NCLEX Practice Questions — Set 9
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
Which action by a nurse would be most helpful in preparing a 2-year-old child for immunization?
Show answer and rationale
Correct answer: D. Give the child a choice of two injection sites.
a toddler would best respond to the nurse who allows a choice of injection sites. Giving the child a choice provides a sense of control during this stressful situation.
A client who is pregnant asks a nurse about when she should be able to hear her baby’s heart sounds at her physician’s appointment. The nurse tells her that fetal heart tones can first be heard using a Doppler at approximately:
Show answer and rationale
Correct answer: B. 12 weeks’ gestation.
fetal heart tones can first be heard using a Doppler at about 11 to 12 weeks’ gestation.
The correct technique for administration of phenytoin (Dilantin), 300 mg IV, would be:
Show answer and rationale
Correct answer: B. Direct IV over 6 to 8 minutes.
phenytoin (Dilantin) may be given via direct IV no faster than 50 mg/min. If diluted, use saline.
A client, who is gravida 1, para 0, is attending her initial prenatal visit. The client asks a nurse if it is safe to have sexual intercourse during pregnancy. Which is the best response by the nurse?
Show answer and rationale
Correct answer: C. "Although interest in sex may change during pregnancy, intercourse is safe during an uncomplicated pregnancy."
sexual intercourse is safe for an uncomplicated pregnancy. This answer gives the best information about sexual relations during pregnancy.
During cardiac resuscitation for ventricular fibrillation, which drug would a nurse most likely prepare first?
Show answer and rationale
Correct answer: C. Epinephrine.
the first-line drug for ventricular fibrillation according to advanced cardiac life support protocol is epinephrine, a sympathomimetic.
A nurse assesses a client who is 13 years old and 28 weeks pregnant. For which complication is this adolescent client at an increased risk?
Show answer and rationale
Correct answer: B. Iron-deficiency anemia.
iron-deficiency anemia is defined as hemoglobin below 11 grams. Anemia is more likely to occur in adolescent pregnancy. Adolescent pregnancy has also been linked to poor maternal weight gain, premature birth, preeclampsia, and STIs.
A client, who is gravida 6, para 5, presents to an obstetric clinic 6 weeks after giving birth. She has decided to use the rhythm method as her choice for natural family planning. Which client statement should indicate to a nurse that the teaching about the rhythm method has been successful?
Show answer and rationale
Correct answer: D. "It is important to take my temperature at about the same time every morning before getting out of bed."
taking the temperature at the same time every day before getting out of bed is essential for determining the true basal body temperature. Successful natural family planning is dependent on accurate basal body temperature.
A primiparous client at 20 weeks’ gestation reports symptoms of thick white vaginal discharge and intense itching. A wet mount specimen reveals a diagnosis of Candida albicans. The client asks a nurse what she can do to prevent future infections. Which response by the nurse is most accurate?
Show answer and rationale
Correct answer: B. "Eat a serving of live-culture yogurt daily."
evidence suggests that ingestion of live-culture yogurt may decrease the incidence of vaginal yeast infections.
The desired outcome following hydrocortisone injection for rheumatoid arthritis is to:
Show answer and rationale
Correct answer: D. Reduce joint pain.
clients with rheumatoid arthritis have joint swelling, thickening of the synovial membrane, and pain. The anti-inflammatory action of the steroid will hopefully reduce swelling and decrease pain.
A primiparous client at 26 weeks’ gestation presents to a prenatal clinic with concerns about her symptoms of nosebleeds, nasal stuffiness, and slight bilateral hearing loss. She asks a nurse about the cause of her symptoms. Which explanation by the nurse is most accurate?
Show answer and rationale
Correct answer: D. "These symptoms are common in pregnancy because pregnancy hormones cause increased blood flow, which causes head congestion."
the elevated levels of estrogen during pregnancy cause an increased blood flow in the upper respiratory tract. Nasal stuffiness, some hearing loss, and nosebleeds are common during pregnancy.
The desired clinical outcome of pseudoephedrine (Sudafed) is:
Show answer and rationale
Correct answer: C. Relief of upper airway congestion.
pseudoephedrine (Sudafed) is a familiar over-the-counter (OTC) allergy or cold preparation used for upper respiratory congestion. The drug has both alpha and beta effects, which also can cause hypertension, increased cardiac stimulation, increased respirations, erratic behavior, and delirium.
A nurse observes a group of preschool children playing at a day-care facility. What play practices should the nurse recognize as characteristic of children in this stage of development? Select all that apply.
Show answer and rationale
Correct answer: A. Small groups of children are seen playing "house."
this is characteristic of preschool children’s play.
A client, who is 18 years old and primigravida, is attending a prenatal class on pregnancy discomforts and breastfeeding. Which statement, if given by the client, should indicate to a nurse that further teaching is needed?
Show answer and rationale
Correct answer: B. "My areolas will get smaller and lighter in color."
pregnancy causes the areolas to darken and enlarge.
How many drops per minute should an IV run to deliver 75 mL/hr (drop factor = 15 gtt/mL)?
Show answer and rationale
Correct answer: D. 19 gtt/min.
the formula to determine the correct rate is (75 15)/60 19 gtt/min.
A 39-year-old career woman is pregnant for the first time. She is attending her first prenatal visit at 10 weeks’ gestation and tells a nurse that her pregnancy was planned, but that she is feeling like maybe this was not such a good idea at this stage in her life. Which response by the nurse would be most appropriate?
Show answer and rationale
Correct answer: B. "Many women have mixed emotions when they are first pregnant."
ambivalence is a normal response experienced by any individual preparing for a new role, especially an older primigravida.
Which change in fluid or electrolyte status would a nurse identify as being consistent with syndrome of inappropriate antidiuretic hormone (SIADH)?
Show answer and rationale
Correct answer: D. Urine specific gravity of 1.036.
in SIADH, there is an increase in the antidiuretic hormone, which results in increased total body water and hyponatremia. Urine is concentrated and volume is decreased.
A client, who is gravida 5, para 2 at 41 weeks’ gestation, is in active labor. She is having contractions every 2 to 3 minutes and they are moderate in intensity. Her cervix is 6 cm dilated, 90% effaced, and a -1 station. The fetal heart rate (FHR) baseline is 120 with moderate longterm variability, no accelerations in the past 30 minutes, and three late decelerations noted within the last 15 minutes. Which nursing action is most appropriate?
Show answer and rationale
Correct answer: D. Turn the client to her left side.
late decelerations are caused by decreased uteroplacental perfusion. Turning a woman on her side increases placental perfusion and subsequent fetal oxygenation. This position change may end the late decelerations.
A client, who is 41 years old, gravida 3, para 2, is 8 weeks pregnant. She presents to an emergency department for right-sided, severe abdominal pain. Upon assessment, her temperature is 98.9�F, blood pressure is 60/40 mm Hg, pulse is 126, and respirations 22. Based on these assessment findings, a nurse should suspect that this client probably has:
Show answer and rationale
Correct answer: A. Ruptured ectopic pregnancy.
ruptured ectopic pregnancy is consistent with the assessment findings. The client has blood loss internally and her vital signs reflect shock due to hypovolemia. Advanced maternal age is a risk factor for ectopic pregnancy.
A client is attending a childbirth preparation class. The topic of the class is the process of labor and pain relief. Which statement by the client should indicate to a nurse that more teaching is needed?
Show answer and rationale
Correct answer: B. "The first phase of labor is cervical dilation through the delivery of the placenta."
the first stage of labor is the onset of labor through complete cervical dilation. The first phase of the first stage of labor is the latent phase of labor, characterized by 0 to 3 cm of cervical dilation.
What time of day would a nurse expect to see signs of hypoglycemia in a client following NPH insulin given at 7:30 a.m.?
Show answer and rationale
Correct answer: C. 2:00 p.m. to 5:00 p.m.
NPH is an intermediate-acting insulin with peak effects between 6 and 12 hours after administration.
Which documentation would be appropriate by a nurse who suspects child abuse or neglect? Select all that apply.
Show answer and rationale
Correct answer: B. Child states, "My little brother hit me."
the nurse charts the child’s words exactly as they were spoken, using quotes.
A client, who is 15 years old, gravida 1, para 0, is admitted to a labor and delivery unit with a diagnosis of HELLP syndrome. Which laboratory finding, associated with HELLP syndrome should be of greatest concern to a nurse?
Show answer and rationale
Correct answer: C. Elevated liver enzymes.
HELLP syndrome stands for hemolysis, elevated liver enzymes, and low platelet count. Elevated hepatic enzymes are associated with HELLP syndrome.
Which imbalance is a client recovering from hyperglycemia at greatest risk of developing?
Show answer and rationale
Correct answer: B. Hypokalemia.
as glucose moves back into the cell with insulin treatment, potassium moves back into the cell, causing a low serum level and a risk of hypokalemia.
A client, who is gravida 2, para 1, is admitted at 34 weeks’ gestation with severe preeclampsia. A nurse is assessing the client’s deep tendon reflexes. Which method should the nurse use to elicit the biceps reflex?
Show answer and rationale
Correct answer: A. Placing the thumb on the tendon in the antecubital space and tapping the thumb briskly with the reflex hammer.
this is the correct method to elicit the biceps reflex.
A 25-year-old client is being seen in a clinic for the first time for possible osteoarthritis. Which statement by the client would be consistent with an early symptom of arthritis?
Show answer and rationale
Correct answer: A. "When I get up in the morning, I feel stiff."
morning stiffness usually lasts less than 30 minutes and decreases with movement. Pain and functional impairment are also manifestations of osteoarthritis.
A child is admitted to the hospital for suspicion of leukemia. Which test is needed to confirm the suspected diagnosis?
Show answer and rationale
Correct answer: D. Bone marrow biopsy.
the diagnosis of leukemia is confirmed by assessing the bone marrow through a needle biopsy.
A client, who is a 16-year-old primigravida and 34 weeks pregnant, is complaining of constantly feeling tired. Which assessment should lead a nurse to suspect that the client’s blood volume has increased?
Show answer and rationale
Correct answer: D. Decreased hematocrit.
decreased hematocrit is an indicator of increased blood volume, which is normal in pregnancy and peaks between 32 and 34 weeks’ gestation.
A newborn suspected of having Down syndrome is held in the nursery for observation. For what acute health problems should a nurse observe? Select all that apply.
Show answer and rationale
Correct answer: B. Cleft palate.
children with Down syndrome have a greater incidence of cleft palate. A nurse should assess the oral cavity for structural abnormality.
A 28-year-old client is admitted to an intensive care unit (ICU) following a construction accident. Which assessment finding requires an immediate response by a nurse?
Show answer and rationale
Correct answer: D. Extremity capillary refill 5 seconds.
this is too slow and peripheral blood flow is sluggish, indicating impaired circulation. Normal reperfusion occurs in 3 seconds.
Following the diagnosis of hemophilia after the birth of their first baby boy, a nurse should immediately counsel the parents regarding the need for:
Show answer and rationale
Correct answer: A. Genetic counseling.
genetic counseling is essential as soon as possible after the diagnosis. This will determine if the hemophilia is an X-linked recessive disorder or a gene mutation and assist the parents to determine the desirability of future pregnancies.
A 37-year-old client, who is a multipara, delivered an 8-pound, 9-ounce infant about 24 hours ago. A nurse is performing a routine assessment of the client’s lower extremities for the possible development of thrombophlebitis. For which sign should the nurse assess?
Show answer and rationale
Correct answer: A. Homans’ sign.
Homans’ sign is pain in the back of the calf or knee when the foot is dorsiflexed, and is typically associated with thrombosis in veins of the calf.
A client with acute viral hepatitis has a serum bilirubin of 3.6 mg/dL on admission. A nurse should expect the client to report:
Show answer and rationale
Correct answer: B. Dark orange urine.
when total bilirubin is elevated (normal 0 to 0.9 mg/dL), bilirubin is excreted in the urine, which becomes deep orange and foamy.
A child has ingested a toxic amount of aspirin. Which order written by a pediatrician should a nurse question?
Show answer and rationale
Correct answer: A. Warming blanket as needed.
hyperthermia is associated with toxic ingestions of aspirin. Therefore, external cooling (such as a cooling blanket) rather than warming is indicated.
A client has just been weaned from ventilation therapy. While working closely with a respiratory therapist, what other member of the health team should be consulted first?
Show answer and rationale
Correct answer: A. Dietitian, because high carbohydrate intake increases carbon dioxide production.
nutrition plays an essential role in respiratory care. The increased carbon dioxide production from a high carbohydrate intake would promote hypercapnea and respiratory acidosis, adding to the pulmonary workload.
A toddler with hemophilia strikes the right knee against a coffee table. A nurse could best evaluate the effectiveness of the teaching the mother received regarding the early signs of hemarthrosis when the mother reports:
Show answer and rationale
Correct answer: B. Stiffness, tingling, and aching in the involved joint, followed by a decrease in ability to move the joint.
early signs of hemarthrosis include a feeling of stiffness, tingling, and aching in the involved joint, followed by a decrease in ability to move the joint.
A client, who is gravida 6, para 2, is attending her regular prenatal appointment. She complains to a nurse about pain from her hemorrhoids. The nurse knows additional teaching would be required if the client states:
Show answer and rationale
Correct answer: D. "I should stop taking my iron supplements."
the client should not stop taking iron supplements to relieve pain from hemorrhoids. Since iron can be constipating, the client should be given instructions to increase fiber and fluid intake to avoid constipation.
Which nursing diagnosis reflects the basic rationale for symptoms in a client with acute respiratory distress syndrome (ARDS)?
Show answer and rationale
Correct answer: D. Impaired gas exchange.
ARDS affects the arterial-alveolar capillary membrane gas exchange. The basic pathophysiology in ARDS is alveolar capillary damage, decreased surfactant, and the resultant noncardiogenic pulmonary edema. As a result, carbon dioxide cannot be eliminated, oxygen cannot be absorbed, and severe hypoxemia and acidosis result.
A parent of a child who ingested a toxic dose of acetaminophen (Tylenol) refuses to allow a nurse to administer N-acetylcysteine (Mucomyst) because "it smells spoiled." A nurse should correctly:
Show answer and rationale
Correct answer: C. Discuss the medication with the parents.
N-acetylcysteine (Mucomyst) has an offensive odor (e.g., "rotten eggs"), but this is a normal side effect of the medication and does not interfere with the medication’s efficacy. The parents should be informed of these characteristics and encouraged to allow the nurse to administer the medication to the child.
Following external radiation, a client reports dry, irritated skin in the treatment area. Additional teaching by a nurse would be needed if the client says: Select all that apply.
Show answer and rationale
Correct answer: C. "The sunlamp feels good and seems to help."
a sunlamp may cause thermal burn to the area.
The parents of a child newly diagnosed with hemophilia ask, "Why do we have to learn how to give the medicine?" A nurse’s best response would be:
Show answer and rationale
Correct answer: B. "It will promote immediacy of treatment."
immediate treatment of bleeding may help to promote a more rapid recovery with a decreased likelihood of complications.
A client, who is gravida 4, para 1, is admitted for preterm labor at 32 weeks’ gestation. She is 1 cm dilated, 90% effaced, and a 1 station. A nurse is monitoring her preterm labor using an external fetal monitor. Which statement, if made by the client, should indicate to the nurse that further teaching is needed?
Show answer and rationale
Correct answer: C. "I’ll need to lie flat on my back to monitor the contractions."
women who are pregnant should avoid lying directly on their backs. A right or left tilt is the correct position during pregnancy, to avoid vena cava compression.
A nurse is counseling a group of parents of young children regarding the prevention of iron poisoning. The nurse should correctly inform the parents to:
Show answer and rationale
Correct answer: A. Not purchase iron tablets that look like candy.
iron tablets resemble candy (e.g., M&Ms) and present a special temptation to a young child who cannot differentiate between medication and candy.
A nurse is to give meperidine (Demerol) 75 mg IV and scopolamine 0.3 mg IV preoperatively to a client with a history of glaucoma. Which action should be taken by the nurse?
Show answer and rationale
Correct answer: C. Do not give the drugs and call the physician.
clients with glaucoma should not receive anticholinergic drugs (e.g., scopolamine), which dilate the pupils and increase intraocular pressure.
Prior to administering a dose of theophylline, a nurse checks a child’s serum theophylline level and notes that it is 14.2 mcg/mL. What should the nurse do? Select all that apply.
Show answer and rationale
Correct answer: C. Administer the medication as ordered.
the serum theophylline level should range from 10 to 20 mcg/mL. It is safe to administer the medication to the child.
A client, who is gravida 3, para 1, is at 29 weeks’ gestation. Upon examination, her cervix is 2 cm dilated, 40% effaced, and a -2 station. A physician admits the client for preterm labor. What is an appropriate nursing intervention for this client?
Show answer and rationale
Correct answer: D. Encourage adequate hydration.
dehydration can lead to preterm labor contractions. Encouraging adequate hydration can decrease mild uterine irritability.
A client has just been extubated. Which assessment by a nurse should indicate signs of laryngeal edema?
Show answer and rationale
Correct answer: B. High-pitched crowing sounds on inspiration.
the high-pitched crowing sounds, or stridor, are indications of edema of the larynx. Clients with this sign must be watched for obstruction and the need for possible re-intubation. Recognition of early signs of edema of the larynx prevents respiratory complications from occurring.
A nurse is teaching a parent about childhood poisonings. The nurse should instruct the parent that the first action to take is to:
Show answer and rationale
Correct answer: C. Treat the child’s obvious signs and symptoms.
the first and most important principle in dealing with a poisoning is to treat the child’s signs and symptoms (e.g., assess for shock or absence of respiratory function). The nurse should teach the parent basic first aid and life support measures to begin immediately upon discovering that the child has ingested a poison.
A client is diagnosed with heart failure and has an ejection fraction of 30% and is receiving an angiotensinconverting enzyme (ACE) inhibitor. Which finding would be an expected drug effect?
Show answer and rationale
Correct answer: A. Decreases cardiac afterload.
ACE inhibitors (potent vasodilators) are used to lower the BP by decreasing both cardiac afterload and workload, actions that are essential for a client with a low ejection fraction. A systolic BP of 90 mm Hg would be acceptable in these clients as long as they remain asymptomatic.
A nurse instructs the parents of an infant with developmental dysplasia of the hip in the care for a Pavlik harness. Instructions to prevent skin breakdown from the harness should include: Select all that apply.
Show answer and rationale
Correct answer: B. Put an undershirt under the chest straps of the harness.
putting an undershirt under the chest straps of the harness prevents the straps from rubbing the skin and causing skin breakdown.
A 41-year-old client, who is gravida 4, para 2, is 37 weeks pregnant. She states to a nurse that her varicose veins are intolerable and she would like the physician to induce her labor. The best suggestion for the nurse to give the client would be:
Show answer and rationale
Correct answer: D. "You can try lying down with your feet elevated."
lying down with the feet elevated can provide some relief for pain caused by varicose veins. Having varicose veins is usually not an indication for induction of labor
A nurse should know that an important aspect of the care following surgery for glaucoma includes:
Show answer and rationale
Correct answer: B. Rest for 24 hours, then a return to normal activities.
activity following the filtering procedure is liberal. Unless contraindicated, the client may resume normal activities. The client should avoid any activity that increases pressure in the eye.
Which orders, regarding a 2-month-old infant born to a mother who is HBsAg- (hepatitis B surface antigen negative), should a nurse question during the infant’s well-baby checkup?
Show answer and rationale
Correct answer: C. "Withhold HepB immunization #2 today."
an infant born to a HBsAg- mother would not have any active immunity to the disease and should receive the immunization on schedule. The nurse should question this order.
A child with osteomyelitis of the tibia is hospitalized. The nurse’s priority instruction to the parents would be to:
Show answer and rationale
Correct answer: A. Keep the child from weight-bearing on the affected limb until healing is well underway.
weight-bearing on the affected limb is not permitted until healing is well underway. This is done to prevent a pathological fracture.
A client, who is a primigravida about 8 weeks pregnant, has been experiencing abdominal cramping, bright red vaginal spotting, and passing some small clots. A sterile speculum examination in a physician’s office reveals cervical dilation. A nurse determines that this client is most likely experiencing:
Show answer and rationale
Correct answer: B. Inevitable abortion.
the symptoms of an inevitable abortion are abdominal cramping, bright red vaginal spotting, passing clots, and cervical dilation.
A client is scheduled for a bilateral herniorrhaphy. Teaching about preparation of the skin before surgery should include:
Show answer and rationale
Correct answer: C. Shaving or clipping depends on the amount of body hair.
skin preparation for a hernia repair may include the client scrubbing with an antispetic sponge (Hibiclens) for several days before surgery. Hair removal is usually done in the operating room (OR), and whether clipped or shaved depends on the amount of hair.
The parents of a child recently diagnosed with LeggCalv�-Perthes disease ask a nurse, "Why does our child have to be in bed for so long?" The nurse’s most factual response is because bedrest:
Show answer and rationale
Correct answer: D. Reduces the inflammation and restores motion.
initial therapy is rest and non-weight-bearing in order to reduce the inflammation and restore motion. There will be other treatment modalities used in arresting this disease, but the first action is aimed at reducing the inflammation and restoring motion through rest and non-weight-bearing.
An older client in a long-term care facility reports severe pain in the groin while walking to the activities center. The first action by a nurse should be to:
Show answer and rationale
Correct answer: C. Suspect a fracture and eliminate weight-bearing.
severe groin or hip pain is a common complaint of a possible hip fracture when the client is able to bear weight.
While a school-age child is on bedrest for Legg-Calv�- Perthes disease, a nurse’s priority intervention would be to encourage the school-age child to:
Show answer and rationale
Correct answer: A. Begin a hobby.
the school-age child is in the developmental stage of industry, and enforced long-term bedrest interferes with the achievement of this milestone. Assembling collections, building models, engaging in crafts, and the like will fulfill the child’s need for a creative outlet and assist in achieving the desired milestone.
A client, who is gravida 3, para 1, is at 41 weeks’ gestation. The client is 6 cm dilated, 80% effaced, and a -1 station. A nurse is assessing the client’s fetal monitor tracing. Which assessment should indicate to the nurse that the fetus is in distress?
Show answer and rationale
Correct answer: C. A uniform decrease in the heart rate that begins after each contraction for the past four contractions.
a uniform decrease in the heart rate that begins after each contraction for the past four contractions describes late decelerations, which is an indication of fetal distress.
An adolescent with juvenile idiopathic arthritis states to a nurse, "I don’t feel any better since I started the NSAIDs a week ago." The nurse’s most accurate response would be:
Show answer and rationale
Correct answer: A. "You need another 2 weeks of NSAIDs."
the child must take a nonsteroidal anti-inflammatory drug (NSAID) for at least 3 weeks before the effectiveness of the medication can be evaluated.
A week after chemotherapy, a client’s absolute neutrophil count (ANC) is 300/mm3. Which nursing interventions are appropriate? Select all that apply.
Show answer and rationale
Correct answer: A. Use an alcohol-based hand wash.
this client has few white blood cells (WBCs), and must be protected from infection. Neutrophils make up 55% to 70% of WBCs. An ANC below 1,000/mm3 places the client at significant risk for infection. Alcohol-based hand cleaners that are at least 60% alcohol eliminate microbes as well as soap and water.
An adolescent with juvenile idiopathic arthritis has daytime sleepiness. The nurse would encourage: Select all that apply.
Show answer and rationale
Correct answer: A. Implementing relaxation techniques prior to bedtime.
implementing relaxation techniques prior to bedtime (listening to music, meditation, etc.) may promote nighttime sleep, which may prevent daytime sleepiness.
On her first postpartum day, a woman who is diabetic has been eating a full diet, and her insulin was reduced to one third of the dosage received during pregnancy. Which sign(s) and/or symptom(s) would indicate that the client is experiencing hyperglycemia? Select all that apply.
Show answer and rationale
Correct answer: A. Irritability.
irritability, confusion, and lethargy are associated with high blood sugar levels.
A client with acute pancreatitis and fluid volume deficit is in an ICU. Which assessment finding should a nurse report to a physician?
Show answer and rationale
Correct answer: B. CVP of 12 mm Hg.
the normal central venous pressure (CVP) is 0 to 8 mm Hg. A value of 12 mm Hg reflects hypervolemia. The right ventricular function of this client reflects fluid volume overload, and the physician should be alerted.
The parents of an infant in a hip spica cast who is being treated for developmental dysplasia of the hip inform the nurse that they are having difficulty with positioning the infant. A nurse should suggest that they try: Select all that apply.
Show answer and rationale
Correct answer: D. Supine position with the head elevated.
this is an appropriate position for an infant in a hip spica cast. It is especially effective when feeding a young infant.
A client with acute pancreatitis reports numbness with circumoral tingling and muscle cramps. Which nursing intervention is most appropriate?
Show answer and rationale
Correct answer: C. Assess for hypocalcemia.
calcium is lost in the fat necrosis, and saponification (formation of calcium soap) may occur. Circumoral tingling and muscle cramps are early signs of hypocalcemia. Assess for signs of tetany by checking Chvostek’s and Trousseau’s signs.
A nurse notes that a 2-week-old infant with a cyanotic heart defect and mild congestive heart failure has an apical pulse rate of 100 beats/min. Which action should the nurse take?
Show answer and rationale
Correct answer: D. Withhold the digoxin because the heart rate is too low.
a normal heart rate for a 2-week-old infant is 120 to 160 beats per minute. A heart rate of 100 beats per minute is too low in a 2-week-old infant, and the digoxin should be withheld pending further assessment of the infant.
A nurse performs an assessment on a newborn, 39 weeks’ gestation, with Apgar scores of 8 and 9. Which findings are not "normal" in a newborn of this gestational age? Select all that apply.
Show answer and rationale
Correct answer: B. A slight heart murmur heard at 6 hours of age.
a murmur heard after 4 hours can be indicative of a cardiac condition and needs further investigation.
A client is admitted with acute pancreatitis after a holiday celebration including excessive food and alcohol. Which assessment finding reflects this diagnosis?
Show answer and rationale
Correct answer: C. Sudden onset of continuous epigastric and back pain.
the autodigestion of tissue by the pancreatic enzymes results in pain from inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric and/or back pain reflect the inflammatory process in the pancreas.
A client is admitted for a cholecystectomy because of cholelithiasis. A nurse notes that the serum amylase report shows a level of 900 units/L. Which action should the RN take?
Show answer and rationale
Correct answer: C. Call and report the findings to the physician.
cholelithiasis may block the pancreatic duct and initiate pancreatitis. The elevated serum amylase report indicates that the client has pancreatitis and the operation should be canceled because of the acute inflammatory process.
The pediatrician assesses a child with an acute episode of hemophilia that involves the lower extremities Which pediatrician’s order should a nurse question?
Show answer and rationale
Correct answer: C. Passive range-of-motion exercises twice daily.
passive range-of-motion exercises should never be part of an exercise regimen after an acute episode of hemophilia because the joint capsule could easily be stretched and bleeding could recur.
A client with chronic pancreatitis is placed on pancrelipase (Pancrease) three times daily. What information is essential to teach with this medication?
Show answer and rationale
Correct answer: B. Take the medication with meals.
pancreatic enzymes must be taken with meals to assist in digestion. Food will protect the enzymes in the medication from destruction by the hydrochloric acid in the stomach, making them available for digestion.
An adolescent with acne is placed on a course of tetracycline. What important environmental controls should a nurse emphasize to the adolescent when teaching the adolescent about the medication? Select all that apply.
Show answer and rationale
Correct answer: A. Wearing a hat.
a side effect of tetracycline is photosensitivity/ phototoxicity. The nurse’s teaching should include instructing the adolescent to avoid exposure to the sun or to minimize exposure to the sun with the use of a hat.
When explaining the purpose of radiation to a client with multiple myeloma, which treatment goal should be described?
Show answer and rationale
Correct answer: A. Shrinking invasive tumor masses.
multiple myeloma is a malignancy of the bone and bone marrow; radiation may be used to shrink the size of a tumor that interferes with movement and causes pain.
An infant receives an engraved pewter rattle as a gift. A nurse correctly teaches the parents that this gift should be:
Show answer and rationale
Correct answer: C. Displayed in a locked cabinet.
pewter contains lead. Infants are known to suck on rattles and could be exposed to the lead on a continuous basis. The item should be displayed in a locked cabinet.
A woman, who is 36 weeks pregnant, is admitted directly from clinic with a blood pressure of 146/98 mm Hg, puffy face and hands, and "awful headaches and problems seeing." The admission note states: "Admit for preeclampsia." Which nursing orders should not be implemented? Select all that apply.
Show answer and rationale
Correct answer: A. Up as desired, activities as desired.
if possible, women hospitalized for treatment of preeclampsia should be on bedrest in a quiet environment to minimize stimuli.
Upon a client’s admission for extracapsular fracture of the left femur, how should a nurse expect the extremity to appear?
Show answer and rationale
Correct answer: B. Shorter than the other leg.
the affected leg will be shorter and externally rotated. "Extracapsular" means "outside the capsule."
Which activity should a nurse counsel an adolescent with severe hemophilia to not participate in?
Show answer and rationale
Correct answer: B. Soccer.
it is a contact sport and should be discouraged, as the risk of injury outweighs the physical and psychosocial benefits of participating in this sport. This is especially important in adolescents with severe hemophilia.
Which statement correctly describes the four-point gait that should be used when partial weight-bearing is permitted?
Show answer and rationale
Correct answer: C. Move the right crutch ahead, then follow with the left foot.
the idea of four points means a crutch, the opposite foot, the other crutch, then the opposite foot. Each moves separately.
A child receives a dose of atropine. A nurse should anticipate that the expected effect of the medication would require that the nurse monitor the child’s: Select all that apply.
Show answer and rationale
Correct answer: A. Heart rate.
atropine is an anticholinergic medication. It blocks vagal impulses to the myocardium and stimulates the cardioinhibitory center in the medulla, thereby increasing heart rate and cardiac output while decreasing blood pressure as small blood vessels are dilated. Therefore, the nurse should monitor the child’s heart rate and blood pressure.
A nurse is observing a primigravida client admitted in active labor. Which observation would be the most reliable guide to assess the progression of the client’s labor?
Show answer and rationale
Correct answer: C. Cervix that is progressively dilating.
a cervix that is progressively dilating is the definition of labor progress.
To prevent contractures, in which position should a nurse place a client 72 hours after an above-the-knee amputation?
Show answer and rationale
Correct answer: B. Lying on the abdomen several times daily.
at approximately 48 to 72 hours following the procedure, the client must be turned onto the abdomen to prevent flexion contractures.
A nurse prepares to administer 0.3 mL of a medication intramuscularly to a 4-month-old infant. Which equipment should the nurse collect? Select all that apply and place in sequential order.
Show answer and rationale
Correct answer: C. 1-mL syringe with a 25-gauge needle.
a 1-mL syringe does allow for precise measurement of the small amount of medication that the infant is to receive. In addition, a 25-gauge needle will provide a degree of safety as well as comfort for the infant. Selection of the most appropriate syringe and needle is the first action that the nurse should take.
Which choice best describes the pain associated with a duodenal ulcer?
Show answer and rationale
Correct answer: A. Gnawing, epigastric pain 1 to 3 hours after eating.
the pain is described as aching, burning, cramp-like, and gnawing, occurring at some time after eating, depending on where the ulcer is located.
Before administering gentamicin to a child, a nurse should check the results of the child’s: Select all that apply.
Show answer and rationale
Correct answer: B. Renal function tests.
gentamicin can cause renal impairment and acute renal failure; thus baseline renal functions (I&O, daily weights, urine specific gravity, urinalysis, creatinine levels, and blood urea nitrogen) must be evaluated prior to administering the medication.
What physical assessment data should a nurse consider typical for a client during an acute attack of M�ni�re’s disease?
Show answer and rationale
Correct answer: C. Jerking eye movements, normal vital signs.
the most objective sign of M�ni�re’s disease is nystagmus, or jerking eye movements. The vital signs are normal in clients with this disease. M�ni�re’s disease affects the inner ear, which would cause the eye movements.
Following a mastoidectomy, which changes should a nurse anticipate if cranial nerve VII was damaged? Select all that apply.
Show answer and rationale
Correct answer: A. Drooling and drooping of the mouth.
these changes are associated with cranial nerve VII damage.
In assisting a physician to perform a thoracentesis, how should the nurse position a client with pleural effusion of the left lung?
Show answer and rationale
Correct answer: D. Sitting at the side of the bed with both arms resting on a locked over-the-bed table.
having the client’s pleural cavity in a good vertical, yet safe, comfortable position will achieve maximum access to the pleural fluid. The fluid will gravitate to the lowest point for maximal aspiration.
A client, who is gravida 6, para 5, has a sudden urge to push. A nurse performs a sterile vaginal examination and finds that the cervix is completely dilated and the fetus is at a 2 station. Which nursing intervention is most important at this time?
Show answer and rationale
Correct answer: D. Call the physician for delivery, apply gentle pressure to the perineum and guide the fetus’ head as it is delivered.
calling the physician for delivery, applying gentle pressure to the perineum, and guiding the fetus’ head as it is delivered is the proper method for managing a precipitous delivery. By using gentle pressure on the perineum, the head is controlled during delivery, and the chance of perineal tearing is reduced.
Which over-the-counter (OTC) medications should a nurse instruct a client with glaucoma to avoid?
Show answer and rationale
Correct answer: A. Antihistamines.
antihistamines cause pupil dilation and should be avoided with glaucoma.
A client, who is a 38-year-old gravida 4, para 2, has an ultrasound at 34 weeks’ gestation, which reveals a marginal placenta previa. The client has some bright red spotting, but no contractions or abdominal pain. A nurse should anticipate that the expected management for a client with marginal placenta previa will be:
Show answer and rationale
Correct answer: B. Limiting activity to bedrest, with bathroom privileges.
since the client is not having significant active bleeding, the pregnancy can safely be extended by limiting activity to bedrest with bathroom privileges.
The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first?
Show answer and rationale
Correct answer: C. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints.
This client may or may not be stable. The client may have "no complaints" at this time, but the nurse must assess this client first to determine whatever the complaint was that brought the client to the ED has stabilized. This client should be seen first
The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first?
Show answer and rationale
Correct answer: A. The antidysrhythmic to the client in ventricular fibrillation.
The client in ventricular fibrillation is in a life-threatening situation; therefore, the antidysrhythmic, such as lidocaine or amiodorone, should be administered first.
Which client should the telemetry nurse assess first after receiving the a.m. shift report?
Show answer and rationale
Correct answer: D. The client diagnosed with congestive heart failure who has pink frothy sputum.
The client would not expect the client with congestive heart failure to have pink, frothy sputum because this is a sign of pulmonary edema. This client should be assessed first.
The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?
Show answer and rationale
Correct answer: C. The 75-year-old client scheduled for a cardiac catheterization.
A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab.
The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse?
Show answer and rationale
Correct answer: C. Assign an UAP to complete the a.m. care.
A UAP is capable of performing the morning care. This is an appropriate nursing task to delegate.
The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager?
Show answer and rationale
Correct answer: D. Provide the case manager with any information that is required for continuity of care.
The case manager’s job is to ensure continuity and adequacy of care for the client. This individual has a "need to know."
The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement?
Show answer and rationale
Correct answer: B. Check the client’s telemetry leads.
The UAP should be instructed to check the telemetry lead placement; this reading cannot be ventricular fibrillation because the client is talking to the nurse over the intercom system. This telemetry is an artifact; therefore, the leads should be checked and the UAP can do this because the client is stable.
The charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department?
Show answer and rationale
Correct answer: A. The nurse who just transferred from critical care to the cardiac unit.
The nurse with critical care experience would be the best choice to float to the emergency department.
The cardiac nurse is preparing to administer one unit of blood to a client. Which interventions should the nurse implement? Rank in order of priority.
Show answer and rationale
Correct answer: A. Assess the client’s vital signs and lung sounds, and assess for a rash.
The nurse needs to complete the pre-transfusion assessment including assessing for any signs of allergic reaction prior to administering the unit of blood.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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