NCLEX Practice Questions — Set 10
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first?
Show answer and rationale
Correct answer: B. The client with coronary artery disease who is complaining that the nurses are being rude and won’t answer the call lights.
The charge nurse is responsible for all clients. At times it is necessary to see clients with a psychosocial need before other clients who have situations that are expected and are not life threatening.
The nurse is preparing to administer digoxin 0.25 mg IVP to a client in severe congestive heart failure who is receiving D5W/0.9 NaCL at 25 mL/hr. Rank in order of importance.
Show answer and rationale
Correct answer: A. Dilute the medication with normal saline.
The nurse should dilute the medication with normal saline to a 5- to 10-mL bolus to help decrease pain during administration and maintain the IV site longer. Administering 0.25 mg of digoxin in 0.5 mL is very difficult, if not impossible, to push over 5 full minutes, which is the manufacturer’s recommended administration rate. If the medication is diluted to a 5- to 10-mL bolus, it is easier for the nurse to administer the medication over 5 minutes.
The client is in the cardiac intensive care unit on dopamine, a vasoconstrictor, and B/P increases to 210/130. Which intervention should the intensive care nurse implement first?
Show answer and rationale
Correct answer: D. Discontinue the client’s vasoconstrictor, dopamine.
The nurse should first discontinue the medication that is causing the increase in the client’s blood pressure prior to doing anything else.
The charge nurse is making client assignments in the cardiac critical care unit. Which client should be assigned to the most experienced nurse?
Show answer and rationale
Correct answer: A. The client who is showing multifocal premature ventricular contractions (PVCs).
Multifocal PVCs are an emergency and are possibly life threatening. An experienced nurse should care for this client.
The primary cardiac nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which delegation task warrants intervention by the charge nurse of the cardiac unit?
Show answer and rationale
Correct answer: A. The UAP is told to feed a client who is dysphagic.
This client is at risk for choking and is not stable; therefore, the charge nurse should intervene and not allow the UAP to feed this client.
The nurse is administering medications to clients in the cardiac critical care area. Which client should the nurse question administering the medication?
Show answer and rationale
Correct answer: D. The client receiving a calcium channel blocker (CCB) who is drinking a glass of grapefruit juice.
The client receiving a CCB should avoid grapefruit juice because it can cause the CCB to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and the intestinal wall. This inhibition affects the metabolism of some drugs and can, as is the case with CCBs, lead to toxic levels of the drug. For this reason, the nurse should investigate any medications the client is taking if the client drinks grapefruit juice.
The charge nurse on the cardiac unit is counseling a female staff nurse because the nurse has clocked in late multiple times for the 7:00 a.m. to 7:00 p.m. shift. Which conflict resolution uses the win-win strategy?
Show answer and rationale
Correct answer: B. The charge nurse discovers that the staff nurse is having problems with child care; therefore, the charge nurse allows the staff nurse to work a 9:00 a.m. to 9:00 p.m. shift.
This is a win-win strategy that focuses on goals and attempts to meet the needs of both parties. The charge nurse keeps an experienced nurse and the staff nurse keeps her position. Both parties win.
Which client warrants immediate intervention by the nurse?
Show answer and rationale
Correct answer: C. The client diagnosed with atherosclerosis who has slurred speech and drooling.
Slurred speech and drooling are signs of a cerebrovascular accident (stroke or brain attack) and is not normal for a client with atherosclerosis; therefore, this client should be assessed first.
The UAP working in a long-term care facility notifies the nurse that the client diagnosed with congestive heart failure who is on a low-sodium diet is complaining that the food is inedible. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Check to see what the client has eaten in the past 24 hours.
Assessing the client’s intake will help the nurse to determine the extent of the client’s complaints. This is the first intervention.
The nurse and the UAP enter the client’s room and discover that the client is unresponsive. Which action, according to the American Heart Association (AHA) guidelines, should the nurse assign to the UAP first?
Show answer and rationale
Correct answer: B. Instruct the UAP to get the crash cart.
The nurse can tell the UAP to get the crash cart while the nurse assesses the client. This is the best task to assign the UAP at this time because this client may be unstable and until that is determined, the nurse should not delegate any client care.
The elderly client on a cardiac unit has a do not resuscitate (DNR) order written. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Continue to care for the client’s needs as usual.
The nurse should care for the client as if the DNR order was not on the chart. A DNR order does not mean the client no longer wishes treatment. It means the client does not want CPR or to be placed on a ventilator if the client’s heart stops beating.
The nurse is initiating discharge teaching to a 68-year-old male client who had quadruple coronary bypass surgery. Which priority question should the nurse ask the client?
Show answer and rationale
Correct answer: D. "Are you sexually active?"
The nurse should be aware that sexual activity is important to most adults and should not decide that the client is not sexually active because of a client’s age. The nurse should provide instructions regarding sexual activity before the client is discharged. This is the question that should be asked because many clients may be embarrassed to bring up the subject.
The LPN informs the clinic nurse that the client diagnosed with atrial fibrillation has an INR of 4.5. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: A. Tell the LPN to notify the clinic healthcare provider (HCP).
The LPN can contact the HCP and give pertinent information. The INR is high (therapeutic is 2 to 3), and the HCP should be informed.
The nurse at a disaster site is triaging victims when a woman states, "I am a certified nurse aide. Can I do anything to help?" Which action should the nurse implement?
Show answer and rationale
Correct answer: D. Tell the woman to try and keep the victims calm.
Unlicensed assistive personnel (UAP) have the ability to keep the victims calm; therefore, this is an appropriate action. This action is not critical to the safety of the victims.
The cardiac clinic nurse hears the UAP tell the client, "You have gained over 15 pounds since your last visit." The scale is located in the office area. Which action should the clinic nurse implement?
Show answer and rationale
Correct answer: B. Explain to the UAP, in private, that this is an inappropriate comment and violates HIPAA.
The clinic nurse should correct the UAP’s behavior, but it should be done in private and with an explanation as to why the action is inappropriate. This is a violation of confidentiality because the scale is located in the office area and any client or visitor passing by, as well as other staff members, can hear the comment.
The nurse on the cardiac unit is discussing case management with a client who asks, "Why do I need a case manager for my heart disease?" Which statements are most appropriate for the nurse to respond? Select all that apply.
Show answer and rationale
Correct answer: D. "Case management helps contain the costs of your healthcare."
Case managers help coordinate healthcare between multiple sources of healthcare attempting to contain healthcare cost.
The client diagnosed with arterial hypertension and has been taking a calcium channel blocker, a loop diuretic, and an ACE inhibitor for 3 years. Which statement by the client would warrant intervention by the nurse?
Show answer and rationale
Correct answer: A. "I drink grapefruit juice every morning with my breakfast."
Grapefruit juice can cause calcium channel blockers to rise to toxic levels. Grapefruit juice inhibits cytochrome P450-3A4 found in the liver and intestinal wall. This statement warrants intervention by the nurse.
The director of nurses in the cardiac clinic is counseling an unlicensed assistive personnel (UAP) in the clinic who returned late from her lunch break seven times in the past 2 weeks. Which conflict resolution uses the win-lose strategy?
Show answer and rationale
Correct answer: B. The director of nurses terminates the UAP, explaining that all staff must be on time so that the clinic runs smoothly.
This is a win-lose strategy during which the conflict shows one party (the director of nurses) exerts dominance and the other party (UAP) must submit and loses.
The cardiac clinic nurse has told the female unlicensed assistive personnel (UAP) twice to change the sharps container in the examination room, but it has not been changed. Which action should the nurse implement first?
Show answer and rationale
Correct answer: A. Change the sharps container as per clinic policy.
A full sharps container is a violation of Occupational Health and Safety Administration (OSHA) regulations and may result in a $25,000 fine. The nurse should first take care of this situation immediately and then discuss it with the UAP. This is modeling appropriate behaviour.
The wife of a client calls the clinic and tells the nurse her husband is having chest pain but won’t go to the hospital. Which action should the nurse implement first?
Show answer and rationale
Correct answer: D. Tell the wife to have the client chew an aspirin.
The AHA recommends the client having chest pain chew an aspirin to help decrease platelet aggregation. This is the first intervention the clinic nurse should tell the wife to do. The client is in distress; therefore, the nurse should have the wife do something.
The home health (HH) nurse received phone messages from the agency secretary. Which client should the nurse phone first?
Show answer and rationale
Correct answer: A. The client diagnosed with chronic atrial fibrillation who is having chest pain.
The client with chronic atrial fibrillation is at risk for pulmonary emboli, a potentially life-threatening complication. Chest pain is a common symptom of pulmonary embolism. The nurse should contact this client first.
The client is diagnosed with end-stage congestive heart failure. The nurse finds the client lying in bed, short of breath, unable to talk, and with buccal cyanosis. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Assist the client to a sitting position.
The nurse’s first intervention is to assist the client to a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. This will, it is hoped, help relieve the client’s respiratory distress.
The home health (HH) nurse is visiting a client diagnosed with congestive heart failure. The client has an out-of-hospital do not resuscitate (DNR) order, has stopped breathing, and has no pulse or blood pressure. The client’s family is at the bedside. Which intervention should the HH nurse implement first?
Show answer and rationale
Correct answer: C. Pronounce the client’s death.
Nurses in home health have been given the authority to pronounce death for clients who are on service and death is imminent. This intervention should be implemented first.
The cardiac nurse received laboratory results on the following clients. Which client warrants immediate intervention from the nurse?
Show answer and rationale
Correct answer: C. The client who has a serum digoxin level of 2.6 mg/dL.
The client’s digoxin level is higher than the therapeutic level for digoxin, which is 0.8 to 2 mg/dL. This client should be contacted first to assess for signs/ symptoms of digoxin toxicity.
The home health (HH) nurse is completing the admission assessment for an obese client diagnosed with a myocardial infarction with comorbid type 1 diabetes and arterial hypertension. Which priority intervention should the nurse implement?
Show answer and rationale
Correct answer: B. Refer the client to a cardiac rehabilitation unit.
Cardiac rehabilitation includes progressive exercise, diet teaching, and classes on modifying risk factors. This supervised setting would be the priority intervention for this client when the client is discharged from HH.
The home health (HH) nurse is preparing for the initial visit to a client diagnosed with congestive heart failure. Which intervention should the HH nurse implement first?
Show answer and rationale
Correct answer: C. Review the client’s referral form/pertinent data.
The nurse should review the client’s referral form and other pertinent data concerning the client’s condition first before taking any further steps. The nurse may need to contact the referring agency if the information is unclear or if important information is missing. This is assessment.
Which information should the experienced home health (HH) nurse discuss when orienting a new nurse to HH nursing?
Show answer and rationale
Correct answer: B. Inform the agency of the times of the client’s scheduled visits.
The agency should be informed of the schedule so the nurse can be located if the nurse does not return when expected.
The home health (HH) aide tells the HH nurse that the grandson of the client she is caring for asked her out on a date. Which statement is the HH nurse’s best response?
Show answer and rationale
Correct answer: C. "You should not go out with him as long as she is a client of our agency."
This statement protects the HH aide. This is professional boundary crossing. The employee should not date any relatives of the client because this may pose a conflict of interest. The HH aide should wait until the client is no longer on service.
The cardiac nurse is teaching the client diagnosed with congestive heart failure. Which teaching interventions should the nurse discuss with the client? Select all that apply.
Show answer and rationale
Correct answer: A. Keep the head of the bed elevated when sleeping.
Keeping the head of the bed elevated will help the client breathe easier; therefore, this is an appropriate teaching intervention.
The nurse is administering medications on a cardiac unit. Which medication should the nurse question administering?
Show answer and rationale
Correct answer: B. Digoxin (Lanoxin), a cardiac glycoside, to a client with a potassium level of 3.3 mEq/L.
This potassium level is very low. Hypokalemia potentiates dysrhythmias in clients receiving digoxin. This nurse should discuss potassium replacement with the HCP before administering this medication.
The nurse is providing end-of-life care to the client diagnosed with cardiomyopathy who is in hospice. Which priority assessment intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Assess the client’s support system.
The client’s support system is the priority assessment for the hospice nurse. The client will be cared for in the home and the nurse must know who is available to help the client.
The husband of the client diagnosed with infective endocarditis and who has a do not resuscitate (DNR) tells the nurse, "My wife is not breathing." Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Stay with the client and her husband.
The nurse should stay with the client and her husband and not make any liferescuing interventions while the client is dying. The husband should not be left alone.
The hospice nurse is triaging phone calls from clients. Which client should the nurse call first?
Show answer and rationale
Correct answer: C. The client whose pain is not being controlled with the current medications.
One of the main goals of hospice is pain and symptom control. This client should be seen first so that appropriate pain control can be obtained immediately.
The hospice nurse is working with a volunteer. Which task could the nurse delegate to the volunteer?
Show answer and rationale
Correct answer: C. Sit with the client while he or she reminisces about life experiences.
Encouraging the client to review his or her life experiences assists the client tocome to a closure of his or her life. This is an important intervention the volunteer can perform.
The nurse delegates post-mortem care to the unlicensed assistive personnel (UAP). The UAP tells the nurse she has never performed post-mortem care. Which statement is the best response by the nurse to the UAP?
Show answer and rationale
Correct answer: C. "It can be uncomfortable. I will go with you and show you what to do."
The nurse should provide instruction and support to the UAP. This is the best response.
The unlicensed assistive personnel (UAP) tells the nurse the client is complaining of chest pain. Which task should the nurse delegate to the UAP?
Show answer and rationale
Correct answer: D. Get the client’s medical records and bring them to the client’s room.
The nurse should immediately go to the client’s room and assess the client. Sometimes the nurse may need the client’s chart and medical administration record (MAR) to assist in the assessment of findings. The UAP can bring these documents to the room.
The registered nurse (RN) and licensed practical nurse (LPN) are caring for a group of clients on a cardiac unit. Which nursing task should not be assigned to the LPN?
Show answer and rationale
Correct answer: A. Assess the client diagnosed with stage IV heart failure.
The nurse cannot assign assessment. This is the inappropriate task to assign to the LPN.
The hospice nurse is discussing the clients’ care with the unlicensed assistive personnel (UAP). Which statement contains the best information about caring for a client with end-stage heart failure who is dying?
Show answer and rationale
Correct answer: D. "Be careful not to promise to withhold healthcare information from the team."
This is an important statement for the UAP to understand. If information revealed to the UAP is necessary to provide appropriate care to the client, then the information must be shared on a needto-know basis with the healthcare team.
The client on telemetry is showing ventricular tachycardia. Which action should the telemetry nurse delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: A. Tell the UAP to answer the other call lights on the unit.
Answering the call lights of the other clients on the unit can be delegated to the UAP.
The female family member of the client experiencing a cardiac arrest refuses to leave the client’s room. Which intervention should the administrative supervisor implement?
Show answer and rationale
Correct answer: C. Stay with the family member and explain what the team is doing.
If the family is not causing a disruption in the code, the family member should be allowed to stay in the room with the supervisor remaining near the family member and explaining why the interventions are being implemented will help the client to survive. The supervisor should be ready to escort the family member out of the code if the family member becomes disruptive.
The male client presents to the emergency department with a complaint of chest pain but does not have the ability to pay for the services. Which action should the emergency department nurse implement first?
Show answer and rationale
Correct answer: B. Place the client on a telemetry monitor and assess the client.
Federal law requires that clients presenting to an emergency department must be assessed and treated without regard to payment. The nurse should initiate steps to assess the client.
The nurse is caring for clients on a cardiac unit. Which client should the nurse assess first?
Show answer and rationale
Correct answer: B. The client diagnosed with angina who is reporting chest pain.
The client with angina should be asymptomatic; when the client is complaining of chest pain, this is abnormal data. Therefore, this client should be assessed first. Remember Maslow’s Hierarchy of Needs identifies physiological needs as priority and pain is priority.
Which medication should the nurse administer first after receiving the morning shift report?
Show answer and rationale
Correct answer: B. The IVPB antibiotic to the client with endocarditis admitted at 0530 today.
First-dose intravenous antibiotic medications are priority medications and should be administered within 1 to 2 hours of when the order was written. This should be the first medication administered.
The nurse in a critical care cardiac unit is administering medications to a client. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Obtain the latest PTT results on the client with a heparin drip.
Intravenous heparin increases the client’s partial thromboplastin time and causes an anticoagulant effect. The nurse should always be aware of the client’s most current PTT levels when therapeutic heparin is being administered.
The surgical nurse is admitting a client having heart surgery to the operating room. Which information would require the nurse to call a time-out?
Show answer and rationale
Correct answer: D. The consent form states mital valve replacement and the client states aortic valve replacement.
Whenever there is a discrepancy on the chart or with what the client says, the nurse should call an immediate time-out until the situation has been resolved.
The nurse is administering medications to clients on a cardiac unit. Which medication should the nurse question administering?
Show answer and rationale
Correct answer: B. The antiplatelet ticlopidine (Ticlid) to a client being prepared for surgery.
The nurse should not administer an antiplatelet medication to a client going to surgery because this will increase postoperative bleeding. The nurse should hold this medication and discuss this with the surgeon.
The intensive care unit nurse and a UAP are caring for a client who has had a coronary artery bypass graft (CABG). Which nursing task should the nurse assign to the UAP?
Show answer and rationale
Correct answer: D. Assist the client to take a sponge bath.
The UAP can assist with hygiene needs; this is one of the main tasks that may be delegated to UAPs.
The nurse is preparing to administer two units of PRBCs to a client diagnosed with congestive heart failure (CHF). Which HCP order should the nurse question?
Show answer and rationale
Correct answer: B. Administer each unit over 2 hours.
The nurse should administer a unit of blood over the greatest length of time possible (4 hours) to a client diagnosed with congestive heart failure to prevent fluid volume overload. The nurse should question this order.
The elderly client on the cardiac unit was found on the floor by the bed. Which information should the nurse document in the client’s chart?
Show answer and rationale
Correct answer: C. Found on floor. No complaints of pain. Able to move all extremities.
The nurse should document exactly what was observed. This statement is the correct documentation.
The home health (HH) nurse is caring for an elderly client. Which nursing task should the nurse delegate to the HH aide?
Show answer and rationale
Correct answer: A. Assist the client to sit on the front porch.
The home health aide is responsible for assisting the client with activities of daily living and transferring from the bed to the chair. Sitting outside is good for the client and is a task that can be delegated to the home health aide.
The client admitted to rule out (R/O) a myocardial infarction is complaining of substernal chest pain radiating to the left arm and jaw. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Place sublingual nitroglycerin 1/150 g under the tongue.
Placing nitroglycerin under the client’s tongue may relieve the client’s chest pain and provide oxygen to the heart muscle. This is the nurse’s first intervention.
The client on the cardiac unit has a cardiac arrest. Which is the administrative supervisor nurse’s first intervention during the code?
Show answer and rationale
Correct answer: B. Make sure all the jobs are being done.
The first intervention for the supervisor is to ensure that all the jobs in the code are being filled.
Which client should the cardiac nurse assess first after receiving the p.m. shift report?
Show answer and rationale
Correct answer: B. The client who is crying after being informed of a terminal diagnosis.
The client has been given devastating news. When all the information in the options is expected and not life threatening, then psychological issues have priority. This client should be seen first.
Which client should Ms. Teresa assign to the most experienced RN on the unit?
Show answer and rationale
Correct answer: D. The client diagnosed with congestive heart failure who is coughing up pink, frothy sputum.
Pink, frothy sputum indicates pulmonary edema, which is a serious complication of CHF; therefore, the most experienced nurse should be assigned this client.
The telemetry technician tells the primary nurse the client in room 420 has a straight line. Which intervention should the primary nurse implement first?
Show answer and rationale
Correct answer: B. Check to see if the client has the telemetry leads on the chest.
The nurse should first determine if the client’s telemetry leads are in place on the chest. If the leads are off then it will show as a flat line at the telemetry station. The telemetry technician cannot leave the station.
The primary nurse has instructed the unlicensed assistive personnel (UAP) to assist the client in 410 to the bathroom for a shower. Which action by the UAP warrants intervention by the primary nurse?
Show answer and rationale
Correct answer: A. The UAP did not notify the desk the telemetry was being removed.
This warrants intervention because the telemetry technician needs to know if the client’s telemetry is being removed so the technician won’t think the client is in asystole.
Ms. Teresa is looking over the morning laboratory results. Which client warrants Ms. Teresa notifying the healthcare provider (HCP)?
Show answer and rationale
Correct answer: C. The client receiving IVP digoxin who has a digoxin level of 2.4 mg/dL.
The therapeutic digoxin level is 0.8 to 2.0 mg/dL; therefore, Ms. Teresa should notify the client’s HCP because this is above the therapeutic level.
Which client should Ms. Teresa assign to the LPN?
Show answer and rationale
Correct answer: B. The client who had a left femoral cardiac catheterization this morning.
The LPN could care for a client who has had a diagnostic test; this would be an appropriate client assignment.
Ms. Teresa is transcribing the healthcare provider’s admissions orders for a client being admitted for R/O myocardial infarction. Which HCP’s order should Ms. Teresa question?
Show answer and rationale
Correct answer: C. Schedule client for endoscopy in a.m.
An endoscopy is not an usual diagnostic test for a client diagnosed with R/O myo – cardial infarction; therefore, Ms. Teresa should question this order.
Which nursing task is most appropriate for Ms. Teresa to delegate to the UAP?
Show answer and rationale
Correct answer: C. Request the UAP to obtain the newly admitted client’s weight.
The UAP can obtain the client’s weight. The nurse cannot delegate assessment, teaching, evaluation, medications, or an unstable client.
The client in room 420 is complaining of severe chest pain of 10 on a 1-to-10 pain scale. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Administer a sublingual nitroglycerin to the client.
The nurse should treat the pain, so administering sublingual nitroglycerin, a coronary vasodilator, is the nurse’s first intervention.
The client is in ventricular tachycardia. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Assess the carotid pulse.
The nurse must determine if the client has a pulse or not prior to taking any further action; therefore, this is the nurse’s first intervention.
Ms. Teresa is completing discharge teaching for the client diagnosed with angina. Which statement indicates the client needs more teaching?
Show answer and rationale
Correct answer: B. "I will decrease the number of cigarettes I smoke daily."
This is a modifiable risk factor; the client must stop smoking altogether. Decreasing the number of cigarettes a day indicates the client needs more teaching.
The nurse is caring for clients on a vascular disorder unit. Which laboratory data warrant immediate intervention by the nurse?
Show answer and rationale
Correct answer: B. The PTT of 98 seconds for a client diagnosed with deep vein thrombosis (DVT).
Therapeutic levels for PTT should be 11 /2 to 2 times the normal value, which is 39 seconds; therefore, this client is at risk for bleeding. The prolonged PTT indicates the client is receiving heparin (drug of choice to treat DVT). The nurse should stop the infusion and follow the facility protocol.
The unlicensed assistive personnel (UAP) tells the nurse the client has a blood pressure of 78/46 and a pulse of 116 using a vital signs machine. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Assess the client’s cardiovascular status.
The nurse should immediately go to the client’s room to assess the client.
The charge nurse on a vascular unit is working with a new unit secretary. Which statement concerning laboratory data is most important for the charge nurse to tell the unit secretary?
Show answer and rationale
Correct answer: B. "Be sure to show me any lab information that is called in to the unit."
Because laboratory values called into a unit usually include critical values, the charge nurse should tell the unit secretary "to show me any lab information that is called in immediately." The charge nurse must evaluate this information immediately.
The nurse on the vascular unit is preparing to administer medications to clients on a medical unit. Which medication should the nurse question administering?
Show answer and rationale
Correct answer: C. Vitamin K (AquaMephyton), a vitamin, to a client with an International Normal Ratio (INR) of 2.8.
Vitamin K is the antidote for warfarin (Coumadin) overdose and is administered to a client when his or her INR level is above the therapeutic 2-3; therefore, the nurse should question administering this medication.
The nurse has received the shift report. Which client should the nurse assess first?
Show answer and rationale
Correct answer: C. The client with a deep vein thrombosis who is complaining of dyspnea and coughing.
This client is exhibiting signs/symptoms of a potentially fatal complication of DVT- pulmonary embolism. The nurse should assess this client first.
The female client diagnosed with atherosclerosis tells the clinic nurse her stomach hurts after she takes her morning medications. The client is taking a calcium channel blocker, a daily aspirin, and a statin. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Assess the client for abnormal bleeding.
Because the client has been on the daily aspirin for more than a year, the nurse should assess for bleeding by asking questions such as, "Do your gums bleed after brushing teeth?" or "Do you notice blood when you blow your nose?"
The nurse educator on a vascular unit is discussing delegation guidelines to a group of new graduates. Which statement from the group indicates the need for more teaching?
Show answer and rationale
Correct answer: B. "The UAP will be practicing on my brand-new nursing license."
This statement indicates the new graduate needs more teaching because the nurse is responsible for delegating the right task to the right individual. Absolutely no one works on the nurse’s license but the nurse holding the license.
The nurse is reviewing the literature to identify evidence-based practice research that supports a new procedure using a new product when changing the central line catheter dressing. Which research article would best support the nurse’s proposal for a change in the procedure?
Show answer and rationale
Correct answer: B. The review-of-literature article that cited numerous studies supporting the product.
The more research articles there are that support a change proposal, the more valid is the information, which increases the possibility for change to be considered by the healthcare facility.
The nurse and the unlicensed assistive personnel are caring for clients on a vascular unit. Which task is most appropriate for the nurse to delegate?
Show answer and rationale
Correct answer: B. Provide indwelling catheter care to a client on bed rest.
The unlicensed assistive personnel (UAP) can clean the perineal area of a client who is on bed rest and who has an indwelling catheter. Because the client is stable, this nursing task could be delegated to the UAP.
The nurse asks the female UAP to apply the sequential compression devices (SCDs) to a client who is on strict bed rest. The UAP tells the nurse that she has never done this procedure. Which action would be priority for the nurse to take?
Show answer and rationale
Correct answer: A. Demonstrate the procedure for applying the SCDs.
This is the priority action because the nurse will ensure the UAP knows how to apply SCDs correctly, thereby enabling the nurse to delegate the task to the UAP successfully in the future.
The nurse in the vascular critical care unit is working with an LPN who was pulled to the unit as a result of high census. Which task is most appropriate for the nurse to assign to the LPN?
Show answer and rationale
Correct answer: A. Hang the bag of heparin for a client diagnosed with a pulmonary embolus.
The LPN can administer medications; therefore, the LPN could hang a bag of heparin on an IV pump to this client.
The nurse is administering one unit of packed red blood cells to a client. Fifteen minutes after initiation of the blood transfusion, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Stop the transfusion at the hub.
Any time the nurse suspects the client is having a reaction to blood or blood products, the nurse should stop the infusion at the spot closest to the client and not allow any more of the blood to enter the client’s body. This is the nurse’s first intervention.
The staff nurse on a vascular disorder unit asks the charge nurse, "What should I be looking for when I read a research article?" Which response indicates the charge nurse does not understand how to read a nursing research article?
Show answer and rationale
Correct answer: C. "You should look to find out how much money was used for the study."
The cost of the research is not pertinent when reading a research article and determining whether the research supports evidence-based practice. This statement indicates the charge nurse does not understand how to read a research article.
The nurse calls the HCP for an order for pain medication for a client who is 2 days postoperative aortic aneurysm repair. The HCP gives the nurse an order for "Demerol 50 mg IVP now and then every 4 hours as needed." Which action should the nurse implement first?
Show answer and rationale
Correct answer: A. Read back the order to the HCP before hanging up the phone.
The Joint Commission has implemented this requirement for all telephone orders. The nurse should document on the HCP’s order "repeat order verified."
The charge nurse on the vascular unit is reviewing laboratory blood work. Which result warrants intervention by the charge nurse?
Show answer and rationale
Correct answer: A. The client whose platelet count is 65,000 per milliliter of blood.
A platelet count of less than 100,000 per milliliter of blood indicates thrombocytopenia; therefore, this client warrants intervention by the charge nurse.
A client on the vascular unit tells the day shift primary nurse that the night nurse did not answer the call light for almost 1 hour. Which statement would be most appropriate by the day shift primary nurse?
Show answer and rationale
Correct answer: A. "I will notify my charge nurse to come and talk to you about the situation."
The nurse should have someone come talk to the client who is in a position to then investigate what happened on the night shift and determine why this happened. The day shift primary nurse does not have this authority.
The nurse is preparing to administer a unit of packed red blood cells to an elderly client who is 1 day postoperative abdominal aortic aneurysm. Which interventions should the nurse implement? List in order of performance.
Show answer and rationale
Correct answer: A. Have the client sign the permit to receive blood products.
The client must agree to the risks and benefits of a blood transfusion before the nurse can administer the blood product. This is the first intervention.
The elderly client diagnosed with deep vein thrombosis is complaining of chest pain during inhalation. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Place oxygen on the client via nasal cannula.
The nurse should suspect the client has a pulmonary embolus, a complication of the thrombophlebitis. Pulmonary emboli decrease the oxygen supply to the body, and the nurse should immediately administer oxygen to the client.
Which laboratory data should the nurse in the long-term care unit notify the healthcare provider about?
Show answer and rationale
Correct answer: D. The client receiving digoxon who has a digoxin level of 2.6.
The therapeutic level for digoxin is 0.8 to 2.0 so this warrants notifying the HCP.
The occupational nurse is caring for the client who just severed two fingers from the right hand. Which intervention should the occupational nurse implement first?
Show answer and rationale
Correct answer: A. Don non-sterile gloves on both hands.
The nurse should first put on non-sterile gloves to protect from getting any blood-borne diseases.
The clinic nurse is making assignments to the staff. Which assignment/delegation is most appropriate?
Show answer and rationale
Correct answer: C. Ask the unlicensed assistive personnel (UAP) to prepare the room for the next client.
The UAP can make sure the room is clear of the previous client’s gown and equipment used with the previous client. The UAP can also make sure there are gowns, tongue blades, and additional equipment in the examination room.
The female client tells the charge nurse the unlicensed assistive personnel (UAP) did not know how to take her blood pressure. Which action should the charge nurse implement first?
Show answer and rationale
Correct answer: B. Retake the BP and inform the client of her BP reading.
The nurse should first take the client’s BP correctly and address the client’s concern.
Which medication is most appropriate for the nurse to assign to the LPN to administer?
Show answer and rationale
Correct answer: C. The PO pentoxifylline (Trental) to the client who has intermittent claudication.
Trental is a PO medication prescribed specifically to treat intermittent claudication. It increases erythrocyte flexibility and reduces blood viscosity.
The clinic nurse is assessing a client who is complaining of right leg calf pain. The right calf is edematous and warm to the touch. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Notify the clinic HCP immediately.
The nurse should realize the client probably has deep vein thrombosis, which is a medical emergency. The HCP should be notified immediately so the client can be started on IV heparin and admitted to the hospital.
The fire alarm starts going off in the family practice clinic. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Determine whether there is a fire in the clinic.
The nurse should first determine whether there is a fire or whether someone accidentally or purposefully pulled the fire alarm. Because this is a clinic, not a hospital, the nurse should keep calm and determine the situation before taking action.
The female unlicensed assistive personnel (UAP) tells the clinic nurse, "One of the medical interns asked me out on a date. I told him no but he keeps asking." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: C. "You should inform the clinic’s director of nurses."
This is the most appropriate response because sexual harassment allegations are a legal matter. The clinic nurse implemented the correct action by making sure the unlicensed assistive personnel (UAP) reported the allegation to the director of nurses.
The clinic nurse overhears another staff nurse telling the pharmaceutical representative, "If you bring us lunch from the best place in town, I will make sure you get to see the HCP." Which action should the clinic nurse take?
Show answer and rationale
Correct answer: D. Report this behavior to the clinic’s director of nurses immediately.
This behavior is unethical and is making promises that the staff nurse may or may not be able to keep. Because this situation includes the HCP, an outside representative, and the staff nurse, this situation should be reported to the director of nurses for further action.
The home health (HH) nurse in the office is notified the female client on warfarin (Coumadin), an oral anticoagulant, has an International Normalized Ratio (INR) of 3.8. Which action should the HH nurse implement first?
Show answer and rationale
Correct answer: B. Contact the client and ask whether or not she has any abnormal bleeding.
The therapeutic value for INR is 2 to 3; levels higher than that increase the risk of bleeding. The nurse should first contact the client and determine whether she has any abnormal bleeding and then instruct the client to not take any more Coumadin.
The home health (HH) nurse is caring for a client with arterial hypertension who has had a cerebrovascular accident. Which priority intervention should the nurse discuss with the client when teaching about arterial hypertension?
Show answer and rationale
Correct answer: B. Explain the need for the client to take antihypertensive medications as prescribed.
The priority intervention for the client with arterial hypertension is to take antihypertensive medications.
Which action by the unlicensed assistive personnel (UAP) indicates to the nurse the UAP understands the correct procedure for applying compression stockings to the client recovering from a pulmonary embolus?
Show answer and rationale
Correct answer: C. The UAP checked to make sure the client’s toes were warm after putting the stockings on.
Warm toes mean the stockings are not too tight and there is good circulation. Checking that the toes are warm indicates the HH aide understands the correct procedure for applying the compression stockings.
The home health (HH) nurse enters the yard of a client and is bitten on the leg by the client’s dog. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Clean the dog bite with soap and water and apply antibiotic ointment.
The nurse should first take care of the bite and then determine whether the dog is up to date on the required vaccinations. The nurse should be concerned about the possibility of rabies.
The nurse on the vascular unit is caring for a client diagnosed with arterial occlusive disease. Which statement by the client warrants immediate intervention by the nurse?
Show answer and rationale
Correct answer: C. "My legs were so cold I had to put a heating pad on them."
This comment warrants immediate intervention because the client’s legs have decreased sensation secondary to the arterial occlusive disease, and a heating pad could burn the client’s legs without the client’s realizing it. The client should not use a heating pad to keep the legs warm.
The home health (HH) nurse has completed a home assessment on a client and finds out there are no smoke detectors in the home. The client tells the nurse they just cannot afford them. Which action should the nurse implement first?
Show answer and rationale
Correct answer: D. Contact the local fire department to see if they can provide smoke detectors for the client.
The nurse should contact the fire department. Many fire departments will supply and install smoke detectors for people who cannot afford them. The nurse should investigate this option first because it is the most immediate response to the safety need.
The nurse is admitting a 72-year-old female client and notes multiple bruises on the face, arms, and legs along with possible cigarette burns on her upper arms. The client states she fell on an ashtray and doesn’t want to talk about it. Which nursing intervention is priority?
Show answer and rationale
Correct answer: A. Report the situation to the Adult Protective Services.
The bruises and burns should make the nurse suspect elder abuse, and the nurse is mandated by law to report this to Adult Protective Services.
The nurse is admitting a client diagnosed with deep vein thrombosis (DVT) in the right leg. Which statement by the client warrants immediate intervention by the nurse?
Show answer and rationale
Correct answer: B. "I take a baby aspirin every day at breakfast."
Aspirin, an antiplatelet agent, puts the client at risk for bleeding. The client diagnosed with deep vein thrombosis will be on warfarin (Coumadin), an anticoagulant, which puts the client at risk for bleeding; therefore, this comment requires immediate intervention by the nurse.
The male client with peripheral vascular disease tells the nurse, "I know my foot is really bad. My doctor told me I don’t have any choice and I must have an amputation, but I don’t want one." Which action supports the nurse being a client advocate?
Show answer and rationale
Correct answer: B. Tell the client she will go with him to discuss his decision with the doctor.
This action shows the nurse being the client’s advocate. Offering to go talk to the HCP about the amputation and making sure the HCP hears the client’s opinion is being a client advocate. Another discussion may change the client’s decision, but either way, client advocacy is supporting the client’s decision.
The charge nurse observes the unlicensed assistive personnel (UAP) crying after the death of a client. Which is the charge nurse’s best response to the UAP?
Show answer and rationale
Correct answer: A. "It can be difficult when a client dies. Would you like to take a break?"
Hospital personnel are not immune to human emotions. The UAP needs a short time to compose him- or herself. The nurse should offer the UAP compassion. If this occurred with every death, the UAP could be counselled to transfer to a different area of the hospital.
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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