NCLEX Practice Questions — Set 1
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
A 38-year-old client, who is gravida 4, para 2 with gestational diabetes, is scheduled for an amniocentesis at 33 weeks’ gestation because of unstable blood sugar. The results of the amniocentesis reveal the lecithin/ sphingomyelin ratio (L/S) is 1:1, and the phosphatidylglycerol (PG) is negative. How should a nurse best interpret this data?
Show answer and rationale
Correct answer: C. The infant is at high risk for respiratory distress syndrome.
the test is performed to determine fetal lung maturity. The L/S ratio should be 2:1 with + PG for the infant who would be at low risk for respiratory distress syndrome.
A client, who is overweight and has diabetes, has a blood pressure of 148/92 mm Hg. The client’s urinalysis reveals microalbuminuria. The client does not want to take drugs despite a family history of brain attack (cerebrovascular accident [CVA]). The correct response by a nurse is:
Show answer and rationale
Correct answer: C. "Use a drug while lifestyle changes are instituted."
The client has genetic risks and risks from hypertension (HTN), obesity, and diabetes. The client already has early renal disease. While losing weight and exercising potentially could bring down the client’s BP to under 130/80, the client will be exposed to risks over the months it will take to change.
Which clinical feature found on assessment should indicate to a nurse that a client has congestive heart failure?
Show answer and rationale
Correct answer: B. Fatigue and dyspnea.
congestive heart failure (CHF) or right-sided heart failure reduces cardiac output; and circulating O2 is reduced, producing fatigue and shortness of breath.
A nurse is caring for a client at 32 weeks’ gestation who has been admitted to an obstetrical unit with complete placenta previa. Which symptoms should the nurse identify as being a result of this client’s condition? Select all that apply.
Show answer and rationale
Correct answer: C. Painless vaginal bleeding.
painless vaginal bleeding is the common symptom of complete placenta previa.
A 4-year-old is hospitalized with acute glomerulonephritis. A nurse should feel most confident that the client teaching has been effective and the child has a basic understanding of this condition if the child states:
Show answer and rationale
Correct answer: C. "I don’t have much pee pee come out when I use the toilet."
because the child’s statement demonstrates a basic knowledge that the main reason for hospitalization pertains to a urinary problem. Acute glomerulonephritis involves altered kidney function, resulting in decreased urine output.
A 34-year-old client, who is gravida 6, para 4, delivered a healthy infant at full term about 18 hours ago. She reports a sharp pain in her left calf while walking to the bathroom. A nurse assesses the client’s left calf, which has a confined area of redness, warmth, and tenderness. Which nursing actions are appropriate for this client’s nursing care? Select all that apply.
Show answer and rationale
Correct answer: A. Encourage the client to ambulate to increase circulation.
the client should be encouraged to ambulate in addition to receiving anticoagulant therapy, since bedrest itself may enhance venous stasis.
The nurse is conducting a seminar on sudden infant death syndrome (SIDS) with a group of first-time parents of newborns. The nurse’s teaching should emphasize:
Show answer and rationale
Correct answer: B. Avoiding soft bedding.
because the use of soft bedding for a newborn should be avoided. It is believed that newborns sleeping on soft bedding may not be able to move their heads to the side, increasing the risk of suffocation, which may be a cause of SIDS.
The laboratory values for an adult client who is NPO are: Na+ 128, K+ 3.5, and glucose 130. Which IV solution should a nurse expect will be ordered?
Show answer and rationale
Correct answer: D. D5NS with 20 mEq KCl/L at 75 mL/hr.
which cannot be replaced with enteral feedings. Fluids are needed when NPO, but the low serum sodium should not be further diluted with rapid administration of hypotonic solutions; thus, normal saline is appropriate. Even though the blood sugar is slightly elevated, it is appropriate to give clients who are NPO some energy source. Dextrose 5% contains only 17 calories/100 mL.
A client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion has a Na+ of 128 mEq/L and is confused. A nurse’s primary goal should be to:
Show answer and rationale
Correct answer: C. Restore fluid and electrolyte balance.
SIADH causes water retention and dilutional hyponatremia
The school nurse inspects the toddlers attending the school’s day-care center. Which observation by the nurse is cause for follow-up for pinworms?
Show answer and rationale
Correct answer: D. Most of the toddlers are wearing cloth diapers.
because the use of superabsorbent disposable diapers, which prevent leakage, are preferred over cloth diapers. Cloth diapers leak, which could result in feces that may be infested with pinworms (enterobiasis) to be spread from toddler to toddler. Cloth diapers would also be taken home to be laundered, which is another way to spread the infestation. The superabsorbent disposable diapers should be disposed of in a closed receptacle as soon as they are soiled.
A client, who is gravida 4, para 2, is admitted to a labor and delivery unit. A nurse performs a vaginal examination and determines that the client’s cervix is 6 cm dilated, 75% effaced, and a +1 station. Based on the nurse’s assessment, in which stage of labor is this client?
Show answer and rationale
Correct answer: B. First stage, active phase.
there are four stages of labor and the first stage covers all phases of cervical dilation. This client is in the first stage, active phase, which is 4 to 8 cm dilation.
A client is admitted with a history of an abdominal aortic aneurysm. A nurse should know that the client has an impending rupture of the aneurysm if the client reports:
Show answer and rationale
Correct answer: B. Persistent or intermittent lower back pain.
the aneurysm is pressing on the lumbar nerves. Severe back or middle or lower abdominal pain are signs of impending rupture. If the aneurysm ruptures, the back pain will be constant.
A clinic nurse is preparing to administer several scheduled immunizations to a 6-month-old infant. What are the appropriate actions for the nurse to take when preparing and administering immunizations? Select all that apply.
Show answer and rationale
Correct answer: B. Administer injections in either dorsogluteal muscle.
appropriate injection site for an infant is the thigh muscle.
A nursing student is assigned to care for a client who is 2 days post-total left hip replacement. Which observation should be reported immediately to a staff nurse?
Show answer and rationale
Correct answer: B. Temperature, 99.6°F; reddened incision.
an infection following hip replacement is aserious complication that may require removal of the implant. Total joint infections may be disastrous, with prevention of an infection a priority. Usually prophylactic antibiotics are ordered; therefore, the appearance of a wound infection would be a grave concern.
A client, who is gravida 2, para 1, ruptures her membranes spontaneously with a large amount of clear fluid. A nurse performs a vaginal examination and discovers a loop of umbilical cord in the vagina. Which immediate action should be taken by the nurse?
Show answer and rationale
Correct answer: C. Elevate the client’s hips.
elevating the client’s hips is the immediate intervention that helps to release the pressure from the umbilical cord until an emergency cesarean section can be performed.
When assessing a child for symptoms of neurogenic diabetes insipidus, what should a nurse anticipate?
Show answer and rationale
Correct answer: C. Increased urine output.
the child with neurogenic diabetes insipidus (DI) will experience severe diuresis resulting from a decrease in ADH secretion.
Which observation in the newborn of a mother with diabetes would require an immediate nursing intervention?
Show answer and rationale
Correct answer: A. Jitteriness.
jitteriness can be indicative of hypoglycemia and the nurse needs to obtain a heel stick blood glucose.
In teaching a client with vision loss from glaucoma about proper lighting, a nurse knows that:
Show answer and rationale
Correct answer: D. Using fluorescent lighting avoids shadows.
glaucoma causes tunnel vision (loss of peripheral vision) and low vision. The client needs increased light, and sees best in natural lighting (sunlight). Fluorescent lighting does not produce glare and reduces shadows. A task light that can be directed is helpful.
A nursing student is performing an initial newborn assessment. The newborn is observed to have a caput succedaneum. What are likely causes of this condition? Select all that apply.
Show answer and rationale
Correct answer: B. Prolonged active phase of labor.
caput succedaneum is a diffuse swelling of the scalp in a newborn caused by pressure from the uterus or vaginal wall during a headfirst (vertex) delivery. Prolonged active phase increases the pressure on the fetal head.
A 65-year-old man with a 45-year history of smoking reports a change in his cough pattern, a nonproductive cough, and generally not feeling well. The chest x-ray reveals an infiltrate. A nurse should suspect:
Show answer and rationale
Correct answer: A. Pneumonia.
the symptoms are characteristic of pneumonia.
A nurse is monitoring the progress of a gravida 3, para 1 client in active labor. Which finding should be reported to a physician immediately?
Show answer and rationale
Correct answer: D. The presence of green-tinged amniotic fluid.
the presence of green-tinged amniotic fluid is not a normal finding and needs to be reported to the physician immediately. Meconium staining can be indicative of fetal distress.
The blood pressure of a 28-year-old client who is overweight and does not have diabetes is 136/78 mm Hg. Client education should include:
Show answer and rationale
Correct answer: A. Losing 20 pounds would bring the blood pressure down by as much as 20 points and reduce the risk of stroke.
this client has prehypertension without compelling indications for drug treatment. Lifestyle changes are indicated. The client is not recognizing the risk. In one sentence, the risk to the client and how to control the risk were addressed.
A client with a history of Graves’ disease is admitted for uncontrolled hyperglycemia and a foot ulcer. This client requires close monitoring because of the increased risk of: Select all that apply.
Show answer and rationale
Correct answer: C. Hypotension.
the client is at risk for thyroid storm because of a second illness, which can lead to hypotension and if untreated,
Which order written by a pediatrician for a 2-month-old infant during a well-infant visit should a nurse question?
Show answer and rationale
Correct answer: B. Administer MMR (measles, mumps, and rubella) vaccine.
MMR (measles, mumps, and rubella) vaccine is not administered until the infant is 12 to 15 months of age. The second dose of this vaccine is given at 4 to 6 years of age.
Treatment for hypertension is important in the prevention of heart failure. A nurse tells a client that the greatest decrease in blood pressure is most likely to occur with:
Show answer and rationale
Correct answer: C. Weight loss.
a weight loss of 10 kg can reduce the systolic BP up to 20 mm Hg.
A client, who is gravida 3, para 1, is diagnosed with diabetes at 28 weeks’ gestation. A nurse is providing instruction about the role of insulin in managing the client’s diabetes. Which statement by the nurse is true regarding insulin needs during pregnancy?
Show answer and rationale
Correct answer: B. Insulin requirements will increase as the pregnancy progresses.
insulin requirements will increase as the pregnancy progresses. The placenta creates increasing amounts of human placental lactogen, causing the client to be more insulin resistant, increasing the need for insulin.
A nursing student selects a 1 /2-inch needle with which to administer a DTaP (diphtheria, tetanus, and acellular pertussis) vaccine to a 4-month-old infant. A nursing instructor’s best action would be to:
Show answer and rationale
Correct answer: D. Question the nursing student regarding the injection route used to administer the vaccine.
it will stimulate the nursing student to think in a critical manner. DTaP (diphtheria, tetanus, and acellular pertussis) vaccine is given intramuscularly and a 1-inch/2.5-cm needle must be used to deposit the vaccine deep in the muscle mass.
A client, who is gravida 1, para 0 at 38 weeks’ gestation, is found to have a blood pressure of 170/90 mm Hg. Which action should a nurse take first?
Show answer and rationale
Correct answer: D. Evaluate the urine protein.
a high blood pressure (170/90 mm Hg) may be indicative of preeclampsia, or may be due to gestational hypertension, pain, or severe anxiety. The nurse needs to determine if the client has proteinuria. If there is proteinuria, the high blood pressure is suggestive of preeclampsia
A 12-year-old child is seen in a pediatrician’s office for a well-adolescent checkup. The adolescent’s most important vaccine status for a nurse to assess would be:
Show answer and rationale
Correct answer: B. HPV (human papillomavirus).
the HPV (human papillomavirus) vaccine is given between 11 and 12 years of age. This would be the most likely vaccine that the adolescent has yet to receive.
A client, who fell 10 feet onto a concrete floor, presents to an emergency department. The client does not speak English. The correct action by a nurse to determine the severity of the client’s pain would be to:
Show answer and rationale
Correct answer: A. Use an illustrative pain scale.
pain scales, like the Oucher Scale, are accurate with many ethnic groups and languages.
The parents of a 6-month-old infant express their concerns regarding the number of vaccines their infant has already received. A nurse’s best action would be to:
Show answer and rationale
Correct answer: A. Provide the parents with accurate, user-friendly information regarding vaccines.
information is always the best way to reduce parents’ anxieties and concerns over vaccines. The information should include the need for each vaccine and what disease each vaccine prevents. Lack of information could needlessly prevent an infant from getting protection against life-threatening diseases.
An undesired consequence of acute pain is the progression to a chronic pain syndrome. The correct approach by a nurse to prevent chronic pain syndrome would be to:
Show answer and rationale
Correct answer: B. Adequately control acute pain.
the most common cause of chronic pain syndrome is failure to control acute pain. Chronic pain syndrome consists of chronic anxiety and depression, anger, and changed lifestyle, all with a variable but significant level of genuine neurologically based pain.
A 42-year-old, who is gravida 1, para 0, has a successful in-vitro fertilization and is 7 weeks pregnant. Based on the client’s history, a nurse knows the infant is at risk for:
Show answer and rationale
Correct answer: C. Down syndrome.
the client’s age (42) puts her at a higher risk for an infant with Down syndrome.
A client delivers a 4-pound, 8-ounce neonate at 35 weeks’ gestation. A meconium drug screen shows the presence of heroin. The neonate is admitted to the nursery with narcotic abstinence syndrome. Nursing care of the neonate should include:
Show answer and rationale
Correct answer: C. Wrapping the neonate snugly in a blanket.
wrapping the newborn snugly in a blanket decreases the hyperirritability and increases feeling of security.
A client, who is 32 years old, gravida 4, para 1 at 31 weeks’ gestation, has been recently diagnosed with gestational diabetes. She has attended a class about managing diabetes during pregnancy. Which statements should indicate to a nurse that the client understands what was taught about gestational diabetes? Select all that apply.
Show answer and rationale
Correct answer: B. "I need to keep my blood sugar well controlled so the baby won’t grow too large."
keeping the blood sugar well controlled has a direct relationship to decreasing the risk for macrosomia and hypoglycemia in the neonate
A client with a known history of IV drug use is found to have acute appendicitis with perforation. Following surgery, the client reports severe pain at the surgical incision. There are no signs of abscess formation or other postoperative complications. The correct approach to manage the client’s pain would be to:
Show answer and rationale
Correct answer: C. Give the ordered opioid.
the client must be treated for pain as expressed. The IV drug use may require that a higher dose be given, but the presence of pain as expressed by the client should not be ignored.
The mother of a school-age child who is isolated at home with chickenpox (varicella) informs a school nurse that, "My child is miserable from the itching. What can I do?" The school nurse’s best response would be to suggest:
Show answer and rationale
Correct answer: A. Giving diphenhydramine hydrochloride.
diphenhydramine hydrochloride (Benadryl) is a nonprescription antihistamine that will safely and effectively reduce the child’s itching for up to 4 to 6 hours following a dose of the medication.
An 84-year-old with diabetes and left leg cellulitis is brought to an emergency department. Vital signs are: BP 132/90 mm Hg, T 99.4�F, P 95, and R 20. Blood glucose is 98. Left leg is red and swollen. The client is admitted to a nursing unit. Which order should be a priority for the nurse?
Show answer and rationale
Correct answer: A. Draw blood cultures.
a low-grade temperature and elevated pulse in an older adult are consistent with infection. The specific bacteria causing the infection of the skin and subcutaneous tissue should be identified to prevent sepsis.
A client, who is gravida 4, para 0 at 39 weeks’ gestation, states, "I would like to breastfeed, but my mother-in-law told me my breasts are too small and I won’t have enough milk for my baby." Which would be the best response by the nurse?
Show answer and rationale
Correct answer: B. "The size of the breasts doesn’t matter. All women have about the same amount of milk-producing tissue."
the amount of milkproducing glandular tissue in all women is approximately the same. The size of large breasts is due to increased fatty tissue.
An African American infant with an umbilical hernia is brought to a well-infant clinic for routine immunizations. During the visit, a nurse notes that the parent has taped the umbilical hernia down on the abdomen to flatten the protrusion. The nurse would be correct in telling the parent that:
Show answer and rationale
Correct answer: A. Taping the umbilical hernia down to the abdomen does not help.
taping the umbilical hernia down to the abdomen does not aid in resolution of the hernia. It can produce skin irritation and breakdown. This practice should be discouraged.
A client, who is gravida 3, para 2, is asking a nurse for advice concerning her nightly leg cramps. Which response by the nurse is correct?
Show answer and rationale
Correct answer: A. "Increase your calcium intake."
leg cramps are caused by low blood calcium levels; increasing calcium intake can decrease leg cramps.
A child hospitalized with measles (rubeola) cries every time a nurse enters the room and turns on the overhead light. The nurse should investigate if the child has:
Show answer and rationale
Correct answer: A. An intolerance of light.
an intolerance of light (photophobia) is a common side effect of measles (rubeola). Dimming lights in the child’s room is suggested if photophobia is present.
A nurse knows that a client with hypercalcemia may experience: Select all that apply.
Show answer and rationale
Correct answer: B. Loss of appetite.
the high calcium increases gastric acid secretion and may intensify gastrointestinal manifestation. Anorexia, nausea, and vomiting are intensified by increased gastric residual volume.
A child is hospitalized with scarlet fever. Which food item should the nurse remove from the child’s breakfast tray?
Show answer and rationale
Correct answer: B. Orange juice.
scarlet fever is associated with an inflamed oral cavity. Because of this, rough foods and irritating fluids are to be avoided. Citrus juices, such as orange juice, would further irritate the inflamed oral cavity
A client comes to the prenatal clinic to begin care. The nurse would advise her that the routine test(s) during the initial examination is/are: Select all that apply.
Show answer and rationale
Correct answer: B. Rubella titer.
rubella titer is part of the initial prenatal laboratory panel.
The most appropriate nursing intervention to encourage a child to eat who had a tonsillectomy 24 hours ago is to:
Show answer and rationale
Correct answer: D. Apply an ice collar to the throat 30 minutes prior to the meal.
an ice collar applied to the throat 30 minutes prior to the meal will serve as a local anesthetic and reduce the child’s oral and throat pain, which will assist in eliciting the child’s cooperation with eating.
With which conditions is a risk of postpartum hemorrhage associated? Select all that apply.
Show answer and rationale
Correct answer: D. The birth of a macrosomatic neonate.
a macrosomatic (very large) baby can predispose a woman to uterine atony, and thus to hemorrhage.
A client with Sjögren’s syndrome, an autoimmune disorder in women, is scheduled for surgery. The correct nursing action would be:
Show answer and rationale
Correct answer: D. Lubricate the client’s eyes with ointment before surgery.
with Sjögren’s syndrome, lacrimal glands are destroyed, resulting in dry eyes (keratoconjunctivitis).
A school-age child is hospitalized with mumps (parotitis). Which food item should the nurse remove from the child’s lunch tray?
Show answer and rationale
Correct answer: C. An apple.
mumps (parotitis) is associated with swelling at the jaw line, followed by an earache that is aggravated by chewing. A soft, bland diet is suggested, as well as avoiding foods that require chewing. An apple would require chewing on the child’s part.
A client with a history of GI bleeding is admitted with complaints of fatigue, weakness, and shortness of breath. Hgb is 7.4 mg/dL, T 97.8�F, BP 86/45 mm Hg, P 118, and R 22. Two units of packed RBCs are ordered. As a nurse begins the blood transfusion, the client suddenly complains of chills and chest pain. Which actions should be taken by the nurse? Select all that apply.
Show answer and rationale
Correct answer: D. Stopping the blood transfusion.
the client should not receive any more blood, which is the source of the antigen that is causing the allergic response.
A client, who is gravida 5, para 4, delivered a 6-pound, 5-ounce infant 2 hours ago. The client is complaining of severe uterine cramping while breastfeeding. A nurse knows that these symptoms are most likely due to:
Show answer and rationale
Correct answer: D. Uterine atony.
breastfeeding causes the release of prolactin and oxytocin. Oxytocin is a hormone that causes uterine contractions. The release of oxytocin while breastfeeding speeds uterine involution. This may also cause cramps while breastfeeding in the postpartum period. Cramping is more severe in clients who are multiparous.
A child is isolated at home with whooping cough (pertussis). Which parental behavior indicates the need for additional teaching by the nurse?
Show answer and rationale
Correct answer: B. Using the fireplace as an additional means of heating the house.
using the fireplace as an additional means of heating the house creates dust and smoke that may cause paroxysms of coughing associated with whooping cough (pertussis).
A client, who is a 22-year-old primigravida, is at 38 weeks’ gestation and 9 cm of dilation. Her contractions are 2 to 4 minutes apart and her uterus palpates soft between very firm contractions. She is very irritable and screaming in pain. A nurse should instruct this client to:
Show answer and rationale
Correct answer: C. Do shallow chest breathing.
this client is in the transition phase of the first stage of labor. The proper breathing technique is shallow chest breathing, which prevents hyperventilation and bearing down before she is completely dilated.
A charge nurse on a pediatric unit is preparing the daily assignment sheet. Which nurse is the best choice to care for a child hospitalized with German measles (rubella)?
Show answer and rationale
Correct answer: C. A 50-year-old woman with 25 years of pediatric nursing experience.
German measles (rubella) has a teratogenic effect on fetuses. At 50 years of age, this likely would not be a concern. And, the nurse’s 25 years of pediatric nursing experience would be a plus in caring for the child.
A 5-year-old child is diagnosed with acute tonsillitis for the third time in a year. The mother asks the nurse, "Can’t the pediatrician just take the tonsils out now? Why wait until the infection is over?" The nurse’s most accurate response would be:
Show answer and rationale
Correct answer: A. "The inflammation and infection increase the risk of bleeding during the surgery."
acute inflammation and infection ("itis") of tonsillar tissue increase the risk of bleeding at the time of surgery. The operative site for a tonsillectomy is highly vascular, with the risk of postoperative bleeding already a concern. An active inflammation and infection would increase this concern.
A 30-year-old man has been recently diagnosed with Cushing’s syndrome. He asks a nurse if he will be able to continue riding off-road motorcycles. The correct response by the nurse is:
Show answer and rationale
Correct answer: C. "Muscle weakness and the increased risk for fractures will require a change in activities."
the overproduction of adrenocortical hormone results in excessive protein breakdown, causing compression fractures and weakness.
The care of a client post-traumatic brain injury includes monitoring for signs of brainstem herniation and occlusion of cerebral blood flow. A nurse should recognize a deterioration in the client if which vital sign changes occurred? Select all that apply.
Show answer and rationale
Correct answer: A. Bradycardia.
bradycardia is one of the vital sign changes with Cushing’s triad, a grave sign, indicating herniation of the brainstem and occlusion of the cerebral blood flow if treatment is not initiated.
When counseling the parents of a child with severe hemophilia, the nurse would correctly inform the parents that:
Show answer and rationale
Correct answer: C. Primary prophylaxis should be given on a regular basis before the onset of joint damage.
primary prophylaxis (the infusion of factor VIII concentrate on a regularly scheduled basis before the onset of joint damage) has been proven to be effective in preventing arthropathy.
A child is being prepared for a tonsillectomy. The laboratory telephones the pediatric unit and reports that the child’s prothrombin time (PT) is 14.1 seconds. The nurse’s first action should be to:
Show answer and rationale
Correct answer: D. Note the laboratory result in the child’s chart.
a normal prothrombin time (PT) in a child is 11 to 15 seconds. A value of 14.1 seconds is within normal limits and the child is a safe candidate for the surgery. Because the tonsillar operative site is highly vascular, bleeding is a concern and coagulation studies are always conducted prior to the surgery. Since other health-care personnel (e.g., the pediatric surgeon, operating room surgical team, etc.) will also need this information before proceeding with the surgery, the nurse’s first action should be to note the laboratory result in the child’s chart.
Which assessment findings should alert a nurse to the potential of an addisonian crisis in a client? Select all that apply.
Show answer and rationale
Correct answer: A. Cyanosis and weak pulse.
addisonian crisis is characterized by cyanosis and signs of circulatory collapse.
A 92-year-old client, who recently had a below-the-knee leg amputation, is resisting attempts at rehabilitation. The most likely reason for the resistance is that the client:
Show answer and rationale
Correct answer: B. Has goals that differ from the rehabilitation care plan.
resistance or noncompliance is often related to different priorities or goals.
A nurse prepares to discontinue the IV of a child with a low platelet count. Special precautions taken by the nurse when performing this nursing action should include:
Show answer and rationale
Correct answer: A. Applying direct pressure to the IV site for 5 minutes.
a child with a low platelet count will have bleeding tendencies. When discontinuing the IV, the nurse should treat the IV site as an arterial puncture and apply direct pressure to the site for a minimum of 5 minutes.
A nursing student is being mentored by a charge nurse on a pediatric unit. The nursing student is assigned to care for a child who has increased intracranial pressure following a head trauma. The charge nurse questions the nursing student regarding positions that would be contraindicated or ineffective when caring for the child. The nursing student should correctly identify: Select all that apply.
Show answer and rationale
Correct answer: B. Prone position.
this position would not promote the drainage of cranial fluids that have accumulated due to increased intracranial pressure. In addition, placing the child on the abdomen (prone) could prevent an adequate airway from being maintained.
A client is combative and demanding and refuses to swallow any medication following a brain attack (CVA). The correct nursing action is to:
Show answer and rationale
Correct answer: D. Determine what the client’s personality was before the CVA.
the behavior may be a pattern. Family may have suggestions that will help.
A nurse is concerned that a client may be at risk for oversedation from opioid therapy using a patientcontrolled analgesia (PCA) pump. The most reliable assessment for possible oversedation would be to check:
Show answer and rationale
Correct answer: C. The level of carbon dioxide in the blood using capnography.
opioids will depress ventilation, causing a buildup of carbon dioxide in the blood. If hypoventilation is present, measuring the level of carbon dioxide is the most reliable indication of possible respiratory depression. Capnography measures breath-by-breath the level of CO2 and is most often used during anesthesia, in critical care, and in emergency medicine to prevent respiratory depression. If capnography is not available with the client who is on PCA, monitoring the client’s respiratory rate and depth and assessing sedation levels are essential
The parents of a 2-year-old child ask a nurse how to best manage their child’s temper tantrums. What advice should the nurse give the parents?
Show answer and rationale
Correct answer: D. Tantrums may be prevented by alerting the child in advance about a change in activities.
toddlers may have temper tantrums to express their frustration. Sudden changes in activities should be avoided, and the toddler should be given forewarning about what is coming next.
A client, who is a 24-year-old gravida 6, para 5, delivered a 10-pound, 10-ounce baby 6 hours ago, after a 26-hour labor. Upon assessment, an RN finds the client’s fundus is 2 fingerbreadths above the umbilicus and slightly deviated to the right. Based on the information provided, for which complication is this client at risk?
Show answer and rationale
Correct answer: C. Postpartum hemorrhage.
this client’s fundus is higher than expected for this stage after delivery and is deviated to the right, indicating she has a full bladder that can impede the uterus from contracting adequately. This can result in a postpartum hemorrhage.
A client is seen in an emergency department for rotator cuff tendonitis. What is the correct immediate treatment?
Show answer and rationale
Correct answer: C. A sling for the arm.
because the injured tissue needs to be immobilized.
The correct nursing action to prevent infection in a client with an external fixation device for an open fracture is to:
Show answer and rationale
Correct answer: D. Give prophylactic antibiotics.
open fractures create opportunities for microbes to enter the wound. Antibiotics throughout the perioperative period reduce the risk.
During the active phase of labor, a client, who is a gravida 2, para 0, begins to complain of dizziness, tingling in her fingers, and numbness in her lips. The most appropriate nursing intervention for this client would be to:
Show answer and rationale
Correct answer: C. Have her breathe into a paper bag.
this client is hyperventilating, resulting in a reduction of carbon dioxide in her blood and causing her symptoms. Having her breathe into a paper bag will increase the carbon dioxide in her blood and alleviate the symptoms.
A client has been receiving warfarin (Coumadin) and heparin for 2 days following a total knee arthroplasty. Laboratory results show that INR is 1.2, Hct is 34%. A nurse should:
Show answer and rationale
Correct answer: D. Continue both drugs as ordered.
clients having knee surgery are at very high risk for thrombus formation and need anticoagulation. Coumadin is convenient because it can be taken for several days of therapy before achieving therapeutic results (an INR level of 2). Until achieved, the quicker acting drug, heparin, is also used.
Which assessment finding should a nurse most expect in a newborn infant with a cyanotic heart defect?
Show answer and rationale
Correct answer: B. Tachycardia.
the newborn with a cyanotic heart defect will most likely experience tachycardia as the heart attempts to improve oxygenation.
A client will receive a spinal anesthetic for cesarean birth. As the client discusses the surgery, she asks an RN about the possibility of postanesthesia headaches. Which is the most appropriate response by the RN?
Show answer and rationale
Correct answer: C. "This problem may be prevented by keeping the head of the bed flat."
keeping the head of the bed flat can alleviate the headache caused by the difference in pressure. Sitting up can make the headache worse by increasing the pressure difference.
A 50-year-old client, who is overweight, is tested at a health fair and the result of a nonfasting blood sugar is 210 mg/dL. A nurse should:
Show answer and rationale
Correct answer: D. Tell the client that follow-up is needed later in the week.
even for a nonfasting sample, and is suggestive of diabetes. The client should be seen soon.
A clinic nurse prepares to administer an IM injection to a school-age child. Which pain management technique would be best suited for this child and should be applied during the procedure?
Show answer and rationale
Correct answer: B. Guided imagery.
the school-age child is old enough to understand and comply with instructions regarding guided imagery, a technique to help the child focus on a pleasant mental image during the procedure.
What advice should a nurse give to a person with type 1 diabetes who is beginning a running program in an effort to get in shape?
Show answer and rationale
Correct answer: D. Carry a sugar source.
people with diabetes should carry a sugar source, especially when beginning an exercise program. Exercise facilitates glucose uptake into cells independent of insulin. If the client took a regular dose of insulin before exercising, the client could become hypoglycemic.
How should a nurse caring for an elderly client with receptive and expressive aphasia communicate with the client? Select all that apply.
Show answer and rationale
Correct answer: A. Use a picture board or flash cards.
a visual mode is helpful when the client has difficulty hearing (auditory aphasia, receptive) or writing (expressive aphasia, visual).
Which client has the best control of diabetes?
Show answer and rationale
Correct answer: B. A client who has trouble remembering meds, but good compliance with diet and exercise. FBS is 110 mg/dL, HgbA1c is 7%.
the A1c measures average blood sugar over the previous 3 months. The goal is less than 7%. Short-term compliance can give the client a normal fasting blood sugar, but this is not considered good control of the disease.
A client, who is 17 years old, has delivered a 6-pound, 6-ounce girl at 38 weeks’ gestation 3 hours ago. A nurse is completing a routine postpartum assessment. Which assessments should the nurse report to a physician immediately? Select all that apply.
Show answer and rationale
Correct answer: D. Positive Homans’ sign.
a positive Homans’ sign can be a symptom of deep vein thrombosis and needs to be reported to the physician immediately.
If a client’s blood sugar is lowered too rapidly, for what manifestation or dangerous outcome should a nurse observe?
Show answer and rationale
Correct answer: D. Confusion from cerebral edema.
sugar adds to the osmolarity of the blood. Lowering the sugar level too fast makes the intracellular osmolarity relatively higher than that in the bloodstream. Water will move from areas of low concentration to areas of high concentration, swelling the cells and resulting in confusion or change in level of consciousness. If this happens in the brain it could have life-threatening consequences.
A nurse assesses a child diagnosed with measles. Which symptom is the nurse least likely to observe in a child diagnosed with measles?
Show answer and rationale
Correct answer: C. Slapped cheek appearance.
the child with measles is likely to exhibit all of the symptoms listed except for a slapped cheek appearance. The slapped cheek appearance is associated with both fifth disease (erythema infectiosum) and scarlet fever.
Health teaching for a client who is newly diagnosed with diabetes should include:
Show answer and rationale
Correct answer: D. Call provider if breath smells fruity.
fruity-smelling breath implies the production of ketones, which would occur with inadequate delivery of glucose to the cells. This can cause a dangerous acidosis and should be corrected immediately.
A client, who is gravida 3, para 1, is 6 cm dilated, 80% effaced, and a 0 station. The external fetal monitor shows baseline heart rate of 145 bpm, moderate variability, and variable decelerations. What are appropriate nursing interventions for this client? Select all that apply.
Show answer and rationale
Correct answer: A. Perform a sterile vaginal exam.
performing a sterile vaginal examination will eliminate the possibility of a prolapsed umbilical cord that may be causing the variable decelerations. Answer 2 is correct because changing the client’s position can help alleviate cord compression that could be causing the variable decelerations.
Following a nephrectomy, which complication does a client have the greatest risk of developing?
Show answer and rationale
Correct answer: A. Possible altered gas exchange related to shallow breathing from pain.
the kidneys are located just under the diaphragm. Postoperative pain, particularly with deep breathing, would be anticipated. The client is therefore likely to do shallow breathing.
An infant is admitted for pyloric stenosis. Which symptoms should a nurse expect to find? Select all that apply.
Show answer and rationale
Correct answer: D. Metabolic alkalosis.
the infant with pyloric stenosis experiences metabolic alkalosis as a result of excessive vomiting.
A postpartum nurse instructed a client on proper perineal care after delivery of a healthy neonate vaginally after a midline episiotomy. Which client activities should indicate to the nurse that the client has understood the instructions? Select all that apply.
Show answer and rationale
Correct answer: B. The client consistently uses the peri bottle to clean the perineum after each void or bowel movement.
consistently using the peri bottle to clean the perineum after each void or bowel movement demonstrates proper perineal care. The nurse should give instructions to keep the perineum clean to increase comfort and prevent infection. Using a peri bottle and water to rinse after each void or bowel movement helps keep the perineum clean and decreases the chance of infection.
Older adults often present with atypical assessment findings. Which symptom will an older adult with a urinary tract infection (UTI) most often develop first?
Show answer and rationale
Correct answer: A. Confusion.
confusion is often the first indication of infection, which progresses rapidly to urosepsis.
While visiting a local park, a nurse witnesses the collapse of a preschool-age child. The nurse assesses the child and finds no pulse and no respirations. The nurse begins compressions. At what rate per minute should the nurse deliver the compressions?
Show answer and rationale
Correct answer: D. 100 compressions per minute.
The appropriate number of compressions per minute during CPR on a child is 100 per minute
A client reports sharp pain in the calf of the left leg when walking to the bathroom. A nurse notes that the leg has a confined area of warmth, tenderness, and redness. Which nursing action is most appropriate for this client?
Show answer and rationale
Correct answer: B. Elevating the affected extremity to promote venous blood flow.
this client has a superficial thrombophlebitis. Elevation of the affected extremity, a few days of bedrest, and local application of heat are often all that is needed to treat superficial thrombophlebitis.
A graduate nurse has been working on a medical unit for 3 months. The nurse manager has posted the team leader assignments for the following week. The graduate nurse knows that the major responsibility of the team leader is to: Select all that apply.
Show answer and rationale
Correct answer: A. Know the condition of the clients on the team.
it describes the role of the team leader. Answer 2 is correct because it describes the role of the team leader.
A woman has chosen a patch applied to her skin as her method to deliver contraceptive medication. A nurse should instruct the client to call the clinic immediately if the client experiences: Select all that apply.
Show answer and rationale
Correct answer: D. Pain in the legs while walking.
pain in the legs while walking can be a sign of thrombophlebitis, a life-threatening complication of hypercoagulability caused by the increased hormone levels. Answer 4 is correct because a headache unrelieved by analgesics can be a symptom of a blood clot in the brain, another life-threatening complication of hypercoagulability caused by the increased hormone levels.
Suddenly, during a labor contraction, a pregnant client experiences a gush of amniotic fluid. Which assessment finding should indicate to a nurse that the client is experiencing a deviation from normal labor patterns?
Show answer and rationale
Correct answer: D. Colored amniotic fluid.
normal amniotic fluid is basically colorless; any color may signify fetal or maternal problems. For example, yellow or green amniotic fluid indicates meconium release due to fetal hypoxia or breech presentation; bloody amniotic fluid may indicate a placental abruption or marginal placenta previa.
A nurse provides health teaching to the parents of a school-age child diagnosed with attention deficithyperactivity disorder (ADHD). What should the nurse include in the teaching plan?
Show answer and rationale
Correct answer: A. The home’s televisions and radios should be kept at a low to moderate volume.
excess environmental stimulation can increase the hyperactivity and distractibility of a child with ADHD.
A client with a 6-month history of burning pain and weakness to the thumb and first and middle fingers has a carpal tunnel release done with regional anesthesia. In the PACU, the priority nursing assessment should be:
Show answer and rationale
Correct answer: B. Color, temperature, movement of the fingers.
checking circulation and sensation in the fingers helps to establish that no damage to blood vessels or nerves occurred during surgery, and that postoperative swelling is not damaging those structures. This procedure is usually done under regional anesthesia; return of sensation and movement indicates anesthesia is wearing off appropriately
A client, who is a primigravida, is 6 cm dilated, 100% effaced, and a -3 station. She suddenly has a gush of fluid. Which nursing assessments indicate a complication and should be reported to a physician? Select all that apply.
Show answer and rationale
Correct answer: B. Green-tinged fluid.
green-tinged fluid is indicative of meconium staining, a possible indicator of fetal distress, and should be reported to the physician.
Which conditions would most likely contribute to an increase in a client’s need for oxygen (O2)? Select all that apply.
Show answer and rationale
Correct answer: C. Burns over trunk and legs.
burns increase cellular metabolism, resulting in an increased oxygen demand.
A primigravida presents to a labor and delivery unit at 30 weeks’ gestation. Her major complaints are abdominal pain, vaginal bleeding, and dysuria. Which interventions or assessments should a nurse perform when caring for this client? Select all that apply.
Show answer and rationale
Correct answer: D. Place the client on an external fetal monitor.
placing the client on an external fetal monitor is standard nursing procedure to evaluate the fetal wellbeing and the pattern of contractions. With preterm labor, it is important to evaluate uterine activity on the external fetal monitor.
The parents of a child isolated with scarlet fever ask a nurse. "Why didn’t our child get a vaccine for this disease?" The nurse’s best response is:
Show answer and rationale
Correct answer: D. "The disease is bacterial in nature and responds well to antibiotics."
scarlet fever is bacterial in nature (Group A ?-hemolytic streptococci) and responds well to antibiotics (usually penicillin). Vaccines are generally developed for communicable diseases that are viral in nature.
The K+ level of a client in acute renal failure is 6.8 mEq/L. Which treatments will decrease the potassium level? Select all that apply.
Show answer and rationale
Correct answer: C. Sodium bicarbonate IV.
correcting the acidosis with sodium bicarbonate will cause potassium to shift back into the cell.
A client, who is 38 years old, gravida 5, para 0, with type 1 diabetes, is 13 weeks pregnant. Her hemoglobin A1c level is 8.2%. She is attending a prenatal class for clients with highrisk pregnancies. Which possible complications should a nurse anticipate in this client? Select all that apply.
Show answer and rationale
Correct answer: D. Polyhydramnios.
polyhydramnios, or too much amniotic fluid, is a condition resulting from poor glycemic control during pregnancy, which causes hyperglycemia of the fetus and fetal polyuria (fetal urine is a major source of amniotic fluid). This client’s hemoglobin A1c is elevated at 8.2% (the normal is less than 6.0%), indicating poor glycemic control during early pregnancy. Answer 3 is correct because macrosomia, a fetus who is oversized, is a condition resulting from poor glycemic control during pregnancy. The fetus produces too much insulin in response to the maternal hyperglycemia; insulin acts as a growth hormone during fetal development, producing a large fetus. Answer 4 is correct because this client’s hemoglobin A1c is elevated at 8.2% (the normal is less than 6.0%), indicating poor glycemic control during early pregnancy, which is highly correlated with spinal anomalies.
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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