NCLEX Practice Questions — Set 17
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
Ms. Helen is making assignments in the labor and delivery department. Which client should be assigned to Ms. Judy, the most experienced nurse?
Show answer and rationale
Correct answer: D. The 38-week gestational client who is 100% effaced and 10 cm dilated.
This client is ready to deliver; therefore Ms. Judy should be assigned to this client since the other three clients are not experiencing any life-threatening complications.
Which task should Ms. Glada, postpartum nurse, delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: A. Instruct the UAP to take the client whose fundus is not midline to the bathroom.
The UAP can assist the client to the bathroom to urinate. The UAP cannot assess the client’s fundus. The number one reason for a non-midline fundus is a full bladder. Ms. Glada cannot delegate assessment, teaching, evaluation, medication administration, or an unstable client to the UAP.
A float nurse from the medical-surgical unit is assigned to the postpartum unit. Which client should Ms. Helen assign to the float nurse?
Show answer and rationale
Correct answer: A. The client who had a fetal demise at 34 weeks’ gestation.
The float nurse should be able to address the psychosocial concerns of the mother and family. The client has no physiological problems so the float nurse could care for this client. Often, the mother with a fetal demise is transferred to a medicalsurgical unit so she does not have to hear babies crying.
Ms. Judy is administering medications to clients on a postpartum floor. Which medication should Ms. Judy question administering?
Show answer and rationale
Correct answer: A. The rubella vaccine to the postpartum client who has a positive titer.
The nurse would question administering this medication because a positive titer means the client is immune to rubella (German measles).
Which client should Ms. Kathy, the newborn nursery nurse, assess first after receiving shift report?
Show answer and rationale
Correct answer: C. The African American newborn who has edema between suture lines.
A cephalohematoma results when there is bleeding between the periosteum and the skull from pressure during birth. The firm swelling, edema, is not present at birth but develops within the first 24 to 48 hours. Any time a client is bleeding, it warrants intervention by the nurse.
Ms. Kathy, the nursery nurse, is assessing newborns. Which newborn would require further assessment by Ms. Kathy?
Show answer and rationale
Correct answer: D. The newborn who remains in the fetal position when lying supine.
When the infant is placed in the supine position, the infant should extend the arm and leg on the side to which the head is turned and then flex the extremities on the other. This is known as the tonic-neck reflex or fencing reflex, which is normal for the newborn. The newborn remaining in a fetal position when supine warrants further intervention to assess for neurological problems.
The nurse is working in the emergency department (ED) of a children’s medical center. Which client should the nurse assess first?
Show answer and rationale
Correct answer: D. The 6-year-old school-age child who was hit by a car while riding a bicycle.
The child hit by a car should be assessed first because he or she may have lifethreatening injuries that must be assessed and treated promptly.
The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Assess the client’s neurological status.
Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident (CVA) by assessing the client’s neurological status and then determine whether it is a headache that can be treated with medication.
The 6-year-old client who has undergone abdominal surgery is attempting to make a pinwheel spin by blowing on it with the nurse’s assistance. The child starts crying because the pinwheel won’t spin. Which action should the nurse implement first?
Show answer and rationale
Correct answer: C. Praise the child for the attempt to make the pinwheel spin.
The nurse should always praise the child for attempts at cooperation even if the child did not accomplish what the nurse asked.
The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess first?
Show answer and rationale
Correct answer: D. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is life threatening; therefore, this child should be assessed first.
The nurse has received the a.m. shift report for clients on a pediatric unit. Which medication should the nurse administer first?
Show answer and rationale
Correct answer: D. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
Sliding scale insulin is ordered ac, which is before meals; therefore, this medication must be administered first after receiving the a.m. shift report.
The nurse enters the client’s room and realizes the 9-month-old infant is not breathing. Which interventions should the nurse implement? Prioritize the nurse’s actions from first (1) to last (5).
Show answer and rationale
Correct answer: A. Determine unresponsiveness.
The nurse must first determine the infant’s responsiveness by thumping the baby’s feet.
The clinic nurse is preparing to administer an intramuscular (IM) injection to the 2-year-old toddler. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Explain the procedure to the child.
The nurse must explain any procedure in words the child can understand. It does not matter how old the child is.
The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis. Which client problem is priority?
Show answer and rationale
Correct answer: A. Fluid volume deficit.
The child diagnosed with gastroenteritis is at high risk for hypovolemic shock resulting from vomiting and diarrhea; therefore, maintaining fluid and electrolyte homeostasis is priority.
Which data would warrant immediate intervention from the pediatric nurse?
Show answer and rationale
Correct answer: C. Drooling for a child diagnosed with acute epiglottitis.
Drooling indicates the child is having trouble swallowing, and the epiglottis is at risk of completely occluding the airway. This warrants immediate intervention. The nurse should notify the HCP and obtain an emergency tracheostomy tray for the bedside.
Which client should the pediatric nurse assess first after receiving the a.m. shift report?
Show answer and rationale
Correct answer: C. The 13-month-old child diagnosed with diarrhea who has sunken eyeballs and decreased urine output.
Sunken eyeballs and decreased urine output are signs of dehydration, which is a life-threatening complication of diarrhea; therefore, this child should be assessed first.
The pediatric clinic nurse is triaging telephone calls. Which client’s parent should the nurse call first?
Show answer and rationale
Correct answer: B. The 4-month-old child who had immunizations yesterday and the parent is reporting a high-pitched cry and a 103�F fever.
A high fever and high-pitched crying may indicate a reaction to the immunizations; therefore, this parent needs to be called first to bring the child to the clinic.
The parent of a 12-year-old male child with a left below-the-knee cast calls the pediatric clinic nurse and tells the nurse, "My son’s foot is cold and he told me it feels like his foot is asleep." Which action should the nurse implement first?
Show answer and rationale
Correct answer: A. Instruct the parent to elevate the left leg on two pillows.
The nurse should first take care of the client’s body by having the parent elevate the left leg.
Which child requires the nurse to notify the healthcare provider?
Show answer and rationale
Correct answer: B. The 5-year-old child with rheumatic heart fever who is having difficulty breathing.
A complication of rheumatic heart disease is valvular disorders that may be manifested by respiratory problems; therefore, the nurse should notify the child’s healthcare provider.
The pediatric nurse on the surgical unit has just received a.m. shift report. Which client should the nurse assess first?
Show answer and rationale
Correct answer: C. The 3-week-old child 1 day postoperative with surgical repair of a myelomeningocele who has bulging fontanels.
Bulging fontanels is a sign of increased intracranial pressure, which is a complication of neurological surgery; therefore, this child should be assessed first.
The charge nurse has assigned a staff nurse to care for an 8-year-old client diagnosed with cerebral palsy. Which nursing action by the staff nurse would warrant immediate intervention by the charge nurse?
Show answer and rationale
Correct answer: B. The staff nurse places the child in semi-Fowler’s position to eat lunch.
The child should be positioned upright to prevent aspiration during meals; therefore, this action would require the charge nurse to intervene.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on the pediatric unit. Which action by the nurse indicates appropriate delegation?
Show answer and rationale
Correct answer: D. The nurse checks to make sure the UAP’s delegated tasks have been completed.
The last step of delegating to a UAP is for the nurse to evaluate and determine whether the delegated tasks have been completed and performed correctly. This indicates the nurse has delegated appropriately.
The nurse on a pediatric unit has received the a.m. shift report and tells the unlicensed assistive personnel (UAP) to keep the 2-year-old child NPO for a procedure. At 0830, the nurse observes the mother feeding the child. Which action should the nurse implement first?
Show answer and rationale
Correct answer: B. Determine what the UAP did not understand about the instruction.
Communication to the UAP must be clear, concise, correct, and complete. The nurse must determine why there was a lack of communication, which resulted in the child receiving food; therefore, this action should be implemented first.
The charge nurse on the six-bed pediatric burn unit is making shift assignments and has one registered nurse (RN), one scrub technician, one unlicensed assistive personnel (UAP), and a unit secretary. Which client care assignment indicates the best use of the hospital personnel?
Show answer and rationale
Correct answer: C. The unit secretary transcribes the HCP’s orders.
One of the responsibilities of the unit secretary is to transcribe the HCP’s orders, but the licensed nurse retains total responsibility for the correctness and accuracy of the transcribed orders.
The RN and the UAP are caring for clients on a pediatric surgical unit. Which tasks would be most appropriate to delegate to the UAP? Select all that apply.
Show answer and rationale
Correct answer: D. Pass dietary trays to the clients.
The UAP can pass the dietary trays to the clients because it does not require judgment.
Which client should the charge nurse on the pediatric unit assign to the most experienced nurse?
Show answer and rationale
Correct answer: D. The 11-year-old child newly diagnosed with rheumatoid arthritis.
The child newly diagnosed with a chronic disease, which will have acute exacerbations, requires extensive teaching; therefore, the most experienced nurse should be assigned to this child and family.
The charge nurse is making shift assignments on a pediatric oncology unit. Which delegation/assignment would be most appropriate?
Show answer and rationale
Correct answer: B. Assign the chemotherapy-certified RN to administer chemotherapeutic medication.
Only chemotherapy-certified RNs can administer antineoplastic, chemotherapeutic medications. This is a national minimal standard of care according to the Oncology Nursing Society.
The nurse observes the unlicensed assistive personnel (UAP) bringing a cartoon video to a 6-year-old female child on bed rest so that she can watch it on the television. Which action should the nurse take?
Show answer and rationale
Correct answer: B. Praise the UAP for providing the child with an appropriate activity.
Part of the delegation process is to evaluate the UAP’s performance of duties, and the nurse should praise any initiative on the part of the UAP in being a client advocate.
Which newborn should the nurse in the neonatal intensive care unit (NICU) assign to a new graduate who has just completed an NICU internship?
Show answer and rationale
Correct answer: A. The 2-week-old infant who was born 6 weeks premature.
The new graduate who has completed the NICU internship should be able to care for a premature infant because care is primarily supportive.
Which task is most appropriate for the pediatric nurse to delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: C. Ask the UAP to orient the parents and child to the room.
The UAP can orient the parents and child to the room, and demonstrate how to use the call light, how the bed works, or how the television works.
Which behavior by the unlicensed assistive personnel (UAP) warrants intervention by the nurse?
Show answer and rationale
Correct answer: C. The UAP applies wrist restraints on the 7-month-old who is 1 day postoperative cleft palate repair.
The 7-month-old should have elbow restraints, not wrist restraints. Elbow restraints prevent the child from putting fingers into the mouth, but allow the child to move the arms.
The nurse is caring for pediatric clients. Which tasks are most appropriate to assign to an unlicensed assistive personnel (UAP) and/or a licensed vocational nurse (LPN)? Select all that apply.
Show answer and rationale
Correct answer: D. Tell the UAP to apply an ice collar to the child who is 1 day postoperative tonsillectomy.
The UAP can apply an ice collar since the client is stable.
The nurse is discharging a 4-month-old child with a temporary colostomy. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Request the UAP to escort the parent and child to the car.
The UAP can escort the child and parents to the car.
The unlicensed assistive personnel (UAP) tells the nurse the child with Down syndrome who is 2 days postoperative appendectomy is having pain. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Assess the child’s abdominal dressing and pain immediately.
A rule of thumb-if anyone else gives the nurse information about a client, the nurse should first assess the client before taking any further action.
The 8-year-old male child in the pediatric unit is refusing to ambulate postoperatively. Which intervention would be most appropriate?
Show answer and rationale
Correct answer: A. Give the child the option to ambulate now or after lunch.
The nurse should offer the child choices that ensure cooperation with the therapeutic regimen. The choices are when the child will ambulate, not whether the child will ambulate.
The clinic nurse overhears a mother in the waiting room tell her 6-year-old son, "If you don’t sit down and be quiet, I am going to get the nurse to give you a shot." Which action should the nurse implement?
Show answer and rationale
Correct answer: D. Tell the mother this behavior will cause her son to be afraid of the nurses.
The nurse should explain to the mother that threatening the child with a shot will cause the child to be frightened of healthcare professionals. This type of comment is inappropriate and should not be used to discipline a child.
The parents of an infant born with Down syndrome are holding their infant and crying. The father asks, "I have heard children like this are hard to take care of at home." Which referral would be most appropriate for the parents?
Show answer and rationale
Correct answer: B. A Down syndrome support group.
According to the NCLEX-RN� test plan, referrals are included in management of care. The most appropriate referral would be to a support group where other parents who have special needs children can share their feelings and provide advice on how to care for their child in the home.
The charge nurse on the pediatric unit hears the overhead announcement of Code Pink (infant abduction), newborn nursery. Which action should the charge nurse implement?
Show answer and rationale
Correct answer: A. Station a staff member at all the unit exits.
Code Pink means an infant has been abducted from the newborn nursery. The priority intervention is to prevent the abductor from taking the child from the hospital, which can be prevented by placing a staff member at all of the unit exits.
The mother of a 4-year-old child diagnosed with Duchenne’s muscular dystrophy is overwhelmed and asks the nurse, "I have been told a case manager will come and talk to me. What will they do for me?" Which statement indicates the nurse understands the role of the case manager?
Show answer and rationale
Correct answer: D. "She will help you find the resources you need to care for your child."
According to the NCLEX-RN� test blueprint, questions on case management are included. The case manager will coordinate the care for a client with a chronic illness with other members of the multidisciplinary healthcare team. This attempts to prevent duplication of ser – vices and allows the mother to have a specific individual to coordinate services to meet the child’s needs.
The nurse is assigned to the pediatric unit performance improvement committee. The unit is concerned with IV infection rates. Which action should the nurse implement first when investigating the problem?
Show answer and rationale
Correct answer: A. Identify how many IV infections have occurred in the last year.
The first intervention is to determine the extent of the problem and who owns the problem. The NCLEX-RN� test blueprint includes performance improvement (quality improvement) in the management of care content.
The clinic nurse is discussing a tubal ligation with a 17-year-old adolescent with Down syndrome. The adolescent does not want the surgery, but her parents (who are also in the room) are telling her she must have it. Which statement by the nurse would be an example of the ethical principle of justice?
Show answer and rationale
Correct answer: D. "I think this requires further discussion before scheduling this procedure."
The ethical principle of justice is to treat all clients fairly, without regard to age, socioeconomic status, or any other variable, including clients with special needs. This statement supports the adolescent’s right to her opinion even though she has Down syndrome.
The school nurse has referred an 8-year-old student for further evaluation of vision. The single mother has told the school nurse she does not have the money for the evaluation or glasses. Which action by the nurse would be an example of client advocacy?
Show answer and rationale
Correct answer: C. Refer the mother to a local service organization.
This is an example of client advocacy because many local service organizations, such as the Lions Club or the Rotary Club, will subsidize the cost of the vision test and glasses.
The emergency department (ED) nurse is scheduling the 16-year-old client for an emergency appendectomy. Which intervention should the nurse implement when obtaining permission for the surgery?
Show answer and rationale
Correct answer: B. Have the client’s parent or legal guardian sign the operative permit.
Legally, a child under the age of 18 must have a parent or legal guardian sign for informed consent. The nurse should determine whether the child is aware of the situation and assents to the procedure.
The unit manager has been notified by central supply that many client items are missing from stock and have not been charged to the client. Which action should the nurse manager implement regarding the lost charges?
Show answer and rationale
Correct answer: C. Schedule a staff meeting to discuss how to prevent further lost charges.
Because the staff is responsible for following the hospital procedure for charging for items used in client care, the unit manager should discuss this with staff to determine what should be done to correct the problem.
Which child’s behavior warrants notifying the child developmental specialist?
Show answer and rationale
Correct answer: D. The 4-year-old child who throws frequent temper tantrums.
The toddler (age 1-3) is expected to throw temper tantrums, but a 4-year-old child should not be doing this; therefore, the child is not developmentally on target and the child developmental specialist should be notified.
Which child should the nurse assign to the new graduate who has just completed orientation to the pediatric unit?
Show answer and rationale
Correct answer: A. The 16-year-old female diagnosed with scoliosis who is being admitted for insertion of a spinal rod in the morning.
The new graduate should be able to complete preoperative teaching and prepare the young client for surgery. This client is stable.
Which action by the emergency department (ED) nurse warrants intervention by the charge nurse?
Show answer and rationale
Correct answer: A. The nurse is assessing the tonsils on a 4-year-old child who has a sore throat and is drooling.
A child who is drooling may have epiglottitis and opening the mouth may lead to respiratory distress. This action warrants intervention by the charge nurse.
Which interventions should the nurse implement to help establish a nurse/parent relationship? Select all that apply.
Show answer and rationale
Correct answer: C. Include the parents when developing the plan of care for their child.
Including the parents in developing the plan of care will help establish a positive relationship.
The nurse is caring for clients on the pediatric unit. Which child would warrant a referral to the early childhood development specialist?
Show answer and rationale
Correct answer: B. The 8-month-old child who sits by leaning forward on both hands.
The 8-month-old infant should be able to sit steadily unsupported; therefore, this child is developmentally delayed and warrants a referral to the early childhood development specialist. Leaning forward on both hands to sit is normal for a 6-month-old.
The 10-year-old child diagnosed with leukemia is scheduled for a bone marrow aspiration. Which intervention is most important when obtaining informed consent for the procedure?
Show answer and rationale
Correct answer: D. Obtain assent from the child.
The most important intervention for this child is to make sure the child has some control and input into the decision making. It is customary to obtain assent from children 7 years of age and older. Assent means the child has been fully informed about the procedure and concurs with those giving the informed consent.
The 13-year-old client has just delivered a 4-pound baby boy. The stepfather of the client becomes verbally abusive to the nurse when he is asked to leave the room. The client is withdrawn and silent. Which legal action should the nurse implement?
Show answer and rationale
Correct answer: C. Contact Child Protective Services.
Legally, the nurse is required to report any suspected child abuse. A 13-year-old child who is having a baby and is withdrawn and silent along with a potential abuser who is trying to control access to the child should make the nurse suspect child abuse.
The fire alarm on the pediatric unit has just started sounding. Which action should the charge nurse implement first?
Show answer and rationale
Correct answer: A. Ensure that all visitors and clients are in the room with the door closed.
Safety of the clients and visitors is priority; therefore, ensuring that they are in a room with the door closed is the first intervention.
A nurse overhears two other nurses talking about a client in the hospital dining room. Which action should the nurse implement first?
Show answer and rationale
Correct answer: B. Tell the two nurses they are violating the client’s confidentiality.
This is a violation of HIPAA; therefore, the nurse must first confront the two nurses and correct the behavior.
The nurse is caring for newborns in the nursery. Which newborn warrants immediate intervention by the nurse?
Show answer and rationale
Correct answer: B. The 4-hour-old newborn who is jittery and irritable.
A newborn who is jittery and irritable needs to be assessed first for possible hypoglycemia. The nurse could feed the newborn glucose water or provide more frequent, regular feedings.
The nurse who has never worked on the maternity ward has been pulled from the surgical unit to work in the newborn nursery. Which assignment would be most appropriate for the nurse to accept?
Show answer and rationale
Correct answer: D. Transport newborns to the mothers’ room.
Any nurse can take an infant to the mother’s room and check the bands to ensure the right infant is with the right mother. This is an appropriate task for a nurse who has never worked in the nursery.
The nurse is instructing the unlicensed assistive personnel (UAP) on gross motor skill activity that is appropriate for a developmentally delayed 9-month-old infant. Which activity should the nurse delegate to the UAP?
Show answer and rationale
Correct answer: A. Help the child to sit without support.
The 9-month-old infant should be able to sit without support. Therefore, the nurse should instruct the UAP to perform the developmental task of helping the child sit without support.
Which incident should the primary nurse report to the clinical manager concerning a violation of information technology guidelines?
Show answer and rationale
Correct answer: D. The nurse shares the computer access code with another nurse.
According to the NCLEX-RN� test blueprint, the nurse must be knowledgeable of information technology. Giving another nurse his or her access code is a very serious violation of information technology guidelines and should be reported.
The nurse is caring for clients in a pediatric emergency department (ED). Which client should the nurse assess first?
Show answer and rationale
Correct answer: B. The child who has ingested a bottle of prenatal vitamins.
A child who ingested a bottle of prenatal vitamins presents a medication poisoning that is a potentially life-threatening situation. This child must be assessed first to determine how many vitamins were taken, how long ago they were taken, and whether or not the vitamins contained iron. The child’s neurological status must also be assessed.
The nurse is caring for a client in a children’s medical center. Which behavior indicates the nurse understands the pediatric client’s rights?
Show answer and rationale
Correct answer: C. The nurse covers the 5-year-old child’s genitalia during a code.
The pediatric client has a right to be treated with dignity and respect. Just because the child is being coded does not mean the nurse should allow the child’s body to be exposed to everyone in the room.
The home health nurse is planning the care of a 14-year-old client diagnosed with leukemia who is receiving chemotherapy. Which psychosocial problem is priority for this client?
Show answer and rationale
Correct answer: B. Social isolation.
The client will be isolated from peers and schools because of the high risk of infection resulting from the immunosuppression secondary to chemotherapy and the disease process. At this stage, the child needs to be developing peer relationships and independence from parents. Therefore, social isolation is the priority psychosocial problem for this client.
The nurse is administering IV fluids to a 3-year-old client. Which action by the nurse would warrant intervention by the charge nurse?
Show answer and rationale
Correct answer: A. The nurse does not use a volume-controlled chamber.
A volume-controlled chamber (Buretrol) is a device that is used with children when administering IV fluids. The chamber is filled with 1 hour’s amount of fluid so that the child will not inadvertently receive an overload of fluid. Fluid volume overload is a potentially life-threatening situation in children.
The nurse is caring for clients on a psychiatric pediatric unit. Which action by the nurse is reportable to the state board of nursing?
Show answer and rationale
Correct answer: D. The nurse leaves for lunch and does not return to complete the shift.
Abandonment is a reportable offense to the state board of nursing in every state. Reportable offenses could result in stipulations made to the nurse’s license.
The nurse is working in a free healthcare clinic. Which client situation warrants further investigation?
Show answer and rationale
Correct answer: B. The father who tells the nurse that the child receives a variety of herbs every day.
Herbal products are not regulated by the Food and Drug Administration, and there is very little (if any) research on herbal use with children. The nurse should at least investigate which herbs the child is receiving before taking further action.
The unlicensed assistive personnel (UAP) tells the primary nurse that the 4-year-old child is alone in the room because the mother went to the cafeteria to get something to eat. Which action should the nurse implement first?
Show answer and rationale
Correct answer: A. Tell the UAP to stay with the child until the mother returns.
The child’s safety is priority; therefore, the nurse should have the UAP stay with the child until the mother returns.
The nurse is evaluating an 18-month-old child in the pediatric clinic. Which data would indicate to the nurse that the child is not meeting tasks according to Erikson’s Stages of Psychosocial Development?
Show answer and rationale
Correct answer: A. The child does not interact with the mother.
An 18-month-old child should cling to the mother and interact continuously with the primary caregiver. A child not interacting with the mother is not meeting the task of developing a sense of autonomy.
Which statement by the female charge nurse indicates she has an autocratic leadership style?
Show answer and rationale
Correct answer: C. "You must complete all the a.m. care before you take your morning break."
An autocratic manager uses an authoritarian approach to direct the activities of others. This individual makes most of the decisions alone without input from other staff members.
The nurse is evaluating the care of a 5-year-old client with a cyanotic congenital heart defect. Which client outcome would support that discharge teaching has been effective?
Show answer and rationale
Correct answer: C. The nurse finds unopened packs of salt on the meal tray.
This behavior indicates the child understands the importance of salt restriction because of potential congestive heart failure.
The unconscious 4-year-old child is brought to the emergency department by paramedics; the child has bruises covering the torso in varying stages of healing. The nurse notes small burn marks on the child’s genitalia. Which actions should the nurse implement? Select all that apply.
Show answer and rationale
Correct answer: B. Notify Child Protective Services.
This child has injuries consistent with child abuse. Child Protective Services and the police should be notified.
The 24-month-old toddler is admitted to the pediatric unit with vomiting and diarrhea. Which interventions should the nurse implement? Rank in order of performance.
Show answer and rationale
Correct answer: B. Take the toddler’s vital signs.
Taking the vital signs is part of the assessment and a beginning point for the nurse.
Which child should Ms. Laura assess first?
Show answer and rationale
Correct answer: D. The 1-month-old infant who crying, is inconsolable, and has inspiratory retractions.
The child who is having respiratory difficulty, inspiratory retractions, should be assessed first. Remember Maslow’s Hierarchy of Needs.
Which task should Ms. Laura delegate to Ms. Michelle, the UAP?
Show answer and rationale
Correct answer: A. Obtain the weight of the child who is diagnosed with nephrotic syndrome.
The child with nephrotic syndrome experiences weight gain secondary to edema, which is expected with this disease process. This child is stable, and the UAP can obtain weights; therefore, Ms. Laura can delegate this task to the UAP.
Ms. Laura is observing Mr. Aaron administer an intramuscular (IM) injection to a 2-year-old toddler. Which action by Mr. Aaron warrants intervention by Ms. Laura?
Show answer and rationale
Correct answer: B. He recaps the needle after administering the medication.
Mr. Aaron should not recap the needle after administering the medication, so this warrants intervention by Ms. Laura. The syringe and needle should be disposed of in the sharps container.
Which task should Ms. Ruth not delegate to the Ms. Diane, the UAP?
Show answer and rationale
Correct answer: D. Feed the child who is experiencing an acute exacerbation of inflammatory bowel disease (IBD).
The child with an acute exacerbation of IBD must be NPO; therefore, this task should not be delegated to Ms. Diane. This cannot be delegated by Ms. Ruth.
Which client should Ms. Laura assign to Ms. Polly, the most experienced pediatric emergency department nurse?
Show answer and rationale
Correct answer: A. The 6-year-old child who is wheezing and complaining of chest tightness.
Ms. Laura should suspect this child is experiencing an acute exacerbation of reactive airway disease and assign Ms. Polly to this child. This child is in a potentially life-threatening situation.
The 13-year-old child is admitted to the emergency department with nucal rigidity, a positive Kernig’s sign, a positive Brudzinki’s sign, and an elevated temperature. Which intervention should Ms. Laura implement first?
Show answer and rationale
Correct answer: A. Place the child in droplet isolation.
Ms. Laura should suspect bacterial meningitis and place the child in isolation until definitive diagnosis is made. Ms. Laura must protect the child but also all the other clients, visitors, and staff in the emergency department. This intervention must be implemented first.
Mr. Aaron answers the phone and a distraught woman says, "My daughter just drank a bottle of cleaning solution." Which intervention should Mr. Aaron implement first?
Show answer and rationale
Correct answer: D. Tell Ms. Laura to call poison control immediately.
Contacting Poison Control is the first intervention. Poison Control will be able to provide Mr. Aaron with the correct instructions to give to the mother to help dilute this poison and remove it from the daughter’s body.
The 8-year-old child is brought to the emergency department by his parents with a pencil penetrating the right eye. Which intervention should Ms. Laura implement first?
Show answer and rationale
Correct answer: D. Stabilize the pencil in place and patch the left eye.
Ms. Laura should first stabilize the pencil in place so further damage will not take place. The left eye should be patched to prevent eye movement. If the uninjured eye moves, the injured eye will also move involuntarily, possibly causing more damage.
Mr. Aaron is caring for a 7-year-old child who was hit in the head with a baseball. One hour ago the child had a 15 on the Glasgow Coma Scale and now has a 12. Which intervention should Mr. Aaron implement first?
Show answer and rationale
Correct answer: C. Notify the hospital neurologist immediately.
The best response on the Glasgow Coma Scale is 15, so a score of 12 indicates neurological deterioration and requires notifying the neurologist first. Mr. Aaron cannot implement any independent nursing interventions to help the child.
Which client should Ms. Laura assign to Mr. Aaron, the least experienced nurse in the emergency department?
Show answer and rationale
Correct answer: D. The child who has an edematous and contused right ankle.
This child is stable and will need an x-ray; therefore, an inexperienced nurse could care for this client.
Which nursing task should Ms. Ruth delegate to Ms. Michelle, the UAP?
Show answer and rationale
Correct answer: A. Escort the child who is being discharged via wheelchair out to the parent’s car.
The child is stable and Ms. Michelle can escort the child to the car. This task can be delegated by Ms. Ruth.
The nurse in the outpatient psychiatric unit is returning phone calls. Which client should the psychiatric nurse call first?
Show answer and rationale
Correct answer: C. The male client diagnosed with schizophrenia who is hearing voices telling him to hurt his mother.
The nurse should contact this client first because the client realizes the voices are telling him to hurt his mother. The nurse should inform this client to come to the clinic immediately, and he should be admitted to a psychiatric unit.
The nurse is caring for children in a psychiatric unit. Which client requires immediate intervention by the psychiatric nurse?
Show answer and rationale
Correct answer: B. The 7-year-old child diagnosed with conduct disorder who is throwing furniture against the wall in the day room.
The child with conduct disorder is aggressive to people and animals, bullies and threatens others, destroys property, and sets fires. Throwing furniture could endanger the child or other clients. This behavior warrants immediate intervention.
The male client diagnosed with major depression is returning to the psychiatric unit from a weekend pass with his family. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Check the client for sharps or dangerous objects.
The nurse’s first intervention should be to ensure the client’s safety by checking to make sure the client has no sharps or dangerous objects that he could use to hurt himself, since he is diagnosed with major depression.
The client on the psychiatric unit is yelling at other clients, throwing furniture, and threatening the staff members. The charge nurse determines the client is at imminent risk for harming the staff/clients and instructs the staff to place the client in seclusion. Which intervention should the charge nurse implement first?
Show answer and rationale
Correct answer: B. Obtain a restraint/seclusion order from the HCP.
The use of restraints and seclusion requires an HCP’s order every 24 hours. The nurse must obtain this order first after placing the client in the seclusion room. The nurse can place the client in seclusion for the safety of the client/ staff/other clients, but the nurse must then immediately obtain a HCP’s order.
A woman comes to the emergency department (ED) and tells the triage nurse she was raped by two men. The woman is crying and disheveled, and has bruises on her face. Which action should the triage nurse implement first?
Show answer and rationale
Correct answer: A. Request an ED nurse to take the client to a room and assess for injuries.
The triage nurse’s first intervention is to address the client’s physiological needs, which means to assess for any type of trauma or injury.
The nurse is working in an outpatient mental health clinic and returning phone calls. Which client should the psychiatric nurse call first?
Show answer and rationale
Correct answer: A. The client diagnosed with post-traumatic stress disorder (PTSD) who is threatening his wife.
Post-traumatic stress disorder is an illness that occurs to someone who has experienced a traumatic event. The client feels a numbing of general responsiveness but has outbursts of anger. The nurse should return this call first and assess the situationto determine whether the client should be seen in the clinic.
The psychiatric nurse is working in an outpatient mental health clinic. Which client should the nurse intervene with first?
Show answer and rationale
Correct answer: C. The client whose wife just died and who wants to go to heaven to be with her.
This client who says he wants to go to heaven to be with his wife may be suicidal and should be assessed first to see whether he has a plan.
The emergency department nurse is assessing a female client who has a laceration on the forehead and a black eye. The nurse asks the man who is with the client to please leave the room. The man refuses to leave the room. Which action should the nurse take first?
Show answer and rationale
Correct answer: C. Tell the man the client needs to go to the x-ray department.
The nurse needs to remove the man from the room so that the nurse can talk to the client and discuss probable abuse. Taking the client to the x-ray department may not arouse suspicion in the man and may allow the client to discuss the situation.
The charge nurse received laboratory data for clients in the psychiatric unit. Which client data warrants notifying the psychiatric healthcare provider?
Show answer and rationale
Correct answer: D. The client on clozapine (Clozaril) whose white blood cell count is 13,000.
The WBC count is elevated, which may indicate that the client is experiencing agranulocytosis, a life-threatening complication of clozapine. This laboratory data would warrant notifying the psychiatric healthcare provider.
The client diagnosed with a panic attack disorder in the busy day room of a psychiatric unit becomes anxious, starts to hyperventilate and tremble, and is diaphoretic. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Escort the client from the day room to a quiet area.
The first intervention is to remove the client from the busy day room to a quiet area to help decrease the anxiety attack.
The client diagnosed with a somatization disorder is complaining of vomiting, having diarrhea, and having a fever. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Check the client’s vital signs.
The nurse should first determine if the client’s vital signs are abnormal, which rules out any physiological reason for the client’s complaints.
Which nursing intervention is priority for the client diagnosed with anorexia who is admitted to an inpatient psychiatric unit?
Show answer and rationale
Correct answer: B. Assess the client’s laboratory values.
The client’s laboratory values are priority because these reflect long-term effects of anorexia and possible life-threatening values that must be corrected immediately, especially potassium.
Which client should the psychiatric clinic nurse assess first?
Show answer and rationale
Correct answer: A. The client who is a cocaine abuser who is having chest discomfort.
Cocaine causes vasoconstriction of the coronary arteries and can lead to lifethreatening cardiovascular problems; therefore, this client should be seen first.
The client diagnosed with schizophrenia is being seen by the psychiatric clinic nurse for the initial visit. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Develop a trusting nurse/client relationship.
If the nurse does not establish the foundation for a trusting nurse/client relationship, then the nurse will not be effective in caring for this client. This is the first nursing intervention.
The client diagnosed with hypochondriasis is angry and yells at the psychiatric clinic nurse, "No one believes I am sick! Not my family, not my doctor, and not you." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "I can see you are upset. Sit down and let’s talk."
The nurse must first calm the client, assess the situation, and ensure a therapeutic nurse/client relationship. This response addresses all these issues.
The clinical manager assigned the psychiatric nurse a client diagnosed with major depression who attempted suicide and is being discharged tomorrow. Which discharge instruction by the psychiatric nurse would warrant intervention by the clinical manager?
Show answer and rationale
Correct answer: C. The nurse gives the client a prescription for a 1-month supply of antidepressants.
The client should be given a 7-day supply of antidepressants because safety of the client is priority. As antidepressant medications become more effective, the client is at a higher risk for suicide; therefore, the nurse should ensure that the client cannot take an overdose of medication. This instruction warrants intervention by the clinical manager.
The charge nurse is caring for clients in an acute care psychiatric unit. Which client would be most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)?
Show answer and rationale
Correct answer: B. The client diagnosed with dementia who is confused and disoriented.
The client diagnosed with dementia would be expected to have confusion and disorientation; therefore, the LPN could be assigned this client. This client is not experiencing any potentially life-threatening complication of dementia.
Which task would be inappropriate for the psychiatric charge nurse to delegate to the mental health worker (MHW)?
Show answer and rationale
Correct answer: C. Request the MHW to draw blood for a serum carbamazepine (Tegretol) level.
The MHW does not draw blood, and this would be an inappropriate task to delegate. The laboratory technician draws the client’s blood work.
The male client in the psychiatric unit asks the MHW to mail a letter to his family for him. Which action would warrant intervention by the psychiatric nurse?
Show answer and rationale
Correct answer: D. The MHW informs the client he cannot send mail to his family.
The nurse should explain to the MHW that mental health clients retain all of the civil rights afforded to all persons, except the right to leave the hospital in the case of involuntary commitments. The client has the right to mail and receive letters.
The male client admitted to the medical unit after a motor vehicle accident (MVA) admits using heroin. The unlicensed assistive personnel (UAP) tells the nurse the client is really agitated and anxious, and has slurred speech. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Assess the client for heroin withdrawal.
Whenever the nurse is given information that indicates a complication or is potentially life threatening, the nurse must first assess 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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