NCLEX Practice Questions — Set 14
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
The nurse is triaging phone calls in a neurosensory clinic. Which client should the nurse contact first?
Show answer and rationale
Correct answer: D. The client with external otitis who has serosanguineous drainage and otalgia.
This client needs to be contacted so culture and sensitivity (C&S) can be done and mild analgesics prescribed. The ear canal has to be cleansed and antibiotic eardrops administered to the ear. Otalgia is ear pain. This client should be contacted for treatment.
The nurse is planning care for the client diagnosed with Parkinson’s disease (PD). Which client problem is priority?
Show answer and rationale
Correct answer: C. Altered mobility.
Altered mobility is a problem experienced by clients diagnosed with Parkinson’s disease. It leads to many other concerns, including the risk for falls resulting from the client’s shuffling gait. This is the priority problem.
A client comes to the emergency department after having bleach splash in the eyes. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Irrigate the eyes with sterile solution.
For chemical injuries, the nurse should begin ocular irrigation with sterile, pH-balanced, physiological solution.
The 24-year-old client diagnosed with a traumatic brain injury is being transferred to a rehabilitation unit. Which healthcare provider order should the nurse question?
Show answer and rationale
Correct answer: C. Methylprednisolone (Solu-Medrol), a steroid, IVP q 6 hours.
A client in a rehabilitation unit for a brain injury should not require IV medications. The nurse should question this order.
The rehabilitation nurse is planning the discharge of a 68-year-old client whose status post-subarachnoid hemorrhage includes residual speech and balance deficits. Which referral should the nurse initiate at this time?
Show answer and rationale
Correct answer: B. Referral to a home health agency.
The client is being discharged. The nurse should plan for continuity of care by arranging for a home health agency to follow the client at home.
The client is postoperative a right eye enucleation. Which statement indicates the client needs more discharge teaching?
Show answer and rationale
Correct answer: B. "It will be approximately 2 weeks before I can get a prosthetic eye."
It will take approximately 6 weeks for the wound to sufficiently heal prior to being fitted for a prosthetic eye.
The nurse is caring for a client newly diagnosed with multiple sclerosis. Which referral is appropriate at this time?
Show answer and rationale
Correct answer: D. To a psychological counselor for therapy.
The client should be referred to a psychological counselor to develop skills for coping with the long-term chronic illness.
The nurse and LPN have been assigned to care for clients on a neurology unit. Which nursing task is most appropriate to assign to the LPN?
Show answer and rationale
Correct answer: C. Administer the adrenocorticotropic hormone to the client with multiple sclerosis.
The LPN can administer medications to clients; therefore, this task is appropriate for the nurse to assign to the LPN.
The charge nurse observes the new graduate nurse delegating tasks to the unlicensed assistive personnel (UAP) and the UAP appears to be ignoring the graduate nurse. Which action should the charge nurse implement first?
Show answer and rationale
Correct answer: A. Wait and observe how the graduate nurse handles the situation.
The charge nurse will not always be available to intercede for the new graduate. The charge nurse should wait and see whether the new graduate is capable of handling the situation before intervening.
Elizabeth, who is the day staff nurse, and the UAP are caring for a client with a right-sided cerebrovascular accident (CVA) with hemi-paralysis. Which action by the UAP requires Elizabeth to intervene?
Show answer and rationale
Correct answer: A. The UAP places the call light on the client’s left side.
The client with a right-sided CVA has left-sided paralysis, so placing the call light on the left side is inappropriate. The client would not be able to use the call light since the left side is paralyzed; Elizabeth should intervene.
The client diagnosed with a right-sided cerebrovascular accident (CVA) is complaining of a severe headache. Which intervention should Elizabeth implement first?
Show answer and rationale
Correct answer: C. Assess the client’s neurological status.
Elizabeth must first assess the client to determine whether the client’s neurological status is deteriorating, which requires notifying the HCP; or, if the headache is expected, then it would require a narcotic analgesic.
Courtney is caring for the following clients on the Neurological Intensive Care unit. Which client should Courtney assess first?
Show answer and rationale
Correct answer: D. The client with traumatic brain injury who has a Glasgow Coma Scale score of 6.
A 15 on the Glasgow Coma Scale indicates the client is neurologically intact, and a 6 indicates the client is not neurologically intact; therefore, Courtney should see this client first.
The ICU unit is very busy and Mr. Leo is transcribing the healthcare provider’s admission orders for a client with a closed head injury. Which medication order should Mr. Leo question?
Show answer and rationale
Correct answer: C. A subcutaneous anticoagulant.
This medication could possibly cause bleeding; therefore, this medication should be questioned by Mr. Leo.
Jessie is caring for a client who had a C-6 SCI 2 years ago and is admitted for Stage IV pressure ulcers in the coccyx area. The client is complaining of a severe headache and the B/P is 190/110. Which intervention should Jessie implement first?
Show answer and rationale
Correct answer: B. Palpate the client’s bladder.
The nurse should first palpate the client’s bladder to determine if the client is experiencing autonomic dysreflexia, which is what Jessie should consider first with the client’s signs/symptoms.
Mr. Leo is making rounds and as he enters the room the client is having tonic-clonic seizure. Which priority intervention should Mr. Leo implement?
Show answer and rationale
Correct answer: C. Place the client on the side.
Placing the client on the side to maintain patent airway is Mr. Leo’s priority intervention.
The UAP is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which intervention should Mr. Leo take first?
Show answer and rationale
Correct answer: A. Instruct the UAP to stop inserting the oral airway.
Mr. Leo’s first intervention is to stop the UAP from inserting the oral airway. Once the seizure has started, there should be no attempts to insert anything in the mouth. At times an oral airway could be inserted if the client has an aura and prior to the seizure, but not once the seizure has started.
Mr. Leo is telling one of his graduate nurses the correct procedure for assisting the healthcare provider with a lumbar puncture to R/O meningitis. Which interventions should Mr. Leo discuss with the graduate nurse? Select all that apply.
Show answer and rationale
Correct answer: D. Obtain an informed consent from the client or significant other.
A lumbar puncture is an invasive procedure; therefore, an informed consent is required.
Which task is most appropriate for the medical nurse to delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: D. Request the UAP to take the diabetic client’s HS snack to the client.
The UAP can take food to the client since this is not a medication and the client is stable.
Which task is most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)?
Show answer and rationale
Correct answer: D. Tell the LPN to change the client’s subclavian dressing.
The LPN can change sterile dressings according to his or her scope of practice.
The new graduate nurse on the endocrine unit is having difficulty completing the workload in a timely manner. Which suggestion could the preceptor make to help the new graduate become more organized?
Show answer and rationale
Correct answer: D. Tell the new nurse to start the shift with a work organization sheet for the assigned clients.
The preceptor should recommend that the new graduate use some tool to organize the work so important tasks, such as medication administration and taking vital signs, are not missed.
The charge nurse on the endocrine surgical unit is making assignments. Which task should be delegated/assigned to the team members?
Show answer and rationale
Correct answer: A. Tell the LPN to perform an in and out catheterization for the client diagnosed with acromegaly.
The LPN can perform a sterile procedure such as completing an in and out catheterization.
Which task is most appropriate for the nurse to delegate/assign when caring for clients on a surgical unit?
Show answer and rationale
Correct answer: D. Ask another nurse to administer an IVP pain medication to a postoperative client in severe pain.
The nurse could request that another nurse administer pain medication so that the client obtains immediate pain relief.
The client diagnosed with Addison’s disease is being prepared for emergency surgery and is asking to complete an advance directive. Which type of advance directive should the nurse recommend the client complete at this time?
Show answer and rationale
Correct answer: A. Durable power of attorney for healthcare.
This document would be most appropriate for the nurse to recommend because it names an individual to be responsible in the event the client cannot make healthcare decisions for himself or herself.
The nurse is caring for clients in the post-anesthesia care unit (PACU). Which client requires immediate intervention by the PACU nurse?
Show answer and rationale
Correct answer: B. The client who had a bilateral adrenalectomy who is exhibiting masseter rigidity.
Masseter rigidity is a sign of malignant hyperthermia, which is a life-threatening complication of surgery. The client will also exhibit tachycardia (a heart rate greater than 150 bpm), hypotension, decreased cardiac output, and oliguria. It is a rare muscle disorder chemically induced by anesthesia.
The charge nurse on a busy 20-bed endocrinology unit must send one staff member to the nursery. Which staff member is most appropriate to send to the nursery?
Show answer and rationale
Correct answer: A. The licensed practical nurse (LPN) who has worked in a newborn nursery at another facility.
The LPN with maternal child area experience would be most helpful to the nursery.
The nurse is working in an endocrinology unit. Which client warrants immediate intervention by the nurse?
Show answer and rationale
Correct answer: C. The client with pheochromocytoma who has a severe pounding headache and chest pain.
The client diagnosed with pheochromocytoma, a tumor of the adrenal medulla that produces excessive catecholamine, is expected to have a severe pounding headache and chest pain; but of these four clients this client is having pain, which is priority. This client warrants intervention by the nurse.
The night nurse enters the client’s room and finds the client crying. The client asks the nurse, "Am I dying? I think something is terribly wrong with me, but no one is telling me." The nurse knows the client has pancreatic cancer and has less than 6 months to live. Which response is an example of the ethical principle of veracity?
Show answer and rationale
Correct answer: B. "Your diagnosis is pancreatic cancer."
The ethical principle of veracity is the duty to tell the truth.
Which client should the charge nurse on a medical unit assign to a nurse who is 3 months pregnant?
Show answer and rationale
Correct answer: B. The client who is receiving chemotherapy who is immunosuppressed.
The pregnant nurse can administer antineoplastic medications to clients. The nurse should not be exposed to antineoplastic agents outside of the administration bags and tubing. The pregnant nurse can care for a client who is immunosuppressed.
The client with hypothyroidism and a diagnosis of myxedema coma is admitted to the critical care unit. Which assessment data warrants immediate intervention by the nurse?
Show answer and rationale
Correct answer: C. The client’s ABG values are pH, 7.33; PaO2, 78; PaCO2, 48; HCO3, 25.
These ABGs indicate respiratory acidosis (ph 45) and hypoxemia (O2 can result in death if not treated immediately.
The nurse is preparing to administer morning medications. Which medication should the nurse administer first?
Show answer and rationale
Correct answer: D. The Humulin N insulin, a pancreatic hormone, to a client diagnosed with type 2 diabetes.
Insulin should be administered before a meal for best effects. This medication should be administered first.
The nurse is working on an endocrinology unit. Which client should the nurse assess first?
Show answer and rationale
Correct answer: A. The client who is 1 day postoperative thyroidectomy who has neck edema.
The nurse should assess the client with a thyroidectomy for hemorrhaging every 2 hours. Neck edema, irregular breathing, and frequent swelling are signs of hemorrhaging; therefore, the nurse should assess this client first.
The client is admitted to the endocrinology unit newly diagnosed with an acute exacerbation of central diabetes insipidus (DI). Which intervention is the priority nursing intervention?
Show answer and rationale
Correct answer: B. Administer intravenous hypotonic saline.
In acute DI, hypotonic saline is administered intravenously and is titrated to replace urinary output. Restoring circulatory volume is the priority intervention. Remember Maslow’s Hierarchy of Needs; physiological needs are priority.
The unlicensed assistive personnel (UAP) tells the nurse the client who had a thyroidectomy has a T 104�F, P 128, RR 26, B/P 164/88. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Assess the client’s vital signs and surgical dressing.
Since the UAP gave the nurse this information, the nurse must assess the client prior to taking any further action.
The unlicensed assistive personnel (UAP) tells the nurse that a client is crying and upset because she has been told her husband has just died. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Make a referral for the chaplain to see the client.
A chaplain is a spiritual adviser who can stay with the client until a family member or the client’s personal spiritual adviser can come to the hospital to be with the client.
At 1000, the client diagnosed with type 1 diabetes is complaining of being jittery, having a headache, and being dizzy. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Give the client glucose tablets.
The client is exhibiting signs of hypoglycemia; therefore, the nurse should treat the client’s symptoms with a simple carbohydrate, such as glucose tablets. This is the first intervention.
An elderly client diagnosed with thyroid cancer frequently makes statements that are inappropriate for the situation, and is not oriented to place, time, or date. The HCP has ordered a magnetic resonance imaging (MRI) scan of the client’s brain. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: D. Make sure the client does not have a pacemaker.
The nurse should make sure that the client does not have any medical device implanted that could react with the magnetic field created by the MRI scanner. An implanted ECG device could prevent the client from having an MRI, depending on the age of the pacemaker and the material with which it was made.
An elderly female client is admitted from the long-term care facility with hyperglycemic hyperosmolar nonketotic coma. The client does not have any family or friends present. Which resource(s) should the admission nurse utilize to obtain information about the client?
Show answer and rationale
Correct answer: A. The transfer form from the nursing home and old hospital records.
The nursing home should send a transfer form with the client that details current medications and diagnoses as well as hygiene needs. Previous hospital records will include a history and physical examination and a discharge summary. This is the best place to start to glean information regarding the client.
The nurse administering medications to clients on a medical unit discovers the wrong medication was administered to a client, Mrs. Jones. Mrs. Jones had replied she was Mrs. Smith when the nurse asked her name from the MAR. Which step in medication administration did the nurse violate when administering the medication?
Show answer and rationale
Correct answer: B. Verifying the client’s armband with the MAR.
The step the nurse did not take was to verify the client’s armband against the MAR. Checking the identification band against the MAR would have prevented the error.
The female client diagnosed with type 2 diabetes has frequent urinary tract infections (UTIs). Which priority intervention should the nurse implement?
Show answer and rationale
Correct answer: A. Discuss the importance of taking all the antibiotics.
Antibiotic therapy is the priority intervention for the client with a diagnosed UTI. None of the health promotion activities will treat the UTI, though they will help prevent further UTIs.
Which laboratory data should the nurse monitor for the client receiving the intravenous Solu-Medrol?
Show answer and rationale
Correct answer: B. Glucose level.
Steroids are excreted as glucocorticoids from the adrenal gland and are responsible for insulin resistance by the cells, which may cause hyperglycemia; therefore, the nurse should monitor the glucose level.
The nurse is working in an outpatient clinic triaging phone calls. Which client warrants notifying the healthcare provider?
Show answer and rationale
Correct answer: C. The client with type 1 diabetes who had a kidney transplant and reports decreased urine output and flu-like symptoms.
These are signs of an acute transplant rejection, which is potentially a lifethreatening problem; therefore, the nurse should notify the healthcare provider about this client.
Which client should the endocrinology nurse assess first after receiving the shift report?
Show answer and rationale
Correct answer: B. The client who is 1 day postoperative transsphenoidal hypophysectomy who has clear drainage from the nose.
This client should be seen first because clear nasal drainage could be cerebrospinal fluid (CSF), which is a potentially life-threatening complication from surgery. The nurse needs to determine if the drainage has glucose. If it does, it is CSF and the surgeon needs to be notified.
Which client is priority to be assigned to a case manager in the outpatient clinic so that care can be achieved?
Show answer and rationale
Correct answer: C. The client who has type 2 diabetes and coronary artery disease (CAD).
It would be appropriate to assign this client to a case manager since this client has two chronic illnesses, often having multiple hospitalizations and chronic complications and requires long-term healthcare.
Which client is most appropriate for the parish nurse to care for?
Show answer and rationale
Correct answer: B. The Presbyterian client who is confined to the home due to severe arthritis.
A parish nurse (PN) is a registered nurse with a minimum of 2 years of experience who works in a faith community, addressing health issues of its members as well as those in the broader community or neighborhood. The client is a Presbyterian so that is the reason the parish nurse should care for this client.
Which task should the ambulatory care nurse delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: A. Tell the UAP to take the glucometer reading on the client about to go to surgery.
The UAP can obtain a glucometer reading on a client who is stable, and clients in the ambulatory care unit are stable.
The clinic nurse is caring for clients using complementary alternative medicine (CAM). Which is not an example of CAM?
Show answer and rationale
Correct answer: C. The client with coronary artery disease (CAD) who takes a daily baby aspirin.
Daily baby aspirin is a medically accepted practice and prescribed by medical doctors. This is not an example of a CAM.
Which statement is an example of community-oriented, population-focused nursing?
Show answer and rationale
Correct answer: C. The nurse develops an educational program for the type 2 diabetics in the community.
Community-oriented, population-focused nursing practice involves the engagement of nursing in promoting and protecting the health of populations, not individuals in the community. Therefore, this is an example of community-oriented, population-focused nursing.
Which priority intervention should the nurse implement when teaching the client with type 2 diabetes about glucometer checks?
Show answer and rationale
Correct answer: B. Have the client demonstrate how to correctly perform the glucometer reading.
Have the client demonstrate the skill to ensure the client can correctly perform the glucometer reading. This is the priority when teaching about glucometer checks.
Which client would most benefit from acupressure, a traditional Chinese medicine, which is considered complementary alternative medicine (CAM)?
Show answer and rationale
Correct answer: D. The client with thyroid cancer who has chemotherapy induced nausea.
Acupressure applies pressure along the body’s energy meridian. Applying pressure on the medial forearm helps decrease the client’s feeling of nausea.
The Home Health Director of Nurses hears a nurse and the occupational therapist loudly disagreeing about the care of a newly admitted client while they are sitting in an area that is accessible to anyone coming into the office. Which action should the Director of Nurses implement first?
Show answer and rationale
Correct answer: A. Request both individuals to come into the director’s office.
The nursing supervisor should intervene and listen to both staff members’ concerns and attempt to help resolve the disagreement. This is the director’s first intervention.
Which client should the nurse on the endocrinology unit assess first?
Show answer and rationale
Correct answer: C. The client with hypothyroidism whose vital signs are T 94.2, AP 48, RR 14, B/P 90/68.
These are signs of myxedema coma, which is characterized by subnormal temperature, hypotension, and hypoventilation. This client should be seen first by the nurse.
Which activities are examples of home healthcare nurse responsibilities when caring for clients with endocrine disorders? Select all that apply.
Show answer and rationale
Correct answer: B. Teach the client and family about administration and side effects of medications.
This is an example of an activity the home health nurse would implement in the home.
The unlicensed assistive personnel (UAP) has just taken the blood pressure of a client who had a thyroidectomy. The UAP tells the nurse that the client’s hand turned into a claw when the blood pressure was taken. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Assess the client for signs/symptoms of hypoparathyroidism.
When the UAP gives information to the nurse about a client, the nurse must first assess the client prior to taking any action.
The client diagnosed with type 2 diabetes who has chronic renal disease asks the nurse, "How can I qualify for home healthcare when I go home?" Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "You must be homebound to receive home healthcare."
The client must be confined to the home or require a considerable and taxing amount of effort to leave the home for brief periods to be eligible for home healthcare.
The nurse is providing complementary alternative medicine (CAM) by teaching the client with hyperthyroidism to focus attention, increase self-awareness, and increase concentration on an object. Which type of mind-body intervention is the nurse teaching?
Show answer and rationale
Correct answer: D. Meditation.
This is an example of meditation.
Which priority intervention should the nurse implement for the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)?
Show answer and rationale
Correct answer: C. Maintain the prescribed daily fluid restriction.
The priority intervention is to restrict fluids to help prevent weight gain, edema, or a serum sodium decline.
The home health (HH) agency Chief Nursing Officer (CNO) is making assignments for the nurses. Which client should be assigned to the new graduate nurse who just completed orientation?
Show answer and rationale
Correct answer: B. The client complaining of pain who is diagnosed with diabetic neuropathy.
The client diagnosed with diabetic neuropathy would be expected to have pain; therefore, this client could be assigned to a nurse new to home health nursing. The client is not exhibiting a complication or an unexpected sign/symptom.
The nurse on the endocrinology unit is caring for clients, assisted by an unlicensed assistive personnel (UAP). Which task is most appropriate to delegate to the UAP?
Show answer and rationale
Correct answer: A. Obtain a urine specimen for the client diagnosed with diabetes insipidus.
The UAP is able to obtain a urine specimen from the client. This task is not assessment, teaching, evaluation, medications, or the care of an unstable client.
The clinical nurse manager on the endocrine unit overhears the staff nurses upset and arguing over how the clients are being assigned by the charge nurse. Which statement indicates a democratic leadership style by the clinical nurse manager?
Show answer and rationale
Correct answer: A. "I will schedule a meeting and we will all sit down and discuss the situation."
Democratic managers are people oriented and emphasize efficient group functioning. The environment is open, and communication flows both ways. Meetings to discuss concerns illustrate a democratic leadership style.
The unlicensed assistive personnel (UAP) tells the nurse the client with thyroid cancer who is terminally ill is having deep-rapid breathing, but then doesn’t breathe for about a minute. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Go to the client’s room immediately and assess the client.
The nurse must first assess the client since the UAP gave the nurse the information.
Which interventions should the nurse implement for the client diagnosed with hyperthyroidism? Select all that apply.
Show answer and rationale
Correct answer: B. Place the client in a cool room away from high-traffic areas.
A calm, quiet, cool room should be provided because increased metabolism causes sleep disturbances and the feeling of being hot.
Which statement by the client experiencing exophthalmos indicates the client needs more teaching by the endocrinology nurse?
Show answer and rationale
Correct answer: B. "I should not move my eyes unless absolutely necessary."
To maintain flexibility, the client should exercise the intraocular muscles several times a day by turning the eyes in the complete range of motion. This statement indicates the client needs more teaching.
Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse caring for the client with type 2 diabetes with chronic renal disease who is on hemodialysis?
Show answer and rationale
Correct answer: C. The UAP ties a sheet around the client sitting in the chair.
This is a form of restraint, and the UAP cannot restrain the client in the home or in the acute care setting. This behavior warrants intervention by the nurse.
The nurse supervisor in the home health (HH) office is assigning tasks for the day. Which task is most appropriate for the nurse supervisor to assign the licensed practical nurse (LPN)?
Show answer and rationale
Correct answer: A. Instruct to the LPN to visit the client with type 2 diabetes who is stable and needs a hospital bed.
The LPN can contact medial supply companies and request durable medical equipment (DME); therefore, this is the most appropriate task to assign the LPN.
The charge nurse is checking the morning laboratory results for the clients. Which laboratory results require notifying the client’s healthcare provider?
Show answer and rationale
Correct answer: A. The client with hyperthyroidism who has an increased TSH level.
The client diagnosed with hyperthyroidism should have a decreased TSH level; therefore, the nurse should notify the client’s HCP.
The nurse on the medical unit is preparing to administer 0900 medications. Which medication should the nurse question administering?
Show answer and rationale
Correct answer: C. The metformin (Glucophage) to the type 2 diabetic who just had a CT scan with dye.
Metformin must be held 24 hours after a client has received any type of contrast dye, since it can cause renal failure. This medication should be questioned by the nurse.
The nurse and unlicensed assistive personnel (UAP) are caring for clients on an endocrinology unit. Which task should not be delegated to the UAP?
Show answer and rationale
Correct answer: B. Take the vital signs of a client who has just returned from the post-anesthesia care unit (PACU).
The client just returning from surgery and the PACU should be assessed immediately by the nurse. The UAP is not qualified to identify an unstable situation.
The unit manager of an endocrinology unit is overbudget for the year and must transfer one staff member to another unit. Which option is the best action for the unit manager to take before deciding which staff member to transfer?
Show answer and rationale
Correct answer: B. Assess each staff member’s abilities.
The manager should assess the abilities of each staff member for the needs of the unit before deciding which staff member to transfer.
The clinic nurse is caring for a 10-year-old client diagnosed with diabetes mellitus type 2. Which client problem is priority?
Show answer and rationale
Correct answer: D. Altered nutrition, excessive intake.
Children are being diagnosed with type 2 diabetes mellitus because of excessive intake of calories and lack of exercise. This is the priority problem. Many states are performing screening activities to identify children at risk for developing type 2 DM so that interventions can be made to delay or prevent the child being diagnosed with type 2 DM. Acanthosis nigricans (hyperinsulinemia) can be identified with simple, non-invasive screening.
The overhead page has just announced a Code Red, actual fire, on a unit two floors below the unit where the nurse is working. Which action should the nurse implement first?
Show answer and rationale
Correct answer: C. Close all of the doors to the clients’ rooms.
The first action in a Code Red (actual fire) is to Rescue (R) the clients in immediate danger, followed by confine (C), closing the doors. Doors in a hospital must be fire rated to confine a blaze for an hour and a half.
The nurse is preparing to administer medications for clients on a medical unit. The client diagnosed with hypothyroidism is complaining of being hot all the time, feeling palpations, and being jittery. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Hold the client’s thyroid medication.
The client is describing symptoms of hyperthyroidism. Because the client is diagnosed with hypothyroidism, has been prescribed thyroid hormone replacement, and now has symptoms of hyperthyroidism, it can be assumed that the client now has an excess of thyroid hormone. Therefore, the nurse should hold the thyroid medication and check the client’s thyroid profile.
The nurse is administering medications on an endocrinology unit. Which medication should the nurse question administering?
Show answer and rationale
Correct answer: D. The propranolol (Inderal) to the client diagnosed with hypothyroidism.
The client with hypothyroidism has a decreased pulse rate; therefore, the nurse should not administer a beta blocker, which could further decrease pulse rate. The client with thyrotoxicosis (hyperthyroidism) would receive Inderal. The nurse should question administering this medication.
The hospice nurse caring for a client diagnosed with diabetes mellitus type 2 observes the client eating a bowl of ice cream. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Allow the client to enjoy the ice cream.
A terminally ill client should be allowed comfort measures even when the activity would normally not be encouraged or allowed. The client can receive slidingscale insulin, if needed, to cover the ice cream.
The nurse is caring for the client who is 1 day postoperative transsphenoidal hypophysectomy. Which action by the unlicensed assistive personnel (UAP) warrants intervention by the nurse?
Show answer and rationale
Correct answer: A. The UAP is helping the client splint the incision.
A hypophysectomy is surgery that removes the pituitary gland by making an incision in the inner aspect of the upper lip and gingival. The sella turicica is entered through the floor of the nose and sphenoid sinuses. There are no visual incisions and the nose cannot be splinted.
The charge nurse of a surgical unit has been notified of an external disaster with multiple casualties. Which client should the charge nurse request to be discharged from the hospital to make room for clients from the disaster?
Show answer and rationale
Correct answer: D. The client who had a total abdominal hysterectomy 2 days ago and PCA machine has been discontinued.
This client is stable and could be prescribed oral pain medication. She could be discharged home and followed by home health nursing if needed. This client is the most appropriate client for the charge nurse to request to be discharged.
For which client’s laboratory data should the charge nurse notify the HCP?
Show answer and rationale
Correct answer: B. The blood glucose level of 543 mg/dL in a client diagnosed with uncontrolled diabetes mellitus type 1.
This is a very high blood glucose level, and the client diagnosed with type 1 diabetes will be catabolizing fats at this level and is at risk for diabetic ketoacidosis (DKA) coma.
Which nursing intervention is priority for the intensive care nurse to implement when caring for a client diagnosed with diabetic ketoacidosis (DKA)?
Show answer and rationale
Correct answer: D. Maintain the regular insulin IV rate on an infusion pump.
The client will be on a regular insulin drip, which must be maintained at the prescribed rate on an intravenous pump device. Decreasing the client’s blood glucose level is the priority nursing intervention.
The client diagnosed with diabetes mellitus type 2 has a hemoglobin A1C of 11 mg/dL. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Teach the client about the effects of uncontrolled hyperglycemia.
The client must be taught the long-term effects of hyperglycemia. A hemoglobin A1C of 11 indicates an average blood glucose of 310 mg/dL. Over time, a level higher than 120 to 140 mg/dL can lead to damage to many body systems.
The nurse in the outpatient clinic is working with an unlicensed assistive personnel (UAP). Which tasks are most appropriate for the nurse to delegate to the UAP? Select all that apply.
Show answer and rationale
Correct answer: A. Take the client to the examination room and take the vital signs.
The UAP can escort the patient to the examination room and take the initial vital signs.
The nurse in an outpatient clinic is returning telephone calls. Rank the calls in the order they should be returned, with the highest priority call first.
Show answer and rationale
Correct answer: A. The call from the pharmacist wanting an authorization to change a medication from a trade name to a generic name drug.
The pharmacist needs to know if the substitution can be made in order to fill this prescription. This call should be returned third.
The nurse received the a.m. shift report on the following clients. Which client should the nurse assess first?
Show answer and rationale
Correct answer: A. The client who has full-thickness burns who needs to be medicated before being taken to whirlpool.
The client must be medicated with a narcotic medication prior to being taken to whirlpool, which is a physiological need; therefore, the nurse should see this client first.
The nurse is working in an orthopedic unit. Which client should the nurse assess first?
Show answer and rationale
Correct answer: B. The client who is 1 week postoperative for L3-L4 laminectomy who is complaining of numbness and tingling of the feet.
Numbness and tingling of the legs are signs of possible neurovascular compromise. This client should be assessed first.
The client is 1 week postoperative for right below-the-knee amputation secondary to arterial occlusive disease. The nurse is unable to assess a pedal pulse in the left foot. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Assess for paresthesia and paralysis.
An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease. If the client can move the toes and denies tingling or numbness, then no further action should be taken.
The client tells the nurse, "I have a mole on my back which is darker and getting larger." Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Instruct the client to notify his or her healthcare provider immediately.
A client should consult his or her HCP immediately if a mole or lesion shows any signs of melanoma-asymmetry, border irregularity, color change/variation, and diameter of 6 mm or more (ABCD).
The nurse is at a local playground and her 10-year-old son falls and complains of his left ankle and foot hurting. Which intervention should the nurse implement first at the scene of the accident?
Show answer and rationale
Correct answer: B. Instruct her son not to move the left leg.
The nurse should implement the first intervention, ensuring the client does not move the leg, because doing so may cause further injury. The client should not attempt to move or stand on the injured extremity.
The nurse is preparing to change a dressing on an 82-year-old client with a Stage III pressure ulcer. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Check to determine whether the client has received pain medication.
Dressing changes for a Stage III pressure ulcer will be painful for the client and the nurse should make sure the client has received pain medication at least 30 minutes prior to the procedure. This is showing client advocacy.
Which client should the charge nurse on the rehabilitation unit assess first after receiving the a.m. shift report?
Show answer and rationale
Correct answer: C. The client diagnosed with an open reduction and external fixation (ORIF) of the right hip who has a hemoglobin and hematocrit (H&H) of 8/24.
The H&H is low, which requires the nurse to assess this client first. The nurse must take the client’s vital signs, check the surgical dressing, and determine whether the client is symptomatic for hypovolemia.
The client ambulating down the orthopedic hallway unassisted fell to the floor. Which action should the nurse implement first?
Show answer and rationale
Correct answer: B. Determine whether the client has any injuries.
The nurse must first determine whether the client has any injuries before taking any other action. This is the first intervention the nurse must implement prior to moving the client.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a rehabilitation unit. Which nursing task is most appropriate for the nurse to delegate to the UAP?
Show answer and rationale
Correct answer: A. Assist with bowel training by escorting the client to the bathroom.
The UAP can assist the client to the bathroom as part of the bowel training; the nurse is responsible for the training, but the nurse can delegate this task.
The unlicensed assistive personnel (UAP) tells the nurse the client with a right above-the-knee amputation has a large amount of bright red blood on the right leg residual limb. Which action should the nurse implement?
Show answer and rationale
Correct answer: D. Assess the client’s residual limb dressing.
Because the UAP is informing the nurse of pertinent information, the nurse should assess the client to determine which action to take.
Which action by the unlicensed assistive personnel (UAP) warrants immediate intervention by the nurse?
Show answer and rationale
Correct answer: B. The UAP tied the confused client to a chair with a sheet.
Tying a client to a chair is a form of restraint, and the client cannot be restrained without an HCP order; therefore, the nurse should immediately free the client. This is a legal issue.
The charge nurse, a licensed practical nurse (LPN), and two unlicensed assistive personnel (UAPs) are caring for clients. Which action is most appropriate for the charge nurse to assign/delegate?
Show answer and rationale
Correct answer: C. Request the LPN to apply antifungal cream to the client with tinea pedis.
The LPN can apply medication to the client’s athlete’s foot; therefore, this is an appropriate assignment for the LPN.
The nurse in the rehabilitation unit is caring for clients along with an unlicensed assistive personnel (UAP). Which action by the UAP warrants immediate intervention?
Show answer and rationale
Correct answer: B. The UAP is assisting the client who weighs 181 kg to the bedside commode.
The UAP is attempting to move a client who weighs 400 pounds to the bedside commode. The UAP should request assistance to ensure client safety as well as to protect the UAP’s back. This is a dangerous situation and requires intervention by the nurse.
The unlicensed assistive personnel (UAP) on the rehabilitation unit is placing the client with a left above-the-knee amputation in the prone position. Which action should the nurse implement?
Show answer and rationale
Correct answer: C. Praise the UAP for positioning the client prone.
The nurse should praise the UAP for taking the initiative and placing the client in the prone position. The prone position will help prevent contractures of the residual limb, which will make it easier to apply a prosthetic device.
The unlicensed assistive personnel (UAP) is applying elastic compression stockings to the client. Which action by the UAP indicates to the nurse the UAP understands the correct procedure for applying the elastic compression stockings?
Show answer and rationale
Correct answer: C. The UAP had the client elevate the legs prior to putting on the stockings.
Stockings should be applied after the legs have been elevated for a period of time when the amount of blood in the leg vein is at its lowest. Having the client elevate the legs before placing the stockings on the legs indicates that the UAP understands the procedure for applying the elastic compression stockings.
The charge nurse on the acute care rehabilitation unit is making assignments for the shift. Which client should the charge nurse assign to the most experienced nurse?
Show answer and rationale
Correct answer: D. The client with fractured tibia who has deep, unrelenting pain.
Deep, unrelenting pain is a sign of compartment syndrome, an acute, potentially life-threatening complication, in a client with a fracture; therefore, this client should be assigned to the most experienced nurse.
The charge nurse on the busy 36-bed rehabilitation unit must send one staff member to the emergency department (ED). Which staff member is the most appropriate person to send?
Show answer and rationale
Correct answer: B. The RN who transferred to the rehabilitation unit from the medical unit.
The RN with medical unit experience would be the most appropriate nurse to send to the emergency department because this nurse has experience that would be helpful in the ED. The nurse is also an RN, who would be more helpful in the ED than a UAP or an LPN.
Which task should the rehabilitation nurse delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: D. Encourage the UAP to attend the multidisciplinary team meeting.
The UAP is a vital part of the healthcare team and should be encouraged to attend the multidisciplinary team meeting and provide input into the client’s care.
The client is 8 hours postoperative spinal surgery. Which priority intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Logroll the client with three staff members when turning the client side to side.
Logrolling clients when turning is essential and priority to maintain proper body alignment.
The elderly wife of a client with a total hip replacement who is being discharged home tells the nurse, "I am really worried about taking my husband home. I don’t know how I will be able to take care of him." Which intervention is most appropriate for the nurse?
Show answer and rationale
Correct answer: B. Refer the client to the home health nurse.
This client would benefit from a home healthcare nurse’s evaluation of the client’s home and the wife’s ability to care for the client.
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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