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

Question 1: A nurse is caring for a client with a chest tube following a pneumothorax. The water-seal chamber shows continuous bubbling. What does this finding indicate?

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

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

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

Question 2: A nurse is performing a neurological assessment on a patient with a head injury. Which finding indicates a deteriorating neurological status?

Complaint of a mild headache
Blood pressure of 130/82 mmHg
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 3: A patient is prescribed potassium chloride 40 mEq IV. The nurse should administer this over what minimum time frame?

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

Correct answer: 1 hour

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

Question 4: A patient's wound culture grows methicillin-resistant Staphylococcus aureus (MRSA). Which antibiotic is typically the drug of choice?

Cephalexin
Ampicillin-sulbactam
Penicillin
Vancomycin (Correct answer)

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 5: Which of the following best describes the role of the charge nurse in relation to the nurse manager?

The charge nurse approves all performance evaluations
The charge nurse solely performs direct patient care without management duties
The charge nurse is responsible for shift-level coordination and real-time staffing adjustments (Correct answer)
The charge nurse has equal administrative authority as the nurse manager

Correct answer: The charge nurse is responsible for shift-level coordination and real-time staffing adjustments

Charge nurses manage day-to-day operations, patient flow, and staffing during their shift under the broader authority of the nurse manager.

Question 6: A nurse is preparing to administer a blood transfusion. After hanging the blood, the client develops chills, back pain, and dark urine within 15 minutes. What should the nurse do first?

Stop the transfusion and keep the IV line open with normal saline (Correct answer)
Slow the transfusion rate and monitor vital signs
Obtain a urine specimen and notify the lab
Administer diphenhydramine (Benadryl) IV as ordered

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

These signs indicate an acute hemolytic reaction; the transfusion must be stopped immediately and the IV kept patent with NS to prevent renal failure.

Question 7: A patient complains of having watery diarrhea for the last three days when they arrive at the emergency room. Blood pressure readings of 100/60, a pulse of 98, and dry mucous membranes are other assessment findings. Which of the following fluids would the healthcare provider expect to provide intravenous treatment with?

Hypotonic crystalloid
Colloid solution
Isotonic crystalloid (Correct answer)
Hypertonic crystalloid

Correct answer: Isotonic crystalloid

The patient's symptoms (watery diarrhea, low blood pressure, high pulse, dry mucous membranes) indicate significant fluid volume deficit and dehydration. Isotonic crystalloid solutions, such as 0.9% Normal Saline or Lactated Ringer's, are the most appropriate choice for initial fluid resuscitation as they expand the intravascular volume without causing fluid shifts into or out of cells.

Question 8: Which action by the nurse best prevents a central line-associated bloodstream infection (CLABSI)?

Change central line dressings every 7 days using sterile technique or when soiled/loose (Correct answer)
Change the central line site every 3 days routinely
Access the central line without gloves when time-sensitive
Irrigate the central line with normal saline every 2 hours

Correct answer: Change central line dressings every 7 days using sterile technique or when soiled/loose

Evidence-based CLABSI bundles mandate sterile dressing changes every 7 days (or when soiled/non-occlusive) as a key intervention to prevent insertion-site colonization.

Question 9: Which route of medication administration has the fastest onset of action?

Sublingual
Intravenous (Correct answer)
Transdermal
Intramuscular

Correct answer: Intravenous

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

Question 10: 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?

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

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 11: 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 woman of childbearing age, reported a craving for ice. (Correct answer)
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.

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 12: To treat primary hypertension, a patient is given a prescription for a calcium channel blocker. Which of these foods will the healthcare professional advise the patient to avoid while explaining the medication?

Bananas
Eggs
Grapefruit (Correct answer)
Milk

Correct answer: Grapefruit

Grapefruit and grapefruit juice are known to interact with many medications, including calcium channel blockers, by inhibiting the CYP3A4 enzyme in the gut. This inhibition can lead to increased blood levels of the medication, potentially causing enhanced effects and adverse reactions, making it crucial to avoid.

Question 13: An evaluation of a patient who underwent extensive abdominal surgery five days ago is being done by the nurse. When the client coughed, the client claimed to feel a "pop where my operation was." The nurse examines the area and observes that the borders of the wound have split at the point of the incision. What should the nurse start by doing?

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

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

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

Question 14: Which concept describes a nurse's obligation to advocate for patients even when it conflicts with institutional policies or physician orders?

Fidelity
Autonomy
Beneficence
Patient advocacy (Correct answer)

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

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

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

Always use sterile water for injection regardless of the package insert
Use the diluent specified on the package insert and gently swirl until dissolved (Correct answer)
Shake the vial vigorously for 60 seconds to dissolve the powder
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 17: 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?

Retinopathy (Correct answer)
Bradycardia
Urinary retention
Jaundice

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

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

Correct answer: Zero-based budgeting

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

Question 19: Which lab value is the priority to check before administering an aminoglycoside antibiotic?

Serum glucose
Complete blood count (CBC)
Serum creatinine and BUN (Correct answer)
Liver enzymes (AST/ALT)

Correct answer: Serum creatinine and BUN

Aminoglycosides are nephrotoxic; baseline and ongoing renal function tests (creatinine, BUN) are essential.

Question 20: A nurse is preparing to insert a urinary catheter. Which action is essential to prevent catheter-associated urinary tract infection (CAUTI)?

Maintain a closed drainage system and secure the catheter to the thigh (Correct answer)
Change the catheter every 24 hours
Irrigate the catheter daily with normal saline
Use clean technique for the insertion

Correct answer: Maintain a closed drainage system and secure the catheter to the thigh

A closed drainage system prevents bacteria from ascending into the bladder; catheter securement prevents movement that introduces microorganisms.

Question 21: The Nurse Practice Act is an illustration of

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

Correct answer: statutory law

A Nurse Practice Act is a statutory law, meaning it is a law passed by a legislative body (state legislature). These acts define the legal scope of nursing practice, establish requirements for licensure, and create a state board of nursing to enforce these regulations. Statutory laws are formally written and enacted by government bodies.

Question 22: A client with tuberculosis (TB) is placed on airborne precautions. Which PPE is required when entering the room?

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

Correct answer: N95 respirator, gloves, and gown

An N95 or higher-level respirator is required for airborne precautions; gloves and gown are added for contact with the patient or environment.

Question 23: A patient with bipolar disorder in a manic episode is intrusive, demanding, and has not slept in 3 days. The nurse's priority intervention is:

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

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

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

Question 24: Which action places a mechanically ventilated patient at highest risk for ventilator-associated pneumonia (VAP)?

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

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

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

Question 25: Which action best reduces the risk of a wrong-site surgical procedure?

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

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

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

Question 26: 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:

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

Correct answer: Potential relapse or medication non-adherence

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

Question 27: After discovering his two-year-old son next to an empty aspirin bottle, the father brings him to the emergency room. While unconscious, the youngster is breathing. What will the nurse do right away?

Prepare to intubate the child for respiratory support.
Insert a nasogastric tube (NGT) to prepare for lavage. (Correct answer)
Notify Family Service authorities of child abuse.
Provide education regarding accidental overdose.

Correct answer: Insert a nasogastric tube (NGT) to prepare for lavage.

In an unconscious child with suspected aspirin overdose, the immediate priority after ensuring airway and breathing is to prevent further absorption of the toxic substance. Inserting a nasogastric tube (NGT) allows for gastric lavage or administration of activated charcoal, which are critical interventions to remove the aspirin from the stomach and minimize systemic absorption. This is a life-saving measure to reduce the drug's effects.

Question 28: 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)
Continue monitoring because this is a normal occurrence.
Turn client on right side.
Decrease IV fluids.

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

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

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

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

Question 30: A nurse is caring for a postoperative patient and notes the Jackson-Pratt drain output has suddenly decreased and the site is swelling. What should the nurse do first?

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

Correct answer: Check that the drain bulb is compressed correctly

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

Question 31: A nurse notes that a patient's surgical wound has new separation with yellow drainage. What is the most appropriate nursing response?

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

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

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

Correct answer: The patient with renal failure on hemodialysis

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

Question 33: A school nurse is teaching adolescents about skin cancer prevention. Which statement is most important?

Apply broad-spectrum SPF 30+ sunscreen and reapply every 2 hours during outdoor exposure (Correct answer)
Tanning beds are safer than outdoor sun exposure
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 34: A patient with heart failure has crackles in bilateral lung bases, JVD, and peripheral edema. The nurse recognizes these as signs of:

Hypovolemic shock
Left-sided heart failure only
Both right- and left-sided heart failure (Correct answer)
Right-sided heart failure only

Correct answer: Both right- and left-sided heart failure

Bilateral crackles and orthopnea indicate left-sided failure (pulmonary congestion), while JVD and peripheral edema indicate right-sided failure (systemic congestion).

Question 35: 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?

Absorption
Distribution
Metabolism (Correct answer)
Excretion

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 36: 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?

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

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

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

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 38: 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 fluid intake to dilute serum potassium
Increase intake of bananas and oranges
Avoid foods high in potassium such as potatoes and tomatoes (Correct answer)
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 39: During a sterile dressing change, which action would break sterile technique?

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

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

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

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

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

Question 41: A patient on mechanical ventilation has a sudden decrease in oxygen saturation and increasing peak airway pressures. The nurse's first action should be:

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

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

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

Question 42: Without first getting the client's informed consent, doing a non-emergency intrusive surgery on them can be seen as

fraud
harassment
battery (Correct answer)
malpractice

Correct answer: battery

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

Question 43: What is the appropriate way to respond to a patient at the senior living facility who throws his tray to the ground and yells, "This food is terrible! I can't stand this another minute!"

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

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

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

Question 44: A nurse is caring for a patient who experienced sexual assault. Which statement by the nurse is most therapeutic?

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

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

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

Question 45: A sentinel event occurs on the unit. After immediate patient stabilization, which process does The Joint Commission require the organization to undertake?

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

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

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

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

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

Question 47: A nurse is reviewing a patient's medication list before surgery. Which finding requires the most immediate action?

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

Correct answer: The patient takes warfarin 5 mg daily

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

Question 48: A nurse is caring for a client with a nasogastric (NG) tube. Before administering a tube feeding, which action confirms proper tube placement?

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

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 49: 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?

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

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

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

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

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

Correct answer: Slow the infusion rate and notify the provider

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

Question 52: A nurse is performing a bed bath for an elderly client. Which action best promotes comfort and prevents chilling?

Complete the entire bath before drying any area
Keep the room temperature at 65°F to conserve water heat
Use cold water to stimulate circulation
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 53: A hospital is transitioning from a centralized to a decentralized management structure. What is the PRIMARY advantage for staff nurses?

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

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

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

Question 54: The nurse is giving parents of a 3-year-old who was admitted to the hospital with severe croup guidelines for release. What non-pharmaceutical measures can parents take at home in the event of a subsequent croup attack?

Place the child in a warm, dry room
Encourage the child to cough and cry
Take the child into a steamy bathroom (Correct answer)
Position the child on their back or side

Correct answer: Take the child into a steamy bathroom

For a child experiencing a croup attack, moist, cool air helps to reduce laryngeal swelling and ease breathing. Taking the child into a steamy bathroom (created by running hot water in the shower) or exposing them to cool night air can provide symptomatic relief. The humidity helps to loosen secretions and soothe the inflamed airways, making it easier for the child to breathe.

Question 55: A patient with primary adrenal insufficiency (Addison's disease) is receiving education from the nurse regarding dietary and nutritional adjustments necessary to manage the client's condition. Which of the following statements made by the patient would suggest that the nurse's recommendations were successful?

I should increase sodium and fluids, but limit potassium. (Correct answer)
I will increase sodium and potassium, but limit fluids.
I will increase potassium and fluids, but limit sodium.
I should increase fluids, but limit sodium and potassium.

Correct answer: I should increase sodium and fluids, but limit potassium.

Patients with Addison's disease have primary adrenal insufficiency, leading to decreased aldosterone production. This hormonal imbalance results in hyponatremia (low sodium), hyperkalemia (high potassium), and fluid volume deficit. Therefore, increasing sodium and fluids helps correct these deficits, while limiting potassium prevents further hyperkalemia, making the patient's statement correct.

Question 56: 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?

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

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 57: A patient is started on lisinopril for hypertension and calls reporting a new persistent dry cough. The nurse should:

Advise the patient to continue the medication; this will resolve
Tell the patient to double the dose to overcome the cough reflex
Document and notify the provider, as this is a common ACE inhibitor side effect (Correct answer)
Instruct the patient to take an antihistamine with each dose

Correct answer: Document and notify the provider, as this is a common ACE inhibitor side effect

A persistent dry cough is a common ACE inhibitor side effect caused by bradykinin accumulation and should be reported.

Question 58: A nurse is caring for a patient with a chest tube. Which finding requires the most immediate intervention?

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

Correct answer: Continuous bubbling in the water-seal chamber

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

Question 59: 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)
Ask the patient to bring a parent before discussing treatment
Inform the parents, as the patient is a minor

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

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

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

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

Question 61: A nurse is caring for a patient in sickle cell crisis. Which intervention is the highest priority?

Administer prescribed analgesics (Correct answer)
Apply ice packs to painful areas
Restrict oral fluid intake
Encourage ambulation every 2 hours

Correct answer: Administer prescribed analgesics

Pain management is the highest priority in sickle cell crisis, as vaso-occlusion causes severe ischemic pain requiring prompt opioid analgesia.

Question 62: A nurse receives handoff for a patient on heparin infusion. The aPTT result is 120 seconds (therapeutic range 60-100 seconds). What is the nurse's priority action?

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

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

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

Question 63: Which electrolyte imbalance is most associated with loop diuretic use?

Hypercalcemia
Hypernatremia
Hypokalemia (Correct answer)
Hyperkalemia

Correct answer: Hypokalemia

Loop diuretics inhibit reabsorption in the loop of Henle, causing potassium wasting and hypokalemia.

Question 64: For a patient with PIH, the doctor advises rapid hospital admission. Which of these techniques by the nurse would likely be best after understanding her feelings when she tells the nurse, "It's not so easy for me to just go right to the hospital like that"?

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

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

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

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

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

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

Positive Chvostek's sign (Correct answer)
Mild sore throat and difficulty swallowing
Temperature of 37.8°C (100°F)
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 67: A nurse notes a patient on heparin infusion has an aPTT of 180 seconds (therapeutic range 60–100 seconds). What is the priority intervention?

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

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

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

Correct answer: Conduct an immediate suicide risk assessment

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

Question 69: Which of the following breast cancer risk factors would a nurse rate as being the most important in a client's history?

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

Correct answer: Maternal family history of breast cancer

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

Question 70: A patient develops stridor and urticaria five minutes after receiving IV penicillin. Which medication should the nurse administer first?

Methylprednisolone 125 mg IV
Diphenhydramine 50 mg IV
Epinephrine 0.3 mg IM (Correct answer)
Albuterol via nebulizer

Correct answer: Epinephrine 0.3 mg IM

Epinephrine IM is the first-line treatment for anaphylaxis because it rapidly reverses bronchospasm and hypotension.

Question 71: Which step is most appropriate when providing postmortem care for a patient who will donate an eye?

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

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

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

Question 72: A nurse is preparing a patient for a lumbar puncture. Which position should the nurse help the patient assume?

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

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

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

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

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

Question 74: A nurse manager is informed that a staff nurse has been witnessed accessing a patient's electronic health record without a clinical reason. The FIRST action should be:

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

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

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

Question 75: Which electrolyte imbalance is most commonly associated with prolonged vomiting?

Hyperkalemia
Hypercalcemia
Hypernatremia
Hypokalemia (Correct answer)

Correct answer: Hypokalemia

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

Question 76: Which of the following observations in a postpartum lady would be abnormal?

Chills shortly after delivery
Urinary output of 3000 mL on the second day after delivery
An oral temperature of 101F (38.3C) on the third day after delivery (Correct answer)
Pulse rate of 60 bpm in morning on first postdelivery day

Correct answer: An oral temperature of 101F (38.3C) on the third day after delivery

A temperature of 101°F (38.3°C) on the third postpartum day is considered abnormal and a potential sign of postpartum infection. While a slight elevation (up to 100.4°F or 38°C) might be seen in the first 24 hours due to dehydration or exertion, a persistent or higher fever warrants investigation. The other options (pulse 60 bpm, chills shortly after delivery, increased urinary output) are generally normal postpartum findings.

Question 77: Which transmission-based precaution is required for a patient admitted with active pulmonary tuberculosis?

Droplet precautions with a surgical mask
Airborne precautions with a negative-pressure room and N95 respirator (Correct answer)
Contact precautions only
Standard precautions only

Correct answer: Airborne precautions with a negative-pressure room and N95 respirator

Pulmonary TB is transmitted via airborne droplet nuclei; a negative-pressure room and NIOSH-approved N95 respirator are required to prevent nosocomial transmission.

Question 78: A nurse is caring for a client with a Stage 2 pressure injury on the coccyx. Which dressing is most appropriate?

Dry sterile gauze changed every 8 hours
Transparent film dressing with daily changes
Hydrocolloid dressing changed every 3–5 days (Correct answer)
Wet-to-dry gauze dressing

Correct answer: Hydrocolloid dressing changed every 3–5 days

Hydrocolloid dressings provide a moist wound environment that promotes healing for Stage 2 pressure injuries and require less frequent changes.

Question 79: What is the best way to spot breast cancer tumors in the early stages?

Yearly checkups performed by physician
Monthly breast self-examination (Correct answer)
Mammograms every 3 years
Ultrasounds 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 80: A patient with chronic kidney disease (CKD) is at risk for hyperkalemia. Which food should the nurse instruct the patient to avoid?

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

Correct answer: Bananas and oranges

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

Question 81: A nurse manager is creating the monthly schedule and discovers the unit will be short-staffed on weekends. Using transformational leadership, which action is BEST?

Mandate staff to work extra shifts under threat of termination
Cancel elective admissions for the weekend
Increase patient-to-nurse ratios to cover the gap
Collaborate with staff to explore creative scheduling solutions and incentives (Correct answer)

Correct answer: Collaborate with staff to explore creative scheduling solutions and incentives

Transformational leaders engage and empower staff to co-create solutions, increasing buy-in and sustaining morale.

Question 82: A nurse is caring for a client who reports pain rated 8/10 after repositioning. The nurse has a PRN analgesic order. What should the nurse do first?

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

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

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

Question 83: 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?

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

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

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

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

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

Question 85: Which vaccine is recommended for all adults 65 years and older who have never been vaccinated against pneumococcal disease?

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

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 86: A patient receiving chemotherapy is prescribed ondansetron (Zofran) and dexamethasone. The nurse understands the dexamethasone is given to:

Increase white blood cell production
Prevent peripheral neuropathy
Treat bone marrow suppression
Enhance the antiemetic effect of ondansetron (Correct answer)

Correct answer: Enhance the antiemetic effect of ondansetron

Dexamethasone has antiemetic properties that act synergistically with serotonin antagonists like ondansetron to prevent chemotherapy-induced nausea.

Question 87: A nurse is teaching a client with COPD pursed-lip breathing. What is the primary goal of this technique?

Strengthen the diaphragm and accessory muscles
Slow the respiratory rate to prevent hyperventilation
Prevent airway collapse and promote CO2 elimination (Correct answer)
Increase oxygen delivery to the alveoli

Correct answer: Prevent airway collapse and promote CO2 elimination

Pursed-lip breathing creates positive back-pressure that keeps airways open longer, facilitating more complete exhalation and CO2 removal.

Question 88: A nurse administers the wrong dose of insulin to a patient. Which document should NOT be referenced in the patient's medical record?

The medication administration record correction
Nursing notes documenting the event and patient response
The physician notification note
The incident/occurrence report (Correct answer)

Correct answer: The incident/occurrence report

Incident reports are internal quality improvement tools and should never be referenced, attached, or mentioned in the patient's medical record, as they are protected documents.

Question 89: A nurse is assigned four patients. Which patient should the nurse assess first?

A patient scheduled for discharge who needs medication teaching
A post-operative patient reporting sudden onset of chest pain and shortness of breath 6 hours after surgery (Correct answer)
A patient with stable COPD requesting pain medication for mild discomfort
A patient with type 2 diabetes whose morning blood glucose is 180 mg/dL

Correct answer: A post-operative patient reporting sudden onset of chest pain and shortness of breath 6 hours after surgery

Sudden chest pain and dyspnea in a post-operative patient may indicate pulmonary embolism, a life-threatening emergency requiring immediate assessment using ABCs.

Question 90: When implementing a new evidence-based protocol, which change theory focuses on unfreezing old behaviors, moving to new ones, and refreezing the change?

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

Correct answer: Lewin's Force Field Analysis

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

Question 91: A nurse is caring for a client who has been receiving IV vancomycin for 30 minutes when the client develops flushing and erythema of the face, neck, and upper chest. What is the priority nursing intervention?

Slow the infusion rate and notify the provider (Correct answer)
Stop the infusion and initiate anaphylaxis protocol
Stop the infusion and administer epinephrine
Administer diphenhydramine and continue the infusion at the current rate

Correct answer: Slow the infusion rate and notify the provider

Red Man Syndrome is a rate-related reaction to vancomycin, not a true allergy; slowing the infusion rate typically resolves the flushing and erythema.

Question 92: In order to give the preoperative medication as directed before a patient is sent to surgery, the operating room telephones the unit nurse. The patient did not sign the surgery consent, the unit nurse finds out after administering the drug. What ought the nurse to start with?

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

Correct answer: Notify the nursing supervisor

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

Question 93: Which nursing action is most important to prevent central line-associated bloodstream infection (CLABSI)?

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

Correct answer: Use maximal sterile barrier precautions during CVC insertion

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

Question 94: A unit's medication error rate has increased over three consecutive months. Using the Plan-Do-Study-Act (PDSA) cycle, what is the FIRST step the nurse manager should take?

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

Correct answer: Analyze root causes and plan a targeted intervention

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

Question 95: A nurse is educating a patient newly diagnosed with type 2 diabetes about the signs of hypoglycemia. Which symptom should the nurse include?

Dry flushed skin and deep rapid breathing
Polyuria and polydipsia
Diaphoresis, tremors, and confusion (Correct answer)
Fruity breath and Kussmaul respirations

Correct answer: Diaphoresis, tremors, and confusion

Hypoglycemia presents with adrenergic symptoms (diaphoresis, tremors) and neuroglycopenic symptoms (confusion) due to low blood glucose.

Question 96: A nurse observes a colleague leaving a contact isolation room while still wearing their isolation gown. What is the most appropriate immediate action?

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

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 97: 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:

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

Correct answer: Administer the medication separately

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

Question 98: Diabetes-afflicted pregnant women frequently experience issues with insulin's capacity to regulate their blood sugar levels throughout the second part of pregnancy. <br> The nurse explains to the customer why this is so:

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

Correct answer: Increased human placental lactogen levels

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

Question 99: A staff nurse informs the charge nurse that a patient's family is threatening to leave against medical advice (AMA) due to long wait times. Which action should the charge nurse take FIRST?

Document the threat in the medical record and continue with other duties
Notify the physician and personally assess the family's concerns (Correct answer)
Have the patient sign the AMA form immediately to reduce liability
Call security to monitor the patient's room

Correct answer: Notify the physician and personally assess the family's concerns

Addressing the family's concerns directly and involving the physician may resolve the issue before an AMA discharge occurs.

Question 100: The medical professional is ready to provide a corticosteroid to a patient who has been diagnosed with asthma. What justification exists for giving this medication to this patient?

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

Correct answer: To decrease airway swelling

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

Question 101: A nurse is assigned to care for a patient with active pulmonary tuberculosis (TB). Which type of isolation precautions must be implemented?

Droplet precautions with surgical mask
Airborne precautions with negative-pressure room and N95 respirator (Correct answer)
Contact precautions with gown and gloves
Standard precautions only

Correct answer: Airborne precautions with negative-pressure room and N95 respirator

TB is transmitted via airborne droplet nuclei (<5 microns) that remain suspended in air, requiring a negative-pressure room and an N95 respirator.

Question 102: A patient is admitted with a Clostridium difficile (C. diff) infection. Which precautions should be initiated in addition to standard precautions?

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

Correct answer: Contact precautions

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

Question 103: The nursing diagnostic of Impaired Physical Mobility associated with Neuromuscular Impairment is given to patients with Parkinson's disease. All of these tasks are being performed by a nursing assistant, as you can see. What need do you have to step in?

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

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

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

Question 104: A patient with deep partial-thickness burns to 30% TBSA is at highest risk for which complication in the first 24–48 hours?

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

Correct answer: Hypovolemic shock

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

Question 105: Which intervention is the nurse's priority when caring for a patient in skeletal traction?

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

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

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

Correct answer: After caring for a patient with Clostridioides difficile

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

Question 107: A nurse is caring for a patient with increased intracranial pressure (ICP). Which position is most appropriate?

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

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

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

Correct answer: sodium, potassium, and calcium

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

Question 109: Which nursing action best demonstrates cultural humility when caring for a patient from a different cultural background?

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

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

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

Correct answer: Serum calcium

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

Question 111: A nurse is teaching a new mother about sudden infant death syndrome (SIDS) prevention. Which instruction is correct?

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

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

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

Question 112: A patient with anorexia nervosa is admitted with a BMI of 14. Which nursing action takes priority?

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

Correct answer: Monitor electrolytes and cardiac rhythm

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

Question 113: A patient with COPD has a PaO2 of 55 mmHg and PaCO2 of 60 mmHg on arterial blood gas. How should the nurse interpret this?

Respiratory acidosis with hypoxemia (Correct answer)
Respiratory alkalosis with hypoxia
Metabolic alkalosis
Compensated metabolic acidosis

Correct answer: Respiratory acidosis with hypoxemia

Elevated PaCO2 (>45 mmHg) indicates CO2 retention and respiratory acidosis; PaO2 below 60 mmHg confirms hypoxemia, both characteristic of COPD exacerbation.

Question 114: When performing a focused assessment on a patient with suspected deep vein thrombosis (DVT), which finding is most significant?

Bilateral lower extremity edema
Unilateral calf warmth, redness, and tenderness (Correct answer)
Intermittent bilateral calf cramping at night
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 115: A client's gestational age is determined by the nurse practitioner to be around 9 weeks. The healthcare provider gives the client information on the bodily changes that will occur during the first trimester, such as:

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

Correct answer: Nausea and vomiting

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

Question 116: A nurse is helping a client with chronic obstructive pulmonary disease (COPD) choose foods from the menu. Which option best reduces the work of breathing during meals?

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

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

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

Question 117: A nurse is teaching osteoporosis prevention to a 40-year-old woman. Which combination of recommendations is most effective?

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

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

Methadone
Haloperidol
Naloxone
Lorazepam (Correct answer)

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 119: A patient is admitted to the ICU after falling from a ladder and being diagnosed with traumatic brain damage (TBI). He is becoming more restless, the nurse notices, and his right arm is becoming weaker. He also reports feeling sick. What is the BEST thing the nurse can do right away?

Elevate the head of the bed to 30 degrees. (Correct answer)
Administer oxygen by face mask.
Increase the IV rate and call the physician.
Measure the patient's blood pressure.

Correct answer: Elevate the head of the bed to 30 degrees.

The patient's increasing restlessness, arm weakness, and nausea following a traumatic brain injury are concerning signs that suggest a potential increase in intracranial pressure (ICP). Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, which can help to reduce ICP and is a crucial immediate nursing intervention to prevent further neurological damage.

Question 120: A nurse manager identifies that incident report filings have dropped significantly over the past month. This most likely indicates:

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

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

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

Correct answer: 0.9% NaCl and hydrocortisone

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

Question 122: Which patient is at highest risk for a pressure injury?

A 60-year-old with mild arthritis who requires minimal assistance
An 80-year-old patient with diabetes, incontinence, and limited mobility on bedrest (Correct answer)
A 30-year-old ambulatory patient post-appendectomy
A 45-year-old with controlled hypertension who walks twice daily

Correct answer: An 80-year-old patient with diabetes, incontinence, and limited mobility on bedrest

Advanced age, diabetes (impaired circulation and healing), incontinence (moisture), and immobility are the highest-risk factors for pressure injury development per the Braden Scale.

Question 123: In Maslow's hierarchy of needs applied to staff management, which action addresses esteem needs?

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

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

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

Question 124: A nurse is caring for a client receiving total parenteral nutrition (TPN). Which complication requires the most immediate intervention?

Temperature of 39.2°C (102.6°F) with chills (Correct answer)
Mild nausea without vomiting
Weight gain of 0.5 kg over 24 hours
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 125: A nurse notices a colleague appears intoxicated at work and smells of alcohol. The most appropriate action is:

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

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

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

Question 126: 50% protein binding indicates that a medication is

50% will pass through the intestines
50% less protein should be eaten
50% of the drug is available (Correct answer)
50% of the drug destroys protein

Correct answer: 50% of the drug is available

When a medication is 50% protein-bound, it means that half of the drug molecules are attached to plasma proteins, primarily albumin, and are inactive. The remaining 50% of the drug is 'free' or unbound, meaning it is pharmacologically active and available to exert its therapeutic effect. Only the unbound drug can distribute to tissues, bind to receptors, and be metabolized or excreted.

Question 127: Under the National Labor Relations Act, which nurse manager behavior during a union organizing campaign is PROHIBITED?

Reminding staff of an open-door policy
Meeting with staff in groups to answer questions
Threatening to close the unit if staff vote to unionize (Correct answer)
Explaining the current benefits package to staff

Correct answer: Threatening to close the unit if staff vote to unionize

Threatening reprisals or unit closure to discourage union activity is an unfair labor practice prohibited by the NLRA.

Question 128: 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
Refuse to give because it is not the drug of choice
Withhold the dose because it is too low
Administer the medication as prescribed (Correct answer)

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

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

Correct answer: Colonoscopy every 10 years starting at age 45

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

Question 130: 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 131: 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:

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

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

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

Question 132: A nurse is about to enter a room under airborne precautions. Which room characteristic must be confirmed before entering?

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

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

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

Question 133: Before administering an intramuscular injection into the ventrogluteal site, the nurse should:

Inject the medication at a 45-degree angle
Locate the site using landmarks (iliac crest and greater trochanter) (Correct answer)
Aspirate for 10 seconds to check for blood return
Use a 5/8-inch needle for an average adult

Correct answer: Locate the site using landmarks (iliac crest and greater trochanter)

The ventrogluteal site is identified by placing the palm on the greater trochanter and fingers toward the iliac crest.

Question 134: A client is ordered a low-residue diet. Which food selection indicates understanding of the diet?

Steamed white rice with baked chicken breast (Correct answer)
Bran cereal with whole milk
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 135: Which duty should the nursing assistant be given?

Placing the client in seclusion
Feeding the client with dementia (Correct answer)
Emptying the Foley catheter of the preeclamptic client
Ambulating the client with a fractured hip

Correct answer: Feeding the client with dementia

Feeding a client with dementia is an appropriate task to delegate to a nursing assistant. This task falls within the UAP's scope of practice as it involves assisting with activities of daily living and does not require complex assessment, nursing judgment, or sterile technique. The other options involve higher-level nursing skills or judgment.

Question 136: A patient on lithium therapy complains of tremors, confusion, and has a serum level of 2.1 mEq/L. The nurse anticipates:

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

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

Hypotonic
Isotonic
Colloid
Hypertonic (Correct answer)

Correct answer: Hypertonic

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

Question 138: Which intervention is most effective in preventing catheter-associated urinary tract infections (CAUTI)?

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

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.

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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