NCLEX-RN Practice 100 Questions

  • NCLEX-RN
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| Attempts: 5,517 | Questions: 100 | Updated: Aug 22, 2025
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1. For a client with a neurologic disorder, which of the following nursing assessments is MOST helpful in determining subtle changes in the client's level of consciousness?

Explanation

Strategy: Think about each answer choice.

(1) indicates increased intracranial pressure

(2) correct—Glasgow coma scale score best evaluates changes in a client’s level of consciousness by evaluating eye-opening, motor, and verbal responses

(3) more appropriate for the psychiatric client

(4) more appropriate for the psychiatric client

Submit
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About This Quiz
NCLEX-RN Practice 100 Questions - Quiz

This NCLEX-RN Practice quiz features 100 questions designed to assess and enhance nursing knowledge and skills. It covers critical aspects such as patient nutrition post-surgery, neurological assessments, signs of bulimia, and medication administration, preparing learners for practical nursing challenges.

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2. The nurse assists a nursing assistant in providing a bed bath to a comatose patient with incontinence. The nurse should intervene if which of the following actions is noted?

Explanation

Strategy: "Nurse should intervene" indicates that you are looking for an incorrect action.

(1) correct—contaminated gloves should be removed before answering the phone

(2) correct way to roll a patient to maintain proper alignment

(3) appropriate to use incontinence pad for this patient

(4) appropriate position to prevent aspiration and protect the airway

Submit
3. The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. Which of the following situations require the nurse's IMMEDIATE attention?

Explanation

Strategy: "Require IMMEDIATE intervention" indicates that you are looking for the least stable situation.

(1) should remove to quiet area, decrease environmental stimuli

(2) correct—could indicate impending suicide; requires immediate follow-up

(3) potential suicide is more immediate concern

(4) command hallucination; potential suicide takes priority

Submit
4. A child has a closed transverse fracture of the right ulna. Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?

Explanation

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes.

(1) correct—assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness

(2) assessment; temperature indicates decreased circulation but is subjective and not most important

(3) assessment; upper (not lower) extremity fracture

(4) implementation; should not be done because it would increase skin irritation

Submit
5. A client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which of the following is necessary for the nurse to consider regarding the client's nutrition?

Explanation

Strategy: Think about each answer choice.

(1) correct—tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area

(2) although client has permanent tracheotomy, will be able to eat normally after area has healed

(3) nutritional intake will begin when bowel sounds return and client can tolerate intake

(4) client is not dependent on ventilator

Submit
6. A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection. The patient's preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment includes which of the following?

Explanation

The purpose of frequent oral hygiene with hydrogen peroxide before a hypoglossectomy with lymph node dissection is to minimize the bacterial count in the mouth. This is important because reducing the bacterial count can help prevent infection during and after surgery.

Submit
7. A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. The nurse knows that

Explanation

Strategy: Think about each answer choice.

(1) correct—PSA test has replaced acid phosphatase test in screening for prostatic cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value

(2) inaccurate information about a PSA

(3) inaccurate information about a PSA

(4) inaccurate information about a PSA

Submit
8. A client in a psychiatric facility describes seeing snakes on the walls of the room. Which of the following is an accurate nursing diagnosis?

Explanation

Strategy: Think about each answer choice.

(1) correct—reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist

(2) not relevant to the data

(3) not relevant to the data

(4) not relevant to the data

Submit
9. The nurse teaches nutrition classes at the community center. Which of the following foods should the nurse encourage a low-income client to eat to satisfy essential protein needs?

Explanation

Strategy: Think about each answer choice.

(1) correct—legumes are an economical source rich in protein

(2) high in protein, but more expensive to purchase

(3) high in protein, but more expensive to purchase

(4) high in protein, but more expensive to purchase

Submit
10. The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for a client. Which of the following results indicates to the nurse that the tube feeding can begin?

Explanation

Strategy: Determine how the answers relate to a tube feeding.

(1) mucus may be from lungs

(2) correct—stomach contents are acidic

(3) not a safe way to check placement

(4) not a reliable indication

Submit
11. A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the patient to make which of the following statements about symptoms?

Explanation

Strategy: Remember physiology.

(1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic

(2) correct—cerebellum maintains balance

(3) CN IX, glossopharyngeal responsible for differentiation of taste

(4) not specific symptom of cerebellum dysfunction

Submit
12. The nurse conducts a physical examination of a client suspected to have bulimia. Which of the following observations by the nurse MOST likely indicates bulimia?

Explanation

Strategy: Determine the cause of each symptom. Does it relate to bulimia?

(1) common with anorexia

(2) seen with anorexia

(3) correct—due to frequent vomiting

(4) bulimics are normal in appearance

Submit
13. The nurse knows that which of these plans is MOST successful in caring for a client with dementia?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) unable to learn new skills

(2) correct—client with dementia does not have cognitive abilities to learn new skills or to adapt; environment must be adapted for client with attention to safety and predictability

(3) requires skills the client with dementia does not have

(4) requires skills the client with dementia does not have

Submit
14. A neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively, is admitted to the nursery. Because the infant's mother is diagnosed with a type 1 diabetes, the nurse knows the infant is at GREATEST risk for developing which of the following?

Explanation

Strategy: Determine the cause of each answer choice.

(1) no change in blood volume for infant of diabetic mother

(2) correct—fetus produces increased insulin to match mother’s increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia

(3) infant would be at risk of hypoglycemia due to increased insulin production

(4) thermal receptors in skin are stimulated due to cold environment; increases metabolic rate; infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes; not expected with diabetic mother

Submit
15. The MOST appropriate nursing action before administering captopril (Capoten) is to check the client's

Explanation

Strategy: Think about each answer choice and how it relates to Capoten.

(1) important, but not a priority

(2) correct—Capoten is an antihypertensive that necessitates assessment of BP before administration

(3) important, but not priority

(4) unnecessary to assess prior to the administration of the medication

Submit
16. The nurse makes patient assignments on the obstetrics unit. Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrics unit from outpatient surgery?

Explanation

Strategy: LPN/LVN and "pulled" RN receive stable patients with expected outcomes.

(1) correct—monitor IV therapy, administer antiemetics and nutritional supplements

(2) monitor patient’s response to medication and the status of the fetus

(3) prepare for delivery, closely monitor fetal response

(4) indicates impending seizures, prepare for delivery

Submit
17. The nurse cares for a client after right cataract surgery. The nurse should intervene if which of the following is observed?

Explanation

Strategy: "Nurse should intervene" indicates an incorrect action.

(1) appropriate position

(2) decreases swelling and pain

(3) correct—client should not be positioned with operative side in a dependent position or against the bed

(4) shield is appropriate

Submit
18. The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination?

Explanation

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) regular exercise program facilitates bowel elimination

(2) correct—contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis

(3) normal fluid intake of 1,500 ml/day facilitates bowel elimination

(4) laxatives used as last resort because they become habit-forming

Submit
19. The nurse reviews client assignments on a medical/surgical unit. The nurse determines that the assignment is appropriate if the nursing assistant is caring for which of the following clients?

Explanation

Strategy: Assign clients with standard, unchanging procedures.

(1) correct—standard, unchanging procedure

(2) assign to the RN

(3) assign to the RN

(4) assign to the RN

Submit
20. An 11-year-old boy falls off his bicycle and sustains a minor head injury, which is treated at the outpatient clinic. The nurse instructs the boy's mother about his care at home. The nurse determines that further teaching is necessary if the mother makes which of the following statements?

Explanation

Strategy: Determine how each answer choice relates to a minor head injury.

(1) expected for at least 24 hours

(2) correct—vomiting unexpected; should be reported to physician immediately; also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache

(3) expected for at least 24 hours

(4) expected for at least 24 hours; should not get more intense

Submit
21. A client has a three-way Foley catheter following a transurethral resection. The nurse should rapidly infuse the irrigating solutions if which of the following is observed?

Explanation

Strategy: Think about each answer choice.

(1) not a reason to infuse irrigating solution rapidly

(2) correct—three-way Foley catheter should be irrigated rapidly when bright-red drainage or clots are present; irrigation rate should be decreased to about 40 gtt/min when the drainage clears

(3) not an indication to infuse irrigating solution rapidly

(4) not an indication to infuse irrigating solution rapidly

Submit
22. A 6-month-old infant has had all of the required immunizations. The nurse knows that this would include which of the following?

Explanation

Strategy: Think about each answer choice.

(1) correct—first dose of the DPT may be given at 2 months of age, the second is given around 4 months

(2) MMR is given at 15 months

(3) polio is given at 2 and 4 months and again at 12 to 18 months

(4) recommended for first responders

Submit
23. The nurse caring for a client on suicide precautions makes the following observations: the client is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on these data, which of the following nursing actions is MOST appropriate?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) may reverse the client’s progress

(2) correct—data suggest that client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually on the basis of a full-data picture

(3) may be the team’s decision, but not until a thorough review of the case is completed

(4) premature

Submit
24. The nurse is aware that Rh immune globulin (RhoGAM) is administered to prevent complications in which of the following situations?

Explanation

Strategy: Think about each answer choice.

(1) if both mother and baby are Rh-negative, there is no problem

(2) correct—RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test

(3) medication is not given if the mother has been sensitized by a previous pregnancy

(4) there is no incompatibility here, but the mother needs to be evaluated regarding sensitization in the incomplete pregnancy

Submit
25. A 25-year-old primigravida diagnosed with type 1 diabetes mellitus reviews the insulin regimen with the nurse. The nurse explains to the client that her insulin needs will change in which of the following ways?

Explanation

Strategy: Think about each answer choice.

(1) correct—needs increase during pregnancy due to hormonal interference in glucose metabolism

(2) needs increase during pregnancy due to hormonal interference in glucose metabolism

(3) insulin needs will decrease after delivery

(4) needs increase during pregnancy

Submit
26. The mother of a 7-year-old child is dying. The nurse anticipates the child will have which of the following concepts of death?

Explanation

Strategy: Remember growth and development.

(1) correct–7-year-olds see death as a punishment

(2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible

(3) is a preschool child’s concept of death

(4) is an adolescent’s concept of death

Submit
27. The nurse cares for patients on the pediatric unit. The mother of a 2-year-old who is one day postoperative tells the nurse, "My child is so restless and overactive." The nurse should take which of the following actions?

Explanation

Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment.

(1) no indication that there are any problems

(2) passing the buck

(3) implementation; should first assess

(4) correct—young children typically become restless and overactive if in pain; grimacing, clenching teeth, rocking, and aggressive behavior may also be observed

Submit
28. The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which of the following dietary requirements should be considered by the nurse?

Explanation

Strategy: Think about each answer choice.

(1) contains high fat

(2) correct—impaired intestinal absorption due to cystic fibrosis necessitates a diet higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients

(3) not adequate for this child

(4) contains high fat

Submit
29. The nurse prepares a dopamine (Intropin) infusion on a client. Before beginning the infusion the nurse should take which of the following actions?

Explanation

Strategy: Determine how each answer choice relates to dopamine.

(1) not a critical assessment at this time

(2) contains correct information, but is not a priority

(3) correct—if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects

(4) not a critical assessment at this time

Submit
30. A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is the MOST important nursing diagnosis?

Explanation

Strategy: Think about each answer choice.

(1) constipation is not a problem because the client has diarrhea

(2) correct—skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this

(3) not most important

(4) may be risk of fluid volume deficit due to diarrhea and secretions

Submit
31. A client asks what the difference is between a gastric ulcer and a duodenal ulcer. The nurse's response should be based on which of the following statements?

Explanation

Strategy: Think about each answer choice.

(1) refers to duodenal ulcers

(2) correct—clients with duodenal ulcers experience pain after meals, e.g., midmorning and midafternoon

(3) clients with gastric ulcer may be malnourished because food may cause nausea or vomiting

(4) antacids are given to duodenal ulcer clients

Submit
32. Which observation indicates to the nurse that the client needs further teaching before self-administering insulin?

Explanation

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) when mixing regular insulin with other types of insulin, the client should draw up the clear (regular) before the cloudy (NPH)

(2) bottle of insulin should never be vigorously shaken, but rather gently mixed

(3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption

(4) correct—insulin should be administered at room temperature; temperature extremes should be avoided

Submit
33. The nurse supervises care given to clients on a medical/surgical unit. The nurse should intervene if which of the following is observed?

Explanation

Strategy: "Nurse should intervene" indicates that you are looking for an incorrect action.

(1) appropriate procedure, prevents airborne contamination

(2) insulin is the only medication that can be given, compatible with TPN

(3) correct—applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur

(4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour

Submit
34. An older woman is hospitalized with a fractured left hip. While awaiting surgery, the client is placed in Buck's traction with a 7-pound weight. Which of the following instructions about moving should be given by the nurse to encourage the patient to participate in her care?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—body must move as single, straight unit

(2) turning or twisting from the waist down interferes with countertraction

(3) prevents proper pull of weights

(4) can’t turn from side to side; can only move up and down

Submit
35. A client with newly diagnosed type 1 diabetes says to the nurse, "I know that I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which of the following responses by the nurse is BEST?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) should buy shoes in the afternoon when feet are larger than in the morning

(2) correct—feet enlarge with age, break in shoes gradually rather than all at one time, have measurements for shoes taken while standing (feet are larger)

(3) buy correct shoe size

(4) leather shoes recommended because they "breathe," vinyl could cause foot to perspire and aggravate fungal infections

Submit
36. A client is scheduled for electromyography (EMG). What should the nurse tell the client about the procedure?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) usually performed on the legs

(2) correct—electrodes are attached to legs, length of time for impulse transmission is measured

(3) may impair test results

(4) procedure does not involve general anesthesia or GI system

Submit
37. An elderly man diagnosed with chronic schizophrenia is followed in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse's documentation should include which of the following?

Explanation

Strategy: Think about each answer choice.

(1) assessment of client’s abilities to complete his activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill

(2) measures cognitive function

(3) correct is most widely accepted examination to test for the presence of tardive dyskinesia

(4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population

Submit
38. The nurse obtains a client's temperature of 103°F(39.4°C). The nurse knows body compensatory mechanisms include which of the following?

Explanation

Strategy: Think about each answer choice.

(1) respirations and heart rate will increase with fever

(2) blood pressure and pulse usually increase with fever

(3) correct—hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate

(4) diaphoresis may occur, but the skin will be warm

Submit
39. An elderly alcoholic client receives a long-acting benzodiazepine (Librium) for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which of the following?

Explanation

Strategy: Think about each answer choice.

(1) client has been medicated with benzodiazepines and did not experience untoward reactions

(2) correct—client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations

(3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations

(4) combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium but rather dementia

Submit
40. An adult woman has missed her menstrual period. The client's last menstrual period began May 8 and ended May 12. The nurse determines that the client's EDC (estimated date of confinement) is which of the following?

Explanation

Strategy: Remember Naegele rule.

(1) should add 7 days

(2) correct—when using the Naegele rule, add 7 days to first day of last menstrual period and subtract 3 months

(3) incorrectly started with the last day of the menstrual cycle

(4) incorrect

Submit
41. The nurse assesses a client with severe bilateral peripheral edema. Which of the following is the BEST way for the nurse to determine the degree of edema in a limb?

Explanation

Strategy: Think about each answer choice.

(1) is not the best way to evaluate for peripheral edema

(2) correct—severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting)

(3) not as objective

(4) is used for evaluating hydration

Submit
42. The nurse should include which of the following in a teaching plan for a client receiving tetracycline?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) tetracycline should never be taken with milk or antacids because these inhibit the medication’s action

(2) should take with full glass of water at least 1 hour before or 2 hours after meals

(3) correct—because of problems related to photosensitivity, client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure

(4) should take with full glass of water at least 1 hour before or 2 hours after meals

Submit
43. The nurse cares for a child who is in Buck's traction. During the neurovascular assessment, the nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse should take which of the following actions?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) ignores possibility that Ace bandage is too tight

(2) does not relieve the circulation problem

(3) does not relieve the circulation problem

(4) correct—assessment indicates that Ace bandage is too tight and needs readjusting

Submit
44. The nurse anticipates which of the following when assessing a client with a diagnosis of a ruptured lumbar disc?

Explanation

Strategy: Think about each answer choice.

(1) results from cervical lesions

(2) can occur in a person who has been paralyzed from a spinal cord injury

(3) correct—lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities

(4) is a sign of Huntington chorea, resulting from atrophy of parts of the brain

Submit
45. A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 ml 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity. It is MOST important for the nurse to take which of the following actions?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) antibiotic should be administered within 1 hour

(2) unnecessary for safe infusion

(3) correct—when using a gravity drip, piggyback fluid level needs to be higher than primary infusion

(4) unnecessary for safe infusion

Submit
46. The physician orders morphine sulfate 8 mg IM q 3 to 4 h for pain PRN. In which of the following situations should the nurse consider withholding the medication until further assessment is completed?

Explanation

Strategy: Determine the significance of each answer choice and how it relates to morphine.

(1) morphine used for moderate to severe pain; medication should be given

(2) BP slightly elevated, respirations elevated, may be the result of pain; medication should be given

(3) correct—morphine depresses CNS, especially respiratory center in medulla

(4) may be the result of pain

Submit
47. The nurse cares for a client who presents with confusion, mood lability, impaired communication, and lethargy. The nurse should question which of the following orders?

Explanation

Strategy: Think about each test.

(1) may be ordered to determine the presence of major depression

(2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made

(3) may be ordered to see if the client’s symptoms are caused by excessive use of medications or alcohol

(4) correct—test is used with a client who may have varicose veins, no relationship to the symptoms described in this situation

Submit
48. A client is admitted with irritable bowel syndrome. The nurse anticipates that the client's history will reflect which of the following?

Explanation

Strategy: Think about each answer choice.

(1) correct—condition is often called spastic bowel disease; no inflammation is present

(2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn’s disease

(3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn’s disease

(4) bloody stools do not occur with irritable bowel syndrome

Submit
49. The nurse assesses a client's neurosensory cerebellar functioning. Which of the following assessment techniques is correct?

Explanation

Strategy: Determine how each answer choice relates to the cerebellum.

(1) general central nervous system response, not sensory involvement

(2) evaluates for increased intraocular pressure

(3) correct—coordination is governed by the cerebellum; this test evaluates neurosensory status

(4) evaluates the facial and hypoglossal nerves

Submit
50. The nurse knows that which of the following symptoms is supportive of a diagnosis of Guillain-Barré syndrome?

Explanation

Strategy: All parts of the answer choice must be correct in order for the answer to be correct.

(1) relates to a CVA

(2) correct—classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation

(3) relates to pulmonary edema

(4) relates to peripheral nerve problems

Submit
51. The nurse cares for a patient several days after an above-knee amputation (AKA). Which of the following symptoms are characteristic of an infected residual limb wound?

Explanation

Strategy: Determine how each answer choice relates to an infected wound.

(1) may be due to changes in body image or pain

(2) expected, not indicative of an infection

(3) correct—pain is characteristic of inflammation and infection

(4) warm skin above operative site would indicate infection

Submit
52. The nurse observes a student nurse caring for a client. In addition to following standard precautions, the student nurse is wearing a gown and gloves. The nurse determines care is appropriate if the student nurse performs which of the following activities?

Explanation

Strategy: Determine how the organism of each disease is spread.

(1) requires airborne precautions, particulate respirator

(2) requires droplet precautions; nurse should wear a mask

(3) requires standard precautions

(4) correct—requires contact precautions

Submit
53. The nurse receives report from the previous shift. Which of the following patients should the nurse see FIRST?

Explanation

Strategy: Determine which patient is the least stable.

(1) although the patient requires a high level of nursing care, no indication that the patient is unstable

(2) patient requires preoperative assessment and teaching, no indication that the patient is unstable

(3) correct —epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting

(4) requires monitoring but patient with epidural takes priority

Submit
54. A client is admitted for regulation of insulin dosage. The client takes 15 units of Humulin N insulin at 8 A.M. every day. At 4 P.M., which of the following nursing observations indicates a complication from the insulin?

Explanation

Strategy: Determine the cause of each symptom and how it relates to hypoglycemia.

(1) signs of hyperglycemia

(2) correct—Humulin N insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur

(3) signs of hyperglycemia

(4) signs of hyperglycemia

Submit
55. An 8-year-old has been receiving chemotherapy for 6 months. During her nursing care she asks, "Am I going to die?" Which of the following responses by the nurse is BEST?

Explanation

Strategy: Remember therapeutic communication.

(1) correct—encourages ventilation of thoughts and feelings regarding the concern

(2) inappropriate

(3) ignores the child’s concern with dying

(4) ignores the child’s concern with dying

Submit
56. The nurse in the outpatient clinic assists with the application of a cast to the left arm of a pre-school-aged child. After the cast is applied, the nurse should take which of the following actions?

Explanation

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) done when cast is completely dry, prevents crumbling of plaster into cast

(2) correct—minimizes swelling, elevated for first 24 to 48 hours, protects from pressure and flattening of cast

(3) would delay drying of cast

(4) maintaining mobility of fingers not most important after application of cast

Submit
57. Nursing management prior to an intravenous pyelogram (IVP) would include which of the following?

Explanation

Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?

(1) fat-free meal is associated with a gallbladder series

(2) a retention Foley catheter may be in place, but not for the purpose of dilating the bladder sphincter

(3) correct—because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered

(4) there are few directions the client needs to follow during the test

Submit
58. A 2-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse. An appropriate nursing diagnosis is high risk for

Explanation

Strategy: Think about each answer choice.

(1) no information about swallowing provided with question

(2) this is a medical diagnosis, not a nursing diagnosis

(3) correct—may become dehydrated

(4) not specific for problem described

Submit
59. A mother brings her 9-month-old infant to the pediatrician's office with complaints of a fever of 102.2°F (39°C) and frequent vomiting. The nurse expects which of the following reflexes to still be present?

Explanation

Strategy: Think about growth and development.

(1) correct—stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex; disappears after 1 year of age

(2) sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape; disappears after 3 to 4 months

(3) when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex; disappears by age 3 to 4 months

(4) touching palms of hands or soles of feet causes flexion of hands and toes; palmar grasp disappears after 3 months of age, plantar grasp lessened by 8 months of age

Submit
60. The nurse cares for a multipara client who delivered a female infant 1 hour ago. The nurse observes that the client's breasts are soft; the uterus is boggy to the right of the midline and 2 cm below the umbilicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following actions?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) encourage the client to void before catheterizing

(2) correct—boggy uterus deviated to right indicates full bladder, encourage client to void

(3) will increase uterine tone, but the problem is a full bladder

(4) findings indicate a full bladder

Submit
61. The nurse in the pediatrician's office observes a child in the waiting room. The nurse notes that the child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. The nurse identifies the child's chronological age to be which of the following?

Explanation

Strategy: Picture the child at each age.

(1) unable to walk up and down stairs with hand held until 18 months

(2) unable to jump until 30 months

(3) correct—able to jump with both feet and stand on one foot momentarily at 30 months

(4) behaviors are seen in younger child

Submit
62. A mother brings her 10-year-old and 3-year-old daughters to the pediatrician's office because the younger girl complains of dysuria. The physician orders a catheterization to obtain a urine specimen. The nurse should take which of the following actions?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—children this age need simple explanations

(2) might contaminate the equipment; must be a sterile procedure

(3) not likely to listen to sister

(4) not appropriate for this age

Submit
63. The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a 5-year-old boy?

Explanation

Strategy: Picture the child.

(1) cooperative play occurs in school-aged children

(2) correct—imitative behavior seen at this age

(3) too advanced for this age

(4) too regressed for this age

Submit
64. Which of the following statements, if made by a client to the nurse, indicates that the client is using the defense mechanism of conversion?

Explanation

Strategy: Think about each answer choice.

(1) indicates reaction formation

(2) correct—client has converted his anxiety over school performance into a physical symptom that interferes with his ability to perform

(3) indicates denial

(4) indicates projection

Submit
65. A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client, diagnosed with a spinal cord injury at the level of C4, is tearful, constantly complains of discomfort, and requests to be suctioned. The nurse understands that the client's attention-seeking behaviors may be due to which of the following?

Explanation

Strategy: Think about each answer choice.

(1) is not accurate for situation

(2) correct—is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs

(3) is not accurate for situation

(4) is not accurate for situation

Submit
66. The nurse obtains a history from the father of a 6-year-old boy with a history of epilepsy who was admitted with uncontrolled seizures. It is MOST important for the nurse to ask which of the following questions?

Explanation

Strategy: "MOST important" indicates that this is a priority question.

(1) not most important question

(2) should be included in detailed history, but will not prevent an immediate reoccurrence

(3) correct—seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, drugs)

(4) should be included in detailed history, but will not prevent an immediate reoccurrence

Submit
67. Which of the following statements, if made by the nurse, is accurate about the exercise program required for a patient with rheumatoid arthritis?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) consistency is important to maintain joint mobility

(2) active exercises are better than passive or active-assistive exercises

(3) correct—should reduce repetitions when patient experiences more pain

(4) should do exercises that have been prescribed for patient

Submit
68. The nurse instructs a client who is receiving imipramine (Tofranil). It is MOST important for the nurse to instruct the client to immediately report which of the following?

Explanation

Strategy: Think about each answer choice.

(1) correct—possible side effects of Tofranil, a tricyclic antidepressant medication, which can be resolved by altering the dosage or changing the medication

(2) describes side effects of antidepressants, which client can learn to manage at home without changing the medication

(3) not side effects of Tofranil

(4) not side effects of Tofranil

Submit
69. The nurse responds to a train derailment. After making an initial assessment, which of the following clients should the nurse see FIRST?

Explanation

Strategy: Think ABCs.

(1) requires further assessment; could be amniotic fluid or could be urine.

(2) correct—indicates arterial bleeding; apply direct pressure; high risk for shock

(3) stable patient

(4) possible hip fracture; no indication of respiratory difficulty stated

Submit
70. The nurse cares for a client one day after a thoracotomy. Nursing actions listed on the care plan include turn, cough, and deep breathe q 2 h. The nurse understands that the purpose of this nursing action includes which of the following?

Explanation

Strategy: Think about each answer choice.

(1) correct—primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis

(2) answer choice #1 is better in that it refers to ventilation rather than oxygenation

(3) increasing the pH is not desirable

(4) respiratory alkalosis is not prevented by this nursing measure

Submit
71. The nurse cares for an elderly adult client with multi-infarct dementia. Which of the following actions, if taken by the nurse, is BEST?

Explanation

Strategy: The topic of the question is unstated. Read the answer choices for clues.

(1) do not restrain unless all other options have been exhausted

(2) correct—appropriate assessment to determine if client wanders during specific times of the day; assess before implementing

(3) need to prevent sensory overload; should assess first

(4) offer well-balanced diet

Submit
72. A client has partial-thickness and full-thickness burns over 75% of his body. The nurse is MOST concerned if which of the following is observed?

Explanation

Strategy: Determine how each answer relates to burns.

(1) insignificant for burn client

(2) may be due to pain

(3) correct—body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool, clammy skin, tachycardia, tachypnea, and pale color

(4) may be due to pain

Submit
73. The nurse in the outpatient clinic instructs a client diagnosed with right-sided weakness to walk down stairs using a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is successful?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weak leg and cane

(2) correct—to go down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down

(3) should advance cane and weak leg first

(4) weaker leg and cane advance first

Submit
74. A 4 lb 10 oz baby boy is delivered at 32 weeks' gestation. The infant is admitted to the neonatal intensive care unit and placed in an incubator. The infant has mottling of the skin and acrocyanosis with irregular respirations of 60. The nurse should recognize that these findings indicate which of the following?

Explanation

Strategy: Think about each answer choice.

(1) blood sugar less than 25 mg/dL; would see cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, coma

(2) correct—symptoms describe cold stress

(3) would see meconium-stained amniotic fluid

(4) would see symptoms of shock

Submit
75. The nurse cares for an elderly client who is receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which of the following actions should the nurse take FIRST?

Explanation

Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation.

(1) correct—KVO (20 cc/h) will keep access open

(2) need to notify physician; rate still too much since patient is in fluid overload

(3) IV line may be necessary; diuretics may be ordered

(4) description indicates circulatory overload, not infiltration

Submit
76. The nurse observes the fetal heart monitor for a client in active labor. The fetal heart tracing shows early fetal decelerations. The nurse is aware that this is

Explanation

Strategy: Think about each answer choice.

(1) correct—occurs in response to compression of fetal head; uniform shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal distress

(2) does not indicate fetal distress

(3) slowing is early in the contraction

(4) slowing is early in uterine contraction and is not abnormal

Submit
77. A client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows that which of the following BEST describes the client's need for the repetitive acts of hand-washing?

Explanation

Strategy: Think about each answer choice.

(1) not a manipulation on the client’s part

(2) not an accurate statement regarding the compulsive behavior of this client

(3) correct—compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client is experiencing

(4) client is not subject to depression but to high levels of anxiety

Submit
78. A client has been taking propranolol (Inderal) 40 mg BID and furosemide (Lasix) 40 mg daily for several months. Two weeks ago, the physician added verapamil (Calan) 80 mg TID to the client's medication regimen. The client returns to the outpatient clinic for evaluation. It is MOST important for the nurse to assess for which of the following?

Explanation

Strategy: Determine how each answer choice relates to the medication.

(1) will cause bradycardia

(2) usually causes constipation

(3) correct—Calan is a calcium channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries; when used with other antihypertensives can cause hypotension and heart failure

(4) not most important or frequent side effect

Submit
79. The nurse cares for a client admitted with a diagnosis of acute hypoparathyroidism. It is MOST important for the nurse to have which of the following items available?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—tracheostomy set is the most important for the client's safety due to risk for laryngospasm

(2) nice to have, but not the most important

(3) nice to have, but not the most important

(4) unnecessary

Submit
80. The nurse works with a client who has just indicated a wish to kill herself. The client then asks the nurse not to tell anyone. Which of the following responses by the nurse is BEST?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) does not answer client’s immediate concern or give client accurate information about what the nurse will do

(2) does not answer client’s immediate concern or give client accurate information about what the nurse will do

(3) correct—nurse must let the client know that this information will be shared with the staff so that the client’s safety can be preserved

(4) does not answer client’s immediate concern or give client accurate information about what the nurse will do

Submit
81. A client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which of the following is the INITIAL priority nursing action?

Explanation

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority

(2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client’s internal sense of agitation and aggression

(3) this action is inappropriate at this time

(4) correct—is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents

Submit
82. The nurse cares for an elderly client who has just had a prosthetic hip implant. The nurse should position the client in which of the following positions?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period

(2) flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period

(3) flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period

(4) correct—position of abduction should be maintained

Submit
83. The nurse recognizes that the client diagnosed with an obsessive-compulsive ritual is attempting to achieve which of the following?

Explanation

Strategy: Think about each answer choice.

(1) inaccurate

(2) inaccurate

(3) correct—obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase his self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so

(4) ritual is not a method of expressing anxiety but a strategy to avoid it

Submit
84. An older client diagnosed with pneumonia is admitted to the medical/surgical unit. The nurse should place the patient in a room with which of the following patients?

Explanation

Strategy: Determine the transmission of organisms.

(1) patients with fractures are considered "clean"; don’t place with an infectious patient

(2) don’t know the cause of the fever

(3) correct—generalized nonfollicular infection that involves deeper connective tissue, both patients have infections

(4) elderly are high risk for developing pneumonia

Submit
85. A client with an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L has digoxin (Lanoxin) ordered. Which of the following actions, if taken by the nurse, is BEST?

Explanation

Strategy: The topic of the question is unstated.

(1) although the pulse is normal, level of potassium must be considered

(2) notify physician about low potassium

(3) correct—hypokalemia can precipitate digoxin toxicity; physician should be called to obtain order for potassium supplement

(4) notify physician about the potassium level

Submit
86. The nurse cares for patients on the psychiatric unit. An extremely angry patient with bipolar illness tells the nurse he just learned his wife has filed for divorce and he needs to use the phone. Which of the following responses by the nurse is MOST appropriate?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—patient is able to use phone unless otherwise indicated by court order or physician’s order

(2) has not lost civil right to use phone

(3) denies patient his civil rights

(4) inappropriate

Submit
87. A patient is treated in the telemetry unit for cardiac disease. The patient receives propranolol hydrochloride (Inderal) 20 mg PO at 9 A.M. When the nurse enters the room to give the medication to the patient, the nurse finds the patient wheezing with a nonproductive cough and shortness of breath. INITIALLY, the nurse should take which of the following actions?

Explanation

Strategy: Determine the outcome of each answer choice.

(1) correct—side effects include increased airway resistance; patient is experiencing bronchospasm; should assess and then call the physician

(2) should assess the patient’s condition first

(3) patient is experiencing a side effect; medication should not be given

(4) medication should be held; patient is experiencing a side effect

Submit
88. A client with clear lung sounds and unlabored breathing receives aminophylline IV. Which of the following is the MOST appropriate nursing action if the client's IV infiltrates?

Explanation

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) continued IV medication may not be necessary based on the current assessment

(2) physician should be notified if IV medications are not infusing as scheduled

(3) client has improved breathing, so IV medications may not be indicated

(4) correct—before a new IV is started on this client, physician should be called and PO medications recommended

Submit
89. A teenager diagnosed with anorexia nervosa is admitted to the hospital. In planning to care for the client, the nurse would expect the client to

Explanation

Strategy: Determine how each answer choice relates to anorexia.

(1) usually view their appearance as fat

(2) inaccurate for client with anorexia nervosa

(3) correct—display a marked preoccupation with food

(4) inaccurate for client with anorexia nervosa

Submit
90. The nurse cares for clients in the medical clinic. A nursing assessment of a client with a hiatal hernia is MOST likely to reveal which of the following?

Explanation

Strategy: Think about each answer choice.

(1) suggests an inguinal hernia

(2) suggests an inguinal hernia

(3) pain usually does not develop during the day with an empty stomach

(4) correct—classic symptom of hiatal hernia associated with reflux

Submit
91. The nurse checks the incision of a patient 48 hours after surgery for a hernia repair. Which of the following findings indicates a possible complication?

Explanation

Strategy: Determine the significance of each answer choice.

(1) slight swelling is expected during healing

(2) slight crusting of incision line is normal

(3) correct—should be pink, not red; indicates possible infection; other signs include increased warmth, tenderness, pain, and purulent or odorous drainage

(4) shows healing is taking place

Submit
92. The nurse cares for a client who is receiving a tube feeding around the clock. Which of the following nursing actions is MOST appropriate?

Explanation

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—there is an increased growth of organisms after 4 hours

(2) inappropriate due to increased organism growth

(3) inappropriate due to increased organism growth

(4) not a necessary action to maintain asepsis

Submit
93. An infant is admitted with vomiting and diarrhea. The infant's anterior fontanelle is depressed and temperature is 103.2°F (39.5°C). Which of the following nursing actions is MOST appropriate?

Explanation

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes.

(1) assessment; correct information, but is not what the question asks for

(2) correct—assessment; will assist in determining if hydration can be done through oral fluids alone

(3) implementation; does not do anything to improve the situation; placing a full bottle at the bedside doesn’t guarantee that the infant is taking fluids

(4) implementation; would be implemented later

Submit
94. A client is scheduled for a myelogram at the outpatient clinic. The physician's office nurse reinforces the physician's explanation of the procedure. Which of the following statements, if made by the nurse, correctly describes a myelogram?

Explanation

Strategy: Determine how each answer choice relates to a myelogram.

(1) x-ray examination cannot determine the extent of myelin breakdown

(2) no such procedure

(3) correct—contrast medium or air is injected into spinal subarachnoid space through a spinal puncture; identifies tumors, cysts, herniated vertebral discs

(4) no such procedure

Submit
95. A patient is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows that the purpose of the cuff on the tracheostomy tube includes which of the following?

Explanation

Strategy: Think about each answer choice.

(1) inaccurate, not the purpose of the cuff on a tracheostomy tube

(2) complication of using a cuffed tracheostomy tube

(3) correct—seals trachea, helps to prevent aspiration

(4) trauma from overinflated tube may cause edema

Submit
96. The nurse receives report from the previous shift. Which of the following clients should the nurse see FIRST?

Explanation

Strategy: Determine the least stable client.

(1) not an immediate concern

(2) PTT is within normal limits; should give medication

(3) correct—indicates hypersensitivity reaction; should stop medication and notify the physician

(4) should decrease rate to prevent irritation of the vein, but hypersensitivity reaction requires first attention

Submit
97. The nurse cares for a client after an electroconvulsive therapy (ECT) treatment. The nurse should report which observation to the client's physician?

Explanation

Strategy: You are looking for something unexpected.

(1) expected effect

(2) expected effect

(3) expected effect

(4) correct—client undergoing ECT needs to be instructed about what s/he could experience during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the physician

Submit
98. The nurse observes a client who is taking phenelzine (Nardil) eat another client's lunch. After a few minutes, the client complains of headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which of the following medications?

Explanation

Strategy: Think about the action of each medication.

(1) antianxiety; side effects include light-headedness, confusion, hypotension, palpitations

(2) SSRI antidepressant; side effects include palpitation, bradycardia, nausea and vomiting

(3) antiemetic; side effect include drowsiness, orthostatic hypotension

(4) correct—antihypertensive; client experiencing hypertensive crisis due to ingesting tyramine; side effects include dizziness, headache, nervousness

Submit
99. The nurse cares for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is MOST important for the nurse to take which of the following actions?

Explanation

Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of each implementation.

(1) drains not usually used with amputations

(2) rigid cast dressing frequently used to create a socket for prosthesis

(3) elevation of extremity unnecessary; rigid cast dressing prevents swelling

(4) correct—cast applied to provide uniform compression, prevent pain and contractures

Submit
100. A client is admitted for a series of tests to verify the diagnosis of Cushing syndrome. Which of the following assessment findings, if observed by the nurse, support this diagnosis? Select all that apply.

Explanation

(1) correct—hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections

(2) indication of hyperthyroidism

(3) correct—hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections

(4) correct—hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections

(5) indication of hypothyroidism

(6) indication of hypoparathyroidism

Submit
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