreased level of consciousness (Correct answer)
Orthostatic hypotension and tachycardia
Dry mucous membranes and poor skin turgor

Correct answer: Seizure activity and decreased level of consciousness

Severe hyponatremia (sodium <125 mEq/L) causes cerebral edema, leading to seizures and altered consciousness, which are life-threatening.

Question 5: A nurse is assessing a client for osteoporosis risk. Which client is at highest risk?

A 50-year-old Hispanic female who takes calcium supplements
A 65-year-old White male with a history of high dairy intake
A 60-year-old Asian female with a low BMI who smokes (Correct answer)
A 55-year-old Black male who exercises regularly

Correct answer: A 60-year-old Asian female with a low BMI who smokes

Risk factors for osteoporosis include female sex, Asian ethnicity, low body weight, smoking, and postmenopausal status — this client has multiple risk factors.

Question 6: Which clinical finding is most consistent with severe dehydration in an adult patient?

Peripheral edema and ascites
Poor skin turgor and concentrated urine (Correct answer)
Bradycardia and hypertension
Bounding pulse and jugular vein distension

Correct answer: Poor skin turgor and concentrated urine

Poor skin turgor (tenting) and dark, concentrated urine (high specific gravity) are classic signs of severe dehydration reflecting significant fluid deficit.

Question 7: A client receiving IV fluids develops pitting edema, crackles in the lungs, and a bounding pulse. Which condition does the nurse suspect?

Hyponatremia
Fluid volume deficit
Fluid volume excess (Correct answer)
Hyperkalemia

Correct answer: Fluid volume excess

Pitting edema, pulmonary crackles, and bounding pulse are classic signs of fluid volume excess (hypervolemia).

Question 8: A 72-year-old client is admitted to a long-term care facility. The client expresses feelings of sadness and states, 'I feel like my life has had no purpose.' According to Erik Erikson's stages of psychosocial development, which of the following is the client experiencing?

Stagnation
Role Confusion
Isolation
Despair (Correct answer)

Correct answer: Despair

According to Erikson's theory, the developmental stage for older adults (65 years to death) is 'Ego Integrity vs. Despair.' A person who feels their life has been useless or has regrets is experiencing despair. Stagnation is part of the middle adulthood stage, Isolation is part of the young adulthood stage, and Role Confusion is part of the adolescent stage.

Question 9: A nurse is caring for a patient in airborne precautions for active tuberculosis. Which room assignment is correct?

Any private room with the door closed
A semi-private room with a curtain drawn
A negative-pressure isolation room with the door closed (Correct answer)
A positive-pressure room with HEPA filtration

Correct answer: A negative-pressure isolation room with the door closed

Active TB requires a negative-pressure (airborne infection isolation) room to prevent contaminated air from flowing into the hallway.

Question 10: A postoperative patient develops respiratory acidosis. Which compensatory change would the nurse expect to see in the metabolic component?

Increased serum bicarbonate (HCO3-) (Correct answer)
Decreased pH below 7.20
Decreased PaCO2 below 35 mmHg
Decreased serum bicarbonate (HCO3-)

Correct answer: Increased serum bicarbonate (HCO3-)

In respiratory acidosis, the kidneys compensate by retaining bicarbonate (HCO3-) to buffer excess carbonic acid and gradually restore the blood pH toward normal.

Question 11: A nurse is assessing a client's nutritional status. Which finding is the BEST indicator of chronic protein-calorie malnutrition?

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

Correct answer: Serum albumin level of 2.8 g/dL

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

Question 12: Which electrolyte is primarily responsible for maintaining cardiac rhythm and muscle function?

Potassium (Correct answer)
Chloride
Calcium
Sodium

Correct answer: Potassium

Potassium is the primary intracellular electrolyte responsible for maintaining cardiac rhythm, nerve impulse conduction, and muscle contraction.

Question 13: Drooling is prolonged and swallowing is impeded in stroke patients with right-sided paralysis. What kind of suctioning is recommended?

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

Correct answer: Oropharyngeal.

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

Question 14: A nurse is monitoring a patient who had a cardiac catheterization via the femoral artery 2 hours ago. Which finding requires immediate action?

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

Correct answer: Expanding hematoma at the femoral access site

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

Question 15: Which finding is a classic sign of diabetic ketoacidosis (DKA)?

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

Correct answer: Fruity odor to the breath

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

Question 16: A nurse is caring for a patient with a central venous catheter. Which complication should the nurse monitor for during and immediately after insertion?

Pneumothorax (Correct answer)
Phlebitis
Cellulitis
Peripheral neuropathy

Correct answer: Pneumothorax

Pneumothorax is an acute complication of central venous catheter insertion, particularly with subclavian or internal jugular approaches, caused by accidental lung puncture.

Question 17: A patient taking phenytoin for seizure disorder has a serum level of 25 mcg/mL. Which symptom should the nurse assess for?

Nystagmus, ataxia, and confusion (Correct answer)
Peripheral edema and weight gain
Polyuria and polydipsia
Hypertension and tachycardia

Correct answer: Nystagmus, ataxia, and confusion

Phenytoin toxicity (therapeutic range 10–20 mcg/mL) commonly manifests as nystagmus, ataxia, and mental status changes.

Question 18: A nurse is caring for a patient with hypernatremia (serum Na+ 158 mEq/L). Which IV fluid would the nurse anticipate administering to correct this imbalance?

0.45% sodium chloride (half-normal saline) (Correct answer)
3% sodium chloride
0.9% sodium chloride (normal saline)
Lactated Ringer's solution

Correct answer: 0.45% sodium chloride (half-normal saline)

0.45% sodium chloride (hypotonic saline) provides free water to dilute the elevated serum sodium and restore normal plasma osmolality, correcting hypernatremia gradually.

Question 19: Which position is most appropriate for a patient experiencing difficulty breathing?

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

Correct answer: High Fowler's position

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

Question 20: A nurse is educating a patient about proper use of a metered-dose inhaler (MDI) without a spacer. Which instruction is correct?

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

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

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

Question 21: A nurse accidentally sustains a needlestick injury from a used needle. Which action should be taken FIRST?

Immediately wash the site with soap and water (Correct answer)
Report the incident to the charge nurse
Apply an antiseptic dressing
Squeeze the site to express blood

Correct answer: Immediately wash the site with soap and water

The first action after a needlestick is to immediately wash the wound thoroughly with soap and water.

Question 22: A nurse is caring for a patient in four-point restraints. How frequently must the nurse assess the patient?

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

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

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

Question 23: A nurse notes that a patient's peripheral oxygen saturation (SpO2) reads 85%. What is the priority nursing intervention?

Document the finding and recheck in one hour
Apply supplemental oxygen and assess the patient (Correct answer)
Elevate the head of the bed and encourage coughing
Remove the pulse oximeter and obtain an arterial blood gas

Correct answer: Apply supplemental oxygen and assess the patient

An SpO2 of 85% indicates significant hypoxemia requiring immediate oxygen supplementation and assessment of the patient's respiratory status.

Question 24: A patient with terminal cancer has a Do-Not-Resuscitate (DNR) order. The patient goes into cardiac arrest. What is the nurse's appropriate action?

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

Correct answer: Provide comfort measures only

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

Question 25: A nurse is caring for a patient who speaks a different language. What is the most appropriate action to ensure effective communication?

Ask a family member to translate
Arrange for a certified medical interpreter (Correct answer)
Speak louder and slower
Use hand gestures exclusively

Correct answer: Arrange for a certified medical interpreter

A certified medical interpreter ensures accurate translation of medical terminology and protects patient confidentiality, which family members may not provide.

Question 26: A client with diabetes mellitus is prescribed metformin and is scheduled for a CT scan with contrast dye. Which nursing action is most important prior to the procedure?

Hold metformin before and after the procedure as ordered (Correct answer)
Encourage the client to increase fluid intake the day before
Administer an insulin sliding scale before the scan
Monitor blood glucose every 2 hours post-procedure

Correct answer: Hold metformin before and after the procedure as ordered

Metformin must be held before contrast administration and for 48 hours after because contrast media can impair renal function, causing metformin accumulation and lactic acidosis.

Question 27: Which type of isolation precaution is required for a patient diagnosed with tuberculosis?

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

Correct answer: Airborne precautions

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

Question 28: A client who is scheduled for a cardiac catheterization in the morning tells the nurse, 'My doctor explained the procedure, but I'm still not sure what all the risks are.' The signed consent form is in the client's chart. What is the nurse's most appropriate action?

Provide the client with a printed brochure that details the procedure's risks.
Reassure the client that the procedure is very common and generally safe.
Notify the healthcare provider that the client does not fully understand the procedure. (Correct answer)
Have the client's spouse come in so they can explain the risks again.

Correct answer: Notify the healthcare provider that the client does not fully understand the procedure.

It is the provider's legal responsibility to obtain informed consent, which means ensuring the client understands the risks, benefits, and alternatives to the procedure. If the client expresses a lack of understanding, the nurse must act as an advocate and notify the provider to give further clarification. The nurse's role is to witness the signature, not to provide the primary explanation of risks.

Question 29: A nurse is preparing to administer a tube feeding via nasogastric (NG) tube. Which action should be performed FIRST?

Flush the tube with 30 mL of water
Elevate the head of the bed to 30–45 degrees
Connect the feeding bag and set the pump rate
Verify tube placement by checking gastric pH and auscultating the abdomen (Correct answer)

Correct answer: Verify tube placement by checking gastric pH and auscultating the abdomen

Verifying tube placement is the priority safety step before initiating any tube feeding to prevent aspiration. pH of gastric aspirate should be ≤5.5. This must happen before positioning or starting the feed.

Question 30: A patient in a psychiatric unit attempts to leave against medical advice. The nurse physically blocks the doorway. This action may constitute which legal offense?

Assault
Defamation
Negligence
False imprisonment (Correct answer)

Correct answer: False imprisonment

False imprisonment occurs when a person is confined or restrained without legal authority. Unless the patient meets criteria for involuntary commitment, blocking their exit is false imprisonment.

Question 31: A nurse prepares to insert a urinary catheter. Which action is most important in reducing the risk of catheter-associated urinary tract infection (CAUTI)?

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

Correct answer: Maintaining a closed drainage system

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

Question 32: A patient with diabetes is prescribed NPH insulin and regular insulin. In which order should the nurse draw up the insulins?

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

Correct answer: Regular first, then NPH

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

Question 33: The NACE I PN-RN exam is designed for which population of nursing students?

New nursing students entering an LPN program
Registered nurses pursuing a master's degree
Nursing students entering a doctoral program
Licensed practical nurses seeking registered nurse licensure through an accelerated program (Correct answer)

Correct answer: Licensed practical nurses seeking registered nurse licensure through an accelerated program

The NACE I (Nursing Acceleration Challenge Exam) is designed for LPNs/LVNs who wish to transition to RN status by demonstrating competency in nursing knowledge.

Question 34: A nurse is caring for an older adult client who is confused and has repeatedly attempted to pull out their peripheral intravenous (IV) catheter. After assessing the client, which action should the nurse take first to ensure the client's safety?

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

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

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

Question 35: A nurse receives a change-of-shift report on four clients. Which client should the nurse assess first?

An older adult client who is scheduled for discharge and has questions about their new medications.
A client postoperative day two following a cholecystectomy who is requesting pain medication.
A client admitted with gastritis who is reporting nausea and has not eaten breakfast.
A client with pneumonia who has a new onset of confusion and an oxygen saturation of 88% on 2L of oxygen. (Correct answer)

Correct answer: A client with pneumonia who has a new onset of confusion and an oxygen saturation of 88% on 2L of oxygen.

The client with pneumonia showing a new onset of confusion and low oxygen saturation is the highest priority. These are signs of worsening respiratory status and hypoxia, which is a life-threatening condition requiring immediate assessment and intervention. The other clients are more stable.

Question 36: A nurse finds a patient on the floor next to the bed. After ensuring safety, which action should be taken NEXT?

Administer pain medication if ordered
Reassess vital signs only
Notify the physician and complete an incident report (Correct answer)
Help the patient back into bed immediately

Correct answer: Notify the physician and complete an incident report

After immediate safety is ensured, the nurse must notify the physician and document the fall using an incident report per facility policy.

Question 37: A school nurse notices a 10-year-old with a BMI at the 88th percentile. Which is the most appropriate initial nursing action?

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

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

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

Question 38: Which disinfectant is most appropriate for cleaning surfaces contaminated with C. difficile spores?

Alcohol-based wipes
Hydrogen peroxide spray
Quaternary ammonium compounds
Bleach (sodium hypochlorite) solution (Correct answer)

Correct answer: Bleach (sodium hypochlorite) solution

Bleach (sodium hypochlorite) is sporicidal and is the recommended agent for environmental decontamination of C. diff.

Question 39: A postpartum client develops sudden severe headache, blurred vision, and a blood pressure of 158/104 mmHg on day 2 after delivery. Which is the nurse's priority action?

Administer prescribed PRN analgesic for headache relief
Notify the physician immediately and prepare for magnesium sulfate administration (Correct answer)
Position the client in left lateral recumbent position and document findings
Encourage oral hydration and reassess blood pressure in 30 minutes

Correct answer: Notify the physician immediately and prepare for magnesium sulfate administration

These findings indicate postpartum preeclampsia, a medical emergency requiring immediate physician notification and magnesium sulfate to prevent eclamptic seizures.

Question 40: A client with a new colostomy expresses embarrassment about odor. Which nurse response is MOST therapeutic?

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

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

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

Question 41: During a patient assessment, which technique should the nurse perform first?

Inspection (Correct answer)
Percussion
Auscultation
Palpation

Correct answer: Inspection

Inspection is always performed first in a physical assessment as it provides visual information without touching the patient and can reveal important findings.

Question 42: A nurse is caring for a client on prolonged bed rest. To reduce the client's risk of developing renal calculi, which intervention is the highest priority?

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

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

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

Question 43: Which ethical principle is most directly applied when a nurse ensures a patient receives accurate information about all treatment alternatives?

Beneficence
Veracity (Correct answer)
Justice
Fidelity

Correct answer: Veracity

Veracity is the duty to tell the truth; ensuring patients receive accurate information about treatment alternatives directly reflects this principle.

Question 44: A PN-RN is assessing a client's readiness to learn about a new low-sodium diet. Which factor most directly affects learning readiness?

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

Correct answer: The client's current pain level

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

Question 45: A nurse is educating a client about the DASH diet for hypertension management. Which food choice is consistent with DASH diet principles?

Canned soup with 900 mg sodium
White bread with processed cheese
Grilled salmon with steamed broccoli (Correct answer)
Salted pretzels with cream cheese dip

Correct answer: Grilled salmon with steamed broccoli

The DASH diet emphasizes fruits, vegetables, lean proteins, and low-sodium foods; grilled salmon with steamed broccoli aligns with these principles.

Question 46: A nurse is coordinating discharge planning for an elderly client with heart failure. Which team member should the nurse consult first?

The clinical pharmacist
The social worker (Correct answer)
The dietary consultant
The hospital chaplain

Correct answer: The social worker

The social worker is the key team member for discharge planning, assessing community resources, home support, financial assistance, and placement needs.

Question 47: Which behavior best demonstrates a client successfully resolving Erikson's stage of 'Industry vs. Inferiority'?

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

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

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

Question 48: A nurse is reviewing the lab results for a client with end-stage renal disease. The serum potassium level is 6.2 mEq/L. Which of the following is the priority nursing assessment?

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

Correct answer: Monitoring cardiac rate and rhythm

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

Question 49: A client who recently lost a limb says, 'I know I'll never be normal again, but I'm learning to adapt.' This statement reflects which phase of Kübler-Ross's grief model?

Acceptance (Correct answer)
Bargaining
Anger
Depression

Correct answer: Acceptance

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

Question 50: A nurse is using the five rights of delegation. Which element is NOT one of the five rights?

Right person
Right supervision
Right documentation (Correct answer)
Right task

Correct answer: Right documentation

The five rights of delegation are: right task, right circumstance, right person, right direction/communication, and right supervision — documentation is not one of the five rights.

Question 51: A nurse is assisting a patient with dysphagia. Which dietary modification is most appropriate to reduce the risk of aspiration?

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

Correct answer: Thickened liquids

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

Question 52: Which action by the nurse BEST promotes sleep hygiene for a hospitalized client?

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

Correct answer: Cluster nursing care activities to minimize nighttime interruptions

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

Question 53: A patient diagnosed with schizophrenia reports hearing voices that tell them to harm themselves. How should the nurse classify this symptom?

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

Correct answer: Command auditory hallucination

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

Question 54: Which patient is at HIGHEST risk for developing a healthcare-associated infection (HAI)?

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

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

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

Question 55: A patient with type 2 diabetes is prescribed metformin. Which condition is an absolute contraindication to its use?

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

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

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

Question 56: A nurse notes that a patient's urine output has been 80 mL over the past 4 hours. How should the nurse interpret this finding?

Normal variation during sleep hours
Polyuria; fluid restriction should be initiated
Normal output; no action needed
Oliguria; requires further assessment and notification of provider (Correct answer)

Correct answer: Oliguria; requires further assessment and notification of provider

Normal urine output is at least 30 mL/hour; 80 mL over 4 hours equals only 20 mL/hour, which meets the definition of oliguria and requires provider notification.

Question 57: Which IV solution is considered isotonic and is commonly used for fluid replacement?

0.9% Normal Saline (NS) (Correct answer)
0.45% Half Normal Saline
3% Hypertonic Saline
D5W 0.45% NaCl

Correct answer: 0.9% Normal Saline (NS)

0.9% Normal Saline is an isotonic solution with the same osmolarity as blood plasma, making it ideal for fluid volume replacement without causing fluid shifts.

Question 58: A nurse working on a medical-surgical unit discovers a fire in a client's trash can. What is the nurse's immediate priority action?

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

Correct answer: Rescue any clients in immediate danger.

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

Question 59: What is the most important nursing consideration when applying a cold pack to a patient's injury?

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

Correct answer: Limit application to 20 minutes at a time

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

Question 60: A nurse discovers a patient left the unit without notifying staff (elopement). What is the priority nursing action?

Document the absence in the chart and wait 30 minutes
Call the patient's emergency contact before notifying security
Complete an incident report before taking any other action
Search the facility and notify the charge nurse and security immediately (Correct answer)

Correct answer: Search the facility and notify the charge nurse and security immediately

Patient elopement is a safety emergency; the nurse must immediately alert the charge nurse and security to initiate a search.

Question 61: Which developmental milestone is expected in a healthy 12-month-old child?

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

Correct answer: Walking with assistance or independently

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

Question 62: A nurse is caring for a patient with a nasogastric (NG) tube for enteral feeding. Before administering the feeding, what should the nurse verify first?

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

Correct answer: Correct tube placement

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

Question 63: A nurse is documenting client care. Which principle of accurate documentation should the nurse follow?

Leave blank spaces in the chart for later additions
Document care in advance to save time during a busy shift
Use approved abbreviations and record only objective findings (Correct answer)
Correct errors by using correction fluid (white-out)

Correct answer: Use approved abbreviations and record only objective findings

Accurate documentation requires use of facility-approved abbreviations, objective language, and timely, factual entries without leaving blank spaces.

Question 64: A client with schizophrenia tells the nurse, 'The FBI is putting thoughts in my head.' The nurse's best response is:

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

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

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

Question 65: A nurse is caring for a client on bed rest after surgery. Which action BEST prevents venous thromboembolism (VTE)?

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

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

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

Question 66: The ethical principle of beneficence requires a nurse to take what type of action?

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

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

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

Question 67: A nurse is counseling a client about primary prevention of type 2 diabetes. Which recommendation is most appropriate?

Monitor blood glucose weekly
Maintain a healthy weight and exercise regularly (Correct answer)
Limit fluid intake to 1 liter per day
Take metformin prophylactically

Correct answer: Maintain a healthy weight and exercise regularly

Primary prevention of type 2 diabetes centers on lifestyle modifications including maintaining a healthy weight and regular physical activity.

Question 68: A PN is coordinating care for a patient being discharged to a skilled nursing facility. Which action is the PN's priority?

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

Correct answer: Ensuring transfer documentation and medication reconciliation are complete

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

Question 69: A nurse is caring for a client receiving Total Parenteral Nutrition (TPN) via a central venous catheter. Which of the following is a priority nursing intervention to prevent a metabolic complication?

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

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

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

Question 70: A postoperative client reports sudden onset of chest pain and shortness of breath on day 2 after hip replacement surgery. What is the nurse's priority action?

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

Correct answer: Notify the physician immediately

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

Question 71: What is the correct method for performing surgical hand antisepsis before an operative procedure?

Apply alcohol-based hand rub for 15 seconds
Scrub hands and arms to 2 inches above the elbows for 2-6 minutes (Correct answer)
Apply gloves without hand washing if hands appear clean
Wash hands with regular soap for 30 seconds

Correct answer: Scrub hands and arms to 2 inches above the elbows for 2-6 minutes

Surgical hand antisepsis requires scrubbing hands and forearms to 2 inches above the elbows with an antimicrobial agent for 2-6 minutes to reduce transient and resident flora.

Question 72: A client is admitted with severe dehydration secondary to gastroenteritis. The healthcare provider orders an intravenous fluid to rapidly expand intravascular volume. Which type of IV solution would the nurse anticipate being ordered?

0.45% Sodium Chloride (1/2 NS)
Dextrose 5% in water (D5W)
0.9% Sodium Chloride (Normal Saline) (Correct answer)
3% Sodium Chloride

Correct answer: 0.9% Sodium Chloride (Normal Saline)

0.9% Sodium Chloride (Normal Saline) is an isotonic solution, meaning it has a similar osmolarity to body fluids. It is the fluid of choice for rapid intravascular volume expansion in cases of dehydration or hypovolemia because it primarily stays within the vascular space. 0.45% NaCl is hypotonic and would shift fluid into cells. D5W is isotonic in the bag but becomes hypotonic in the body as dextrose is metabolized. 3% NaCl is a hypertonic solution used for specific electrolyte imbalances like severe hyponatremia, not for general volume expansion.

Question 73: Which therapeutic communication technique involves restating the patient's message in the nurse's own words to verify understanding?

Summarizing
Paraphrasing (Correct answer)
Reflecting
Clarifying

Correct answer: Paraphrasing

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

Question 74: Which of the following factors raises the chance of pulmonary embolism after surgery?

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

Correct answer: Prolonged immobilization.

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

Question 75: A nurse is preparing to transfer a patient from bed to wheelchair. The patient can bear partial weight. Which action by the nurse is most important for safe transfer?

Locking the wheelchair brakes and raising the footrests before the transfer (Correct answer)
Using a wide stance and bending at the waist to maintain balance during the lift
Instructing the patient to place both arms around the nurse's neck for support
Placing the wheelchair at a 90-degree angle to the bed on the patient's weaker side

Correct answer: Locking the wheelchair brakes and raising the footrests before the transfer

Locking wheelchair brakes and raising footrests prevents the chair from rolling and eliminates a tripping hazard, which are essential safety steps before any transfer.

Question 76: A patient with cirrhosis develops ascites and peripheral edema. Which laboratory finding would the nurse expect?

Decreased serum albumin (Correct answer)
Elevated serum albumin
Decreased BUN
Elevated hemoglobin

Correct answer: Decreased serum albumin

The cirrhotic liver cannot produce adequate albumin, leading to decreased oncotic pressure and fluid shifting into the interstitial space and peritoneal cavity.

Question 77: A nurse is preparing to hang a new IV bag. Which assessment finding would require the nurse to discontinue the current IV site?

The IV is infusing at the prescribed rate
The dressing is intact and dated within 72 hours
The IV insertion site is clean and dry
There is redness, swelling, and warmth at the insertion site (Correct answer)

Correct answer: There is redness, swelling, and warmth at the insertion site

Redness, swelling, and warmth at an IV site indicate phlebitis or possible infection, requiring immediate removal of the catheter and insertion at a new site.

Question 78: A nurse is preparing to administer heparin 5,000 units subcutaneously. Which action is correct?

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

Correct answer: Do not rub the injection site after administration

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

Question 79: When administering a peripheral IV infusion, the nurse notices the site is cool, pale, and swollen. What is the priority action?

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

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

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

Question 80: The nurse is preparing to administer insulin glargine (Lantus) to a patient. Which action is correct?

Mix with regular insulin in the same syringe for convenience
Give IV push if the patient is NPO before surgery
Administer subcutaneously at the same time each day (Correct answer)
Shake the vial vigorously to mix before drawing up

Correct answer: Administer subcutaneously at the same time each day

Insulin glargine is a long-acting basal insulin given subcutaneously once daily at the same time; it must never be mixed or given IV.

Question 81: A client is reporting pain rated at 8 on a 0-10 scale. After administering the prescribed analgesic, which non-pharmacological intervention would be most appropriate for the nurse to implement to provide additional comfort?

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

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

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

Question 82: A nurse is caring for a patient in septic shock. Which set of vital signs is most consistent with early (warm) septic shock?

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

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

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

Question 83: A patient is receiving IV vancomycin and develops flushing, erythema, and hypotension during the infusion. What is the most likely cause?

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

Correct answer: Red man syndrome

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

Question 84: What is the primary purpose of the nursing process?

To document patient care for legal purposes
To ensure nurses complete tasks in order of difficulty
To reduce the workload of healthcare providers
To provide a systematic framework for delivering individualized patient care (Correct answer)

Correct answer: To provide a systematic framework for delivering individualized patient care

The nursing process provides a systematic, patient-centered framework with five steps: assessment, diagnosis, planning, implementation, and evaluation.

Question 85: A nurse is admitting a client with suspected active pulmonary tuberculosis (TB). Which of the following environmental controls is essential to implement for airborne precautions?

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

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

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

Question 86: A patient with COPD is receiving oxygen therapy. The nurse notes the oxygen saturation is 96%. What is the nurse's priority concern?

The saturation may be too high, potentially suppressing the hypoxic drive (Correct answer)
This is an expected finding requiring no action
The pulse oximeter must be malfunctioning
The saturation is too low and oxygen should be increased

Correct answer: The saturation may be too high, potentially suppressing the hypoxic drive

COPD patients rely on hypoxic drive for respiratory stimulation. Target SpO2 for COPD patients is typically 88-92%. An SpO2 of 96% may indicate excessive oxygen administration.

Question 87: A nurse is caring for a client with Medicare. Which statement about Medicare Part B is accurate?

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

Correct answer: It covers outpatient physician services and preventive care

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

Question 88: A nurse observes that a patient's Jackson-Pratt (JP) drain has changed from serosanguineous to bright red output. What should the nurse do?

Notify the surgeon, as this may indicate active bleeding (Correct answer)
Empty the drain and record the output as expected
Clamp the drain and reposition the patient
Remove the drain immediately

Correct answer: Notify the surgeon, as this may indicate active bleeding

A change from serosanguineous to bright red drainage in a JP drain suggests active bleeding at the surgical site and requires immediate physician notification.

Question 89: A nurse is preparing to assist with a thoracentesis for a client with a large pleural effusion. To reduce the risk of puncturing the lung, which position should the nurse assist the client into?

In a side-lying position with the affected side up.
Seated on the edge of the bed, leaning forward over a bedside table. (Correct answer)
Lying flat in a supine position.
In Trendelenburg position.

Correct answer: Seated on the edge of the bed, leaning forward over a bedside table.

The upright position, with the client seated and leaning forward over a bedside table, widens the intercostal spaces and allows fluid to accumulate at the base of the lung due to gravity. This positioning makes needle insertion easier and safer, moving the lung tissue up and away from the insertion site, thereby reducing the risk of a pneumothorax.

Question 90: A nurse is initiating a transfusion of packed red blood cells (PRBCs). Fifteen minutes into the transfusion, the client develops shortness of breath, chills, and lower back pain. What is the nurse's priority action?

Slow the rate of the transfusion.
Stop the transfusion immediately. (Correct answer)
Administer an antihistamine as ordered.
Notify the healthcare provider.

Correct answer: Stop the transfusion immediately.

The client's symptoms of chills, shortness of breath, and lower back pain are classic signs of an acute hemolytic transfusion reaction, a life-threatening emergency. The absolute first and most critical action is to stop the transfusion immediately to prevent any more incompatible blood from entering the client's system. After stopping the transfusion, the nurse would then notify the provider and perform other supportive interventions, such as maintaining IV access with normal saline.

Question 91: Which assessment tool is most commonly used by nurses to screen for depression in adult patients?

Patient Health Questionnaire-9 (PHQ-9) (Correct answer)
Braden Scale
CAGE Questionnaire
Glasgow Coma Scale

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

The PHQ-9 is a validated, widely used screening tool that assesses the nine DSM criteria for major depressive disorder over the past two weeks.

Question 92: A nurse is caring for a client with dysphagia. Which food consistency is MOST appropriate to prevent aspiration?

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

Correct answer: Nectar-thickened liquids

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

Question 93: When administering an intramuscular (IM) injection of an irritating medication to an average-sized adult, which of the following actions demonstrates the correct technique?

Using a 25-gauge, 5/8-inch needle for the injection.
Inserting the needle at a 45-degree angle to the skin.
Utilizing the Z-track method during the injection. (Correct answer)
Selecting the dorsogluteal site as the preferred location.

Correct answer: Utilizing the Z-track method during the injection.

The Z-track method is a technique used to prevent the leakage of irritating and discoloring medications into the subcutaneous tissue. This method involves displacing the skin and subcutaneous tissue laterally before injection, which creates a zigzag path that seals the medication in the muscle upon needle withdrawal. The dorsogluteal site is no longer recommended due to the risk of sciatic nerve injury. A 5/8-inch needle is too short for an adult IM injection (typically 1 to 1.5 inches is needed). IM injections are administered at a 90-degree angle.

Question 94: A nurse is monitoring a patient receiving a blood transfusion who develops urticaria (hives) without other symptoms. What is the appropriate initial action?

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

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

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

Question 95: A nurse is teaching a patient about warfarin therapy. Which food should the patient be instructed to consume consistently rather than avoid entirely?

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

Correct answer: Green leafy vegetables

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

Question 96: A nurse is teaching a client about incentive spirometry after abdominal surgery. Which instruction is CORRECT?

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

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

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

Question 97: A client's morning blood glucose is 52 mg/dL and they are conscious and able to swallow. What is the nurse's first action?

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

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

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

Question 98: A nurse is administering total parenteral nutrition (TPN) through a central line. Which nursing action is essential?

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

Correct answer: Monitor blood glucose levels regularly

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

Question 99: A nurse is inserting an indwelling urinary catheter in a female patient. During insertion, urine is not obtained. What should the nurse do?

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

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

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

Question 100: A patient develops hypophosphatemia after several days NPO without phosphate supplementation. Which complication is the nurse most concerned about?

Peaked T waves and cardiac arrhythmias
Renal calculi formation
Muscle weakness and respiratory failure (Correct answer)
Pathological bone fractures from calcification

Correct answer: Muscle weakness and respiratory failure

Hypophosphatemia impairs ATP production, leading to profound muscle weakness that can affect the diaphragm and intercostal muscles, causing life-threatening respiratory failure.

Question 101: A patient who is immobile is at risk for developing deep vein thrombosis (DVT). Which nursing intervention helps prevent this complication?

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

Correct answer: Applying sequential compression devices

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

Question 102: A patient develops compartment syndrome in the left leg after a tibial fracture. Which assessment finding is most diagnostic?

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

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

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

Question 103: When assisting a patient with a bed bath, in which direction should the nurse wash the extremities?

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

Correct answer: Distal to proximal

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

Question 104: A nurse is assessing a patient's nutritional status. Which laboratory value is the best indicator of protein status?

Blood glucose
Serum albumin (Correct answer)
Hemoglobin
Serum potassium

Correct answer: Serum albumin

Serum albumin reflects protein status and is commonly used as a marker of nutritional health, though it has a long half-life of approximately 20 days.

Question 105: A patient with cirrhosis develops asterixis, confusion, and elevated ammonia levels. Which physiological process is occurring?

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

Correct answer: Hepatic encephalopathy from impaired ammonia detoxification

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

Question 106: A PN receives a verbal telephone order from a physician for a medication. What is the correct process for handling this order?

Write down the order, read it back to the physician for verification, and document it per facility policy (Correct answer)
Administer the medication immediately based on the verbal order alone
Have a UAP transcribe the order to free up the nurse's time
Refuse all verbal orders and insist on written orders only

Correct answer: Write down the order, read it back to the physician for verification, and document it per facility policy

The read-back process for verbal orders is a Joint Commission-required safety practice to verify accuracy before implementation.

Question 107: A nurse is preparing to administer a continuous intravenous infusion of heparin. Which of the following laboratory values is essential for the nurse to review immediately before initiating the infusion?

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

Correct answer: Activated Partial Thromboplastin Time (aPTT)

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

Question 108: Which medication requires the nurse to monitor for ototoxicity as a serious adverse effect?

Lisinopril
Amoxicillin
Gentamicin (Correct answer)
Metformin

Correct answer: Gentamicin

Gentamicin is an aminoglycoside antibiotic with well-documented ototoxic and nephrotoxic effects. Peak and trough levels must be monitored.

Question 109: According to Erikson's theory, which developmental task is the primary focus for adolescents?

Identity versus role confusion (Correct answer)
Intimacy versus isolation
Industry versus inferiority
Trust versus mistrust

Correct answer: Identity versus role confusion

Erikson identified identity versus role confusion as the central developmental task of adolescence (ages 12-18), where teens develop a sense of personal identity.

Question 110: Which intervention is the nurse's highest priority when caring for a postoperative patient in the PACU who has a SpO₂ of 89%?

Notify the surgeon immediately
Document the finding and continue monitoring
Encourage the patient to cough and deep breathe
Apply supplemental oxygen and reposition the airway (Correct answer)

Correct answer: Apply supplemental oxygen and reposition the airway

Applying supplemental oxygen and opening the airway addresses the immediate physiologic threat of hypoxemia before notifying the provider.

Question 111: A nurse is caring for a terminally ill patient who has a valid DNR order. The patient goes into cardiac arrest. The patient's adult son demands that the nurse 'do everything.' What is the appropriate nursing response?

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

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

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

Question 112: A registered nurse is delegating tasks to a nursing assistant (NA). Which task is appropriate to delegate to the NA?

Administering a scheduled oral medication
Assessing a client's respiratory status post-bronchodilator
Measuring and recording urine output for a stable client (Correct answer)
Evaluating a client's response to pain medication

Correct answer: Measuring and recording urine output for a stable client

Measuring and recording urine output is a non-invasive, routine task within the nursing assistant's scope of practice for stable clients.

Question 113: What is the recommended daily fluid intake for an average healthy adult?

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

Correct answer: 2500-3000 mL

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

Question 114: A nurse is assessing a newborn's APGAR score at 1 minute. The infant has a heart rate of 96, weak cry, some flexion, grimace with stimulation, and pink body with blue extremities. What is the APGAR score?

6 (Correct answer)
5
8
7

Correct answer: 6

APGAR scoring: HR <100 = 1, weak cry = 1, some flexion = 1, grimace = 1, acrocyanosis = 1; total = 6.

Question 115: A patient reports pain at a level of 7 on a 0-10 scale following surgery. Which non-pharmacological intervention can the nurse implement independently?

Apply guided imagery and relaxation techniques (Correct answer)
Apply a warm compress to the surgical site
Increase the IV opioid drip rate
Administer a PRN analgesic

Correct answer: Apply guided imagery and relaxation techniques

Guided imagery and relaxation techniques are independent nursing interventions that can complement pharmacological pain management without requiring a physician order.

Question 116: A patient who had a colectomy for a bowel obstruction is being uncooperative and won't turn over or get out of bed. Which evaluation has precedence?

Emotional status.
Pain. (Correct answer)
Vital signs.
Wound

Correct answer: Pain.

The most frequent cause of inability to move following surgery is pain, thus a patient who has had a colectomy for a bowel blockage and is unwilling to turn, get out of bed, or cooperate should probably first be evaluated for pain. The wound should next be checked, vital signs obtained, and the patient's emotional state should be assessed. The patient could worry that moving will make their discomfort worse or might rip or open their wound.

Question 117: A nurse is preparing to transfuse packed red blood cells. What is the maximum time allowed for a single unit of PRBC to infuse?

8 hours
1 hour
2 hours
4 hours (Correct answer)

Correct answer: 4 hours

Packed red blood cells must be infused within 4 hours of removal from the blood bank refrigerator to minimize the risk of bacterial proliferation.

Question 118: When repositioning a patient to prevent pressure injuries, how frequently should the nurse turn the patient?

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

Correct answer: Every 2 hours

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

Question 119: A charge nurse observes a licensed practical nurse (LPN) performing a task outside their scope of practice. What is the charge nurse's immediate priority?

File a formal incident report before speaking to the LPN
Allow the LPN to complete the task and address it later
Immediately stop the task and ensure client safety (Correct answer)
Ask the client if they consent to the LPN performing the task

Correct answer: Immediately stop the task and ensure client safety

Client safety is the immediate priority; the charge nurse must stop the out-of-scope activity at once, then follow up with documentation and education.

Question 120: What is the purpose of performing a 'time out' immediately before a surgical procedure?

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

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

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

Question 121: Which behavior modification technique is MOST appropriate when counseling a client about smoking cessation?

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

Correct answer: Setting a specific quit date

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

Question 122: A PN is supervising a UAP who reports that a patient's blood pressure is 88/52 mmHg. What is the nurse's best initial action?

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

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

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

Question 123: A patient with chronic kidney disease has a potassium level of 6.2 mEq/L. Which cardiac rhythm change should the nurse anticipate?

ST elevation
Absent P waves with regular rhythm
Peaked T waves (Correct answer)
Prolonged QT interval

Correct answer: Peaked T waves

Hyperkalemia characteristically produces tall, peaked T waves on ECG as one of the earliest changes, followed by widened QRS and eventual sine wave pattern.

Question 124: A nurse is assessing a newborn's Apgar score at 5 minutes. The infant has a heart rate of 110, strong cry, active motion, grimaces with stimulation, and is completely pink. What is the Apgar score?

10 (Correct answer)
7
8
9

Correct answer: 10

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

Question 125: A client with chronic kidney disease has a serum phosphate of 6.5 mg/dL. The nurse anticipates which secondary electrolyte imbalance?

Hypocalcemia (Correct answer)
Hypernatremia
Hypercalcemia
Hyperkalemia

Correct answer: Hypocalcemia

Elevated phosphate binds calcium in the bloodstream, causing hypocalcemia in clients with chronic kidney disease.

Question 126: A nurse is teaching a pregnant client about neural tube defect prevention. Which nutrient is most important to emphasize?

Vitamin D
Folic acid (Correct answer)
Calcium
Iron

Correct answer: Folic acid

Adequate folic acid intake (400–800 mcg/day) before and during early pregnancy significantly reduces the risk of neural tube defects such as spina bifida.

Question 127: A patient in hypovolemic shock has a BP of 80/50 mmHg and HR of 128 bpm. Which physiological response explains the tachycardia?

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

Correct answer: Baroreceptor-mediated sympathetic activation

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

Question 128: A patient post-thyroidectomy develops tingling around the mouth and carpopedal spasms. Which lab value should the nurse check immediately?

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

Correct answer: Serum calcium

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

Question 129: A client is brought to the emergency department following a significant traumatic injury with suspected internal bleeding. Which of the following findings is considered an early compensatory sign of hypovolemic shock?

Hypotension
Decreased respiratory rate
Tachycardia (Correct answer)
Bradycardia

Correct answer: Tachycardia

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

Question 130: A nurse is caring for a dying patient. The patient's family asks the nurse to 'do everything possible' despite the patient's documented wish for comfort measures only. What is the most appropriate response?

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

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

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

Question 131: A nurse is teaching a group of parents about childhood immunizations. Which vaccine is recommended at birth in the US?

Varicella
DTaP
Hepatitis B (Correct answer)
MMR

Correct answer: Hepatitis B

The Hepatitis B vaccine is administered at birth as part of the recommended immunization schedule in the United States.

Question 132: A nurse is caring for a client who is verbally refusing a prescribed antipsychotic medication. The nurse proceeds to crush the medication, mix it in applesauce, and administer it to the client without their knowledge. This action constitutes which of the following intentional torts?

Battery (Correct answer)
Malpractice
Negligence
Assault

Correct answer: Battery

Battery is the intentional and wrongful physical contact with a person without their consent. Administering medication to a competent client who has refused it, especially through concealment, is a form of unwanted touching and a violation of the client's right to autonomy. Assault is the threat of harmful contact, while negligence and malpractice are unintentional torts related to failing to meet the standard of care.

Question 133: A terminally ill patient is experiencing Cheyne-Stokes respirations. The family asks what this means. The nurse's BEST response is:

'This pattern—cycles of rapid breathing followed by pauses—is a normal sign that death is approaching.' (Correct answer)
'We should call the physician to start mechanical ventilation.'
'This means the patient needs supplemental oxygen immediately.'
'This breathing pattern means the patient is in pain and needs more medication.'

Correct answer: 'This pattern—cycles of rapid breathing followed by pauses—is a normal sign that death is approaching.'

Cheyne-Stokes respirations (irregular cycles of apnea and hyperpnea) are a normal physiological sign of imminent death caused by decreased cerebral perfusion. Educating the family that this is expected and not distressing to the patient provides comfort and reduces panic. It does not indicate a need for aggressive intervention.

Question 134: Which arterial blood gas result indicates metabolic alkalosis with respiratory compensation?

pH 7.32, PaCO2 55, HCO3 28
pH 7.28, PaCO2 30, HCO3 14
pH 7.48, PaCO2 30, HCO3 22
pH 7.50, PaCO2 48, HCO3 36 (Correct answer)

Correct answer: pH 7.50, PaCO2 48, HCO3 36

pH 7.50 (alkalotic), elevated HCO3 36 (metabolic cause), and elevated PaCO2 48 (respiratory compensation by retaining CO2) indicate compensated metabolic alkalosis.

Question 135: A nurse discovers a medication error was made by a previous nurse. Which documentation action is correct?

Document the error in the patient's chart and file an incident report (Correct answer)
Notify the supervisor verbally and make no written record until instructed
File only an incident report and omit it from the patient's chart
Correct the previous nurse's charting and add a note

Correct answer: Document the error in the patient's chart and file an incident report

Medication errors must be documented in the patient's chart (objective facts only—what happened and patient's response) and reported via an incident/occurrence report. Altering another's documentation is falsification; omitting it from the chart is incomplete documentation.

Question 136: A nurse notices a client has been isolating herself and crying frequently since her husband's death two weeks ago. The nurse's best initial action is to:

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

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

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

Question 137: A nurse is caring for a client who had a stroke and has dysphagia. Which of the following interventions is the priority to ensure the client's safety and comfort during meals?

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

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

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

Question 138: A 30-year-old client is recovering from a major surgery that has resulted in a significant change in body image. The client refuses to look at the surgical site. This behavior is an example of which defense mechanism?

Projection
Rationalization
Sublimation
Denial (Correct answer)

Correct answer: Denial

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

Question 139: A patient's durable power of attorney for healthcare (DPAHC) designates a spouse as surrogate decision-maker. The patient is now unconscious. The adult children disagree with the spouse's decision. Who has legal authority?

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

Correct answer: The spouse designated in the DPAHC

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

Question 140: The ethical principle of justice is most clearly demonstrated when a nurse:

Keeps a promise made to a patient
Advocates for equitable distribution of healthcare resources among patients (Correct answer)
Provides accurate information to support informed consent
Acts to prevent harm to a vulnerable patient

Correct answer: Advocates for equitable distribution of healthcare resources among patients

Justice in nursing ethics refers to fair, equitable treatment and distribution of resources, regardless of personal characteristics.

Question 141: A nurse is monitoring a client receiving an IV infusion of 0.9% sodium chloride. The client complains of pain and swelling at the IV site, and the surrounding skin appears cool and blanched. Which action should the nurse take first?

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

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

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

Question 142: A nurse is caring for a client receiving furosemide for heart failure. The client reports significant muscle weakness, and the cardiac monitor shows flattened T waves and prominent U waves. The nurse should suspect which electrolyte imbalance?

Hypokalemia (Correct answer)
Hyponatremia
Hypomagnesemia
Hypercalcemia

Correct answer: Hypokalemia

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

Question 143: A client preparing for a colonoscopy is consuming the prescribed polyethylene glycol solution and reports feeling nauseated and bloated. The client states, "I don't think I can drink any more of this." Which nursing response is most appropriate to reduce the risk of an incomplete bowel preparation?

"It's important to finish the prep; try to drink the rest as quickly as possible."
"I will bring you some solid food to help settle your stomach."
"You can take a short break for about 30-60 minutes, then resume drinking the solution at a slower pace." (Correct answer)
"Stop drinking the solution immediately and we will notify the doctor to cancel the procedure."

Correct answer: "You can take a short break for about 30-60 minutes, then resume drinking the solution at a slower pace."

Nausea and bloating are common side effects of bowel preparation solutions. The most effective strategy is to temporarily pause for 30-60 minutes, allow the symptoms to subside, and then resume drinking at a slower rate. This approach increases the likelihood of completing the prep, which is essential for adequate visualization during the colonoscopy, thus reducing the risk of a failed or repeated procedure.

Question 144: A nurse is developing a plan of care for an older adult client at risk for pressure injuries. Which of the following interventions should be included?

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

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

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

Question 145: An RN on a medical-surgical unit is planning assignments for the upcoming shift. The team consists of another RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which task is most appropriate for the RN to delegate to the LPN?

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

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

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

Question 146: Which finding indicates that fluid resuscitation for a client in hypovolemic shock is effective?

Heart rate increases from 110 to 130 bpm
Skin becomes cool and clammy
Urine output increases from 10 mL/hr to 40 mL/hr (Correct answer)
Blood pressure drops from 90/60 to 80/50 mmHg

Correct answer: Urine output increases from 10 mL/hr to 40 mL/hr

Urine output of 30–50 mL/hr indicates adequate renal perfusion and is a key indicator of effective fluid resuscitation.

Question 147: A nurse is teaching a 45-year-old female client about recommended health screenings. Which screening should the nurse prioritize for this age group?

Annual mammogram (Correct answer)
Pap smear every 2 years
Colonoscopy every 5 years
Bone density scan annually

Correct answer: Annual mammogram

The American Cancer Society recommends annual mammograms for average-risk women beginning at age 45.

Question 148: A nurse administers the wrong dose of a medication but the patient experiences no harm. This event is classified as a:

Sentinel event
Near miss (Correct answer)
Adverse event
Never event

Correct answer: Near miss

A near miss (close call) is an error that reaches the patient but causes no harm.

Question 149: A nurse receives a physician's order that appears to be incorrect. What is the nurse's responsibility?

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

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

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

Question 150: A nurse is assisting a client who uses a cane. On which side should the cane be held?

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

Correct answer: The unaffected (stronger) side

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

Question 151: A bedridden client has a stage II pressure injury on the coccyx. Which intervention is the PRIORITY?

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

Correct answer: Reposition the client every 2 hours

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

Question 152: A client states, 'My doctor says I have cancer, but I know the lab results are wrong.' This is an example of which defense mechanism?

Rationalization
Denial (Correct answer)
Projection
Displacement

Correct answer: Denial

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

Question 153: When teaching a client how to use a standard cane, the nurse should instruct the client to hold the cane on which side?

On the affected (weaker) side.
Alternating sides with each step.
On whichever side feels more comfortable.
On the unaffected (stronger) side. (Correct answer)

Correct answer: On the unaffected (stronger) side.

The cane should be held on the client's stronger (unaffected) side to provide the best support and stability. The cane then moves forward with the weaker leg, creating a wide base of support and allowing the client to lean on the stronger side.

Question 154: A client reports constipation. Which non-pharmacological intervention should the nurse recommend FIRST?

Recommend a low-fiber diet
Administer a bisacodyl suppository
Suggest bed rest to conserve energy
Increase fluid intake to 2–3 liters per day (Correct answer)

Correct answer: Increase fluid intake to 2–3 liters per day

Increasing fluid intake softens stool and is the first-line non-pharmacological intervention for constipation.

Question 155: Which assessment finding in a patient taking lithium carbonate requires immediate intervention?

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

Correct answer: Serum lithium level of 2.5 mEq/L

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

Question 156: Which of the following interventions by a nurse best promotes the psychosocial well-being of a hospitalized adolescent client?

Encouraging frequent family visits to reduce feelings of loneliness.
Scheduling structured quiet time for rest and reflection.
Allowing friends to visit and providing access to social media. (Correct answer)
Providing detailed medical information to increase their sense of control.

Correct answer: Allowing friends to visit and providing access to social media.

Adolescents are in the 'Identity vs. Role Confusion' stage of development, where peer relationships are extremely important for developing a sense of self. Allowing interaction with friends and access to social media helps maintain these crucial social connections and promotes a sense of normalcy, which is vital for their psychosocial health during hospitalization.

Question 157: Which compensatory mechanism occurs in a patient with metabolic acidosis?

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

Correct answer: Kussmaul respirations to blow off CO2

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

Question 158: Which of the following best describes the concept of 'continuity of care' in nursing practice?

Ensuring all nursing documentation is completed before the end of each shift
Limiting the number of care providers involved in a patient's treatment plan
Coordinating and communicating patient care across all providers and settings to ensure seamless transitions (Correct answer)
Assigning the same nurse to a patient every shift to build rapport

Correct answer: Coordinating and communicating patient care across all providers and settings to ensure seamless transitions

Continuity of care involves coordinating information and services across providers and settings so patient care remains consistent and uninterrupted.

Question 159: A patient with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which ECG change should the nurse anticipate first?

Flattened P waves
Peaked T waves (Correct answer)
Widened QRS complex
Prolonged PR interval

Correct answer: Peaked T waves

Peaked T waves are the earliest ECG manifestation of hyperkalemia, preceding widened QRS and other changes.

Question 160: A nurse is working in a case management role. Which action best reflects the case manager's primary function?

Coordinating services across the continuum of care to optimize outcomes (Correct answer)
Providing direct bedside care to complex patients
Conducting surgical procedures for high-risk clients
Prescribing medications for chronic illness management

Correct answer: Coordinating services across the continuum of care to optimize outcomes

Case managers coordinate care across settings and disciplines to ensure cost-effective, quality outcomes along the continuum of care.

Question 161: Which teaching point should a nurse include when instructing a client about breast self-examination (BSE)?

BSE replaces annual clinical breast exams
Perform BSE 1 week before the menstrual period
BSE should be performed only by women over 50
Perform BSE on the same day each month (Correct answer)

Correct answer: Perform BSE on the same day each month

BSE should be performed consistently on the same day each month; for menstruating women, performing it 5–7 days after the period begins is ideal.

Question 162: A patient is at risk for falls. Which intervention is most effective for fall prevention?

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

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

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

Question 163: A nurse suspects that an elderly patient is being financially exploited by a family member. What is the nurse's legal obligation?

Discuss the concern with the family member first
Wait for definitive proof before reporting
Report the suspected abuse to Adult Protective Services (Correct answer)
Document the suspicion but take no further action

Correct answer: Report the suspected abuse to Adult Protective Services

Nurses are mandated reporters of suspected elder abuse, including financial exploitation. Reasonable suspicion is sufficient to trigger reporting.

Question 164: Which finding during a well-child visit in a 6-month-old warrants further evaluation by the nurse?

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

Correct answer: Absence of babbling

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

Question 165: Which behavior by a nurse demonstrates cultural humility rather than cultural competence?

Assuming a patient's pain tolerance is high based on their ethnic background
Applying the same assessment tool to all patients regardless of cultural background
Acknowledging personal biases and asking patients to share their own cultural health beliefs (Correct answer)
Memorizing the health beliefs of the top five cultural groups in the service area

Correct answer: Acknowledging personal biases and asking patients to share their own cultural health beliefs

Cultural humility involves ongoing self-reflection, acknowledging the limits of one's cultural knowledge, and centering the patient as the expert on their own culture. Memorizing cultural 'facts' can lead to stereotyping. Cultural humility is a process, not a fixed competency—it prioritizes asking over assuming.

Question 166: In the event of a fire on a nursing unit, what is the correct sequence of actions?

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

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

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

Question 167: Which quality improvement model uses the cycle of Plan, Do, Study, Act?

PDSA cycle (Correct answer)
Six Sigma
Failure Mode and Effects Analysis
Lean methodology

Correct answer: PDSA cycle

The PDSA (Plan-Do-Study-Act) cycle is a quality improvement model that tests changes on a small scale before implementing them broadly.

Question 168: A nurse witnesses a healthcare provider explaining a surgical procedure to a client who speaks a different language, using the client's 12-year-old grandchild as an interpreter. Which ethical principle is most immediately compromised in this situation?

Justice
Fidelity
Autonomy (Correct answer)
Nonmaleficence

Correct answer: Autonomy

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

Question 169: A client is admitted with a stage III pressure injury to the sacrum. Which intervention has the highest priority?

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

Correct answer: Reposition the client every 2 hours

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

Question 170: A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). The nurse notes that the client is breathing very deeply and rapidly. The nurse recognizes this respiratory pattern, Kussmaul respirations, as the body's attempt to compensate for which acid-base imbalance?

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

Correct answer: Metabolic Acidosis

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

Question 171: A patient has a nursing diagnosis of 'Risk for Falls.' Which intervention is the priority?

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

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

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

Question 172: When providing oral care to an unconscious client, which position is MOST appropriate?

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

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

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

Question 173: A nurse is using the SBAR communication tool to report a change in patient condition. What does the 'R' stand for?

Report
Recommendation (Correct answer)
Review
Reassessment

Correct answer: Recommendation

In SBAR, 'R' stands for Recommendation — the nurse's suggestion for what action should be taken.

Question 174: A nurse is providing anticipatory guidance to parents of a 2-year-old. Which safety measure is the highest priority?

Enrolling the child in swimming lessons immediately
Teaching the child not to touch the stove
Installing safety locks on cabinets containing cleaning products (Correct answer)
Removing all toys with small parts from the home

Correct answer: Installing safety locks on cabinets containing cleaning products

Toddlers are at high risk for poisoning; securing household chemicals in locked cabinets is the highest priority safety measure for this age group.

Question 175: A nurse is caring for a patient with Clostridioides difficile (C. diff) infection. Which personal protective equipment (PPE) is essential when entering the room?

N95 respirator and eye protection
Gown and gloves only (Correct answer)
Surgical mask and gloves
Gown, gloves, and surgical mask

Correct answer: Gown and gloves only

C. diff is transmitted via contact, so a gown and gloves are required; a mask is not routinely needed unless splashing is anticipated.

Question 176: When removing PPE after caring for a patient on contact precautions, which item should be removed FIRST?

Gloves (Correct answer)
Goggles
Gown
Mask

Correct answer: Gloves

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

Question 177: Which IV fluid is considered isotonic and is most appropriate for replacing extracellular fluid losses?

D10W
3% NaCl
0.9% NaCl (Correct answer)
0.45% NaCl

Correct answer: 0.9% NaCl

0.9% NaCl (normal saline) is isotonic and expands extracellular fluid without shifting water into or out of cells.

Question 178: A client's urine output for the past 8 hours totals 200 mL. How should the nurse document this finding?

Anuria
Polyuria
Nocturia
Oliguria (Correct answer)

Correct answer: Oliguria

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

Question 179: A nurse has finished providing care for a client on contact and droplet precautions. To minimize the risk of self-contamination, which of the following represents the correct sequence for removing (doffing) personal protective equipment (PPE)?

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

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

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

Question 180: A client with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department with increased shortness of breath. An arterial blood gas (ABG) analysis reveals the following: pH 7.28, PaCO2 55 mmHg, HCO3 26 mEq/L. How should the nurse interpret these findings?

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

Correct answer: Respiratory Acidosis, Uncompensated

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

Question 181: Which situation represents a breach of patient confidentiality under HIPAA?

Discussing patient status with the treatment team during rounds
Sharing patient information with the patient's designated healthcare proxy
Discussing a patient's diagnosis in the hospital elevator with a colleague (Correct answer)
Reporting a communicable disease to the health department

Correct answer: Discussing a patient's diagnosis in the hospital elevator with a colleague

Discussing patient information in a public area like an elevator where unauthorized individuals may overhear is a HIPAA violation.

Question 182: A patient with SIADH has a serum sodium of 118 mEq/L. Which symptom is most concerning?

Dry mucous membranes
Seizures and altered consciousness (Correct answer)
Increased urine output
Pitting edema in lower extremities

Correct answer: Seizures and altered consciousness

Severe hyponatremia causes cerebral edema, leading to seizures and altered consciousness, which are life-threatening neurological complications.

Question 183: What drug is most likely to offer relief right away if an asthmatic patient is having an acute exacerbation with wheezing and dyspnea?

prednisone (corticosteroid)
albuterol (beta-adrenergic agonist). (Correct answer)
montelukast (leukotriene receptor antagonist).
ipratropium (anticholinergic).

Correct answer: albuterol (beta-adrenergic agonist).

Albuterol, a beta-adrenergic agonist frequently used during the acute stage of asthma, is likely to provide the most immediate relief if a patient with a history of asthma is going through an acute exacerbation with wheezing and dyspnea. This is because this class of medications offers quick bronchodilation. These medications should be avoided in patients who have uncontrolled cardiac dysrhythmias and a high risk of stroke since they have some vasoconstrictive effects.

Question 184: A postoperative client is encouraged to ambulate as soon as possible. Which of the following is the primary rationale for early ambulation?

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

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

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

Question 185: A PN is caring for four patients. Which patient should be assessed first?

A patient requesting a pain medication refill rated 4/10
A patient with a stable wound dressing that needs to be changed
A patient who became suddenly confused and restless one hour post-surgery (Correct answer)
A patient awaiting discharge instructions for diabetes management

Correct answer: A patient who became suddenly confused and restless one hour post-surgery

Acute onset confusion and restlessness post-surgery may indicate hemorrhage, hypoxia, or other life-threatening complications requiring immediate assessment.

Question 186: A nurse is assessing a 3-year-old who insists on doing tasks 'by myself.' According to Erikson, this behavior reflects which developmental stage?

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

Correct answer: Autonomy vs. shame and doubt

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

Question 187: A patient receiving total parenteral nutrition (TPN) develops sudden onset of chest pain, dyspnea, and decreased breath sounds on the left. The nurse should first suspect:

Pneumothorax from central line insertion (Correct answer)
Catheter-related bloodstream infection
Hypoglycemia from incorrect TPN formulation
Air embolism from a disconnected tubing

Correct answer: Pneumothorax from central line insertion

Pneumothorax is a known complication of central venous catheter insertion (required for TPN). Sudden chest pain, dyspnea, and unilateral absent breath sounds after line placement are classic signs. This is a medical emergency requiring immediate intervention.

Question 188: A nurse is caring for a patient experiencing status epilepticus. Which intervention takes priority?

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

Correct answer: Maintaining a patent airway and administering IV benzodiazepine

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

Question 189: A new mother two weeks postpartum tells the nurse she has thoughts of harming her baby. What is the priority nursing action?

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

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

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

Question 190: A client who was just informed of a terminal diagnosis begins yelling at the nurse, 'This is your fault! You didn't push for more tests!' The nurse recognizes this response as:

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

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

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

Question 191: What is the main responsibility of young adults, according to Erikson?

identify versus role confusion.
integrity versus despair.
intimacy versus isolation. (Correct answer)
autonomy versus shame.

Correct answer: intimacy versus isolation.

According to Erik Erikson's stages of psychosocial development, the primary developmental task for young adults (typically ages 18-40) is 'Intimacy versus Isolation.' In this stage, individuals strive to form deep, meaningful relationships and connections with others, moving beyond self-absorption to establish intimate bonds.

Question 192: Which assessment is most important before administering digoxin?

Respiratory rate
Apical heart rate for one full minute (Correct answer)
Blood pressure
Temperature

Correct answer: Apical heart rate for one full minute

The apical heart rate must be assessed for one full minute before administering digoxin. The medication should be held if the rate is below 60 bpm in adults.

Question 193: A nurse is providing health promotion education to a community group. Which statement best describes secondary prevention?

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

Correct answer: Screening hypertensive clients to detect complications early

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

Question 194: A client is prescribed 3% hypertonic saline for severe hyponatremia. Which complication should the nurse monitor for during infusion?

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

Correct answer: Osmotic demyelination syndrome if corrected too rapidly

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

Question 195: A nurse is monitoring a patient after a thyroidectomy. Which complication should the nurse assess for within the first 24 hours?

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

Correct answer: Hypocalcemia

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

Question 196: A nurse is caring for an elderly patient who recently lost a spouse and expresses feelings of loneliness. Which intervention is most appropriate?

Advise the patient to stay busy to avoid thinking about the loss
Tell the patient they will feel better with time
Facilitate participation in a bereavement support group (Correct answer)
Encourage the patient to suppress grief to avoid depression

Correct answer: Facilitate participation in a bereavement support group

A bereavement support group provides peer connection, normalized grief expression, and social support, which directly addresses loneliness and facilitates healthy grieving.

Question 197: A nurse is caring for a client who is visually impaired. Which approach is MOST appropriate when assisting with ambulation?

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

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

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

Question 198: A nurse is caring for a 45-year-old client who recently received a diagnosis of a chronic illness. The client is withdrawn and has not been adhering to the treatment plan. Which of the following psychosocial needs is the highest priority for the nurse to address?

Coping and adaptation (Correct answer)
Esteem and recognition
Love and belonging
Self-actualization

Correct answer: Coping and adaptation

While all the listed needs are important, the client's withdrawal and non-adherence to treatment indicate a primary struggle with coping and adapting to a major life change. Addressing the client's coping mechanisms is crucial for their physical and emotional well-being and is a prerequisite for addressing higher-level needs like esteem or self-actualization.

Question 199: A nurse is inserting a urinary catheter in a female client. After cleansing the urinary meatus, the catheter accidentally touches the labia. What is the CORRECT action?

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

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

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

Question 200: A patient receiving total parenteral nutrition (TPN) develops sudden shortness of breath and chest pain after the central line is repositioned. What should the nurse suspect first?

Fluid overload
Hyperglycemia
Air embolism (Correct answer)
Catheter occlusion

Correct answer: Air embolism

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

NACE I PN-RN: Foundations of Nursing Exam

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

200

Questions

240 min

Time Limit

75%

To Pass

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