NCLEX Practice Questions — Set 11
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 nursing staff confronts the hospice nurse overseeing the care of a client in a longterm care facility. The nursing staff wants to send the client who is diagnosed with gangrene of the left leg secondary to peripheral occlusive disease to the hospital for treatment. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Check with the client to see whether or not the client wants to go to a hospital.
Clients receiving hospice can decide to discontinue the service and resume standard healthcare practices and treatments whenever they wish. The nurse should assess the client’s wishes before continuing.
The client diagnosed with an abdominal aortic aneurysm died unexpectedly, and the nurse must notify the significant other. Which statement made by the nurse is the best over the telephone?
Show answer and rationale
Correct answer: D. "Could you come to the hospital? The client is not doing well."
This response allows the family/ significant other to know there has been some incident, but it does not disclose the death. This is the best statement for the nurse at this time. The family will be able to arrive safely at the hospital before hearing the news their loved one has died.
The nurse has been pulled from a medical unit to work on the vascular unit for the shift. Which client should the charge nurse assign to the medical unit nurse?
Show answer and rationale
Correct answer: D. The client with varicose veins who is complaining of deep, aching pain of the legs.
The client with varicose veins would be expected to have deep aching pain in the legs; therefore, the nurse who is being floated to the vascular unit could be assigned to this client.
The charge nurse in the vascular intensive care unit assigns three clients to the staff nurse. The staff nurse thinks this is an unsafe assignment. Which action should the staff nurse implement first?
Show answer and rationale
Correct answer: C. Tell the supervisor that he or she is concerned about the unsafe assignment.
The nurse should notify the supervisor that the nurse is concerned that the assignment will not allow the nurse to provide adequate care to any of the three clients. This is the first step the nurse should implement.
The matriarch of a family has died on the vascular unit. The family tells the nurse the daughter is coming to the hospital from a nearby city to see the body. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: A. Plan to allow the daughter to see the client in the room.
The daughter lives in a "nearby" city. The client should not be moved anywhere until the daughter arrives.
The unit manager on the vascular unit is planning a change in the way post-mortem care is provided. Which is the first step in the change process?
Show answer and rationale
Correct answer: D. Collect data.
The change process can be compared to the nursing process. The first step of each process is to assess the problem. Assessment involves collecting the pertinent data that support the need for a change.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a vascular unit. Which task should the nurse delegate to the UAP?
Show answer and rationale
Correct answer: D. Elevate the leg of the client who is one day postoperative femoral-popliteal bypass.
The leg should be elevated to prevent postoperative edema; therefore, this task could be delegated to the UAP.
The charge nurse on a vascular postsurgical unit observes a new graduate telling an elderly client’s spouse not to push the client’s patient-controlled analgesia (PCA) pump button. Which action should the charge nurse implement?
Show answer and rationale
Correct answer: B. Continue to perform the charge nurse’s other duties.
The nurse is acting appropriately, and there is no reason to discuss the instructions further. The charge nurse should continue with other duties.
Which client should the nurse assess first after receiving the shift report?
Show answer and rationale
Correct answer: D. The client with a right above-the-knee amputation who is complaining of right foot pain.
This client may be having phantom pain, but it must be assessed and the client must be medicated. The nurse should assess this client first.
The nurse observes an LPN crushing nifedipine (Procardia XL) before administering the medication to a client with arterial hypertension who has difficulty swallowing pills. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Tell the LPN this medication cannot be crushed.
The XL in the name of the medication indicates that this medication is a sustained-released formulation and should not be crushed. The nurse should speak directly with the LPN to correct the behaviour.
A 90-year-old male client was recently widowed after more than 60 years of marriage. The client was admitted to a long-term care facility and is refusing to eat. Which intervention is an example of the ethical principle of autonomy?
Show answer and rationale
Correct answer: D. Allow the client to refuse to eat if he wants to.
This is an example of autonomy.
The nurse is admitting a client with an abdominal aortic aneurysm who is a member of the Church of Jesus Christ of Latter-Day Saints (Mormon). Which action by the nurse indicates cultural sensitivity to the client?
Show answer and rationale
Correct answer: D. The nurse keeps the client’s undershirt on during the bath.
The devout Mormon client wears a religious undershirt that should not be removed; this action indicates cultural sensitivity on the part of the nurse.
Which client should the nurse on the vascular unit assess first after receiving the shift report?
Show answer and rationale
Correct answer: B. The client with lymphedema whose ABG results are pH 7.33, PaO2 89, PaCO2 47, HCO3 25.
These ABGs show respiratory acidosis, which needs immediate intervention; therefore, this client should be assessed first.
The charge nurse of a long-term care facility is making assignments. Which client should be assigned to the most experienced unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: B. The client with an above the knee amputation who needs a full body lift to get in the wheelchair.
This client requires an experienced UAP who is skilled in client lifts, so the client is lifted safely and the UAP is not injured in the process. The most experienced UAP should be assigned this client.
The client complains of chest pain on deep inspiration. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Place the client on oxygen.
Chest pain on deep inspiration is a symptom of pulmonary embolism. The nurse should first place the client on oxygen.
Which of the staff nurse’s personal attributes is an important consideration for the unit manager when discussing making an experienced nurse a preceptor for new graduates? Select all that apply.
Show answer and rationale
Correct answer: A. The nurse’s ability to organize the work.
The nurse should be able to organize his or her own workload before becoming a role model for a new nurse. If the nurse is not organized, taking on new responsibilities will be very frustrating for the preceptor and for the preceptee.
The nurse just received the a.m. shift report. Which client should the nurse assess first?
Show answer and rationale
Correct answer: C. The client who is 6 hours post-op vein ligation who has absent pedal pulses.
This client is experiencing neurovascular compromise and requires immediate attention. The client with venous problems should have palpable pedal pulses. This procedure is for clients with varicose veins.
The nurse is teaching the client diagnosed with arterial occlusive disease. Which statement indicates the client needs more teaching?
Show answer and rationale
Correct answer: A. "I must wear knee-high stockings."
This statement indicates the client needs more teaching because knee-high stockings will further decrease circulation to the legs.
The nurse is caring for clients on a vascular unit. Which nursing task is most appropriate to delegate to an unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: B. Request the UAP to elevate the feet of the client with chronic venous insufficiency.
The client is stable and elevating the feet is an appropriate intervention for a client with venous problems; therefore, the UAP could feed this client.
A client is 2 days postoperative abdominal aortic aneurysm repair. Which data require immediate intervention from the nurse?
Show answer and rationale
Correct answer: D. The client refuses to take deep breaths and cough.
The nurse needs to intervene because the client is at high risk for developing pneumonia, especially due to the abdominal incision.
The nurse is caring for clients on a vascular surgical floor. Which client should be assessed first?
Show answer and rationale
Correct answer: D. The client who is 1 day postoperative abdominal aortic aneurysm who is complaining of numbness and tingling of both feet.
Parasthesia (numbness and tingling) indicates a graft occlusion from the surgical procedure, which is a potentially lifethreatening complication; therefore, this client should be assessed first.
The unlicensed assistive personnel (UAP) is caring for a client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse?
Show answer and rationale
Correct answer: B. The UAP is cutting the client’s toenails after soaking the client’s feet in tepid water.
The client should have a podiatrist cut his or her toenails. The unlicensed assistive personnel (UAP) should not do this because if the UAP accidently cuts the skin, it could cause a sore that may not heal, and then result in amputation of the extremity.
The nurse has just received the a.m. shift report. Which client would the nurse assess first?
Show answer and rationale
Correct answer: C. The client with a venous stasis ulcer who is refusing to eat the high protein meal.
The client with a venous stasis ulcer should eat a diet high in protein (meat, beans, cheese, tofu), vitamin A (green, leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood). The nurse needs to talk to this client, but it is not a life-threatening condition or a complication; therefore, the client is not assessed first.
The client in the day surgical unit is scheduled to have vein ligation on the right leg. The client states, "I am having surgery on my left leg." Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Call a time out until clarifying which leg is having the vein ligation.
The nurse must stop everything and clarify which leg will have the surgical procedure. This is the first and priority intervention the nurse must implement.
The male post-op femoral popliteal client notifies the desk via the intercom system he has fallen and is now bleeding. Which interventions should the nurse implement? Rank in order of performance.
Show answer and rationale
Correct answer: A. Assist the client to a recumbent position in the bed.
When the bleeding has stopped, the client can be assisted back to bed so a thorough assessment of the injuries can be performed.
JC just received the a.m. shift report. Which client should JC assess first?
Show answer and rationale
Correct answer: A. The client diagnosed with aortic abdominal aneurysm who has low back pain.
The client with a triple AAA who has a low back pain could have a leak, which could be life threatening; therefore, this client should be assessed first.
Which assessment data would warrant immediate intervention by DH, charge nurse for the client diagnosed with arterial occlusive disease?
Show answer and rationale
Correct answer: D. The client has paralysis and parasthesia.
Numbness, tingling, and inability to move his or her toes would warrant intervention by the nurse. This indicates no arterial blood flow to the extremities.
The nurse and the unlicensed assistive personnel (UAP) are caring for a client who is 4 hours postoperative right femoral-popliteal bypass surgery. Which nursing task should JC delegate to the UAP?
Show answer and rationale
Correct answer: A. Elevate the client’s leg on two pillows.
The leg should be elevated to help decrease edema secondary to surgery and this can be delegated to a UAP.
Which interventions should DH discuss with the client diagnosed with atherosclerosis? Select all that apply.
Show answer and rationale
Correct answer: C. Maintain a sedentary lifestyle as much as possible.
Sedentary life style is a "couch potato" lifestyle, which is not recommended for clients with atherosclerosis.
The client is 2 days postoperative abdominal aortic aneurysm. Which intervention should BN implement first when making initial rounds?
Show answer and rationale
Correct answer: B. Assess the client’s surgical dressing.
BN should first assess the surgical dressing to assess for bleeding or any type of drainage, then continue with the rest of the assessment, including bowel sounds, vital signs, and IV therapy.
The client is diagnosed with a small abdominal aortic aneurysm. Which statement by the client indicates to BN the client needs more discharge teaching?
Show answer and rationale
Correct answer: D. "I will need to wear a truss at all times after the surgery."
A truss is a kind of surgical appliance used for clients with a hernia. It provides support for the herniated area using a pad and belt arrangement to hold it in the correct position. This client would not be prescribed a truss; therefore, the client needs more discharge teaching.
PN is assigned the following clients. Which client should PN assess first?
Show answer and rationale
Correct answer: C. The client who had an abdominal aortic repair who had a urine output of 150 mL in the last 8 hours.
The client is going into renal failure (should be 30 mL/hr), which is a potentially life-threatening complication of triple AAA surgery; therefore, this client must be assessed first.
The unlicensed assistive personnel (UAP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention by PN?
Show answer and rationale
Correct answer: D. The UAP is instructing the client to stay in the bed.
The client with varicose veins should not be on bed rest. The client should have bathroom privileges and up ad lib.
The nurse on a medical unit has a client with adventitious breath sounds, but the nurse is unable to determine the exact nature of the situation. Which multidisciplinary team member should the nurse consult first?
Show answer and rationale
Correct answer: B. The respiratory therapist.
Respiratory therapists assess and treat clients with lung problems multiple times every day. Therefore, this is the best person to consult when the nurse needs help identifying a respiratory problem.
Which client should the charge nurse assign to the new graduate on the respiratory unit?
Show answer and rationale
Correct answer: A. The client diagnosed with tuberculosis who has a non-productive cough and orange colored urine.
The orange-colored urine is secondary to rifampin, an antitubercular medication, and a non-productive cough is expected. Therefore, this client is stable and should be assigned to a new graduate nurse.
Which client should the medical unit nurse assess first after receiving the shift report?
Show answer and rationale
Correct answer: D. The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless.
Elderly clients diagnosed with pneumonia may not present with the "normal" symptoms, such as fever. The client’s increased restlessness may indicate a decrease in oxygen to the brain. This client should be seen first.
The client who is 2 days postoperative following a left pneumonectomy has an apical pulse (AP) rate of 128 beats per minute and a blood pressure (BP) of 80/50 mm Hg. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Increase the client’s intravenous (IV) rate.
Increasing the IV rate will provide the client with circulatory volume immediately. Therefore, this is the first intervention.
The client who is 1 day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Notify the Rapid Response Team.
The Rapid Response Team was mandated by The Joint Commission. It is a team of healthcare professionals who respond to clients who are breathing but who the nurse thinks are in an emergency situation. A code is called if the client is not breathing.
The client in the post-anesthesia care unit (PACU) has noisy and irregular respirations (Rs) with a pulse oximeter reading of 89%. Which intervention should the PACU nurse implement first?
Show answer and rationale
Correct answer: A. Tilt the head back and push forward on the angle of the lower jaw.
The client is exhibiting signs/symptoms of hypopharyngeal obstruction, and this maneuver pulls the tongue forward and opens the air passage.
The day surgery admission nurse is obtaining operative permits for clients having surgery. Which client should the nurse question signing the consent form?
Show answer and rationale
Correct answer: D. The 39-year-old client diagnosed with paranoid schizophrenia.
An incompetent client cannot sign the consent form. An incompetent client is an individual who is not autonomous and cannot give or withhold consent, for example, individuals who are cognitively impaired, mentally ill, neurologically incapacitated, or under the influence of mind-altering drugs. The client may be able to sign the permit, but the nurse should question the client’s ability to sign the permit because paranoid schizophrenia is a mental illness.
The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Check the ventilator to resolve the problem.
The client is having respiratory distress and the ventilator is sounding an alarm; therefore, the nurse should first assess the ventilator to determine the cause of the problem and correct it because the client is totally dependent on the ventilator for breathing. This is one of the few situations wherein the nurse would assess the equipment before assessing the client.
The charge nurse on the critical care respiratory unit is evaluating arterial blood gas (ABG) values of several clients. Which client would require an immediate intervention by the charge nurse?
Show answer and rationale
Correct answer: A. The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23.
The ABG shows respiratory alkalosis; therefore, the nurse should assess this client first to determine if the client is hyperventilating, in pain, or has an elevated temperature.
The primary nurse in the critical care respiratory unit is very busy. Which nursing task should be the nurse’s priority?
Show answer and rationale
Correct answer: D. Obtain a tracheostomy tray for a client who is exhibiting air hunger.
The client who is exhibiting air hunger indicates respiratory distress; therefore, a tracheostomy tray should be obtained first.
The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse?
Show answer and rationale
Correct answer: D. Auscultate the client’s posterior breath sounds.
After 3 days, the nurse should assess the lung sounds to determine whether the lungs have re-expanded. This would be the nurse’s first intervention.
The client with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Check for any kinks in the tubing.
The nurse should first determine why there is no tidaling in the water-seal chamber. Since the client just had the chest tubes inserted, it is probably a kink or a dependent loop, or the client is lying on the tubing. The nurse should first check for this prior to taking any other action.
Which client requires the immediate attention of the intensive care unit nurse?
Show answer and rationale
Correct answer: C. The client with acute respiratory distress syndrome (ARDS) who has difficulty breathing.
The client with ARDS is expected to have difficulty breathing but of these four clients, the client with breathing difficulty has priority. Apply Maslow’s Hierarchy of Needs. ARDS is the sudden failure of the respiratory system. A person with ARDS has rapid breathing, difficulty getting enough air into the lungs and low blood oxygen levels.
The unlicensed assistive personnel (UAP) is bathing the client diagnosed with adult acute respiratory distress syndrome (ARDS) who is on a ventilator. The bed is in the high position with the opposite side rail elevated. Which action should the ICU nurse take?
Show answer and rationale
Correct answer: C. Give the UAP praise for performing the bath safely.
Part of the delegation process is to evaluate the UAP’s performance and the nurse should praise any action on the part of the UAP that ensures the client’s safety.
The female charge nurse on the respiratory unit tells the male nurse, "You are really cute and have a great body. Do you work out?" Which action should be taken by the male nurse if he thinks he is being sexually harassed?
Show answer and rationale
Correct answer: A. Ask the charge nurse to stop making comments like this.
The first action is to ask the person directly to stop. The harasser needs to be told in clear terms that the behavior makes the nurse uncomfortable and that he wants it to stop immediately.
The client diagnosed with abdominal pain of unknown etiology has a nasogastric tube draining green bile and reports abdominal pain of 8 on a scale of 1 to 10. The client’s arterial blood gas values are pH 7.48, PaO2 98, PaCO2 36, HCO3 28. Which intervention should the nurse implement based on the client’s ABGs?
Show answer and rationale
Correct answer: A. Check the amount of suction on the client’s nasogastric tube.
The ABG indicates metabolic alkalosis, which could be caused by too much hydrochloric acid being removed via the N/G tube. Therefore, the nurse should check the N/G wall suction.
The charge nurse in the intensive care unit asks a nurse to float from the medical/ surgical unit to the ICU. Which client should the charge nurse assign to the float nurse?
Show answer and rationale
Correct answer: C. The client who is diagnosed with bacterial pneumonia.
The float nurse from the medical unit is able to administer antibiotic therapy and complete respiratory assessments; therefore, this client would be the most appropriate client to assign to the float nurse.
The client has arterial blood gas values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which intervention should the critical care nurse implement?
Show answer and rationale
Correct answer: D. Administer oxygen 6 L/min via nasal cannula.
The client’s PaO2 is below the normal level of 80-100; therefore, the nurse should administer oxygen.
The husband of a client diagnosed with a terminal lung cancer asks the nurse, "How am I going to take care of my wife when we go home?" Which action by the nurse is most appropriate?
Show answer and rationale
Correct answer: A. Notify the social worker about the husband’s concerns.
A social worker is qualified to assist the client with referrals to any agency or personnel that may be needed after the client is discharged home.
The clinic nurse is returning phone messages from clients. Which phone message should the nurse return first?
Show answer and rationale
Correct answer: A. The elderly client with pneumonia who reports being dizzy when getting up.
The elderly client should be called first so that the nurse can determine whether the dizziness when getting up is the result of medication or some other reason. Orthostatic hypotension can be life threatening; therefore, this client may need to be assessed immediately.
The client diagnosed with active tuberculosis tells the public health nurse, "I am not going to take any more medications. I am tired of them." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "You must take your TB medications. It is not an option."
The client with active TB must take the medication as prescribed for 9-12 months. If the client refuses to take the medication, a court order will be obtained to make the client take the medication because tuberculosis is a community threat.
The nurse is working in an outpatient clinic along with a licensed practical nurse (LPN). Which client should the nurse assign to the LPN?
Show answer and rationale
Correct answer: A. The client with acute bronchitis who has a chronic clear mucous cough and low fever.
Acute bronchitis is an inflammation of the bronchial tubes, the major airways into the lungs. The client is exhibiting expected signs/symptoms; therefore, the LPN could care for this client.
The unlicensed assistive personnel (UAP) tells the clinic nurse that the male client in Room 1 is "really breathing hard and can’t seem to catch his breath." Which instruction should the nurse give to the UAP?
Show answer and rationale
Correct answer: A. Go with the nurse to the client’s room.
This is the first intervention because the nurse must assess the client. Asking the UAP to accompany the nurse will allow the nurse to stay with the client while the UAP obtains any needed equipment.
The clinic nurse is scheduling a 14-year-old client for a tonsillectomy. Which intervention should the clinic nurse implement?
Show answer and rationale
Correct answer: C. Request the laboratory to draw a PT and a PTT.
A PT/PTT will assess the client for any bleeding tendencies. This is priority before this surgery because bleeding is a life-threatening complication.
The client calls the clinic nurse and asks, "What is the best way to prevent getting influenza?" Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: A. "The best way to prevent getting influenza is to get a yearly flu vaccine."
Influenza, or flu, is a serious respiratory illness. It is easily spread from person to person and can lead to severe complications, even death. The best way to prevent the influenza is to get a flu vaccine every year. The influenza virus is constantly changing. Each year, scientists work together to identify the virus strains that they believe will cause the most illness, and a new vaccine is made based on their recommendations.
The clinic nurse is evaluating vital signs for clients being seen in the outpatient clinic. Which client would require nursing intervention?
Show answer and rationale
Correct answer: D. The 24-week gestational woman who has a BP of 142/96 mm Hg.
A 24-week gestational woman with a BP of 142/96 would warrant intervention because the average systolic BP should be between 90 and 140 mm Hg and the diastolic BP should be between 60 and 85 mm Hg. This BP could indicate pregnancy-induced hypertension.
The nurse is accidentally stuck with a needle used to administer an intradermal injection for a PPD. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Immediately wash the area with soap and water.
The nurse should wash the area with soap and water and attempt to squeeze the area to make it bleed.
The clinic nurse is reviewing laboratory results for clients seen in the clinic. Which client requires additional assessment by the nurse?
Show answer and rationale
Correct answer: D. The client who has a hemoglobin of 9 g/dL and a hematocrit of 29%.
The normal hemoglobin level is 12 to 15 g/dL, and normal hematocrit is 39% to 45%. This client’s H&H is low. The nurse should contact the client and make an immediate appointment.
The Hispanic female client diagnosed with bacterial pneumonia is being admitted to the medical unit. The Hispanic husband answers questions even though the nurse directly asks the client. Which action should the nurse take?
Show answer and rationale
Correct answer: B. Continue to allow the husband to answer the wife’s questions.
This behavior may be cultural, and the nurse should continue to allow the husband to answer the questions, while the nurse looks at the client. The nurse must be respectful of the client’s culture. The nurse can, however, ask whether the client agrees with the husband’s answers.
The clinic nurse encounters a client who does not respond to verbal stimuli and initiates cardiopulmonary resuscitation (CPR). What should the nurse do? Prioritize the nurse’s actions from first (1) to last (5).
Show answer and rationale
Correct answer: D. Assess the client for unresponsiveness.
The nurse needs to determine if the client is unresponsive prior to taking any action. If the client is unresponsive, then perform compressions.
The home health nurse is visiting the client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) while the unlicensed assistive personnel (UAP) is providing care. Which action by the UAP would warrant intervention by the nurse?
Show answer and rationale
Correct answer: A. Keeping the bedroom at a warm temperature.
The client with end-stage COPD usually prefers a cool climate, with fans to help ease breathing. A warm area would increase the effort the client would require to breathe. This action would warrant intervention by the nurse.
Which task is most appropriate for the home health nurse to delegate to unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: D. Getting the client up in a chair three times a day.
The UAP can transfer the client from the bed to the chair three times a day.
In the local restaurant, the nurse overhears another hospital staff member talking to a friend about a client. The staff member discloses that the client was just diagnosed with lung cancer. What is the most appropriate action by the nurse?
Show answer and rationale
Correct answer: B. Ask the staff member not to discuss anything about the client.
The nurse should first ask the staff member not to discuss the client with a friend. Discussing any information about a client is a violation of HIPAA.
The 92-year-old client has a hospital bed in the home and is on strict bed rest. The unlicensed assistive personnel (UAP) cares for the client in the morning 5 days a week. Which statement indicates that the UAP needs additional education by the nurse?
Show answer and rationale
Correct answer: A. "I do not give her a lot of fluids so she won’t wet the bed."
This statement warrants intervention because fluids will help prevent dehydration and renal calculi. The nurse should explain the client needs to increase fluids.
The home health client is diagnosed with chronic obstructive disease. The unlicensed assistive personnel (UAP) tells the home health nurse that the client has trouble breathing when the client lies in a supine position. Which priority instruction should the nurse provide to the UAP?
Show answer and rationale
Correct answer: A. To allow the client to sleep in a recliner.
Because the client has difficulty breathing while lying in bed, allowing the client to sit in a recliner will help the client; therefore, this is the priority intervention.
The wife of a client diagnosed as terminal is concerned that the client is not eating or drinking. Which is the home health nurse’s best response?
Show answer and rationale
Correct answer: B. "This is normal at the end of life; the dehydration produces a type of euphoria."
Refusal to take in food and liquids produces a natural euphoria and makes the dying process easier on the client. This is an appropriate teaching statement.
The client has just been told a medical condition cannot be treated successfully and the client has a life expectancy of about 6 months. To whom should the nurse refer the client at this time?
Show answer and rationale
Correct answer: B. A hospice agency.
One of the guidelines for admission to a hospice agency is a terminal process with a life expectancy of 6 months or less. These organizations work to assist the client and family to live life to its fullest while providing for comfort measures and a peaceful, dignified death.
The hospice client asks the nurse, "What should I do about my house? My son and daughter are fighting over it." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "What do you want to happen to your house? It is your decision."
This response allows the client to make his or her own decision. It validates that the nurse heard the concern but does not advise the client.
The female nurse manager is discussing the yearly performance evaluation with a male nurse. Which information regarding communication styles should the nurse manager employ when talking with the employee?
Show answer and rationale
Correct answer: D. Men often see the work environment from a logical, focused perspective.
Men often see the world from a logical perspective and focus on a specific intervention.
The newly hired nurse manager has identified that whenever a specific staff member is unhappy with an assignment, the entire unit has a bad day. Which action should the unit manager take to correct this problem?
Show answer and rationale
Correct answer: B. Discuss the staff member’s attitude and the way it affects the unit.
The first step is an informal meeting with the staff member to discuss the inappropriate attitude and how it affects the staff. The manager should document the conversation informally with the date and time (the staff member does not need to see this documentation) for future reference. If the situation is not resolved, a formal counseling must take place.
The healthcare facility where the nurse works uses e-mail to notify the staff of in-services and mandatory requirements. Which is important information for the nurse manager to remember when using e-mail to disseminate information?
Show answer and rationale
Correct answer: C. Make the e-mail notices quick and easy to read.
E-mail communication should be concise and easy to read. If the e-mail requires a lot of information, then the writer should use bullets to separate information.
At 1700, the HCP is yelling at the nursing staff because the early morning lab work is not available for a client’s chart. Which is the most appropriate response by the charge nurse?
Show answer and rationale
Correct answer: D. Call the lab and have the lab supervisor talk with the HCP.
The problem is not a nursing problem. The HCP should be discussing the problem with an individual from the department that "owns" the problem.
The nurse is caring for a client who has a chest tube. What should the nurse do? Prioritize the nurse’s actions from first (1) to last (5).
Show answer and rationale
Correct answer: B. Assess the client’s lung sounds.
The nurse should begin the care by assessing the client. Remember the nursing process.
The nurse is assessing clients on a respiratory unit. Which client should be the nurse’s first priority?
Show answer and rationale
Correct answer: C. The client diagnosed with cystic fibrosis who has a pulse oximeter reading of 91%.
Cystic fibrosis (CF) is an inherited disease that causes thick, sticky mucus to form in the lungs, pancreas, and other organs. In the lungs, this mucus blocks the airways, causing lung damage and making it hard to breathe. A pulse oximeter reading of 90% equates to approximately a 60% arterial saturation. The nurse should assess this client first.
The nurse is developing a nursing care plan for a client diagnosed with chronic obstructive pulmonary disease (COPD). What should be the client’s priority nursing diagnosis?
Show answer and rationale
Correct answer: B. Impaired gas exchange.
Impaired gas exchange is the priority problem for this client. If the client does not have adequate gas exchange, the client will die. Remember Maslow’s Hierarchy of Needs.
The nurse assists with the insertion of a chest tube in a client diagnosed with a spontaneous pneumothorax. Which data indicates that the treatment has been effective?
Show answer and rationale
Correct answer: A. The client has bilateral breath sounds.
Bilateral breath sounds indicate the left lung has re-expanded and the treatment is effective.
The healthcare provider ordered the loop diuretic, bumetanide (Bumex), to be administered STAT to a client diagnosed with pulmonary edema. After 4 hours, which of the following assessment data indicates the client may be experiencing a complication of the medication?
Show answer and rationale
Correct answer: A. The client complains of painful leg cramps.
Leg cramps may indicate a low serum potassium level, which can occur as a result of the administration of a diuretic.
The client involved in a motor vehicle accident is being prepped for surgery when the client asks the emergency department nurse, "What happened to my child?" The nurse knows the child is dead. Which statement is an example of the ethical principle of nonmalfeasance?
Show answer and rationale
Correct answer: D. "I will find out for you and let you know after surgery."
Nonmalfeasance means to do no harm. This statement is letting the client know that the concern has been heard but does not give the client bad news before surgery. The nurse is aware that someone having surgery should be of sound mind, and finding out your child is dead would be horrific.
The new graduate has accepted a position at a facility that is accredited by the Joint Commission. Which statement describes the purpose of this organization?
Show answer and rationale
Correct answer: B. The Commission reviews facilities for compliance with standards of care.
The Joint Commission is an organization that monitors healthcare facilities for compliance with standards of care. Accreditation is voluntary, but most third-party payers will not reimburse a facility that is not accredited by some outside organization.
The client in a critical care unit died. What action should the nurse implement first?
Show answer and rationale
Correct answer: B. Stay with the significant other.
The nurse should "offer self " to the significant other. Ignoring the needs of the significant other at this time makes the significant other feel that the nurse does not care, and if the nurse does not care for "me," then did the nurse provide adequate care to my loved one? This action is very important to assist in the grieving process.
In the intensive care unit (ICU), the critical care nurse assesses a client diagnosed with an asthma attack who has a respiration rate of 10 and an oxygen saturation of 88%. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Increase the oxygen to 10 LPM.
The client in the intensive care unit (ICU) has been on a ventilator for 2 weeks with an endotracheal tube in place. Which intervention should the nurse prepare the client for next?
The client in the intensive care unit (ICU) has been on a ventilator for 2 weeks with an endotracheal tube in place. Which intervention should the nurse prepare the client for next?
Show answer and rationale
Correct answer: C. Placement of a tracheostomy.
A client who has been intubated for 10 to 14 days and still requires mechanical ventilation should have a surgically placed tracheostomy to prevent permanent vocal cord damage.
The UAP enters the elderly female client’s room to give the bath, but the client is watching her favorite soap opera. Which instructions should the nurse give to the UAP?
Show answer and rationale
Correct answer: B. Instruct the UAP to give the bath after the program.
This is the best instruction for the nurse to give to the UAP.
The nurse has been made the chairperson of a quality improvement committee. Which statement is an example of effective group process?
Show answer and rationale
Correct answer: C. The nurse involves all committee members in the discussion.
Effective group process involves all members of the group.
The client diagnosed with acute respiratory distress syndrome (ARDS) is having increased difficulty breathing. The arterial blood gas indicates an arterial oxygen level of 54% on O2 at 10 LPM. Which intervention should the intensive care unit nurse implement first?
Show answer and rationale
Correct answer: D. Prepare the client for intubation.
Acute respiratory distress syndrome is diagnosed when the client has an arterial blood gas of less than 50% while receiving oxygen at 10 LPM. The nurse should prepare for the client to be intubated.
The client’s arterial blood gas (ABG) results are pH 7.34, PaCO2 50, HCO3 24, PaO2 87. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Have the client turn, cough, and deep breathe.
These blood gases indicate respiratory acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn, cough, and deep breathe.
The client is admitted to the emergency department with an apical pulse rate of 134, respiration rate of 28, and BP of 92/56, and the skin is pale and clammy. What action should the nurse perform first?
Show answer and rationale
Correct answer: A. Start two IVs with large-bore catheters.
The client is exhibiting symptoms of shock. The nurse should start IV lines to prevent the client from progressing to circulatory collapse.
The charge nurse of the respiratory care unit is making assignments. Which clients should be assigned to the intensive care nurse who is working on the respiratory care unit for the day? Select the patient/patients that apply.
Show answer and rationale
Correct answer: A. The client who will be moved to the intensive care unit when a bed is available.
This client’s status is uncertain. The ICU nurse would be an appropriate assignment for this client since the patient will be moved to ICU soon.
The emergency department nurse is preparing to assist the surgeon to insert chest tubes in a client with a right hemothorax. Which position is appropriate for the procedure?
Show answer and rationale
Correct answer: C. Have the client sit upright and bend over the over bed table.
This position allows for access to the client’s back area. The chest tube for a hemothorax is positioned low and posterior to allow for gravity to assist in the removal of fluid from the thoracic area.
The nurse is admitting a patient diagnosed with pneumonia. Which healthcare provider’s order should be implemented first?
Show answer and rationale
Correct answer: C. Obtain sputum for Gram stain and culture.
In order to treat the client with the most effective medication and not skew the results of a sputum culture, the specimen must be obtained prior to initiating antibiotics.
The nurse is preparing to make rounds after receiving shift report. Which client should the nurse assess first?
Show answer and rationale
Correct answer: D. The patient diagnosed with a deep vein thrombosis who is requesting an anti-anxiety medication.
Patients diagnosed with deep vein thrombosis are at risk for pulmonary embolism (PE). Anxiety is a symptom of PE. The nurse must determine if interventions are needed for PE, a life-threatening emergency.
Which client should the charge nurse on the respiratory unit assign to the graduate nurse who just completed orientation?
Show answer and rationale
Correct answer: A. The client diagnosed with bronchiolitis who has a wheezy cough and rapid breathing.
Bronchiolitis is an inflammation of the bronchioles, which are the small airways in the lungs. Signs/symptoms include wheezy cough, rapid breathing, cyanosis, nasal flaring, muscle retactions, and fever. Because the client is exhibiting expected signs/symptoms this client should be assigned to the graduate nurse.
The client diagnosed with a community-acquired pneumonia is being admitted to the unit. Which healthcare provider’s order should be implemented first?
Show answer and rationale
Correct answer: D. Obtain a sputum specimen for culture and sensitivity.
The nurse needs to obtain a sputum culture prior to administering antibiotic because the culture and sensitivity will be skewed if the client receives antibiotics. This should be the first HCP implemented.
The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: A. Place the client in the orthopnic position.
Placing the client in the orthopnic position will help the client breathe easier. The position assumed by clients with orthopnea is one in which they are sitting propped up in bed by several pillows.
Which client should Ms. Gail assign to the licensed practical nurse (LPN)?
Show answer and rationale
Correct answer: A. The client who had a laryngectomy 2 days ago and has crepitus.
The LPN would be able to care for a client 2 days postoperative; crepitus is air in the subcutaneous tissue but is not life threatening.
Ms. Gail and the UAP are caring for the following clients. Which information provided by the UAP requires immediate intervention by Ms. Gail?
Show answer and rationale
Correct answer: A. The client with a left-sided pneumothorax has 200 mL of blood in the collection chamber of the Pleuravac.
The client with a pneumothorax should not have blood in the collection chamber; the client with a hemothorax would be expected to have bloody drainage. This client requires immediate intervention by Ms. Gail.
One of Ms. Gail’s staff nurses is preparing to administer a.m. medications to clients. Which medication should the nurse question administering to the client?
Show answer and rationale
Correct answer: A. The aminoglycoside antibiotic to the client with an elevated trough level.
The client on an aminoglycoside antibiotic with an elevated trough level should not receive the medication. The elevation could lead to ototoxicity or nephrotoxicity; therefore, the nurse should question administering this medication.
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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