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

Question 1: A nurse is applying antiembolism stockings (TEDs) to a client. Which action is correct?

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

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

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

Question 2: A 3-year-old patient with acute otitis media is given the medication amoxicillin suspension 200 mg PO every 8 hours by the pediatrician. The youngster is 38 pounds (17.2 kg). For kids up to 40 kg, the suggested dose range is 20–40 mg/kg/day, divided into eight-hour intervals. What is the nurse's BEST course of action when following the 10 Rights of Medication Administration?

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

Correct answer: Administer the medication as prescribed

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

Question 3: A nurse is performing a neurological assessment on a patient with a head injury. Which finding indicates a deteriorating neurological status?

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

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

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

Question 4: When a nurse manager uses the 'sandwich' feedback technique during a counseling session, what is the intended outcome?

To present critical feedback between positive observations to maintain motivation (Correct answer)
To shorten the duration of the counseling session
To ensure the employee does not file a grievance
To obscure negative feedback within excessive praise

Correct answer: To present critical feedback between positive observations to maintain motivation

The sandwich technique frames corrective feedback between positive statements to support receptiveness while clearly communicating areas for improvement.

Question 5: In order to give the preoperative medication as directed before a patient is sent to surgery, the operating room telephones the unit nurse. The patient did not sign the surgery consent, the unit nurse finds out after administering the drug. What ought the nurse to start with?

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

Correct answer: Notify the nursing supervisor

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

Question 6: A nurse is preparing to administer a cleansing enema. At what angle should the rectal tube be inserted in an adult?

Perpendicular to the body
Directed downward toward the umbilicus
Directed laterally toward the left hip
Directed upward toward the umbilicus (Correct answer)

Correct answer: Directed upward toward the umbilicus

The rectal tube is inserted at about a 30–40° angle directed toward the umbilicus to follow the natural curve of the rectum and sigmoid colon.

Question 7: A nurse is caring for a client with chronic kidney disease (CKD) who has a potassium level of 6.2 mEq/L. Which dietary instruction is most important?

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

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

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

Question 8: Which vaccine is recommended for all adults 65 years and older who have never been vaccinated against pneumococcal disease?

PCV15 followed by PPSV23 (Correct answer)
Varicella vaccine only
Influenza vaccine only
Hepatitis B vaccine series

Correct answer: PCV15 followed by PPSV23

CDC recommends PCV15 (or PCV20) for adults 65 and older; if PCV15 is used, it should be followed by PPSV23 to provide broader coverage against pneumococcal strains.

Question 9: A client is ordered a low-residue diet. Which food selection indicates understanding of the diet?

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

Correct answer: Steamed white rice with baked chicken breast

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

Question 10: A patient on lithium therapy complains of tremors, confusion, and has a serum level of 2.1 mEq/L. The nurse anticipates:

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

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

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

Question 11: A non-immune nurse must care for a patient with active varicella (chickenpox). Which combination of PPE is required?

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

Correct answer: N95 respirator, gown, and gloves

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

Question 12: To avoid perinatal mortality in women with diabetes during pregnancy, glucose levels must be tightly controlled metabolically. The nurse is aware of the recommended range for serum glucose levels during pregnancy, which is:

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

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

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

Question 13: A nurse is preparing to administer a unit of packed red blood cells. Which action is essential just before starting the infusion?

Prime the tubing with dextrose 5% in water (D5W)
Administer diphenhydramine prophylactically to all patients
Have a second nurse verify the blood product with the patient's identification band (Correct answer)
Warm the blood product in a microwave for 30 seconds

Correct answer: Have a second nurse verify the blood product with the patient's identification band

Two-nurse verification of blood product compatibility with the patient's identification is mandatory to prevent a potentially fatal transfusion error.

Question 14: Which positioning is ideal for the client before to a soap suds enema?

Lithotomy
Supine
Sims (Correct answer)
Prone

Correct answer: Sims

The Sims position, where the patient lies on their left side with the right knee and thigh drawn up, is the ideal positioning for a soap suds enema. This position allows gravity to assist the flow of the enema solution into the descending colon and rectum. It also helps to relax the anal sphincter, making the procedure more comfortable and effective for the client.

Question 15: A patient in restraints must be reassessed at minimum every:

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

Correct answer: 15 minutes for behavioral restraints

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

Question 16: A nurse is caring for a client with acute pancreatitis. Which position provides the most comfort?

Fetal position with knees drawn to chest (Correct answer)
Trendelenburg position
Semi-Fowler's with knees extended
Supine with legs extended

Correct answer: Fetal position with knees drawn to chest

The fetal (knee-chest) position reduces tension on the inflamed pancreas and surrounding abdominal structures, alleviating pain.

Question 17: A unit-based quality improvement team identifies a high rate of catheter-associated urinary tract infections (CAUTIs). Which tool would BEST help map the steps in the current catheter care process?

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

Correct answer: Flowchart

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

Question 18: Which of the following is the MOST effective strategy for preventing nurse burnout on a high-acuity unit?

Implementing regular debriefing sessions and workload monitoring with adequate staffing ratios (Correct answer)
Requiring mandatory overtime to maintain coverage
Eliminating peer-support programs to reduce non-clinical time
Rotating all nurses to different units every week

Correct answer: Implementing regular debriefing sessions and workload monitoring with adequate staffing ratios

Combining psychological support (debriefing) with structural safeguards (adequate staffing) addresses both emotional and workload contributors to burnout.

Question 19: At the local clinic, the healthcare provider is seeing four patients. Which of these people needs to have their risk for iron deficiency anemia identified by the healthcare professional?

The obese patient with a history of gastric bypass surgery.
The patient with diagnosis of chronic renal failure.
The patient who follows a strict vegan diet.
The woman of childbearing age, reported a craving for ice. (Correct answer)

Correct answer: The woman of childbearing age, reported a craving for ice.

Pica, which is a craving for non-nutritive substances like ice (pagophagia), dirt, or clay, is a classic symptom of iron deficiency anemia. While other patients listed may have risk factors for anemia, the reported craving for ice in a woman of childbearing age is a strong indicator specifically for iron deficiency anemia and warrants immediate investigation.

Question 20: Which leadership style is most effective when managing a highly experienced team during a routine, stable workload?

Transformational leadership
Autocratic leadership
Laissez-faire leadership (Correct answer)
Transactional leadership

Correct answer: Laissez-faire leadership

Laissez-faire leadership is appropriate when staff are highly skilled and self-directed and the situation is stable and low-risk.

Question 21: A patient with renal calculi is brought into the emergency room complaining of nausea and moderate to severe flank discomfort. The patient is currently 100.8 degrees Fahrenheit hot. For this client, the top nursing objective is:

Prevent urinary tract infection
Manage pain (Correct answer)
Maintain fluid and electrolyte balance
Control nausea

Correct answer: Manage pain

Renal calculi (kidney stones) often cause excruciating flank pain, which is typically the most distressing symptom for the patient. While preventing infection (indicated by fever), maintaining fluid balance, and controlling nausea are important, addressing the severe pain is the immediate priority to provide comfort and allow the patient to cooperate with further diagnostic and treatment measures. Effective pain management improves patient well-being and facilitates care.

Question 22: Which intervention is the nurse's priority when caring for a patient in skeletal traction?

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

Correct answer: Assessing pin sites for signs of infection

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

Question 23: Which health promotion teaching is most appropriate for a patient who has been newly prescribed metformin for type 2 diabetes?

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

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

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

Question 24: Which teaching should the nurse provide to a patient who is immunocompromised regarding infection prevention?

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

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

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

Question 25: A patient receiving IV morphine shows a respiratory rate of 8 breaths/min and is difficult to arouse. The priority action is:

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

Correct answer: Administer naloxone (Narcan) as ordered

Respiratory depression from opioid overdose requires immediate reversal with naloxone.

Question 26: The nurse is authorized to provide phenergan (Promethazine) 25mg and valium (Diazepam) 10mg prior to surgery. The appropriate way to give these drugs is to:

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

Correct answer: Administer the medication separately

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

Question 27: A nurse is assisting a client with a bedpan. Which action best maintains the client's dignity and comfort?

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

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

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

Question 28: A nurse is performing a surgical time-out before a procedure. Which information must be confirmed during the time-out?

Patient's insurance and billing information
Patient identity, correct procedure, correct site/side, correct position, and availability of correct implants or equipment (Correct answer)
Nurse's credentials and shift assignment
Patient's preferred language and religious beliefs

Correct answer: Patient identity, correct procedure, correct site/side, correct position, and availability of correct implants or equipment

The Universal Protocol requires a pre-procedure time-out to confirm patient identity, correct procedure, correct anatomical site/side, patient position, and availability of required equipment.

Question 29: A patient with post-traumatic stress disorder (PTSD) is startled by a loud noise and begins hyperventilating. The nurse's priority intervention is:

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

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

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

Question 30: When performing a focused assessment on a patient with suspected deep vein thrombosis (DVT), which finding is most significant?

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

Correct answer: Unilateral calf warmth, redness, and tenderness

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

Question 31: The nurse can request that unlicensed assistive personnel (UAP) perform ALL of the following EXCEPT

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

Correct answer: provide patient and family education

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

Question 32: A nurse is caring for a patient receiving IV aminophylline. Which finding indicates toxicity?

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

Correct answer: Tachycardia, tremors, and seizures

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

Question 33: A patient with liver cirrhosis develops sudden onset confusion, asterixis, and fetor hepaticus. The nurse should prepare to administer:

Furosemide
Naloxone
IV dextrose 50%
Lactulose (Correct answer)

Correct answer: Lactulose

These signs indicate hepatic encephalopathy; lactulose is administered to reduce ammonia absorption by acidifying the colon and promoting bowel elimination.

Question 34: A nurse discovers a medication error was made by the previous shift nurse. The correct action is to:

Speak with the nurse privately and decide together not to report it
Only document the error in the chart and monitor the patient
Report the nurse to the state board immediately without assessing the patient first
Assess the patient, notify the physician and charge nurse, document accurately, and complete an incident report (Correct answer)

Correct answer: Assess the patient, notify the physician and charge nurse, document accurately, and complete an incident report

Patient safety requires immediate assessment and physician notification; transparent documentation and an incident report enable systems analysis to prevent future errors.

Question 35: The pediatric unit's healthcare worker has been given her daily tasks. Which of the following patients has to be evaluated first by the medical professional?

The 17-year-old with a left pleural effusion, is complaining of a chest pain of 9 on a 0-10 scale. (Correct answer)
The 3-year-old with asthma, who has an oxygen saturation of 94% on room air.
The 6-year-old with bronchitis, with an intravenous (IV) antibiotic infusing at 30 mL/hour.
The 11-year-old with pneumonia, who is awaiting discharge instructions.

Correct answer: The 17-year-old with a left pleural effusion, is complaining of a chest pain of 9 on a 0-10 scale.

Prioritization in nursing care follows principles such as ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. A 17-year-old with a left pleural effusion complaining of severe chest pain (9/10) indicates a potential for compromised breathing and significant discomfort, which could rapidly escalate. This patient requires immediate assessment and intervention to address pain and potential respiratory distress, making them the highest priority.

Question 36: What is the best way to spot breast cancer tumors in the early stages?

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

Correct answer: Monthly breast self-examination

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

Question 37: What is the single most effective method for preventing the spread of healthcare-associated infections?

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

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

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

Question 38: When implementing a new evidence-based protocol, which change theory focuses on unfreezing old behaviors, moving to new ones, and refreezing the change?

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

Correct answer: Lewin's Force Field Analysis

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

Question 39: A nurse is caring for a patient in alcohol withdrawal. Which medication does the nurse anticipate the provider will order to prevent seizures?

Lorazepam (Correct answer)
Methadone
Haloperidol
Naloxone

Correct answer: Lorazepam

Benzodiazepines such as lorazepam are the first-line treatment for alcohol withdrawal because they cross-react with GABA receptors and prevent withdrawal seizures.

Question 40: The monitor exhibits late decelerations with tachycardia and declining variability while evaluating the status of the fetal heart rate during labor. What steps need to be taken by the nurse?

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

Correct answer: Report to a physician or midwife.

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

Question 41: A nurse is teaching postpartum care to a new mother who had a vaginal delivery. Which instruction is most important for perineal wound care?

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

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

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

Question 42: A 16-year-old patient is seeking treatment for a sexually transmitted infection and asks the nurse to keep the visit confidential from their parents. The nurse should:

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

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

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

Question 43: Which nursing task is most appropriate to delegate to an unlicensed assistive personnel (UAP)?

Assessing a patient's pain level and adjusting care
Administering an oral medication to a stable patient
Performing a sterile wound dressing change
Measuring and recording urine output for a stable patient (Correct answer)

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

Measuring and recording urine output is within the UAP's scope as it involves data collection from a stable patient; assessment, medication administration, and sterile procedures require nursing judgment.

Question 44: Which assessment finding indicates successful treatment of fluid volume deficit in a dehydrated patient?

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

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

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

Question 45: Which concept describes a nurse's obligation to advocate for patients even when it conflicts with institutional policies or physician orders?

Patient advocacy (Correct answer)
Fidelity
Beneficence
Autonomy

Correct answer: Patient advocacy

Patient advocacy requires the nurse to act in the patient's best interest, which may include challenging orders or policies that are not in the patient's favor.

Question 46: During a sterile dressing change, which action would break sterile technique?

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

Correct answer: Reaching over the sterile field to arrange supplies

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

Question 47: Holding a sterile gauze pad over the injection site while removing the needle serves to

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

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

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

Question 48: The healthcare professional gives NPH insulin to a diabetic patient at 6:00 a.m. How soon might the patient exhibit hypoglycemic symptoms?

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

Correct answer: 10:00 AM

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

Question 49: A patient refuses a blood transfusion based on religious beliefs. The nurse should:

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

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

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

Question 50: Which behavior indicates a patient is in the bargaining stage of Kübler-Ross's stages of grief?

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

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

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

Question 51: In the first 24 hours following the procedure, which cardiac catheterization complication should the nurse be on the lookout for?

Thrombus formation (Correct answer)
Angina at rest
Dizziness
Falling blood pressure

Correct answer: Thrombus formation

After a cardiac catheterization, the insertion site (often the femoral artery) is at risk for complications. Thrombus formation, leading to arterial occlusion, is a significant concern in the first 24 hours due to vessel trauma and the presence of a foreign body (catheter). Nurses must diligently monitor for signs of decreased circulation, pain, pallor, and pulselessness in the affected extremity to detect this serious complication early.

Question 52: A nurse is assessing a 2-year-old child. Which finding requires further follow-up?

Anterior fontanel closed
Builds a tower of only 4 blocks (Correct answer)
Uses 2-word phrases
Weight at the 50th percentile

Correct answer: Builds a tower of only 4 blocks

A 2-year-old should stack at least 6 blocks; stacking only 4 blocks suggests a fine motor delay that warrants further evaluation.

Question 53: A nurse manager identifies that incident report filings have dropped significantly over the past month. This most likely indicates:

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

Correct answer: Under-reporting of adverse events

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

Question 54: Tetralogy of Fallot is the reason for the infant's admission to the unit. Which medication would the nurse expect to receive a request for?

Epinephrine
Atropine
Digoxin (Correct answer)
Aminophylline

Correct answer: Digoxin

Tetralogy of Fallot is a congenital heart defect that often leads to right-to-left shunting and decreased pulmonary blood flow, causing cyanosis. While surgical repair is definitive, medications like digoxin may be used to improve cardiac output and manage heart failure symptoms in infants awaiting surgery or to support cardiac function. Digoxin strengthens myocardial contraction, which can be beneficial in managing the heart's workload.

Question 55: A client with a nasogastric tube reports nausea. Before administering an antiemetic, the nurse should first:

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

Correct answer: Check the placement of the nasogastric tube

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

Question 56: A client has a prescription for sitz baths after hemorrhoid surgery. Which instruction is correct?

Avoid the sitz bath if any drainage is present
Sit in the sitz bath for 20 minutes three to four times per day (Correct answer)
Use water at 105–110°F for maximum therapeutic benefit
Add iodine solution to the water to prevent infection

Correct answer: Sit in the sitz bath for 20 minutes three to four times per day

Sitz baths at comfortable warm temperature (98–105°F) for 20 minutes, three to four times daily, promote comfort and healing after anorectal surgery.

Question 57: Which assessment finding is most concerning in a patient 24 hours after a spinal cord injury at C5?

Mild anxiety
Urine output of 50 mL/hour
Temperature of 99.1°F (37.3°C)
Blood pressure of 98/60 mmHg with bradycardia (Correct answer)

Correct answer: Blood pressure of 98/60 mmHg with bradycardia

Hypotension with bradycardia after a high spinal cord injury suggests neurogenic shock due to loss of sympathetic tone, which is a medical emergency.

Question 58: A young client with leukemia is having nausea and vomiting as a result of chemotherapy. Which of the following foods will be the BEST at now supplying enough nutrition?

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

Correct answer: Cold foods with no smell

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

Question 59: The following are the main goals of a newborn's initial Apgar score:

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

Correct answer: Evaluate the infant’s vital functions

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

Question 60: A patient arrives to the emergency room with a headache, disorientation, and a blood pressure of 180/130 mmHg. Which other observation supports the diagnosis of a hypertensive emergency?

Bradycardia
Jaundice
Urinary retention
Retinopathy (Correct answer)

Correct answer: Retinopathy

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

Question 61: A patient with dementia is repeatedly trying to get out of bed and is at high fall risk. The nurse's least restrictive initial intervention is:

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

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

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

Question 62: A patient has gained 10 lb in the past two months and is back for her 6-month pregnancy visit. Her physical examination revealed no abnormalities. How does the nurse assess the efficacy of the diet and weight-control advice?

She needs further instruction and reinforcement. (Correct answer)
She is compliant with her diet as previously taught.
She needs to increase her caloric intake.
She needs to be placed on a restrictive diet immediately.

Correct answer: She needs further instruction and reinforcement.

A weight gain of 10 pounds in two months during the second trimester (6-month visit) is generally considered excessive, as the average recommended gain is about 1 pound per week. This indicates that the client may not be adhering to or fully understanding the dietary and weight-control advice provided. The nurse should assess the client's current diet and activity, then provide further education and reinforcement on healthy weight gain guidelines.

Question 63: A nurse is providing discharge teaching to a patient prescribed warfarin. Which statement by the patient indicates a need for further teaching?

'I will take ibuprofen instead of acetaminophen for pain.' (Correct answer)
'I will have my INR checked regularly at the lab.'
'I will report any unusual bruising or bleeding to my doctor.'
'I will avoid making major changes to my diet without consulting my provider.'

Correct answer: 'I will take ibuprofen instead of acetaminophen for pain.'

NSAIDs like ibuprofen inhibit platelet aggregation and displace warfarin from protein-binding sites, significantly increasing bleeding risk.

Question 64: A nurse is caring for a patient who is 6 hours post-coronary angiography via the right femoral artery. Which assessment finding is most concerning?

Heart rate of 78 beats/min
Blood pressure of 122/76 mmHg
A large expanding hematoma at the puncture site (Correct answer)
Patient complaint of needing to void

Correct answer: A large expanding hematoma at the puncture site

An expanding hematoma at the femoral access site indicates active bleeding and potential vascular injury requiring immediate intervention.

Question 65: A nurse is teaching a patient with type 2 diabetes about foot care. Which instruction is most important?

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

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

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

Question 66: When administering potassium chloride IV, the nurse knows to:

Administer it through a peripheral line as a concentrated solution
Mix it with normal saline in a 1:1 ratio and give bolus
Dilute it and infuse no faster than 10-20 mEq/hr (Correct answer)
Give it as a rapid IV push to restore levels quickly

Correct answer: Dilute it and infuse no faster than 10-20 mEq/hr

Concentrated or rapidly infused IV potassium can cause fatal cardiac arrhythmias; safe infusion is ≤10-20 mEq/hr.

Question 67: A nurse is double-checking a high-alert medication with another RN before administration. This practice is designed to prevent harm from:

Medications given only during night shift
Medications with a low therapeutic index (Correct answer)
All OTC medications dispensed at the bedside
Any medication given orally

Correct answer: Medications with a low therapeutic index

High-alert medications (e.g., insulin, anticoagulants, chemotherapy) have a narrow therapeutic index and can cause significant harm if errors occur.

Question 68: A nurse suspects elder abuse in a patient admitted from a nursing facility. The nurse's legal obligation is to:

Document suspicions privately and wait for the patient to disclose
Inform the nursing facility administrator directly
Report the suspected abuse to Adult Protective Services (APS) as required by mandatory reporting laws (Correct answer)
Consult a social worker and allow them to decide whether to report

Correct answer: Report the suspected abuse to Adult Protective Services (APS) as required by mandatory reporting laws

Nurses are mandated reporters under federal and state law; suspected elder abuse must be reported to APS regardless of whether abuse is confirmed or the patient requests confidentiality.

Question 69: When reconstituting a powdered medication for IV administration, the nurse should:

Shake the vial vigorously for 60 seconds to dissolve the powder
Use the diluent specified on the package insert and gently swirl until dissolved (Correct answer)
Always use sterile water for injection regardless of the package insert
Mix the drug directly in the patient's IV bag without a separate vial

Correct answer: Use the diluent specified on the package insert and gently swirl until dissolved

Package insert instructions specify the correct diluent and volume; gentle swirling prevents foaming or degradation.

Question 70: A charge nurse notices two staff members have a recurring interpersonal conflict that is affecting unit morale. What is the most appropriate initial action?

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

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

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

Question 71: The 49-year-old pedestrian is taken to the emergency room following an automobile and pedestrian collision. Internal bleeding and a femur fracture are the two diagnosis made by the ED doctor. The nurse tries to get in touch with the next of kin for permission when surgery is recommended. What is the correct procedure for obtaining this client's consent?

Spouse, adult child, parent, sibling (Correct answer)
Adult child, spouse, parent, sibling
Parent, spouse, adult child, sibling
Sibling, parent, spouse, adult child

Correct answer: Spouse, adult child, parent, sibling

When a patient is incapacitated and unable to provide consent, the legal hierarchy for obtaining informed consent typically prioritizes the closest legal and emotional relationships. The order generally follows as: spouse, then adult child, followed by parent, and finally sibling. This hierarchy reflects the presumed wishes and legal authority of family members in making medical decisions.

Question 72: Which assessment finding in a post-thyroidectomy patient requires the nurse to immediately notify the provider?

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

Correct answer: Positive Chvostek's sign

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

Question 73: Which of the following would a healthcare professional anticipate when analyzing the arterial blood gases (ABGs) of a patient with a 20-year history of chronic bronchitis?

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

Correct answer: Respiratory acidosis, compensated

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

Question 74: A nurse is performing a newborn assessment and notes the infant's skin is yellow at 10 hours of life. How should the nurse interpret this finding?

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

Correct answer: Pathologic jaundice requiring immediate evaluation

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

Question 75: The National Council of State Boards of Nursing developed and distributed the

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

Correct answer: American Nurses Association

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

Question 76: Congestive heart failure (CHF) patients must follow rigorous intake and output (I&O) guidelines with daily weights. The client's intake was 2200 mL, and their output was 1200 mL throughout the 24-hour I&O, according to the nurse. What would the probable next daily weight be?

1 lb loss
2.2 lb gain (Correct answer)
2 lb loss
1.2 lb gain

Correct answer: 2.2 lb gain

To determine the probable weight change, first calculate the net fluid balance: Intake (2200 mL) - Output (1200 mL) = 1000 mL positive fluid balance. Since 1 liter (1000 mL) of fluid is approximately equivalent to 2.2 pounds, a positive fluid balance of 1000 mL indicates a weight gain of 2.2 lbs. This fluid retention is a common concern for patients with Congestive Heart Failure.

Question 77: A nurse is teaching osteoporosis prevention to a 40-year-old woman. Which combination of recommendations is most effective?

High-protein diet only
Bed rest to prevent fractures
Calcium supplementation alone without exercise
Calcium 1,000 mg/day, vitamin D 600 IU/day, and weight-bearing exercise (Correct answer)

Correct answer: Calcium 1,000 mg/day, vitamin D 600 IU/day, and weight-bearing exercise

Adequate calcium and vitamin D intake combined with weight-bearing exercise are the three cornerstones of osteoporosis prevention in premenopausal women.

Question 78: A patient is scheduled for surgery on the left knee but the consent form reads 'right knee.' The nurse's correct action is:

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

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

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

Question 79: A nurse is caring for a patient receiving a blood transfusion who develops chills, flank pain, and dark-colored urine 30 minutes into the infusion. What is the priority action?

Stop the transfusion and infuse normal saline (Correct answer)
Slow the transfusion rate and notify the provider
Administer diphenhydramine IV as ordered
Obtain a urine culture to rule out infection

Correct answer: Stop the transfusion and infuse normal saline

These symptoms indicate an acute hemolytic transfusion reaction; the transfusion must be stopped immediately and NS infused to maintain kidney perfusion.

Question 80: When a client inquires about her prognosis, which ethical standard is applied?

Veracity (Correct answer)
Fidelity
Beneficence
Nonmaleficence

Correct answer: Veracity

Veracity is the ethical principle of truthfulness and honesty. When a client inquires about their prognosis, the healthcare professional is ethically bound to provide accurate and truthful information, even if it is difficult to hear. This principle upholds the patient's right to know and make informed decisions about their care.

Question 81: A school nurse is teaching adolescents about skin cancer prevention. Which statement is most important?

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

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

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

Question 82: The lab and blood bank need a sample of the patient's blood before the patient can receive a transfusion of whole blood. What tests will be conducted?

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

Correct answer: Blood type and crossmatch

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

Question 83: A nurse observes that a patient with schizophrenia has been isolating themselves in their room and stopped attending group activities. This change in behavior most likely indicates:

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

Correct answer: Potential relapse or medication non-adherence

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

Question 84: Which patient has the highest risk for developing a healthcare-associated infection (HAI)?

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

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

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

Question 85: The nurse checks with the patient to see if there are any drug sensitivities before giving penicillin intramuscularly to a patient with "NKDA" on his medical record. The customer replies, "I'm not certain. One time, when I was ill and received a shot, I might have developed a rash." Which course of action is best for the nurse?

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

Correct answer: Hold the penicillin and contact the prescribing provider

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

Question 86: A nurse is assessing a patient with a suspected pulmonary embolism. Which clinical finding is most consistent with this diagnosis?

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

Correct answer: Sudden onset of pleuritic chest pain and dyspnea

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

Question 87: A patient's wound culture grows methicillin-resistant Staphylococcus aureus (MRSA). Which antibiotic is typically the drug of choice?

Cephalexin
Vancomycin (Correct answer)
Ampicillin-sulbactam
Penicillin

Correct answer: Vancomycin

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

Question 88: A nurse is caring for a patient receiving a blood transfusion who develops sudden chills, back pain, and dark urine after 50 mL has infused. What is the nurse's priority action?

Slow the infusion rate and notify the provider
Obtain a repeat blood type and crossmatch
Stop the transfusion and keep the IV line open with normal saline (Correct answer)
Administer diphenhydramine IV and continue the transfusion

Correct answer: Stop the transfusion and keep the IV line open with normal saline

These signs indicate an acute hemolytic transfusion reaction; the transfusion must be stopped immediately and the line kept open with normal saline.

Question 89: A nurse delegates wound care to an unlicensed assistive personnel (UAP). Later, the UAP performs the task incorrectly. Who bears ultimate accountability?

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

Correct answer: The delegating registered nurse

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

Question 90: A sentinel event occurs on the unit. After immediate patient stabilization, which process does The Joint Commission require the organization to undertake?

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

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

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

Question 91: A nurse caring for a patient in the oliguric phase of acute kidney injury expects which finding?

Urine output greater than 400 mL/day
Metabolic alkalosis
Decreased serum potassium
Elevated BUN and creatinine (Correct answer)

Correct answer: Elevated BUN and creatinine

The oliguric phase is characterized by urine output less than 400 mL/day and accumulation of waste products, resulting in elevated BUN and creatinine.

Question 92: A postoperative client develops a respiratory rate of 6 breaths/min and is difficult to arouse after receiving IV morphine. What is the priority nursing action?

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

Correct answer: Administer naloxone (Narcan) as ordered

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

Question 93: When Nurse John arrives for his shift, he observes that Nurse Jane has an alcoholic odor and slurs her speech. What is Nurse John supposed to do?

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

Correct answer: Report his observation to the charge nurse.

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

Question 94: A nurse notices a colleague appears intoxicated at work and smells of alcohol. The most appropriate action is:

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

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

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

Question 95: Which route of medication administration has the fastest onset of action?

Intramuscular
Intravenous (Correct answer)
Transdermal
Sublingual

Correct answer: Intravenous

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

Question 96: A nurse notes that a patient's surgical wound has new separation with yellow drainage. What is the most appropriate nursing response?

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

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

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

Question 97: A patient newly diagnosed with breast cancer states, 'I can't believe this is happening to me.' The nurse's best therapeutic response is:

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

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

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

Question 98: A patient who has had septic shock is being cared for by a healthcare professional. Which one of these should the medical professional give the patient first?

Vasopressors to increase blood pressure
Antibiotics to treat the underlying infection
Corticosteroids to reduce inflammation
IV fluids to increase intravascular volume (Correct answer)

Correct answer: IV fluids to increase intravascular volume

In septic shock, widespread vasodilation and increased capillary permeability lead to a significant decrease in intravascular volume, causing hypotension and poor tissue perfusion. The immediate priority is to restore circulating volume and improve blood pressure through aggressive intravenous fluid resuscitation. This helps to improve organ perfusion before other interventions like antibiotics or vasopressors can fully take effect.

Question 99: Four patients' care is being planned by a healthcare professional. Which patient is in need of preventative measures for anemia the most?

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

Correct answer: The patient with renal failure on hemodialysis

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

Question 100: A nurse is assessing a 6-month-old during a well-baby visit. Which developmental milestone should the infant have achieved?

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

Correct answer: Sitting with support and rolling over

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

Question 101: A nurse observes a colleague leaving a contact isolation room while still wearing their isolation gown. What is the most appropriate immediate action?

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

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

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

Question 102: A nurse notes a patient on heparin infusion has an aPTT of 180 seconds (therapeutic range 60–100 seconds). What is the priority intervention?

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

Correct answer: Stop the infusion and notify the provider

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

Question 103: In which situation should a nurse use soap and water for hand hygiene instead of an alcohol-based hand rub?

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

Correct answer: After caring for a patient with Clostridioides difficile

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

Question 104: A patient with chronic kidney disease has a serum potassium of 6.8 mEq/L. The nurse's priority intervention is to:

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

Correct answer: Prepare for cardiac monitoring

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

Question 105: A patient with acute pancreatitis is prescribed nothing by mouth (NPO). The patient asks why they cannot eat. What is the nurse's best response?

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

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

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

Question 106: A nurse is about to enter a room under airborne precautions. Which room characteristic must be confirmed before entering?

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

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

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

Question 107: A nurse is performing range-of-motion exercises on a client's shoulder. The client grimaces when the arm is abducted. What should the nurse do?

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

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

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

Question 108: Hepatitis is the patient's diagnosis upon admission to the medical facility. Which phase of pharmacokinetics is most affected by the patient's diagnosis when the healthcare professional is getting ready to administer intravenous medications?

Metabolism (Correct answer)
Absorption
Excretion
Distribution

Correct answer: Metabolism

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

Question 109: A nurse is caring for a patient with borderline personality disorder who says, 'You are the best nurse here — all the others are terrible.' The nurse recognizes this as:

Splitting (Correct answer)
Projection
Transference
Reaction formation

Correct answer: Splitting

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

Question 110: A nurse is inserting a nasogastric tube. After placement, which method best confirms correct placement before beginning a feeding?

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

Correct answer: Aspirating stomach contents and testing pH

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

Question 111: Which action by a nursing student during perineal care of a female client requires correction?

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

Correct answer: Cleaning from the anus toward the urethral meatus

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

Question 112: A patient on mechanical ventilation has a sudden rise in peak airway pressure. What is the nurse's first action?

Adjust the tidal volume setting on the ventilator
Increase the FiO2 setting on the ventilator
Suction the patient's endotracheal tube
Manually ventilate the patient with a bag-valve mask (Correct answer)

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

Manual ventilation with a bag-valve mask ensures the patient receives adequate breaths while the cause of high peak pressure is investigated.

Question 113: A nurse is caring for a patient with increased intracranial pressure (ICP). Which nursing position provides the best outcome?

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

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

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

Question 114: A 3-pound infant being given adult-strength digitalis (Digoxin, Lanoxin) by a nurse in the neonatal intensive care unit (NICU). The result is irreversible brain and cardiac damage in the infant. The nurse could face charges for

tort
assault
malpractice (Correct answer)
negligence

Correct answer: malpractice

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

Question 115: A new patient can't take care of their oral hygiene. What guidance should the nurse provide the nurse's assistant out of the following list?

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

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

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

Question 116: A nurse is caring for a client who is 12 hours post-thyroidectomy. The client reports tingling around the mouth and in the fingertips. What should the nurse assess next?

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

Correct answer: Trousseau's sign for hypocalcemia

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

Question 117: Which nursing action best demonstrates cultural humility when caring for a patient from a different cultural background?

Providing information only in English to ensure accuracy
Asking the patient about their cultural health beliefs and preferences (Correct answer)
Assuming the patient's needs based on their ethnic background
Applying standard Western medical protocols without modification

Correct answer: Asking the patient about their cultural health beliefs and preferences

Cultural humility requires asking about individual beliefs and preferences rather than making assumptions based on ethnicity or applying a one-size-fits-all approach.

Question 118: A nurse is assessing a client with suspected pulmonary embolism (PE). Which clinical finding is most characteristic of PE?

Gradual onset of productive cough with fever
Bilateral crackles with frothy sputum
Dull chest pain relieved by sitting forward
Sudden onset of pleuritic chest pain and dyspnea (Correct answer)

Correct answer: Sudden onset of pleuritic chest pain and dyspnea

Sudden-onset pleuritic chest pain and dyspnea are hallmark symptoms of pulmonary embolism due to abrupt obstruction of pulmonary vasculature.

Question 119: A nurse is teaching a 52-year-old woman about breast cancer screening. According to the American Cancer Society, mammograms should begin at what age for average-risk women?

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

Correct answer: 45 years

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

Question 120: A nurse is preparing to administer medication through a nasogastric tube. Which action must be performed first?

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

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

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

Question 121: After being released, a patient with clotting disease must continue receiving Lovenox (enoxaparin) injections. The client should learn from the nurse that injections of Lovenox should:

Aspirate after the injection
Clear the air from the syringe before injections
Be injected into the abdomen (Correct answer)
Be injected into the deltoid muscle

Correct answer: Be injected into the abdomen

Enoxaparin (Lovenox) is a low molecular weight heparin administered via subcutaneous injection. The recommended site for subcutaneous injection of enoxaparin is the anterolateral or posterolateral abdominal wall, at least two inches from the navel. This site allows for consistent absorption and minimizes the risk of muscle damage or nerve injury compared to other sites.

Question 122: A nurse is caring for a client who has been placed in restraints. Which assessment must be completed and documented every 2 hours?

Urine output and fluid intake
Level of consciousness and pupillary response
Blood pressure and oxygen saturation
Skin integrity, circulation, and the client's need for the restraint (Correct answer)

Correct answer: Skin integrity, circulation, and the client's need for the restraint

Every 2-hour restraint checks must include circulatory status, skin integrity, and re-evaluation of whether the restraint remains necessary per The Joint Commission standards.

Question 123: A nurse is caring for a patient with increased intracranial pressure (ICP). Which position is most appropriate?

Prone position
Head of bed elevated 30 degrees with head midline (Correct answer)
Trendelenburg position
Head of bed flat

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

Elevating the head of the bed 30 degrees with the head in midline promotes venous drainage from the brain, reducing ICP.

Question 124: A nurse is assessing a patient who has been in a house fire. The patient's lips appear cherry-red. Which condition does the nurse suspect?

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

Correct answer: Carbon monoxide poisoning

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

Question 125: An individual with a history of stillbirths is being watched by the nurse. The doctor can request a non-stress test for this patient to:

Show the effect of contractions on fetal heart rate
Determine lung maturity
Measure the fetal activity (Correct answer)
Measure the wellbeing of the fetus

Correct answer: Measure the fetal activity

A non-stress test (NST) is a common prenatal test used to assess fetal well-being by monitoring the fetal heart rate in response to fetal movement. The test measures accelerations in the fetal heart rate, which indicate a healthy and reactive nervous system. It primarily evaluates fetal activity and heart rate patterns without the stress of contractions.

Question 126: A charge nurse is preparing the staffing plan for the evening shift and must prioritize which patients require RN-level care. This decision is based on which principle?

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

Correct answer: Scope of practice and patient acuity

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

Question 127: The nurse manager is reviewing patient satisfaction scores and notices a downward trend in communication ratings. The BEST next step is to:

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

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

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

Question 128: A nurse is caring for a client with a nasogastric (NG) tube. Before administering a tube feeding, which action confirms proper tube placement?

Auscultate for air insufflation over the epigastrium
Aspirate gastric contents and check pH (Correct answer)
Ask the client if they feel the tube in their stomach
Flush the tube with 30 mL of water

Correct answer: Aspirate gastric contents and check pH

Aspirating contents and verifying a pH of ≤5.5 is the most reliable bedside method to confirm gastric versus pulmonary tube placement.

Question 129: A patient receiving a unit of packed red blood cells develops fever, chills, and back pain 15 minutes into the transfusion. The nurse's priority action is:

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

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

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

Question 130: A nurse is preparing a patient for a lumbar puncture. Which position should the nurse help the patient assume?

Sitting upright with arms raised above the head
Supine with head of bed elevated 30 degrees
Prone with a pillow under the abdomen
Lateral recumbent with spine flexed and knees drawn to chest (Correct answer)

Correct answer: Lateral recumbent with spine flexed and knees drawn to chest

The lateral recumbent (fetal) position with the spine flexed maximizes intervertebral space to facilitate needle insertion.

Question 131: Which lab value is the most sensitive early indicator of acute pancreatitis?

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

Correct answer: Elevated serum lipase

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

Question 132: Which intervention is most effective in preventing catheter-associated urinary tract infections (CAUTI)?

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

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

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

Question 133: A nurse is performing a bed bath for an elderly client. Which action best promotes comfort and prevents chilling?

Keep the room temperature at 65°F to conserve water heat
Use cold water to stimulate circulation
Complete the entire bath before drying any area
Expose only the body part being washed, then dry it before moving on (Correct answer)

Correct answer: Expose only the body part being washed, then dry it before moving on

Exposing and drying one area at a time minimizes heat loss, prevents chilling, and preserves the client's dignity.

Question 134: A nurse is caring for a client receiving total parenteral nutrition (TPN). Which complication requires the most immediate intervention?

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

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

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

Question 135: A nurse is conducting a well-child visit for a 2-month-old. Which vaccines are due at this visit?

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

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

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

Question 136: Which of the following assessment results is in line with a volume deficit of extracellular fluid?

Hypertension
Oliguria (Correct answer)
Bradycardia
Hyperglycemia

Correct answer: Oliguria

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

Question 137: A patient is prescribed potassium chloride 40 mEq IV. The nurse should administer this over what minimum time frame?

15 minutes
4 hours
1 hour (Correct answer)
5 minutes

Correct answer: 1 hour

IV potassium must be administered no faster than 10-20 mEq/hour to avoid life-threatening cardiac arrhythmias.

Question 138: Without first getting the client's informed consent, doing a non-emergency intrusive surgery on them can be seen as

fraud
malpractice
battery (Correct answer)
harassment

Correct answer: battery

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

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

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

Questions

300 min

Time Limit

50%

To Pass

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