NCLEX Practice Questions — Set 16
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 staff nurse is caring for a client who was diagnosed with pancreatic cancer during an exploratory laparotomy. Which client problem is priority for postoperative day 1?
Show answer and rationale
Correct answer: C. Fluid and electrolyte imbalance.
After major trauma, the body undergoes a fluid shift. The possibility of fluid and electrolyte imbalance is the top priority problem for 1 day after major abdominal surgery.
The male client who was just told he has 6 months to live tells the nurse, "This can’t be happening. I am too young to die." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: B. "If it is all right with you I am going to sit here with you."
The nurse’s best response is to stay with the client and allow the client to ventilate his feelings of denial, fear, and hopelessness.
The nurse administered pain medication 30 minutes ago to a client diagnosed with terminal cancer. Thirty minutes after the medication, the client tells the nurse "I don’t think you gave me anything. My pain is even worse than before." Which intervention(s) should the nurse implement? Select all that apply.
Show answer and rationale
Correct answer: B. Attempt to determine whether the client is experiencing spiritual distress.
Spiritual distress can greatly affect the perception of pain. If the client is not receiving relief from pain medication, the nurse should explore other variables that could affect the perception of pain.
Which member of the healthcare team should be assigned to a dying client who is having frequent symptoms of distress?
Show answer and rationale
Correct answer: D. The registered nurse (RN) who has experience as a hospice nurse.
A hospice nurse has experience in managing symptoms associated with the dying process. This is the best nurse to care for this client.
The infection control nurse notices a rise in nosocomial infection rates on the surgical unit. Which action should the infection control nurse implement first?
Show answer and rationale
Correct answer: D. Arrange to observe the staff at work for several shifts.
This is an action that will allow the infection control nurse to observe compliance with standard nursing practices such as hand washing. Once the nurse has attempted to determine a cause, then a corrective action can be implemented.
The unlicensed assistive personnel (UAP) is preparing to provide postmortem care to a client with a questionable diagnosis of anthrax. Which instruction is priority for the nurse to provide to the UAP?
Show answer and rationale
Correct answer: B. The UAP should wear a mask, gown, and gloves.
The UAP should wear appropriate personal proactive equipment when providing any type of care.
The client on a medical unit died of a communicable disease. Which information should the nurse provide to the mortuary workers?
Show answer and rationale
Correct answer: A. The nurse should tell the funeral home the client’s diagnosis.
The mortuary service is considered part of the healthcare team. In this case, the personnel in the funeral home should be made aware of the client’s diagnosis.
The nurse and unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which action by the UAP requires immediate intervention by the nurse?
Show answer and rationale
Correct answer: D. The UAP massages the client’s trochanter when turning the client.
Massaging pressure points increases tissue damage and increases the risk of skin breakdown. The nurse should intervene and stop this action by the UAP.
The charge nurse is making assignments on a surgical unit. Which client should be assigned to the least experienced nurse?
Show answer and rationale
Correct answer: A. The client who had a vaginal hysterectomy and still has an indwelling catheter.
This client has had a common surgical procedure and is not experiencing a complication. The least experienced nurse could care for this client.
The unit manager on an oncology unit receives a complaint about the care a client received from the night shift nurse. Which action should the unit manager implement first?
Show answer and rationale
Correct answer: C. Discuss the situation with the client making the complaint.
The first step is to discuss the complaint with the client. This step lets the client know that the client is being heard, and the manager is able to ask any questions to clarify the complaint.
The female client was admitted to the orthopedic unit for injuries received during a domestic argument. The client tells the nurse, "I am afraid my husband will kill me if I leave him. It was my fault anyway." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "Do you have a plan for safety if you go back?"
The nurse must assess the client’s safety and provide a referral to a women’s center. This is the nurse’s best response.
The husband of a client on the surgical unit comes to the desk and asks the nurse, "What is my wife’s biopsy report?" Which intervention is the nurse’s best action?
Show answer and rationale
Correct answer: B. Check the chart to see whether the client has allowed the spouse to have information.
Even though the spouse of the client is making the request, the nurse should still check to make sure that the client has listed the husband as being allowed to receive information. The Health Insurance Portability and Accountability Act (HIPAA) regulations do not allow for release of information to anyone not specifically designated by the client.
A new graduate nurse is assigned to work with an unlicensed assistive personnel (UAP) to provide care for a group of clients. Which action by the graduate nurse is the best method to evaluate whether delegated care is being provided?
Show answer and rationale
Correct answer: B. Make rounds to see that the clients are being turned.
The nurse retains responsibility for the care. Making rounds to see that the care has been provided is the best method to evaluate the care.
The nurse administered erythropoietin alpha (Epogen), a biological response modifier, to a client diagnosed with anemia. Which of the following data indicates the client may be experiencing an adverse reaction?
Show answer and rationale
Correct answer: B. BP 200/124.
Erythropoietin stimulates the bone marrow to produce red blood cells. An adverse reaction to Epogen is hypertension, which this client has, with a BP of 200/124. Hypertension can cause the dose of erythropoietin to be decreased or discontinued.
The client diagnosed with sickle cell disease complains of joint pain rated 10 on a pain scale of 1 to 10. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Assess the client to rule out (R/O) complications.
The first step in administering a PRN pain medication is to assess the client for a complication that may require the nurse to notify the HCP or implement an independent nursing intervention.
The nurse and licensed practical nurse (LPN) are caring for clients on an oncology unit. Which client should be assigned to the LPN?
Show answer and rationale
Correct answer: D. The client diagnosed with an ovarian tumor weighing 22 pounds who is being prepared for surgery in the morning.
This client is pre-op, and the LPN can prepare a client for surgery. A 22-pound tumor indicates a benign ovarian cyst.
The nurse has received the morning shift report on an oncology unit. Which client should the nurse assess first?
Show answer and rationale
Correct answer: D. The client diagnosed with breast cancer who is upset and crying.
The client is upset and crying. When all the information in the options is expected and not life threatening, then psychological issues have priority. This client should be seen first.
The nurse is caring for a female client diagnosed with systemic lupus erythematosus (SLE). Which of the following client-reported data has priority?
Show answer and rationale
Correct answer: B. The client notices a bright red color in the bedside commode.
Bright red in the bedside commode indicates blood, alerting the nurse to possible renal involvement. The healthcare provider must be notified so that diagnostic test can be ordered and steps taken to limit the damage to the kidneys.
The nurse caring for a client newly diagnosed with protein calorie malnutrition secondary to acquired immune deficiency syndrome (AIDS) writes a nursing problem of "altered nutrition: less than body requirements." Which nursing interventions should the nurse implement? Select all that apply.
Show answer and rationale
Correct answer: A. Have the client identify preferred foods.
The client’s preferred foods can be used to help increase the client’s appetite and should be provided whenever possible on the meal trays.
The client diagnosed with congestive heart failure and iron deficiency anemia is prescribed a unit of packed red blood cells (PRBC). Rank the interventions in order of performance.
Show answer and rationale
Correct answer: D. Check the client’s hemoglobin and hematocrit.
Of the steps listed, the nurse should check the client’s hemoglobin and hematocrit. Most healthcare facilities have a procedure to administer PRBCs only when the H/H are less than 8 and 24. Blood is a scarce commodity, and unless the client is scheduled for surgery there are other means of providing care of the client without the administration of blood products.
The nurse working in a rheumatology clinic is teaching a 34-year old female client with rheumatoid arthritis (RA) about the disease-modifying antirheumatic drug methotrexate. Which information has the highest priority?
Show answer and rationale
Correct answer: B. Teach the client to take measures to ensure she does not become pregnant.
Methotrexate can cause fetal abnormalities or loss of the fetus. The client should be placed on birth control for the duration of administration of this medication and for 2 years post.
Ms. Mary and Ms. Brenda are caring for clients. Which client should be assigned to the LPN, Ms. Brenda?
Show answer and rationale
Correct answer: B. The client who is 4 hours post-procedure bone marrow biopsy.
This is post-procedure care for a stable client; therefore, Ms. Mary could assign Ms. Brenda, the LPN, to care for this client. Ms. Mary cannot assign assessment, teaching, evaluation, or an unstable client to Ms. Brenda
Which client should Ms. Cindy assign to the medical-surgical nurse who is being pulled to work on the oncology unit for this shift?
Show answer and rationale
Correct answer: B. The client diagnosed with ovarian cancer who is 1 day postoperative total abdominal hysterectomy.
A medical-surgical nurse should be able to care for a client who is 1 day postoperative abdominal surgery; therefore, this client can be assigned to a floating nurse.
Ms. Kathy, an RN, and Ms. Teresa, the UAP, are caring for a group of clients. Which information provided by Ms. Teresa warrants immediate intervention by Ms. Kathy?
Show answer and rationale
Correct answer: A. The client with a biological response modifier who has a T 99.2�F, P 68, R 24, and BP of 198/102.
Biological response modifiers that stimulate the bone marrow can increase the client’s blood pressure to dangerous levels. This BP is very high and warrants immediate attention.
Ms. Kathy is caring for a client that is 1 day postoperative sigmoid resection and notes bright red bleeding on the midline abdominal incision. Which intervention should Ms. Kathy implement first?
Show answer and rationale
Correct answer: B. Assess the client’s vital signs.
Ms. Kathy should assess the client’s vital signs to determine if the client is hemorrhaging. Hypotension and tachycardia indicate hemorrhaging, potentially a life-threatening emergency.
Which nursing task should Ms. Kathy, the RN, delegate to Ms. Paula, the UAP?
Show answer and rationale
Correct answer: B. Empty the Jackson Pratt drainage tube and record amount.
Ms. Paula can empty the JP and reapply negative pressure. Ms. Kathy cannot delegate assessment, teaching, evaluation, medications, or an unstable client.
The client is 2 days post-ureterosigmoidostomy for cancer of the bladder. Which assessment data warrants Ms. Mary notifying the HCP?
Show answer and rationale
Correct answer: D. The client has a low-grade fever and a hard, rigid abdomen.
This client is exhibiting signs/symptoms of peritonitis, which is a life-threatening complication secondary to abdominal surgery; therefore, the nurse should notify the healthcare provider.
Ms. Mary identifies a problem of "anticipatory grieving" for a client diagnosed with Stage 4 ovarian cancer. Which nursing intervention is priority for this client?
Show answer and rationale
Correct answer: D. Allow the client to verbalize feelings about having cancer.
Therapeutic communication is the priority intervention for a client diagnosed with Stage 4 cancer and an identified problem of anticipatory grieving. Allowing the client to work through the steps of grieving is accomplished by encouraging the client to express feelings.
The client diagnosed with ovarian cancer has had five courses of chemotherapy. Which laboratory data warrant immediate intervention by Ms. Mary?
Show answer and rationale
Correct answer: C. Absolute neutrophil count (ANC) of 681 mm/dL.
An absolute neutrophil count of 681 indicates the client does not have sufficient mature white blood cells or granulocytes to act as a defense against infections. This client needs to be placed in reverse isolation and receive Neulasta, a biological response modifier.
Ms. Mary is performing a head-to-toe assessment on a Hispanic client diagnosed with prostate cancer. The nurse notes an irregular-shaped lesion with some scabbed-over areas surrounding the lesion. Which intervention should Ms. Mary implement first?
Show answer and rationale
Correct answer: D. Assess the lesion by completing the ABCDs of skin cancer.
This is part of assessing the lesion and should be completed. The ABCDs of skincancer detection include the following: (1) Asymmetry-Is the lesion balanced on both sides with an even surface? (2) Borders-Are the borders rounded and smooth or notched and indistinct? (3) Color-Is the color a uniform light brown or is it variegated and darker or reddish purple? (4) Diameter-A diameter exceeding 4-6 mm is considered suspicious.
The female client diagnosed with pancreatic cancer has an advance directive (AD) stipulating no cardiopulmonary resuscitation. Which intervention should Ms. Kathy implement first?
Show answer and rationale
Correct answer: A. Notify the client’s healthcare provider about the AD.
The HCP should be made aware of the AD so a do not resuscitate (DNR) order can be written. Only the HCP can write this order. Ms. Kathy should notify the HCP to get the DNR written immediately. The order must be written before an arrest occurs or CPR will be initiated.
Which client should the postpartum nurse assess first after receiving the a.m. shift report?
Show answer and rationale
Correct answer: A. The client who saturated multiple peri-pads during the night.
Saturating multiple peri-pads indicates heavy bleeding, which may indicate hemorrhaging. The nurse should assess this client first.
Which newborn infant would warrant immediate intervention by the nursery nurse?
Show answer and rationale
Correct answer: A. The 24-hour-old newborn who has not passed meconium.
The newborn who has not passed meconium 24 hours after birth must be evaluated for intestinal obstruction or a congenital abnormality. This could be caused by an imperforate anus, Hirschsprung’s disease, cystic fibrosis, or several other possibilities. This newborn warrants immediate intervention.
The client in labor is showing late decelerations on the fetal monitor. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: C. Place the client in the left lateral position.
The left lateral position will improve placental blood flow and oxygen supply to the fetus. This should be the nurse’s first intervention.
The nurse walks into the client’s room to check on the mother and her newborn. The client states another nurse just took her baby back to the nursery. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Determine whether the infant was returned to the nursery.
The nurse should first determine whether another staff member returned the infant to the nursery. The nurse should not call a false alarm.
The nurse in the labor and delivery department is caring for a client whose abdomen remains hard and rigid between contractions and the fetal heart rate is 100. Which client problem is priority?
Show answer and rationale
Correct answer: A. Risk for fetal demise.
The client is exhibiting signs of abruptio placentae, and a decreased heart rate indicates a compromised fetus. This problem will lead quickly to the death of the fetus. Therefore, it is the priority problem.
The nurse working in a women’s health clinic is returning telephone calls. Which client should the nurse contact first?
Show answer and rationale
Correct answer: B. The 27-year-old primigravida client who is complaining of blurred vision.
Blurred vision is a symptom of preeclampsia, and this is the client’s first pregnancy. This client should be contacted first and told to come into the clinic for further evaluation.
The charge nurse has received laboratory results for clients on the postpartum unit. Which client would warrant intervention by the nurse?
Show answer and rationale
Correct answer: D. The client whose serum glucose level is 280 mg/dL.
This glucose level is elevated, and the nurse should investigate further as to why the glucose level is abnormal. The normal glucose level is 70 to 120 mg/dL.
The nurse on the postpartum unit is administering a.m. medications. Which medication should the nurse administer first?
Show answer and rationale
Correct answer: C. The sliding scale insulin to the client diagnosed with type 1 diabetes.
The client with type 1 diabetes must receive insulin prior to eating; therefore, this must be administered first.
The labor and delivery nurse is performing a vaginal examination and assesses a prolapsed cord. Which intervention should the nurse implement first?
Show answer and rationale
Correct answer: B. Place the client in the Trendelenburg position.
A prolapsed cord is an emergency situation because the prolapsed cord could compromise the fetus’s blood supply. Placing the client in the Trendelenburg position will cause the fetus to reverse back into the uterus, which will take the pressure off the umbilical cord. The safety of the fetus is priority.
Which newborn infant would the nursery nurse assess first?
Show answer and rationale
Correct answer: A. The 4-hour-old newborn delivered at 42 weeks’ gestation.
The newborn delivered at 42 weeks is postmature and is at risk for hypoglycemia and hypothermia because the placenta begins to deteriorate after 40 weeks and subcutaneous fat is utilized to support the infant’s life. The nurse should assess this baby first just because of the 42-week gestation.
Which antepartum client should the charge nurse assign to the most experienced nurse?
Show answer and rationale
Correct answer: B. The 42-week gestation client who has been pushing for 4 hours and has yellow amniotic fluid.
This client is postmature and the fetus is at risk for meconium; therefore, this client should be assigned to the most experienced nurse.
A nurse has been floated from the medical unit to the postpartum unit. Which client should be assigned to this nurse?
Show answer and rationale
Correct answer: D. The 14-hour postpartum client who experienced eclampsia during delivery.
This client is still at risk for a seizure but a medical nurse should be able to care for a client who has a seizure. This client should be assigned to the medical nurse.
Which priority intervention should the nurse implement for the 38-week gestation client who is receiving epidural anesthesia?
Show answer and rationale
Correct answer: B. Assess the client’s respiratory rate.
If the anesthesia ascends the spinal cord the client will quit breathing; therefore, this is the priority intervention.
The 28-year-old female client is being scheduled for an emergency appendectomy. Which priority question should the emergency department nurse ask the client?
Show answer and rationale
Correct answer: D. "Is there any chance you are pregnant?"
Since the client will have to have anesthesia for the surgery and the client is within childbearing age, the nurse should determine whether the client is pregnant.
Which client should the labor and delivery charge nurse assign to the most experienced nurse?
Show answer and rationale
Correct answer: D. The client who has non-reassuring fetal heart rate patterns.
Non-reassuring fetal heart rate patterns indicate the fetus is in danger, which requires a more experienced nurse.
The female unlicensed assistive personnel (UAP) informs the nurse she has helped the 1-day postpartum client change her peri-pad three times in the last 4 hours. Which action should the nurse implement?
Show answer and rationale
Correct answer: B. Go to the room and check the client immediately.
This client may or may not be experiencing excessive bleeding, but the nurse’s first intervention is to assess the client.
The unlicensed assistive personnel (UAP) is assisting the nurse in the newborn nursery. Which action by the UAP would warrant intervention?
Show answer and rationale
Correct answer: B. The UAP is bathing the newborn with a bar of soap.
When bathing a newborn, soap is not necessary. Soap can be very drying to the skin; therefore, this action warrants intervention by the nurse.
The charge nurse is making assignments in the labor and delivery department. Which client should be assigned to the most experienced nurse?
Show answer and rationale
Correct answer: C. The 39-week gestational client who has late decelerations on the fetal monitor.
Late decelerations on the fetal monitor indicate fetal distress; this is a life-threatening situation, and an emergency C-section may be necessary. The charge nurse should assign the most experienced nurse to this client.
Which task should the nurse on the postpartum unit delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: C. Instruct the UAP to prepare a sitz bath for the client.
The UAP can provide hygiene care to the client. A sitz bath requires the UAP to check the temperature of the water and does not require nursing judgment.
A nurse from the medical-surgical unit is assigned to the postpartum unit. Which client should the charge nurse assign to the medical-surgical nurse?
Show answer and rationale
Correct answer: D. The client who had a vaginal hysterectomy and oophorectomy.
This is a routine surgical procedure that would not require the nurse to have any specialized postpartum experience. This client would be most appropriate to assign the float nurse who has experience on the medical-surgical unit.
The unlicensed assistive personnel (UAP) responds to a code in the newborn nursery. Which task should the house supervisor delegate to the UAP?
Show answer and rationale
Correct answer: D. Instruct the UAP to obtain supplies for the code.
The UAP can stand by and be ready to obtain any supplies needed for the code. This would be a most appropriate task to delegate in an emergency situation.
Which action by the nursery nurse would warrant immediate intervention by the charge nurse?
Show answer and rationale
Correct answer: D. The nurse performs the Ortoloni maneuver on the newborn.
The Ortoloni maneuver is performed to assess developmental hip dysplasia. A pediatrician or a nurse practitioner only should perform this maneuver because it can cause further damage if it is done incorrectly.
The RN and unlicensed assistive personnel (UAP) are caring for clients on a postpartum unit. Which task would be most appropriate for the RN to assign to the UAP?
Show answer and rationale
Correct answer: A. Escort the client to the car and check for a car seat.
The infant must be transported in a car safety seat. Many facilities will lend or give the client a car seat if one is not available. The UAP can determine whether there is a car seat and take the appropriate action if there is not one.
The nurse and unlicensed assistive personnel (UAP) are caring for babies in the newborn nursery. Which action by the UAP would warrant immediate intervention?
Show answer and rationale
Correct answer: C. The UAP does not check the mother’s identification (ID) band with the infant’s ID band.
The Joint Commission and safety standards mandate that all hospital personnel must check the parent’s ID band with the infant’s ID band before releasing the infant to the care of the mother or father.
Which task should the postpartum nurse not delegate to the unlicensed assistive personnel (UAP)?
Show answer and rationale
Correct answer: A. Instruct the UAP to administer Rhogam to the client who is Rh-negative.
Rhogam is a medication that cannot be delegated to the UAP.
Which behavior by the unlicensed assistive personnel (UAP) warrants immediate intervention by the postpartum nurse?
Show answer and rationale
Correct answer: D. The UAP pushes the PCA button for the 8-hour post-op C-section client.
Only the client pushes the PCA pump; therefore, this action requires immediate intervention by the nurse.
The charge nurse is making assignments on a postpartum unit that has two registered nurses (RNs), two licensed practical nurses (LPNs), and two unlicensed assistive personnel (UAPs). Which task/assignment is most appropriate?
Show answer and rationale
Correct answer: C. Ask the LPN to administer ibuprofen to the client experiencing afterbirth pains.
The LPN can administer medications, and ibuprofen has an antiprostaglandin effect that is appropriate for a client experiencing afterbirth pains.
The nurse instructed the unlicensed assistive personnel (UAP) to provide a sitz bath to the postpartum client with hemorrhoids. Which priority intervention should the nurse implement?
Show answer and rationale
Correct answer: A. Follow-up to ensure the UAP gave the sitz bath.
The most important intervention for the nurse to do when delegating a task is to follow up to ensure it was done.
Which newborn should the charge nurse in the nursery assign to the licensed practical nurse (LPN)?
Show answer and rationale
Correct answer: B. The 22-hour newborn who was born vaginally after 2 hours of pushing.
The newborn born vaginally after 2 hours’ labor is stable and should be assigned to the LPN.
The client being seen in the obstetric (OB) clinic tells the nurse, "I don’t think it is right that the judge is making me get a contraceptive implant just because they don’t think I am a good mother." Which ethical principle does the requirement violate?
Show answer and rationale
Correct answer: B. Autonomy.
This requirement is violating the client’s autonomy, which is a client’s right to self-determination without outside control. This approach has been used as a condition of probation, to allow women accused of child abuse/neglect to get out of a jail term.
The father of a newborn infant tells the nurse excitedly, "Someone just took our baby and they didn’t know the code word." Which action should the nurse implement first?
Show answer and rationale
Correct answer: D. Page a Code Pink, indicating an infant abduction.
The nurse’s first intervention is to call a Code Pink. Then, the nurse should institute all other nursing interventions. The infant’s safety is priority.
The client who delivered twins 3 days ago calls the women’s health clinic and tells the nurse, "I am having hip pain that makes it difficult for me to walk." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: C. "This often occurs a few days after delivery and will go away with time."
During the first few days after delivery, levels of the hormone relax and gradually subside, and the ligaments and cartilage of the pelvis return to their pre-pregnancy position. These changes cause hip and joint pain that interfere with ambulation. The mother should understand that the pain is temporary and does not indicate a problem.
The 36-week gestational client has just delivered a stillborn infant. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: B. Notify the hospital chaplain of the fetal demise.
According to the NCLEX-RN� test blueprint, management of care includes appropriate use of referrals. The chaplain is responsible for intervening in a case where there is spiritual distress. A loss of a child is devastating.
The client who is 20 weeks’ gestation comes to the women’s health clinic, and the nurse notices bruises on her abdomen and back. Which response is most appropriate for the nurse?
Show answer and rationale
Correct answer: D. "Do you feel safe in your home?"
The nurse’s best intervention is to assess the safety of the client and infant and provide information to the client about a safe haven.
The boyfriend comes to the postpartum unit and demands his girlfriend’s room number. The nurse can smell alcohol on the man’s breath, and he is acting erratically. Which action should the nurse implement?
Show answer and rationale
Correct answer: D. Contact hospital security to come to the unit.
The nurse should first contact hospital security to intervene and escort the boyfriend off the unit.
The nurse is caring for a postpartum client who is a Jehovah’s Witness and needs a RhoGAM injection. Which question should the nurse ask the client?
Show answer and rationale
Correct answer: B. "Rhogam is a blood product. Do you want the injection?"
Jehovah’s Witnesses do not believe in accepting blood products, but it is the individual’s choice. The nurse is a client advocate and should make sure the client is aware that without the injection her next pregnancy could result in erythroblastosis fetalis. However, with the injection her religious belief may be compromised because Rhogam is a blood product.
The nurse is administering medications to clients on a postpartum floor. Which medication should the nurse question administering?
Show answer and rationale
Correct answer: B. The yearly flu vaccine to a client who reports an allergy to eggs.
The flu vaccine is made using duck eggs; therefore, the nurse should question the administration of this vaccine to a client who is allergic to eggs.
Which client would the newborn nursery nurse assess first after receiving shift report?
Show answer and rationale
Correct answer: C. The newborn who has a cephalohematoma.
A cephalohematoma results when there is bleeding between the periosteum and the skull from pressure during birth. The firm swelling is not present at birth but develops within the first 24 to 48 hours. Any time a client is bleeding, it warrants intervention by the nurse.
Which statement indicates to the postpartum nurse the discharge teaching to the first-time mother is effective?
Show answer and rationale
Correct answer: D. "I should contact my baby’s doctor if she refuses two or more feedings."
Refusal of two or more feedings indicates the infant has a problem that requires the mother notify the healthcare provider. This indicates the mother understands the discharge teaching.
Which primigravida client should the clinic nurse report to the certified nurse midwife?
Show answer and rationale
Correct answer: A. The 32-week gestation client reporting of facial edema.
Facial edema is a sign of pregnancyinduced hypertension, which requires the clinic nurse to contact the certified nurse midwife.
Which data should the nurse assess on the 2-hour postpartum client who delivered vaginally? Select all that apply.
Show answer and rationale
Correct answer: A. Palpate the client’s breasts.
The breasts should be palpated to assess for fullness or engorgement.
Which action by the nurse warrants intervention by the charge nurse on the postpartum unit?
Show answer and rationale
Correct answer: C. The nurse offers the Muslim client a ham sandwich and salad for lunch.
The Muslim religion does not allow the consumption of pork products, so this warrants intervention by the charge nurse.
The nurse volunteering in a free clinic has been caring for a female client for several weeks. The client states, "My husband and I been trying to have a baby for 6 years. What can we do?" Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: A. "Infertility treatments are very expensive and you would have to pay for it."
If the couple has not been able to conceive in 6 years, then a referral to an infertility clinic would be appropriate, but the tests and treatment for infertility are very expensive. The client is being seen in a free clinic, which indicates a lack of funds. The nurse has a relationship with this client over the time period "several weeks." The nurse should answer the client’s question.
Which client should the labor and delivery nurse assess first after receiving report?
Show answer and rationale
Correct answer: B. The client who is 10 cm dilated and 100% effaced.
The client who is 10 cm dilated and 100% effaced is ready to deliver the fetus; therefore, the nurse should assess this client first.
The nurse is caring for clients in a women’s health clinic. Which client warrants intervention by the nurse?
Show answer and rationale
Correct answer: C. The pregnant client who has 3+ proteins in her urine.
Protein in the urine indicates the client is at risk for pregnancy-induced hypertension; therefore, this client warrants intervention and further assessment by the nurse.
The client is 1 day postpartum, and the nurse notes the fundus is displaced laterally to the right. Which nursing intervention should be implemented first?
Show answer and rationale
Correct answer: C. Assist the client to the bathroom to urinate.
The number one reason for a displaced fundus is a full bladder. The nurse should always do the least invasive procedure, which is to ask the client to attempt to void. The emptying of the bladder should allow the fundus to return to the midline position.
While making rounds, the charge nurse notices the client’s chart has been left on the bedside table. Which action should the charge nurse implement first?
Show answer and rationale
Correct answer: D. Take the client’s chart back to the nurse’s station.
The charge nurse should first take the client’s chart back to the nurse’s station and then determine who left it at the client’s bedside, and why.
The 27-year-old female client is being scheduled for a chest x-ray. Which question should the nurse ask the client?
Show answer and rationale
Correct answer: D. "Is there any chance you may be pregnant?"
The nurse should ask whether the client may be pregnant because if there is a chance of pregnancy, the client should not have an x-ray. Any time a female client is of childbearing age and is having any type of x-ray, this question should be asked.
The clinical manager is reviewing hospital occurrence reports and notes that the nurse on the postpartum unit has documented three medication errors in the last 2 months. Which action should the clinical manager implement first?
Show answer and rationale
Correct answer: C. Discuss the errors with the nurse to determine whether there is a medication system problem.
This should be the clinical manager’s first intervention, to assess whether the system is responsible for the medication errors or whether it is a nursing error problem. For example, a system error problem would be that the medication is not available at the prescribed time.
The nursery nurse is assessing newborns. Which newborn would require immediate intervention by the nurse?
Show answer and rationale
Correct answer: D. The newborn who remains in the fetal position when lying supine.
When the infant is placed in the supine position, the infant should extend the arm and leg on the side to which the head is turned and then flex the extremities on the other. This is known as the tonicneck reflex or fencing reflex, which is normal for the newborn. The newborn remaining in a fetal position when supine warrants further intervention to assess for neurological problems.
The client on the postpartum unit tells the nurse, "My husband thinks he is the father of my baby but he is not. What should I tell him?" Which response supports the ethical principal of no maleficence?
Show answer and rationale
Correct answer: B. "How do you think your husband will feel if he knows he is not the father?"
No maleficence is the duty to do no harm. Many ethicists think that the principle of no maleficence has priority over other ethical principles except for autonomy. No maleficence allows the nurse to answer a question or make a decision that does not create further complications for the client.
The chief nursing officer of the hospital instructed the clinical manager of the postpartum unit to research a change in the system of delivery of care. Which statement best describes modular nursing?
Show answer and rationale
Correct answer: A. A nurse and UAP are assigned a group of postpartum clients.
Modular nursing is frequently called care pairs, in which nurses are paired with other less well-trained caregivers to provide nursing care to group clients.
Which action by the postpartum clinical manager would be most effective in producing a smooth transition to the new medication delivery system?
Show answer and rationale
Correct answer: A. Have an open-door policy to discuss the change.
To be an effective change agent, the manager needs to develop a sense of trust, establish common goals, and facilitate effective communication.
During an interview, the pregnant client at the women’s health clinic hesitantly tells the nurse, "I think I should let someone know that I can’t stop eating dirt. I crave it all the time." Which action should the nurse implement first?
Show answer and rationale
Correct answer: A. Check the client’s hemoglobin and hematocrit (H&H).
Pica, ingesting substances not normally considered food, may decrease the intake of food and therefore essential nutrients. Iron deficiency was once thought to be a cause of pica but is now considered a result. The nurse must first assess to determine whether the behavior is detrimental to the mother or infant before further action is taken.
The client who is 16 weeks pregnant calls and tells the office nurse, "My husband’s insurance has changed and they say I can’t use you anymore." Which statement is the nurse’s best response?
Show answer and rationale
Correct answer: D. "If we continue to see you it will cost you a lot more money."
Insurance companies contract with certain providers to provide care to the client at a reduced rate. Using this doctor, who is not a preferred provider of care, will result in a greater out-of-pocket expense for the client.
The 16-year-old mother of a 1-day-old infant wants her son circumcised. Which intervention should the nurse implement?
Show answer and rationale
Correct answer: B. Have the 16-year-old client sign for informed consent.
A 16-year-old mother has the right to make decisions for her child; therefore, the mother must sign the informed consent for the procedure.
The clinical manager is presenting a lecture on collective bargaining. One of the nurse participants asks, "What happens if nurses decide to go on strike?" Which statement is the clinical nurse manager’s best response?
Show answer and rationale
Correct answer: D. "The nurses must give a 10-day notice before a strike takes place."
Federal law requires that there must be a 10-day notice before going on a strike. This gives the hospital a chance to prepare for the strike and make changes to ensure client safety.
Which client should the newborn nurse refer to the hospital ethics committee?
Show answer and rationale
Correct answer: A. The newborn who is anencephalic whose parents want everything done.
Anencephaly is a congenital abnormality that entails an absence of all or a major part of the brain. The infant has no chance of life outside of a healthcare institution. The healthcare team refers situations to the ethics committee to help resolve dilemmas when caring for clients.
Which action would be most important for the clinical manager to take regarding a primary nurse who has received numerous compliments from the clients and their families about the excellent care she provides?
Show answer and rationale
Correct answer: D. Document the comments on the nurse’s performance evaluation.
The clinical manager should recognize the comments of clients/families during the performance evaluation. Excellence in care should be documented in writing in nurse’s personnel file to support merit raises, transfers, and promotions. Many healthcare facilities have employee recognition programs.
The nurse is completing the admission assessment on a 12-weeks-pregnant client who is visiting the women’s health clinic. The client tells the nurse, "I am a vegan and will not drink any milk or eat any meat." Which intervention should the nurse implement?
Show answer and rationale
Correct answer: C. Recommend the client eat grains, legumes, and nuts daily.
Vegans are individuals who avoid animal proteins, which are complete proteins that contain all the essential amino acids the body cannot synthesize from other sources. Vegetable proteins lack one or more of the essential amino acids, so the vegan must combine different plant proteins, grains, legumes, and nuts, to allow for intake of all essential amino acids. Vegans avoid all animal products and have difficulty meeting adequate nutritional protein needs.
The charge nurse of the postpartum unit is making assignments. Which patients should be assigned to the medical-surgical nurse who has been assigned to the unit for the day? Select all that apply.
Show answer and rationale
Correct answer: C. The patient who delivered 4 hours ago and is complaining of pain.
This patient has delivered her infant and has pain. The medical-surgical nurse can care for this patient.
The public health nurse is working at a sexually transmitted disease (STD) clinic. The female client has been diagnosed with gonorrhea. Which nursing interventions should the nurse implement? Rank in order of performance.
Show answer and rationale
Correct answer: C. Ask the client to provide a list of sexual partners.
All sexual partners of the client should be notified of possible exposure to an STD. This is the responsibility of the public health nurse.
The emergency department nurse observed a motor vehicle accident (MVA) on her way home from work. The driver of one of the vehicles is obviously several months pregnant. Which nursing intervention should the nurse implement first?
Show answer and rationale
Correct answer: D. Assess the driver for signs of trauma.
The driver must be assessed for signs of trauma before anything else can be done. If the patient dies, then the fetus will die too.
The nurse is caring for a 34-year-old female client who tells the nurse, "I have been diagnosed with a human papillomavirus (HPV) infection in my mouth. I don’t understand. I get cervical smears for that." Which is the nurse’s best response?
Show answer and rationale
Correct answer: B. "This infection is on the rise from oral contact with a person who has the infection."
Human papillomavirus (HPV) infections are increasing exponentially and many younger persons are developing mouth infections and cancers from HPV.
The nurse is teaching a health class for 14- to 18-year-old females. Which information regarding sexually transmitted diseases (STDs) should the nurse include in the discussion?
Show answer and rationale
Correct answer: C. The more sexual contacts an individual has both for oral sex and intercourse, the greater the probability that individual has of contracting an STD.
The more exposure there is to blood or body fluids from another individual (more partners), the greater the chance there is of developing an STD.
Which postpartum client should Ms. Helen assign to the most inexperienced nurse, Ms. Patricia?
Show answer and rationale
Correct answer: A. The client who has hemorrhoids and is complaining of pain.
This pain needs to be assessed and pain medication administered. A new graduate would be able to care for this client safely.
Which newborn infant would warrant immediate intervention by Ms. Kathy, the nursery nurse?
Show answer and rationale
Correct answer: B. The 6-hour-old newborn who has a respiratory rate of 24.
The normal respiratory rate for a newborn is 30 to 60; therefore, this information warrants immediate intervention.
The laboring client is showing late decelerations on the fetal monitor. After placing the client in the left lateral position, which intervention should Ms. Glada implement first?
Show answer and rationale
Correct answer: D. Notify the client’s obstetrician immediately.
The fetus is in distress and after increasing blood supply by placing the client in the left lateral position, Ms. Glada needs to contact the obstetrician for immediate C-section.
Ms. Helen is monitoring laboratory results for clients on the postpartum unit. Which client would warrant intervention by Ms. Helen?
Show answer and rationale
Correct answer: C. The client with preeclampsia who has a platelet count of 90,000 mm3.
HELLP syndrome is a group of symptoms that occur in pregnant women who have hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP), which occurs in women who are severely preeclamptic and eclamptic. Normal platelet count is 150,000 to 450,000, so this client’s platelet count requires immediate intervention.
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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