Free NCLEX-PN Practice Test
The NCLEX-PN Practice Test (2025 Updated) is a vital resource for practical nursing students preparing for the National Council Licensure Examination for Practical Nurses. This practice test consists of multiple-choice questions that assess a student’s knowledge in key nursing areas such as pharmacology, disease management, nursing interventions, patient safety, and therapeutic communication. Each question is accompanied by a detailed explanation to reinforce learning and improve critical thinking. The practice test is structured to reflect real exam conditions, helping students build confidence and competence in providing safe and effective nursing care.
Understanding the NCLEX-PN Exam Format
The NCLEX-PN exam is designed to evaluate the competency of entry-level practical nurses. The test follows the Computer Adaptive Testing (CAT) format, which adjusts the difficulty level of questions based on a candidate’s performance. The exam consists of multiple-choice, select-all-that-apply (SATA), fill-in-the-blank, and prioritization questions. A thorough understanding of these question types is essential for success.
The practice test provided here covers major topics found on the NCLEX-PN, ensuring that candidates are well-prepared for the actual exam. By practicing these questions, test-takers can improve their ability to apply theoretical knowledge to real-world patient scenarios.
Key Topics Covered in the NCLEX-PN Practice Test
The NCLEX-PN test evaluates candidates on the following essential nursing topics:
1. Pharmacology and Medication Administration
Medication safety is a crucial aspect of nursing practice. The test includes questions on commonly prescribed medications such as:
- Digoxin – Nurses must monitor for signs of digoxin toxicity, which include nausea, vomiting, and bradycardia. Patients should be taught to check their pulse before taking the medication.
- Metformin – This medication should be discontinued before any procedure involving contrast dye to prevent lactic acidosis.
- Warfarin – Clients taking warfarin must avoid excessive intake of vitamin K-rich foods (e.g., green leafy vegetables) as they can interfere with the medication’s effectiveness.
- Prednisone – Patients should be educated on the importance of tapering corticosteroids gradually to prevent adrenal insufficiency.
- Nitroglycerin – A common side effect of nitroglycerin is headaches due to vasodilation, which should be explained to patients.
2. Disease Management and Nursing Interventions
The test includes multiple questions related to disease processes and appropriate nursing interventions, such as:
- Heart Failure – Patients with heart failure should be instructed to weigh themselves daily to monitor fluid retention.
- Pneumonia – Deep breathing and coughing exercises are encouraged to prevent atelectasis and mobilize secretions.
- Addison’s Disease – Clients should consume a high-sodium, low-potassium diet to counteract the effects of aldosterone deficiency.
- Increased Intracranial Pressure (ICP) – Bradycardia, hypertension, and irregular respirations (Cushing’s triad) are critical signs that require immediate intervention.
Understanding how to prioritize patient care in these conditions is essential for NCLEX-PN success.
3. Safety and Infection Control
Patient safety is a fundamental nursing responsibility. The test includes questions on:
- Chest Tube Management – Nurses should keep the drainage system below chest level and avoid clamping the tube unless specifically instructed.
- Fall Prevention – Clients at risk for falls should use assistive devices, have bed alarms, and wear non-slip socks.
- Infection Control – Hand hygiene and proper use of personal protective equipment (PPE) are emphasized.
These principles align with the National Patient Safety Goals (NPSGs) established by The Joint Commission.
4. Nutrition and Dietary Considerations
Nutritional knowledge is crucial for nurses. The test includes dietary guidelines for different conditions, such as:
- Iron-Deficiency Anemia – Clients should consume iron-rich foods such as spinach, red meat, and fortified cereals.
- Low-Sodium Diet – Clients with hypertension or heart disease should avoid canned soups, processed foods, and salty snacks.
- Clear Liquid Diet – Appropriate foods include broth, gelatin, and clear juices, while milk and solid foods should be avoided.
These dietary modifications help manage chronic conditions effectively.
5. Therapeutic Communication and Patient Education
Effective communication is a key nursing skill. The test includes scenarios where nurses must use therapeutic communication techniques, such as:
- Active listening – Encouraging patients to express their concerns.
- Providing clear, concise education – Ensuring patients understand their medications and treatment plans.
- Offering emotional support – Helping patients cope with new diagnoses or procedures.
For example, clients with colostomies should be reassured that their condition is manageable, and they should empty their pouch when it is half full to prevent leaks.
Strategies for Success on the NCLEX-PN
To pass the NCLEX-PN, candidates must not only memorize facts but also develop critical thinking and clinical judgment skills. The following strategies can enhance preparation:
1. Understand the Nursing Process (ADPIE)
Most NCLEX-PN questions follow the nursing process:
- Assessment – Gathering patient data before taking action.
- Diagnosis – Identifying the patient’s problem.
- Planning – Setting measurable goals.
- Implementation – Performing nursing interventions.
- Evaluation – Checking if goals were met.
For example, if a client reports dizziness while taking blood pressure medication, the first step is assessment (checking blood pressure and symptoms) before taking further action.
2. Use Test-Taking Strategies
- Eliminate incorrect answers – If two answers are similar, one is usually correct.
- Prioritize using Maslow’s Hierarchy of Needs – Address physiological needs (airway, breathing, circulation) before psychosocial concerns.
- Apply the ABCs (Airway, Breathing, Circulation) – Life-threatening issues always take precedence.
3. Practice with NCLEX-Style Questions
Regular practice with NCLEX-style questions improves familiarity with test formats and builds confidence. Reviewing rationales for correct and incorrect answers reinforces learning.
4. Manage Test Anxiety
Anxiety can affect test performance. Strategies to reduce stress include:
- Deep breathing exercises before the exam.
- Time management skills to avoid rushing through questions.
- Positive mindset and confidence in preparation efforts.
Conclusion
The NCLEX-PN Practice Test (2025 Updated) is a comprehensive resource that helps practical nursing students develop the knowledge, skills, and confidence needed to pass the exam. By covering essential topics such as pharmacology, disease management, patient safety, therapeutic communication, and nursing interventions, this test ensures candidates are well-prepared for real-world nursing challenges.
Through consistent practice, critical thinking, and test-taking strategies, students can approach the NCLEX-PN with confidence and achieve success in their nursing careers.
NCLEX For PN Questions and Answers
Which of the following statements about informed consent is correct?
A) It must always be obtained by a nurse.
B) It is not required for emergency procedures.
C) It requires the patient to sign a document without explanation.
D) It is only valid if the patient is under sedation.
Answer: B) It is not required for emergency procedures.
Explanation: In emergency situations where a patient is unable to provide consent, treatment may be provided without informed consent to preserve life or prevent serious harm.
A client with heart failure is prescribed furosemide (Lasix). What is the most important electrolyte imbalance to monitor?
A) Hypercalcemia
B) Hypokalemia
C) Hypernatremia
D) Hypochloremia
Answer: B) Hypokalemia
Explanation: Furosemide is a loop diuretic that increases urine output and can lead to potassium loss, causing hypokalemia, which may result in muscle weakness and cardiac arrhythmias.
A client with diabetes mellitus is experiencing hypoglycemia. Which symptom is most indicative of this condition?
A) Fruity breath odor
B) Excessive thirst
C) Cold, clammy skin
D) Frequent urination
Answer: C) Cold, clammy skin
Explanation: Hypoglycemia can cause symptoms such as sweating, pallor, dizziness, and clammy skin due to low blood sugar levels affecting the nervous system.
Which type of isolation precaution is required for a patient with tuberculosis (TB)?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions
Answer: C) Airborne precautions
Explanation: TB is an airborne disease that requires the use of an N95 respirator and a negative-pressure isolation room to prevent the spread of infection.
The nurse is reinforcing teaching about digoxin (Lanoxin) therapy. Which statement by the client indicates a need for further teaching?
A) “I should check my pulse before taking the medication.”
B) “If I experience nausea, I should take another dose.”
C) “I should report vision changes to my healthcare provider.”
D) “I need to monitor my potassium levels.”
Answer: B) “If I experience nausea, I should take another dose.”
Explanation: Nausea is a sign of digoxin toxicity. The client should report symptoms rather than taking an extra dose.
A nurse is caring for a client with a Foley catheter. How should the nurse prevent urinary tract infections (UTIs)?
A) Keep the drainage bag level with the bladder
B) Empty the drainage bag only when it is full
C) Clean the perineal area regularly
D) Clamp the catheter frequently to maintain bladder tone
Answer: C) Clean the perineal area regularly
Explanation: Proper perineal hygiene helps reduce the risk of catheter-associated urinary tract infections (CAUTIs).
Which nursing intervention is most appropriate for a client with pneumonia?
A) Encourage fluid restriction
B) Encourage frequent deep breathing and coughing
C) Place the client in a supine position
D) Administer antihistamines as prescribed
Answer: B) Encourage frequent deep breathing and coughing
Explanation: Deep breathing and coughing help mobilize secretions, improve oxygenation, and prevent atelectasis in pneumonia patients.
A nurse is monitoring a client receiving intravenous (IV) potassium chloride. Which finding requires immediate intervention?
A) Mild burning at the IV site
B) Serum potassium level of 4.0 mEq/L
C) Decreased urine output
D) Heart rate of 80 beats per minute
Answer: C) Decreased urine output
Explanation: Potassium is excreted by the kidneys, and decreased urine output can lead to hyperkalemia, which is life-threatening.
A client with COPD is receiving oxygen therapy. What is the most important nursing action?
A) Encourage deep breathing exercises
B) Increase oxygen flow rate as needed
C) Keep the client in a supine position
D) Administer bronchodilators after meals
Answer: A) Encourage deep breathing exercises
Explanation: Deep breathing helps improve lung expansion, prevent mucus buildup, and reduce dyspnea in COPD patients.
Which food should a client taking warfarin (Coumadin) avoid?
A) Bananas
B) Spinach
C) Chicken
D) Rice
Answer: B) Spinach
Explanation: Spinach is high in vitamin K, which can counteract the effects of warfarin, increasing the risk of clot formation.
A nurse is assessing a client with Cushing’s syndrome. Which symptom is expected?
A) Hypotension
B) Moon face
C) Weight loss
D) Decreased blood glucose levels
Answer: B) Moon face
Explanation: Cushing’s syndrome results from excess cortisol, leading to fat redistribution, causing a round “moon face” appearance.
A postpartum client is experiencing heavy vaginal bleeding. What is the nurse’s priority action?
A) Massage the fundus
B) Offer fluids
C) Place the client in a supine position
D) Administer a sedative
Answer: A) Massage the fundus
Explanation: Uterine atony is a common cause of postpartum hemorrhage, and fundal massage helps the uterus contract and reduce bleeding.
Which action by the nurse can help prevent aspiration in a client with dysphagia?
A) Encourage rapid eating
B) Offer thin liquids
C) Position the client upright while eating
D) Allow the client to lie down immediately after eating
Answer: C) Position the client upright while eating
Explanation: An upright position promotes safe swallowing and reduces the risk of aspiration.
A client is experiencing an anaphylactic reaction after receiving penicillin. What should the nurse do first?
A) Start an IV line
B) Administer epinephrine
C) Call the healthcare provider
D) Provide oral diphenhydramine
Answer: B) Administer epinephrine
Explanation: Epinephrine is the first-line treatment for anaphylaxis because it helps reverse airway constriction and circulatory collapse.
Which of the following foods should a client with celiac disease avoid?
A) Rice
B) Oatmeal
C) Corn
D) Quinoa
Answer: B) Oatmeal
Explanation: Oats may be contaminated with gluten, which can trigger symptoms in individuals with celiac disease.
A nurse is caring for a client with a nasogastric (NG) tube. What is the best way to verify correct placement?
A) Inject air and listen for a gurgling sound
B) Check pH of aspirated gastric contents
C) Observe for client discomfort
D) Measure the tube length externally
Answer: B) Check pH of aspirated gastric contents
Explanation: Gastric contents should have a pH of 1-5. pH testing is the most accurate bedside method to confirm placement before feeding or medication administration.
A nurse is reinforcing education on metformin for a client with type 2 diabetes. Which statement requires further teaching?
A) “I will take this medication with meals.”
B) “This medication may cause mild diarrhea.”
C) “I should avoid alcohol while taking this drug.”
D) “I need to stop taking it before a CT scan with contrast.”
Answer: D) “I need to stop taking it before a CT scan with contrast.”
Explanation: Metformin should be temporarily discontinued before contrast dye administration to prevent lactic acidosis, a rare but serious side effect.
A nurse is caring for a client with left-sided heart failure. Which symptom is most concerning?
A) Bilateral lower extremity edema
B) Crackles in the lungs
C) Hepatomegaly
D) Jugular vein distension
Answer: B) Crackles in the lungs
Explanation: Left-sided heart failure leads to pulmonary congestion, causing crackles, dyspnea, and decreased oxygenation.
Which newborn assessment finding requires immediate intervention?
A) Heart rate of 140 bpm
B) Yellow skin tone at 24 hours old
C) Positive Moro reflex
D) Acrocyanosis
Answer: B) Yellow skin tone at 24 hours old
Explanation: Jaundice within the first 24 hours may indicate hemolytic disease or liver dysfunction, requiring urgent evaluation.
A nurse is assisting with the care of a client experiencing opioid withdrawal. Which symptom is expected?
A) Bradycardia
B) Pinpoint pupils
C) Nausea and vomiting
D) Respiratory depression
Answer: C) Nausea and vomiting
Explanation: Opioid withdrawal can cause nausea, vomiting, sweating, muscle pain, and restlessness but does not cause life-threatening effects.
Which intervention is most appropriate for a client with sickle cell crisis?
A) Apply cold packs to painful areas
B) Encourage fluid intake
C) Limit oxygen therapy
D) Administer high doses of acetaminophen
Answer: B) Encourage fluid intake
Explanation: Hydration helps prevent further sickling of red blood cells, reducing pain and complications.
A client with COPD has an oxygen saturation of 88%. What is the best nursing action?
A) Increase oxygen to 6 L/min
B) Continue monitoring the client
C) Encourage deep breathing and coughing
D) Withhold oxygen therapy
Answer: B) Continue monitoring the client
Explanation: COPD clients often have lower baseline oxygen levels, and 88% may be acceptable. Increasing oxygen too much can reduce respiratory drive.
Which symptom indicates a lithium toxicity emergency?
A) Weight gain
B) Increased urination
C) Blurred vision and confusion
D) Mild hand tremors
Answer: C) Blurred vision and confusion
Explanation: Lithium toxicity can cause severe neurological symptoms, including confusion, ataxia, and tremors. Levels should be monitored regularly.
A nurse is preparing to administer insulin lispro. When should it be given?
A) 30 minutes before a meal
B) At bedtime
C) With the first bite of a meal
D) Two hours after a meal
Answer: C) With the first bite of a meal
Explanation: Insulin lispro is a rapid-acting insulin that should be given immediately before or with food to prevent hypoglycemia.
Which is the best intervention for a client experiencing status epilepticus?
A) Apply restraints
B) Administer IV benzodiazepines
C) Place the client in a supine position
D) Offer oral fluids
Answer: B) Administer IV benzodiazepines
Explanation: Status epilepticus is a medical emergency requiring rapid administration of IV benzodiazepines (e.g., lorazepam) to stop prolonged seizure activity.
A nurse is caring for a client with deep vein thrombosis (DVT). Which action should be avoided?
A) Elevating the affected limb
B) Applying compression stockings
C) Encouraging ambulation
D) Administering anticoagulants
Answer: C) Encouraging ambulation
Explanation: Ambulation may dislodge the clot, increasing the risk of pulmonary embolism. The client should rest with the leg elevated.
A nurse is assisting a client experiencing a myasthenic crisis. What is the priority intervention?
A) Administer corticosteroids
B) Ensure airway patency
C) Offer high-calorie snacks
D) Encourage deep breathing exercises
Answer: B) Ensure airway patency
Explanation: Myasthenic crisis can cause respiratory muscle weakness, leading to respiratory failure. Airway support is the priority.
Which finding suggests a client is experiencing a hemorrhagic stroke?
A) Sudden severe headache
B) Gradual onset of weakness
C) Unilateral facial drooping
D) Slurred speech
Answer: A) Sudden severe headache
Explanation: A hemorrhagic stroke often presents with a sudden, intense headache due to bleeding in the brain.
A nurse is caring for a client with pancreatitis. Which lab value is most concerning?
A) Elevated amylase and lipase
B) Low white blood cell count
C) High hemoglobin levels
D) Decreased bilirubin
Answer: A) Elevated amylase and lipase
Explanation: Elevated pancreatic enzymes indicate acute pancreatitis, requiring prompt treatment.
A client with schizophrenia is experiencing auditory hallucinations. What is the best nursing response?
A) “I don’t hear the voices. Are they telling you to hurt yourself?”
B) “You need to ignore those voices because they are not real.”
C) “Why do you think you are hearing voices?”
D) “I will turn on the TV so you won’t hear them anymore.”
Answer: A) “I don’t hear the voices. Are they telling you to hurt yourself?”
Explanation: Validating the client’s experience while assessing for risk of harm is an appropriate nursing intervention for hallucinations.
A nurse is reinforcing teaching with a client prescribed warfarin. Which statement indicates a need for further teaching?
A) “I will avoid green leafy vegetables.”
B) “I should have my INR checked regularly.”
C) “I will take aspirin if I have a headache.”
D) “I should report any unusual bruising or bleeding.”
Answer: C) “I will take aspirin if I have a headache.”
Explanation: Aspirin increases the risk of bleeding when taken with warfarin. Clients should avoid NSAIDs and use acetaminophen instead.
A nurse is caring for a client experiencing an anaphylactic reaction. What is the priority nursing action?
A) Administer diphenhydramine
B) Give epinephrine intramuscularly
C) Provide a bronchodilator
D) Place the client in the Trendelenburg position
Answer: B) Give epinephrine intramuscularly
Explanation: Epinephrine is the first-line treatment for anaphylaxis, as it counteracts severe bronchoconstriction and hypotension.
A client with cirrhosis is receiving lactulose. What is the expected outcome?
A) Decreased ammonia levels
B) Increased urine output
C) Reduced ascites
D) Normalized liver enzymes
Answer: A) Decreased ammonia levels
Explanation: Lactulose helps eliminate ammonia from the body through diarrhea, preventing hepatic encephalopathy in cirrhosis clients.
A nurse is preparing to administer IV potassium chloride. What is the safest method of administration?
A) IV push over 5 minutes
B) Diluted in IV fluids and infused slowly
C) Mixed with normal saline and given rapidly
D) Administered undiluted through a central line
Answer: B) Diluted in IV fluids and infused slowly
Explanation: IV potassium should always be diluted and infused at a controlled rate to prevent cardiac arrhythmias. It should never be given IV push.
Which client is at the highest risk for developing a pressure ulcer?
A) A client with urinary incontinence and limited mobility
B) A client with diabetes and controlled blood glucose
C) A client who ambulates with assistance twice daily
D) A client who is receiving IV fluids and eating well
Answer: A) A client with urinary incontinence and limited mobility
Explanation: Incontinence increases skin breakdown, and immobility prevents repositioning, leading to a higher risk of pressure ulcers.
A nurse is reinforcing teaching about digoxin. Which symptom should the client report immediately?
A) Increased appetite
B) Blurred vision and nausea
C) Weight gain of 1 lb in a week
D) A blood pressure reading of 120/80 mmHg
Answer: B) Blurred vision and nausea
Explanation: These are signs of digoxin toxicity. Other symptoms include confusion, bradycardia, and yellow halos around lights.
A nurse is caring for a client post-surgery who suddenly develops shortness of breath and chest pain. What is the priority action?
A) Administer a bronchodilator
B) Encourage deep breathing and coughing
C) Notify the healthcare provider immediately
D) Elevate the head of the bed and provide oxygen
Answer: D) Elevate the head of the bed and provide oxygen
Explanation: These symptoms suggest a pulmonary embolism. Raising the head of the bed and providing oxygen helps improve oxygenation while notifying the provider.
Which intervention is appropriate for a client receiving continuous enteral tube feeding?
A) Position the client flat while feeding
B) Check residual volume every 8 hours
C) Flush the tube with water regularly
D) Hold feedings if the client reports hunger
Answer: C) Flush the tube with water regularly
Explanation: Regular flushing prevents clogging and maintains tube patency. The client may not feel hunger due to continuous feeding.
A nurse is reviewing lab results of a client with acute kidney injury. Which finding is most concerning?
A) Potassium 6.2 mEq/L
B) Sodium 135 mEq/L
C) Hemoglobin 12 g/dL
D) BUN 18 mg/dL
Answer: A) Potassium 6.2 mEq/L
Explanation: Hyperkalemia (K+ > 5.0 mEq/L) can cause life-threatening cardiac dysrhythmias and requires immediate intervention.
A nurse is reinforcing education on newborn care. Which statement by the parent indicates correct understanding?
A) “I will apply baby powder after diaper changes.”
B) “I will clean the umbilical cord with alcohol daily.”
C) “I should expect the umbilical cord to fall off in 1-2 weeks.”
D) “I will bottle-feed my baby in a completely flat position.”
Answer: C) “I should expect the umbilical cord to fall off in 1-2 weeks.”
Explanation: The umbilical cord usually falls off within 10-14 days. Alcohol is no longer recommended, and powder use can cause respiratory issues.
A nurse is caring for a client who had a hip replacement. Which action is most important to prevent dislocation?
A) Keep the legs crossed when sitting
B) Maintain hip flexion at 90 degrees
C) Place a pillow between the legs when turning
D) Encourage active leg exercises in bed
Answer: C) Place a pillow between the legs when turning
Explanation: A pillow (abduction device) prevents excessive movement that could cause hip dislocation post-surgery.
A nurse is reinforcing teaching to a client prescribed furosemide. What food should the client be encouraged to eat?
A) Apples
B) Bananas
C) Bread
D) Rice
Answer: B) Bananas
Explanation: Furosemide is a loop diuretic that can cause potassium loss. Bananas are rich in potassium and help prevent hypokalemia.
A nurse is preparing to administer a blood transfusion. What is the first action?
A) Start the IV line with normal saline
B) Verify blood compatibility with another nurse
C) Obtain the client’s baseline vital signs
D) Warm the blood bag before administration
Answer: B) Verify blood compatibility with another nurse
Explanation: Double-checking blood compatibility is the first and most crucial step to prevent transfusion reactions.
A client receiving chemotherapy has a white blood cell count of 2,500/mm³. What is the priority intervention?
A) Encourage frequent handwashing
B) Administer pain medication as prescribed
C) Restrict fluid intake
D) Allow fresh flowers in the room
Answer: A) Encourage frequent handwashing
Explanation: A low WBC count (neutropenia) increases infection risk. Strict hand hygiene is essential for infection prevention.
A nurse is providing care for a client with Addison’s disease. Which dietary recommendation is appropriate?
A) Increase sodium intake
B) Follow a low-protein diet
C) Avoid all dairy products
D) Reduce carbohydrate intake
Answer: A) Increase sodium intake
Explanation: Addison’s disease leads to low aldosterone levels, causing sodium loss. Clients often require a high-sodium diet.
A nurse is reinforcing teaching about insulin administration. Which statement indicates correct understanding?
A) “I will shake the NPH insulin bottle before use.”
B) “I will inject insulin at a 45-degree angle if I have little fat.”
C) “I should massage the injection site after administration.”
D) “I will mix regular insulin with glargine before injecting.”
Answer: B) “I will inject insulin at a 45-degree angle if I have little fat.”
Explanation: For clients with minimal subcutaneous tissue, insulin should be injected at a 45-degree angle to ensure proper absorption.
Which action should the nurse take when administering eye drops?
A) Instill drops directly on the cornea
B) Instruct the client to squeeze their eyes shut
C) Pull the lower eyelid down and apply drops into the conjunctival sac
D) Wipe excess medication toward the inner canthus
Answer: C) Pull the lower eyelid down and apply drops into the conjunctival sac
Explanation: Administering eye drops into the conjunctival sac ensures even distribution and prevents corneal irritation.
A client with COPD is receiving oxygen therapy. Which intervention is most appropriate?
A) Keep oxygen flow rate above 5 L/min
B) Monitor for signs of oxygen toxicity
C) Encourage the client to breathe rapidly
D) Limit fluid intake to reduce secretions
Answer: B) Monitor for signs of oxygen toxicity
Explanation: Clients with COPD rely on a hypoxic drive to breathe. High oxygen levels can suppress their respiratory drive, leading to hypoventilation.
A nurse is caring for a client with a chest tube. What is a priority assessment?
A) Ensuring continuous bubbling in the water seal chamber
B) Keeping the drainage system below chest level
C) Clamping the chest tube during repositioning
D) Emptying the drainage chamber every 8 hours
Answer: B) Keeping the drainage system below chest level
Explanation: Keeping the drainage system below the chest prevents fluid backflow, which could cause lung re-expansion failure.
A nurse is assisting with care for a client experiencing a tonic-clonic seizure. What is the priority action?
A) Restrain the client to prevent injury
B) Place a padded tongue blade in the mouth
C) Turn the client to their side
D) Administer naloxone immediately
Answer: C) Turn the client to their side
Explanation: Turning the client to their side prevents aspiration and maintains an open airway during a seizure.
Which food choice is best for a client taking a monoamine oxidase inhibitor (MAOI)?
A) Aged cheese and pepperoni
B) Fresh grilled chicken and rice
C) Red wine and smoked salmon
D) Salami and pickled vegetables
Answer: B) Fresh grilled chicken and rice
Explanation: MAOIs require a low-tyramine diet to prevent hypertensive crises. Aged cheeses, cured meats, and wine should be avoided.
Which client is at the highest risk for developing metabolic syndrome?
A) A 55-year-old client with a waist circumference of 42 inches
B) A 25-year-old athlete with a BMI of 22
C) A 40-year-old client with normal cholesterol levels
D) A 60-year-old client who walks 3 miles daily
Answer: A) A 55-year-old client with a waist circumference of 42 inches
Explanation: Metabolic syndrome is linked to abdominal obesity, hypertension, high triglycerides, and insulin resistance.
A nurse is reinforcing teaching on lithium therapy. Which instruction should be included?
A) Reduce fluid intake to prevent toxicity
B) Avoid excessive salt consumption
C) Take lithium with food to prevent nausea
D) Stop taking lithium if feeling better
Answer: C) Take lithium with food to prevent nausea
Explanation: Lithium can cause gastrointestinal discomfort, so taking it with food reduces nausea.
A nurse is caring for a client with heart failure. Which assessment finding requires immediate intervention?
A) Weight gain of 3 lbs in 24 hours
B) Bilateral lower extremity edema
C) Fatigue and shortness of breath
D) Blood pressure of 130/80 mmHg
Answer: A) Weight gain of 3 lbs in 24 hours
Explanation: Rapid weight gain suggests fluid retention and worsening heart failure, requiring immediate intervention.
A nurse is providing dietary education to a client with osteoporosis. Which food should be encouraged?
A) White bread
B) Leafy green vegetables
C) Fried chicken
D) Carbonated soft drinks
Answer: B) Leafy green vegetables
Explanation: Leafy greens are high in calcium and vitamin K, which support bone health.
A nurse is reinforcing discharge teaching for a client with a new ileostomy. Which statement indicates understanding?
A) “I will drink at least 2-3 liters of fluid daily.”
B) “I should expect my stools to be solid.”
C) “I will limit my intake of salty foods.”
D) “I should avoid drinking fluids between meals.”
Answer: A) “I will drink at least 2-3 liters of fluid daily.”
Explanation: Clients with an ileostomy lose more fluids and electrolytes, so adequate hydration is essential.
A nurse is assisting a client with Alzheimer’s disease. Which intervention promotes safety?
A) Allowing unrestricted access to exits
B) Keeping the environment dimly lit
C) Providing a structured daily routine
D) Encouraging frequent naps throughout the day
Answer: C) Providing a structured daily routine
Explanation: A consistent routine reduces confusion and promotes safety in clients with Alzheimer’s disease.
A nurse is reinforcing education about newborn jaundice. Which statement indicates correct understanding?
A) “Jaundice in the first 24 hours is normal.”
B) “I should expose my baby to direct sunlight for long periods.”
C) “Feeding my baby frequently can help reduce jaundice.”
D) “Jaundice is only caused by liver disease.”
Answer: C) “Feeding my baby frequently can help reduce jaundice.”
Explanation: Frequent feedings promote bilirubin excretion through stool and urine, reducing jaundice.
Which client is at the highest risk for developing deep vein thrombosis (DVT)?
A) A young adult on birth control pills
B) A client ambulating twice daily after surgery
C) A client with hypertension taking aspirin
D) A client with a history of anemia
Answer: A) A young adult on birth control pills
Explanation: Hormonal contraceptives increase the risk of clot formation, leading to a higher chance of DVT.
A nurse is caring for a client with a nasogastric (NG) tube. Which action is most appropriate?
A) Check tube placement by auscultation
B) Flush the tube with 30 mL of sterile water as prescribed
C) Position the client flat while feeding
D) Confirm placement by adding food coloring to the tube feeding
Answer: B) Flush the tube with 30 mL of sterile water as prescribed
Explanation: Regular flushing prevents clogging and maintains tube patency.
A nurse is caring for a client with Cushing’s syndrome. Which finding should be reported immediately?
A) Moon face and buffalo hump
B) Blood glucose level of 210 mg/dL
C) Sudden onset of confusion
D) Purple striae on the abdomen
Answer: C) Sudden onset of confusion
Explanation: Confusion may indicate a hypertensive crisis, infection, or severe electrolyte imbalance, requiring immediate intervention.
A client with pneumonia is receiving IV antibiotics. Which statement by the client requires further teaching?
A) “I will complete my entire antibiotic prescription.”
B) “I should drink plenty of fluids.”
C) “I will stop taking the antibiotics when I feel better.”
D) “I need to rest and take deep breaths frequently.”
Answer: C) “I will stop taking the antibiotics when I feel better.”
Explanation: Stopping antibiotics early can lead to incomplete treatment and antibiotic resistance.
A nurse is reinforcing teaching about warfarin (Coumadin) therapy. Which statement by the client indicates understanding?
A) “I will eat more green leafy vegetables.”
B) “I should use a soft-bristled toothbrush.”
C) “I need to take aspirin for headaches.”
D) “I should stop the medication if my gums bleed.”
Answer: B) “I should use a soft-bristled toothbrush.”
Explanation: Warfarin increases bleeding risk, so using a soft toothbrush prevents gum bleeding.
Which client is at the highest risk for developing hypoglycemia?
A) A client with type 1 diabetes who skipped lunch after taking insulin
B) A client with type 2 diabetes who ate a large carbohydrate meal
C) A client who has an A1C level of 8.2%
D) A client who exercises regularly and follows a diabetic diet
Answer: A) A client with type 1 diabetes who skipped lunch after taking insulin
Explanation: Skipping meals after insulin administration can lead to dangerously low blood sugar levels.
A nurse is caring for a client with a fentanyl patch for chronic pain. What is a priority assessment?
A) Blood glucose monitoring
B) Checking for excessive sweating
C) Monitoring respiratory rate
D) Assessing for hyperactivity
Answer: C) Monitoring respiratory rate
Explanation: Opioids like fentanyl depress the respiratory system, requiring frequent assessment.
A nurse is assisting with the care of a client who has heart failure and is taking furosemide. Which lab result requires immediate intervention?
A) Potassium 2.8 mEq/L
B) Sodium 140 mEq/L
C) Calcium 9.2 mg/dL
D) Glucose 110 mg/dL
Answer: A) Potassium 2.8 mEq/L
Explanation: Hypokalemia can cause serious cardiac dysrhythmias and muscle weakness.
A nurse is reinforcing teaching for a client with rheumatoid arthritis. Which statement indicates understanding?
A) “I should perform range-of-motion exercises daily.”
B) “I will use ice packs on my joints every morning.”
C) “I should remain immobile during flare-ups.”
D) “I will avoid all physical activity.”
Answer: A) “I should perform range-of-motion exercises daily.”
Explanation: Regular movement helps maintain joint function and prevent stiffness.
A nurse is caring for a client receiving a blood transfusion. Which finding requires immediate intervention?
A) Temperature increase from 98.6°F to 100.2°F
B) Blood pressure drop from 130/80 mmHg to 90/60 mmHg
C) Client reports mild itching
D) Slight increase in heart rate
Answer: B) Blood pressure drop from 130/80 mmHg to 90/60 mmHg
Explanation: A sudden drop in blood pressure may indicate a severe transfusion reaction.
A client is receiving heparin therapy. Which lab value should the nurse monitor?
A) PT/INR
B) Hemoglobin
C) aPTT
D) Platelet count
Answer: C) aPTT
Explanation: aPTT is used to monitor heparin therapy effectiveness and safety.
A nurse is caring for a client with a urinary tract infection (UTI). Which instruction should be included in discharge teaching?
A) “Wipe from back to front after using the bathroom.”
B) “Increase fluid intake to at least 2-3 liters per day.”
C) “Avoid urinating frequently to prevent discomfort.”
D) “Take antibiotics only if symptoms worsen.”
Answer: B) “Increase fluid intake to at least 2-3 liters per day.”
Explanation: Fluids help flush bacteria from the urinary tract and prevent further infections.
A nurse is reinforcing teaching on digoxin therapy. Which sign of toxicity should the client report immediately?
A) Increased urine output
B) Blurred vision and yellow halos
C) Mild nausea after meals
D) Slight weight loss
Answer: B) Blurred vision and yellow halos
Explanation: Visual disturbances are a sign of digoxin toxicity and require immediate attention.
A nurse is reinforcing teaching about newborn cord care. Which statement indicates understanding?
A) “I should clean the cord stump with alcohol after each diaper change.”
B) “I should keep the cord stump dry and exposed to air.”
C) “I should remove the stump when it starts to loosen.”
D) “I should apply petroleum jelly to the cord.”
Answer: B) “I should keep the cord stump dry and exposed to air.”
Explanation: Keeping the cord dry promotes healing and prevents infection.
A nurse is caring for a client in the manic phase of bipolar disorder. What is the priority intervention?
A) Encourage group therapy participation
B) Provide a structured environment with minimal stimulation
C) Allow the client to make major decisions
D) Discuss feelings about their behavior
Answer: B) Provide a structured environment with minimal stimulation
Explanation: A calm environment helps prevent overstimulation and agitation.
A nurse is caring for a client with gastroesophageal reflux disease (GERD). Which instruction should be included in discharge teaching?
A) “Eat large meals before bedtime.”
B) “Avoid caffeine, spicy foods, and acidic drinks.”
C) “Lie flat after eating to help digestion.”
D) “Drink carbonated beverages to relieve symptoms.”
Answer: B) “Avoid caffeine, spicy foods, and acidic drinks.”
Explanation: These foods increase acid production and worsen GERD symptoms.
A nurse is reinforcing teaching for a client with iron-deficiency anemia. Which statement indicates correct understanding?
A) “I should take iron supplements with milk.”
B) “I should drink orange juice when taking my iron supplement.”
C) “Iron supplements will not cause any side effects.”
D) “I should take iron on a full stomach.”
Answer: B) “I should drink orange juice when taking my iron supplement.”
Explanation: Vitamin C enhances iron absorption
A nurse is caring for a client with chronic kidney disease (CKD). Which dietary instruction should the nurse reinforce?
A) “Increase your intake of potassium-rich foods.”
B) “Consume a high-protein diet to prevent muscle loss.”
C) “Limit fluid intake to prevent fluid overload.”
D) “Increase sodium intake to maintain blood pressure.”
Answer: C) “Limit fluid intake to prevent fluid overload.”
Explanation: Clients with CKD are at risk for fluid overload due to decreased kidney function.
A nurse is reinforcing teaching about the use of an incentive spirometer. Which statement indicates correct understanding?
A) “I should use the spirometer once a day before bedtime.”
B) “I should inhale quickly to fully expand my lungs.”
C) “I should take slow, deep breaths through the spirometer and hold my breath for a few seconds.”
D) “I should exhale forcefully into the spirometer to measure my lung strength.”
Answer: C) “I should take slow, deep breaths through the spirometer and hold my breath for a few seconds.”
Explanation: This technique promotes lung expansion and prevents atelectasis.
A nurse is assisting with the care of a client experiencing alcohol withdrawal. Which medication should the nurse anticipate administering?
A) Haloperidol
B) Lorazepam
C) Fluoxetine
D) Naloxone
Answer: B) Lorazepam
Explanation: Benzodiazepines like lorazepam help manage alcohol withdrawal symptoms and prevent seizures.
A client is receiving a blood transfusion. Which symptom requires immediate intervention?
A) Mild headache
B) Chills and fever
C) Slight increase in blood pressure
D) Warm sensation in the arm
Answer: B) Chills and fever
Explanation: These symptoms may indicate a transfusion reaction, requiring immediate assessment and intervention.
A nurse is preparing to administer a subcutaneous injection of heparin. Where should the injection be given?
A) Deltoid muscle
B) Vastus lateralis muscle
C) Abdomen, at least 2 inches away from the umbilicus
D) Gluteus maximus muscle
Answer: C) Abdomen, at least 2 inches away from the umbilicus
Explanation: Heparin is best absorbed in the subcutaneous tissue of the abdomen.
A nurse is caring for a client with heart failure who is prescribed furosemide. What should the nurse monitor?
A) Serum potassium levels
B) Blood glucose levels
C) Hemoglobin levels
D) Serum calcium levels
Answer: A) Serum potassium levels
Explanation: Furosemide is a loop diuretic that can cause hypokalemia.
A nurse is reinforcing teaching about metformin for a client with type 2 diabetes. Which statement indicates correct understanding?
A) “I should take my medication on an empty stomach.”
B) “This medication may cause weight gain.”
C) “I should avoid alcohol while taking this medication.”
D) “If I miss a dose, I should double the next dose.”
Answer: C) “I should avoid alcohol while taking this medication.”
Explanation: Alcohol increases the risk of lactic acidosis in clients taking metformin.
A client with cirrhosis has ascites. Which intervention should be included in the plan of care?
A) Encourage a high-sodium diet
B) Restrict fluid and sodium intake
C) Encourage frequent ambulation
D) Position the client flat on the back
Answer: B) Restrict fluid and sodium intake
Explanation: Fluid and sodium restriction help manage ascites and prevent further fluid accumulation.
A nurse is reinforcing teaching about preventing osteoporosis. Which statement by the client indicates understanding?
A) “I should avoid weight-bearing exercises.”
B) “I need to take a vitamin D supplement.”
C) “I will increase my intake of soft drinks.”
D) “I should limit my calcium intake.”
Answer: B) “I need to take a vitamin D supplement.”
Explanation: Vitamin D enhances calcium absorption and helps maintain bone health.
A nurse is caring for a client who is on droplet precautions. Which infection requires these precautions?
A) Tuberculosis
B) Influenza
C) MRSA
D) Hepatitis B
Answer: B) Influenza
Explanation: Influenza is spread through respiratory droplets, requiring droplet precautions.
A nurse is reinforcing discharge instructions to a client who had a total hip replacement. Which statement indicates a need for further teaching?
A) “I should use a raised toilet seat.”
B) “I should cross my legs when sitting.”
C) “I should avoid bending at the waist past 90 degrees.”
D) “I should use an assistive device to help with movement.”
Answer: B) “I should cross my legs when sitting.”
Explanation: Crossing legs can lead to hip dislocation after a total hip replacement.
A nurse is assisting with the care of a client experiencing a seizure. What is the priority action?
A) Insert a tongue blade into the client’s mouth
B) Restrain the client to prevent injury
C) Turn the client on their side
D) Elevate the head of the bed
Answer: C) Turn the client on their side
Explanation: Turning the client on their side prevents airway obstruction.
A nurse is reviewing a client’s lab values. Which finding should be reported immediately?
A) Sodium 138 mEq/L
B) Hemoglobin 11.2 g/dL
C) Potassium 6.2 mEq/L
D) Calcium 9.4 mg/dL
Answer: C) Potassium 6.2 mEq/L
Explanation: Hyperkalemia can cause life-threatening cardiac dysrhythmias.
A nurse is reinforcing teaching to a pregnant client about nutrition. Which food should be avoided?
A) Cooked salmon
B) Pasteurized milk
C) Soft cheeses like brie and feta
D) Whole-grain bread
Answer: C) Soft cheeses like brie and feta
Explanation: Soft cheeses may contain Listeria, which can harm the fetus.
A client with COPD is receiving oxygen therapy. What is the appropriate oxygen flow rate?
A) 1-2 L/min
B) 6-8 L/min
C) 10-12 L/min
D) 15 L/min
Answer: A) 1-2 L/min
Explanation: Higher oxygen levels can suppress the respiratory drive in clients with COPD.
A nurse is reinforcing teaching about digoxin. Which side effect should be reported immediately?
A) Increased appetite
B) Nausea and vomiting
C) Mild fatigue
D) Increased urine output
Answer: B) Nausea and vomiting
Explanation: These are early signs of digoxin toxicity.
A nurse is preparing to administer an IM injection to an adult client. What is the preferred site?
A) Deltoid
B) Ventrogluteal
C) Dorsogluteal
D) Rectus femoris
Answer: B) Ventrogluteal
Explanation: The ventrogluteal site is the safest for IM injections in adults.
A nurse is caring for a client who has an NG tube for gastric decompression. What is the correct nursing action?
A) Keep the client in a supine position
B) Clamp the tube between feedings
C) Confirm placement by checking residual volume
D) Irrigate the tube with normal saline as prescribed
Answer: D) Irrigate the tube with normal saline as prescribed
Explanation: This maintains tube patency and prevents blockage.
A nurse is reinforcing discharge teaching to a client prescribed warfarin. Which statement indicates a need for further teaching?
A) “I will have regular blood tests to monitor my INR levels.”
B) “I should avoid foods high in vitamin K, like spinach and kale.”
C) “I can take aspirin if I have a headache.”
D) “I should use a soft toothbrush to prevent bleeding.”
Answer: C) “I can take aspirin if I have a headache.”
Explanation: Aspirin increases the risk of bleeding when taken with warfarin.
A nurse is monitoring a client receiving IV potassium chloride for hypokalemia. Which finding requires immediate intervention?
A) Reports of burning at the IV site
B) Urine output of 50 mL per hour
C) Serum potassium level of 3.8 mEq/L
D) Heart rate of 78 bpm
Answer: A) Reports of burning at the IV site
Explanation: IV potassium is irritating to veins and should be infused slowly to prevent tissue damage.
A nurse is reinforcing teaching about insulin administration to a client with diabetes. Which instruction is correct?
A) “Shake the insulin vial before drawing up the dose.”
B) “Mix short-acting and long-acting insulin together in the same syringe.”
C) “Rotate injection sites to prevent lipodystrophy.”
D) “Store all insulin in the freezer.”
Answer: C) “Rotate injection sites to prevent lipodystrophy.”
Explanation: Rotating sites prevents fat tissue damage and ensures proper insulin absorption.
A nurse is reinforcing teaching about levothyroxine for hypothyroidism. Which statement indicates correct understanding?
A) “I should take this medication at night with food.”
B) “I will take my medication on an empty stomach in the morning.”
C) “I can stop taking my medication once my symptoms improve.”
D) “I should increase my dose if I feel fatigued.”
Answer: B) “I will take my medication on an empty stomach in the morning.”
Explanation: Levothyroxine is best absorbed on an empty stomach in the morning.
A nurse is assisting with the care of a client receiving a transfusion. What is the first action if the client reports chills and back pain?
A) Slow the transfusion rate
B) Stop the transfusion immediately
C) Administer diphenhydramine
D) Reassure the client that mild reactions are normal
Answer: B) Stop the transfusion immediately
Explanation: Chills and back pain indicate a transfusion reaction, requiring immediate discontinuation.
A nurse is reinforcing teaching to a client taking furosemide for heart failure. Which side effect should the client report?
A) Increased urination
B) Muscle weakness
C) Dry mouth
D) Mild headache
Answer: B) Muscle weakness
Explanation: Muscle weakness may indicate hypokalemia, a side effect of furosemide.
A nurse is caring for a client who has heart failure. Which finding should be reported immediately?
A) Weight gain of 5 pounds in 2 days
B) Bilateral ankle edema
C) Fatigue with mild exertion
D) Crackles in the lower lung fields
Answer: A) Weight gain of 5 pounds in 2 days
Explanation: Rapid weight gain suggests worsening heart failure and fluid retention.
A nurse is assisting in the care of a client with a new colostomy. Which statement by the client indicates understanding of care?
A) “I should avoid drinking fluids to prevent diarrhea.”
B) “I will change the pouch only when it leaks.”
C) “I will empty my pouch when it is one-third full.”
D) “I should scrub my stoma with soap daily.”
Answer: C) “I will empty my pouch when it is one-third full.”
Explanation: This prevents leakage and skin irritation.
A nurse is reinforcing teaching to a client who has been prescribed nitroglycerin for angina. What instruction should the nurse include?
A) “Take this medication with food to avoid nausea.”
B) “Store this medication in a warm place.”
C) “If chest pain is not relieved after one dose, call 911.”
D) “Swallow the tablet whole with water.”
Answer: C) “If chest pain is not relieved after one dose, call 911.”
Explanation: Unrelieved chest pain may indicate a heart attack.
A nurse is reinforcing teaching about proper use of crutches. Which instruction should be included?
A) “Adjust crutches so they press into the underarms.”
B) “Keep crutches 6 inches in front and to the side of each foot.”
C) “Use your arms to bear weight instead of your hands.”
D) “Look down at your feet while walking.”
Answer: B) “Keep crutches 6 inches in front and to the side of each foot.”
Explanation: This provides stability and prevents falls.
A nurse is assisting in the care of a client with pneumonia. Which assessment finding indicates improvement?
A) Respiratory rate of 28 breaths per minute
B) Oxygen saturation of 95% on room air
C) Persistent productive cough
D) Coarse crackles in the lungs
Answer: B) Oxygen saturation of 95% on room air
Explanation: Normal oxygen saturation suggests improved gas exchange.
A client reports severe right lower quadrant pain and nausea. What condition should the nurse suspect?
A) Cholecystitis
B) Appendicitis
C) Pancreatitis
D) Peptic ulcer disease
Answer: B) Appendicitis
Explanation: Right lower quadrant pain and nausea are classic signs of appendicitis.
A nurse is reinforcing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which statement indicates understanding?
A) “I should lie down immediately after eating.”
B) “I should avoid caffeine and spicy foods.”
C) “I should drink carbonated beverages with meals.”
D) “I will eat large meals to prevent acid buildup.”
Answer: B) “I should avoid caffeine and spicy foods.”
Explanation: These can worsen GERD symptoms.
A nurse is reinforcing teaching to a client with asthma about the use of a metered-dose inhaler (MDI). What instruction should the nurse include?
A) “Exhale fully, then inhale quickly while pressing the inhaler.”
B) “Shake the inhaler well before use.”
C) “Hold your breath for 1 second after inhaling the medication.”
D) “Rinse your mouth before using the inhaler.”
Answer: B) “Shake the inhaler well before use.”
Explanation: This ensures proper medication dispersion.
A nurse is reinforcing teaching about the DASH diet for hypertension. Which food should the client avoid?
A) Fresh fruits
B) Whole grains
C) Canned soup
D) Lean poultry
Answer: C) Canned soup
Explanation: Canned soups are high in sodium, which can worsen hypertension.
A nurse is caring for a client who has a stage 3 pressure ulcer. Which intervention is appropriate?
A) Massage the area to increase circulation
B) Apply a transparent film dressing
C) Use a hydrocolloid or foam dressing
D) Keep the area dry at all times
Answer: C) Use a hydrocolloid or foam dressing
Explanation: These dressings promote healing by maintaining a moist environment.
A nurse is reinforcing teaching about proper foot care for a client with diabetes. Which statement indicates understanding?
A) “I will trim my toenails straight across.”
B) “I will soak my feet daily in warm water.”
C) “I will walk barefoot at home to improve circulation.”
D) “I will apply lotion between my toes to prevent dryness.”
Answer: A) “I will trim my toenails straight across.”
Explanation: This prevents ingrown toenails and infections.
A nurse is reinforcing teaching about digoxin for a client with heart failure. Which statement indicates the need for further teaching?
A) “I will check my pulse before taking this medication.”
B) “I will take this medication at the same time every day.”
C) “If I see yellow halos around lights, I should keep taking the medication.”
D) “I should notify my provider if my heart rate is below 60 bpm.”
Answer: C) “If I see yellow halos around lights, I should keep taking the medication.”
Explanation: Yellow halos around lights indicate digoxin toxicity and require immediate medical attention.
A nurse is assisting in the care of a client with COPD. Which finding requires immediate intervention?
A) Oxygen saturation of 89%
B) Productive cough with white sputum
C) Respiratory rate of 32 breaths per minute
D) Clubbing of the fingers
Answer: C) Respiratory rate of 32 breaths per minute
Explanation: Tachypnea may indicate respiratory distress and requires immediate intervention.
A nurse is reinforcing teaching about proper hand hygiene. Which statement indicates correct understanding?
A) “I can use hand sanitizer even if my hands are visibly soiled.”
B) “I should wash my hands for at least 5 seconds.”
C) “I should use friction when washing my hands.”
D) “I can touch the faucet after drying my hands.”
Answer: C) “I should use friction when washing my hands.”
Explanation: Friction removes pathogens effectively during handwashing.
A nurse is reinforcing teaching about preventing osteoporosis. Which statement by the client indicates understanding?
A) “I will increase my intake of calcium and vitamin D.”
B) “I should avoid weight-bearing exercises.”
C) “Smoking does not affect my bone health.”
D) “Drinking soda helps maintain bone density.”
Answer: A) “I will increase my intake of calcium and vitamin D.”
Explanation: Calcium and vitamin D are essential for bone strength.
A nurse is monitoring a client who has just received a dose of IV morphine. Which finding requires immediate intervention?
A) Respiratory rate of 8 breaths per minute
B) Drowsiness
C) Nausea
D) Constipation
Answer: A) Respiratory rate of 8 breaths per minute
Explanation: Respiratory depression is a serious adverse effect of opioids.
A nurse is assisting with the care of a client experiencing an anaphylactic reaction. What is the priority action?
A) Administer diphenhydramine IV
B) Apply oxygen via nasal cannula
C) Stop the infusion and administer epinephrine
D) Obtain a prescription for corticosteroids
Answer: C) Stop the infusion and administer epinephrine
Explanation: Epinephrine is the first-line treatment for anaphylaxis.
A nurse is reinforcing teaching to a client with newly diagnosed type 1 diabetes. Which statement requires further teaching?
A) “I will rotate my insulin injection sites.”
B) “I should monitor my blood sugar levels regularly.”
C) “I can skip meals if I am not hungry.”
D) “I will carry a fast-acting carbohydrate in case of hypoglycemia.”
Answer: C) “I can skip meals if I am not hungry.”
Explanation: Skipping meals can cause hypoglycemia and should be avoided.
A client is experiencing expressive aphasia following a stroke. Which intervention is appropriate?
A) Speak louder to help the client understand
B) Use short and simple sentences
C) Avoid using gestures to prevent confusion
D) Encourage the client to write responses
Answer: B) Use short and simple sentences
Explanation: Short, clear sentences help clients with expressive aphasia communicate effectively.
A nurse is reinforcing teaching about breastfeeding with a postpartum client. Which statement indicates understanding?
A) “I should limit my baby’s feeding sessions to 10 minutes per breast.”
B) “I will feed my baby every 2-3 hours.”
C) “I should supplement with formula after each breastfeeding session.”
D) “I will clean my nipples with soap after each feeding.”
Answer: B) “I will feed my baby every 2-3 hours.”
Explanation: Regular feedings help establish a good milk supply.
A nurse is assisting in the care of a client with a chest tube. What finding requires immediate intervention?
A) Continuous bubbling in the water seal chamber
B) Drainage of 50 mL in the last hour
C) Tidaling in the water seal chamber
D) The chest tube dressing is dry and intact
Answer: A) Continuous bubbling in the water seal chamber
Explanation: Continuous bubbling indicates an air leak and requires immediate attention.
A nurse is reinforcing dietary teaching for a client taking MAOIs. Which food should be avoided?
A) Fresh fruit
B) Grilled chicken
C) Aged cheese
D) White rice
Answer: C) Aged cheese
Explanation: Aged cheese contains tyramine, which can cause a hypertensive crisis with MAOIs.
A nurse is reinforcing teaching to a client with iron deficiency anemia. Which statement indicates understanding?
A) “I should take my iron supplement with milk.”
B) “I should take my iron supplement with vitamin C.”
C) “I should take my iron supplement at bedtime.”
D) “I should avoid drinking water when taking my iron supplement.”
Answer: B) “I should take my iron supplement with vitamin C.”
Explanation: Vitamin C enhances iron absorption.
A nurse is reinforcing teaching to a client about preventing urinary tract infections (UTIs). Which statement indicates correct understanding?
A) “I should wipe from back to front after urinating.”
B) “I will increase my fluid intake.”
C) “I should hold my urine as long as possible.”
D) “I should take bubble baths frequently.”
Answer: B) “I will increase my fluid intake.”
Explanation: Increased fluid intake helps flush bacteria from the urinary tract.
A nurse is caring for a client with a nasogastric tube. What action should the nurse take before administering medications?
A) Flush the tube with 30 mL of water
B) Administer all medications at once
C) Place the client in a supine position
D) Clamp the tube before flushing
Answer: A) Flush the tube with 30 mL of water
Explanation: Flushing prevents tube obstruction.
A nurse is reinforcing teaching about managing hypoglycemia with a client who has diabetes. What is the best source of fast-acting glucose?
A) A glass of whole milk
B) A slice of bread with peanut butter
C) A tablespoon of honey
D) A handful of almonds
Answer: C) A tablespoon of honey
Explanation: Honey is a fast-acting carbohydrate that quickly raises blood sugar levels.
A nurse is reinforcing teaching to a client with peripheral arterial disease (PAD). Which statement indicates understanding?
A) “I should soak my feet in warm water daily.”
B) “I will elevate my legs above heart level when resting.”
C) “I should avoid crossing my legs when sitting.”
D) “I will wear tight compression socks to improve circulation.”
Answer: C) “I should avoid crossing my legs when sitting.”
Explanation: Crossing legs can further impair circulation in clients with PAD.
A nurse is preparing to administer a Mantoux tuberculin skin test. Which technique is correct?
A) Inject 0.1 mL intradermally on the dorsal side of the hand
B) Inject 0.1 mL intradermally on the forearm
C) Inject 0.1 mL subcutaneously on the forearm
D) Inject 0.1 mL intramuscularly in the deltoid
Answer: B) Inject 0.1 mL intradermally on the forearm
Explanation: The Mantoux test is administered intradermally on the inner forearm to assess for tuberculosis exposure.
A nurse is reinforcing teaching to a client taking warfarin. Which food should the client limit?
A) Green leafy vegetables
B) Oranges
C) Lean chicken breast
D) Apples
Answer: A) Green leafy vegetables
Explanation: Green leafy vegetables are high in vitamin K, which can interfere with warfarin’s anticoagulant effects.
A nurse is monitoring a client receiving a blood transfusion. Which finding requires immediate intervention?
A) Back pain and chills
B) Slight increase in temperature
C) Heart rate of 90 beats per minute
D) Blood pressure of 120/80 mmHg
Answer: A) Back pain and chills
Explanation: Back pain and chills may indicate a hemolytic reaction, requiring immediate discontinuation of the transfusion.
A nurse is reinforcing teaching about newborn care. Which statement by the parent indicates the need for further teaching?
A) “I will place my baby on their back to sleep.”
B) “I will keep my baby’s crib free of blankets and pillows.”
C) “I will clean the umbilical cord stump with hydrogen peroxide.”
D) “I will feed my baby on demand.”
Answer: C) “I will clean the umbilical cord stump with hydrogen peroxide.”
Explanation: Hydrogen peroxide can delay healing. The umbilical stump should be kept dry and clean.
A nurse is caring for a client with a tracheostomy. What is the priority action?
A) Keep a suction catheter at the bedside
B) Remove the inner cannula every 8 hours
C) Encourage oral fluids to prevent dehydration
D) Change the tracheostomy ties daily
Answer: A) Keep a suction catheter at the bedside
Explanation: A suction catheter should always be available in case of mucus obstruction.
A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
A) Increased deep tendon reflexes
B) Urine output of 50 mL/hr
C) Respiratory rate of 10 breaths per minute
D) Blood pressure of 140/90 mmHg
Answer: C) Respiratory rate of 10 breaths per minute
Explanation: Respiratory depression is a sign of magnesium toxicity and requires immediate intervention.
A nurse is reinforcing teaching about proper crutch use. Which instruction is correct?
A) Place weight on the axilla when walking
B) Move the crutches forward first, then step with the injured leg
C) Adjust crutches so the top rests against the armpit
D) Keep elbows extended while using crutches
Answer: B) Move the crutches forward first, then step with the injured leg
Explanation: The correct gait pattern prevents falls and improves mobility.
A nurse is reinforcing discharge instructions to a client following cataract surgery. Which statement indicates correct understanding?
A) “I should avoid bending over to tie my shoes.”
B) “I can rub my eye if it feels itchy.”
C) “I should lie flat on my back when sleeping.”
D) “I will resume normal activities immediately.”
Answer: A) “I should avoid bending over to tie my shoes.”
Explanation: Bending over increases intraocular pressure and should be avoided.
A nurse is caring for a client receiving furosemide. Which laboratory result should be monitored closely?
A) Potassium
B) Sodium
C) Calcium
D) Magnesium
Answer: A) Potassium
Explanation: Furosemide is a loop diuretic that can cause potassium depletion.
A nurse is caring for a client who is experiencing delirium. Which intervention is appropriate?
A) Place the client in a dark, quiet room
B) Use reorientation techniques frequently
C) Discourage the client from moving around
D) Avoid talking to the client to reduce stimulation
Answer: B) Use reorientation techniques frequently
Explanation: Frequent reorientation helps reduce confusion and anxiety in clients with delirium.
A nurse is reinforcing teaching about wound care. Which statement indicates correct understanding?
A) “I should apply hydrogen peroxide daily.”
B) “I will keep the wound moist and covered.”
C) “I should remove the dressing and let the wound air out.”
D) “I will use alcohol to clean the wound.”
Answer: B) “I will keep the wound moist and covered.”
Explanation: A moist wound environment promotes healing and prevents infection.
A nurse is reinforcing teaching about managing constipation. Which food should the client increase?
A) White bread
B) Cheese
C) Apples with skin
D) Processed meats
Answer: C) Apples with skin
Explanation: Apples with skin are high in fiber and help relieve constipation.
A nurse is reinforcing teaching to a client receiving chemotherapy. Which instruction should the nurse include?
A) “Avoid fresh fruits and vegetables.”
B) “Drink only 2 glasses of water per day.”
C) “Take aspirin for fever.”
D) “Visit crowded places to build immunity.”
Answer: A) “Avoid fresh fruits and vegetables.”
Explanation: Fresh fruits and vegetables may contain bacteria and increase infection risk in immunocompromised clients.
A nurse is assisting with a lumbar puncture. What is the correct client position?
A) Supine with the head elevated
B) Lying on the side with knees drawn up
C) Prone with arms extended
D) Sitting upright with the head tilted back
Answer: B) Lying on the side with knees drawn up
Explanation: This position helps widen the space between vertebrae for needle insertion.
A nurse is reinforcing teaching about metered-dose inhaler (MDI) use. Which instruction is correct?
A) “Shake the inhaler before each use.”
B) “Exhale fully, then inhale medication quickly.”
C) “Press the inhaler after starting to exhale.”
D) “Hold the inhaler 3 inches away from the mouth.”
Answer: A) “Shake the inhaler before each use.”
Explanation: Shaking the inhaler helps mix the medication properly for effective delivery.
A nurse is caring for a client with COPD. Which oxygen delivery device is most appropriate?
A) Non-rebreather mask
B) Simple face mask
C) Nasal cannula at 2 L/min
D) Venturi mask at 60% FiO₂
Answer: C) Nasal cannula at 2 L/min
Explanation: Clients with COPD require low-flow oxygen to prevent CO₂ retention.
A nurse is assisting with discharge teaching for a client with a new colostomy. Which statement indicates understanding?
A) “I will avoid high-fiber foods.”
B) “I should empty the pouch when it is full.”
C) “I will use mild soap and water to clean the stoma.”
D) “I should expect my stoma to turn dark purple.”
Answer: C) “I will use mild soap and water to clean the stoma.”
Explanation: Mild soap and water prevent irritation and infection.
A nurse is reinforcing teaching to a client with type 1 diabetes. Which statement indicates the need for further teaching?
A) “I will rotate injection sites to prevent lipodystrophy.”
B) “If I feel shaky, I will drink some juice.”
C) “I will skip my insulin dose if I don’t eat breakfast.”
D) “I will check my blood sugar before meals and at bedtime.”
Answer: C) “I will skip my insulin dose if I don’t eat breakfast.”
Explanation: Basal insulin should not be skipped, even if meals are missed.
A nurse is caring for a client with left-sided heart failure. Which symptom should the nurse expect?
A) Peripheral edema
B) Jugular vein distension
C) Crackles in the lungs
D) Weight gain
Answer: C) Crackles in the lungs
Explanation: Left-sided heart failure causes pulmonary congestion, leading to crackles.
A nurse is assisting with a client’s care who has a chest tube. Which intervention is appropriate?
A) Clamp the chest tube when ambulating
B) Keep the drainage system below chest level
C) Strip the tubing every hour
D) Empty the drainage chamber daily
Answer: B) Keep the drainage system below chest level
Explanation: Keeping the system below chest level prevents fluid backflow into the pleural cavity.
A nurse is caring for a client receiving total parenteral nutrition (TPN). What is the priority assessment?
A) Monitor blood glucose levels
B) Measure daily weight
C) Check urine output
D) Assess bowel sounds
Answer: A) Monitor blood glucose levels
Explanation: TPN contains high glucose content, which can cause hyperglycemia.
A nurse is reinforcing teaching about preventing urinary tract infections (UTIs). Which statement indicates correct understanding?
A) “I will drink cranberry juice daily.”
B) “I should wipe from back to front.”
C) “I will urinate every 6-8 hours.”
D) “I should take baths instead of showers.”
Answer: A) “I will drink cranberry juice daily.”
Explanation: Cranberry juice may help prevent UTIs by reducing bacterial adherence.
A nurse is preparing to administer digoxin to a client. Which finding requires the nurse to withhold the dose?
A) Heart rate of 58 beats per minute
B) Blood pressure of 140/90 mmHg
C) Serum potassium of 4.0 mEq/L
D) Respiratory rate of 16 breaths per minute
Answer: A) Heart rate of 58 beats per minute
Explanation: Digoxin slows heart rate, so it should be held if the pulse is below 60 bpm.
A nurse is reinforcing teaching about deep vein thrombosis (DVT) prevention. Which statement indicates understanding?
A) “I will massage my legs if they feel sore.”
B) “I should wear compression stockings as prescribed.”
C) “I will stay in bed as much as possible.”
D) “I should sit with my legs crossed when resting.”
Answer: B) “I should wear compression stockings as prescribed.”
Explanation: Compression stockings help prevent venous stasis and reduce the risk of DVT.
A nurse is assisting with care for a client with suspected meningitis. Which action is the priority?
A) Perform a neurological assessment
B) Place the client in a private room with droplet precautions
C) Obtain a lumbar puncture
D) Monitor urinary output
Answer: B) Place the client in a private room with droplet precautions
Explanation: Meningitis is highly contagious and requires immediate isolation.
A nurse is caring for a client with hypokalemia. Which finding should the nurse expect?
A) Bradycardia
B) Hyperactive reflexes
C) Muscle weakness
D) Hypertension
Answer: C) Muscle weakness
Explanation: Hypokalemia affects muscle function and can cause weakness and cramps.
A nurse is reinforcing teaching about seizure precautions. Which instruction should be included?
A) “Keep the bed in the highest position.”
B) “Place the client in a supine position during a seizure.”
C) “Ensure suction equipment is available at the bedside.”
D) “Restrain the client during the seizure to prevent injury.”
Answer: C) “Ensure suction equipment is available at the bedside.”
Explanation: Suction equipment is needed to clear secretions and prevent aspiration.
A nurse is reinforcing teaching about proper use of a hearing aid. Which statement indicates correct understanding?
A) “I will soak my hearing aid in water overnight.”
B) “I will turn off the hearing aid before removing it.”
C) “I should clean the inner part with alcohol wipes.”
D) “I should store my hearing aid in the refrigerator.”
Answer: B) “I will turn off the hearing aid before removing it.”
Explanation: Turning off the hearing aid conserves battery life.
A nurse is caring for a client with a fractured femur. Which finding is a sign of fat embolism syndrome?
A) Petechiae on the chest
B) Increased urine output
C) Hyperactive bowel sounds
D) Bradycardia
Answer: A) Petechiae on the chest
Explanation: Fat embolism can cause petechiae due to impaired oxygenation.
A nurse is reinforcing teaching about metronidazole. Which instruction should the nurse include?
A) “Avoid alcohol while taking this medication.”
B) “Take this medication on an empty stomach.”
C) “Increase sun exposure while taking this drug.”
D) “Stop the medication if you develop a metallic taste.”
Answer: A) “Avoid alcohol while taking this medication.”
Explanation: Alcohol can cause severe nausea and vomiting when taken with metronidazole.
A nurse is assisting with a lumbar puncture. What should the nurse monitor for after the procedure?
A) Increased blood pressure
B) Sudden severe headache
C) Respiratory depression
D) Hypoglycemia
Answer: B) Sudden severe headache
Explanation: A post-lumbar puncture headache may indicate CSF leakage.
A nurse is reinforcing teaching for a client with a new prescription for warfarin. Which statement indicates the need for further teaching?
A) “I will avoid green leafy vegetables in my diet.”
B) “I will have my INR levels checked regularly.”
C) “I should use a soft-bristled toothbrush.”
D) “I will report any signs of unusual bleeding.”
Answer: A) “I will avoid green leafy vegetables in my diet.”
Explanation: Clients on warfarin should maintain a consistent intake of vitamin K rather than avoiding it completely.
A nurse is caring for a client with a nasogastric (NG) tube. Which action is appropriate?
A) Confirm placement with auscultation
B) Keep the head of the bed flat during feeding
C) Flush the tube with 30 mL of water before and after medication administration
D) Remove the tube if the client coughs frequently
Answer: C) Flush the tube with 30 mL of water before and after medication administration
Explanation: Flushing the tube prevents clogging and ensures medication delivery.
A nurse is assisting in the care of a client who just received a blood transfusion. Which finding requires immediate intervention?
A) Temperature of 99°F (37.2°C)
B) Itching and urticaria
C) Mild headache
D) Blood pressure of 120/80 mmHg
Answer: B) Itching and urticaria
Explanation: Itching and urticaria may indicate an allergic reaction requiring intervention.
A nurse is caring for a client with a cast. Which finding indicates compartment syndrome?
A) Capillary refill less than 2 seconds
B) Pain unrelieved by medication
C) Itching under the cast
D) Warm toes and good circulation
Answer: B) Pain unrelieved by medication
Explanation: Severe pain unrelieved by medication is a classic sign of compartment syndrome.
A nurse is reinforcing teaching about insulin administration. Which instruction should be included?
A) “Shake the vial of insulin before drawing up the dose.”
B) “Rotate injection sites to prevent lipodystrophy.”
C) “Store all insulin at room temperature.”
D) “Inject insulin directly into a muscle for faster absorption.”
Answer: B) “Rotate injection sites to prevent lipodystrophy.”
Explanation: Rotating sites prevents skin thickening and ensures proper absorption.
A nurse is caring for a client receiving furosemide. Which laboratory value requires immediate intervention?
A) Potassium of 2.8 mEq/L
B) Sodium of 140 mEq/L
C) Calcium of 9 mg/dL
D) Chloride of 98 mEq/L
Answer: A) Potassium of 2.8 mEq/L
Explanation: Hypokalemia is a serious side effect of furosemide and requires intervention.
A nurse is reinforcing teaching for a client with hypertension. Which statement indicates correct understanding?
A) “I will limit my sodium intake to 1,500 mg per day.”
B) “I should drink two cups of coffee every morning.”
C) “I will increase my intake of processed foods.”
D) “I should stop taking my medication once my blood pressure is normal.”
Answer: A) “I will limit my sodium intake to 1,500 mg per day.”
Explanation: Reducing sodium intake helps manage hypertension.
A nurse is caring for a client receiving morphine. Which assessment finding requires immediate intervention?
A) Respiratory rate of 8 breaths per minute
B) Pain level of 7/10
C) Drowsiness
D) Blood pressure of 110/70 mmHg
Answer: A) Respiratory rate of 8 breaths per minute
Explanation: Morphine can cause respiratory depression, requiring immediate intervention.
A nurse is reinforcing teaching about osteoporosis prevention. Which statement indicates understanding?
A) “I should increase my intake of calcium and vitamin D.”
B) “I should avoid weight-bearing exercises.”
C) “I will limit dairy products in my diet.”
D) “I will reduce my daily protein intake.”
Answer: A) “I should increase my intake of calcium and vitamin D.”
Explanation: Calcium and vitamin D are essential for bone health.
A nurse is caring for a client with tuberculosis (TB). Which precaution should be implemented?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions only
Answer: C) Airborne precautions
Explanation: TB is transmitted via airborne droplets and requires isolation in a negative-pressure room.
A nurse is reinforcing teaching about proper use of crutches. Which instruction is correct?
A) “Place weight on the underarm pads for support.”
B) “Keep the crutches 2 inches below the axilla.”
C) “Move both crutches together before stepping forward.”
D) “Adjust crutches to a height that allows full extension of the elbows.”
Answer: B) “Keep the crutches 2 inches below the axilla.”
Explanation: Proper crutch positioning prevents nerve damage and ensures safety.
A nurse is caring for a client with Cushing’s syndrome. Which finding is expected?
A) Moon face and truncal obesity
B) Weight loss and dehydration
C) Hyperpigmentation of the skin
D) Hypoglycemia and hypotension
Answer: A) Moon face and truncal obesity
Explanation: Cushing’s syndrome results from excess cortisol, leading to fat redistribution.
A nurse is caring for a client with myasthenia gravis. Which intervention is appropriate?
A) Encourage activity in the evening
B) Administer anticholinesterase medications before meals
C) Teach the client to avoid rest periods
D) Discourage soft foods
Answer: B) Administer anticholinesterase medications before meals
Explanation: Medications should be given before meals to improve muscle strength for swallowing.
A nurse is reinforcing teaching for a client with GERD. Which food should be avoided?
A) Oatmeal
B) Bananas
C) Chocolate
D) Rice
Answer: C) Chocolate
Explanation: Chocolate can relax the lower esophageal sphincter and worsen GERD symptoms.
A nurse is reinforcing teaching about administering ear drops to an adult. Which action is correct?
A) Pull the ear lobe down and back
B) Pull the pinna up and back
C) Place the dropper inside the ear canal
D) Keep the head upright during administration
Answer: B) Pull the pinna up and back
Explanation: Pulling the pinna up and back straightens the ear canal for proper medication administration.
A nurse is reinforcing teaching about lithium therapy for bipolar disorder. Which instruction should be included?
A) “Limit fluid intake to 1 liter per day.”
B) “Avoid high-sodium foods.”
C) “Increase fluid intake to 2-3 liters per day.”
D) “Stop taking lithium if nausea occurs.”
Answer: C) “Increase fluid intake to 2-3 liters per day.”
Explanation: Adequate hydration helps prevent lithium toxicity.
A nurse is caring for a client with chronic kidney disease (CKD). Which dietary choice indicates understanding of dietary restrictions?
A) Baked chicken with mashed potatoes
B) Banana and orange juice
C) Grilled salmon with spinach salad
D) Tomato soup with a baked potato
Answer: A) Baked chicken with mashed potatoes
Explanation: Clients with CKD should avoid high-potassium foods like bananas, oranges, and potatoes.
A nurse is monitoring a client receiving digoxin. Which finding indicates digoxin toxicity?
A) Heart rate of 88 bpm
B) Nausea and yellow-tinged vision
C) Blood pressure of 130/80 mmHg
D) Increased urinary output
Answer: B) Nausea and yellow-tinged vision
Explanation: Digoxin toxicity can cause visual changes, nausea, vomiting, and bradycardia.
A nurse is caring for a client with peripheral artery disease (PAD). Which instruction is appropriate?
A) Elevate the legs above heart level
B) Apply warm compresses to the legs
C) Encourage walking to promote circulation
D) Apply tight compression stockings
Answer: C) Encourage walking to promote circulation
Explanation: Walking helps improve circulation in PAD by promoting collateral blood flow.
A nurse is reinforcing teaching about metered-dose inhaler (MDI) use. Which statement indicates correct understanding?
A) “I will shake the inhaler before each use.”
B) “I should exhale before pressing the inhaler.”
C) “I will hold my breath for 2 seconds after inhaling.”
D) “I should inhale quickly and deeply.”
Answer: A) “I will shake the inhaler before each use.”
Explanation: Shaking the inhaler ensures proper medication mixing.
A nurse is assessing a client with hypothyroidism. Which finding is expected?
A) Heat intolerance
B) Weight gain and bradycardia
C) Exophthalmos
D) Tachycardia
Answer: B) Weight gain and bradycardia
Explanation: Hypothyroidism slows metabolism, leading to weight gain and a slow heart rate.
A nurse is assisting with discharge teaching for a client with heart failure. Which instruction should be included?
A) “Weigh yourself once a week.”
B) “Limit fluid intake to 2 liters per day.”
C) “Increase sodium intake to maintain blood pressure.”
D) “Report a weight gain of 1 pound in a week.”
Answer: B) “Limit fluid intake to 2 liters per day.”
Explanation: Fluid restriction helps prevent fluid overload in heart failure.
A nurse is reinforcing teaching for a client with iron-deficiency anemia. Which food is a good source of iron?
A) Orange juice
B) White rice
C) Red meat
D) Milk
Answer: C) Red meat
Explanation: Red meat is a rich source of heme iron, which is easily absorbed.
A nurse is caring for a client receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention?
A) Blood glucose of 210 mg/dL
B) Weight gain of 1 kg in a week
C) Serum potassium of 4.0 mEq/L
D) Mild discomfort at the catheter site
Answer: A) Blood glucose of 210 mg/dL
Explanation: TPN can cause hyperglycemia, which requires monitoring and insulin administration.
A nurse is caring for a client with cirrhosis. Which finding requires immediate intervention?
A) Jaundice
B) Petechiae and bruising
C) Fatigue
D) Loss of appetite
Answer: B) Petechiae and bruising
Explanation: These may indicate coagulopathy or low platelets, requiring immediate evaluation.
A nurse is assisting in caring for a client with a chest tube. Which action is correct?
A) Clamp the chest tube routinely
B) Keep the drainage system above chest level
C) Ensure the collection chamber remains upright
D) Strip the tubing every hour
Answer: C) Ensure the collection chamber remains upright
Explanation: Keeping the system upright prevents disruption in drainage.
A nurse is caring for a client with appendicitis. Which assessment finding requires immediate intervention?
A) Right lower quadrant pain
B) Nausea and vomiting
C) Sudden relief of pain
D) Low-grade fever
Answer: C) Sudden relief of pain
Explanation: Sudden pain relief may indicate appendix rupture, which is a medical emergency.
A nurse is reinforcing teaching about newborn care. Which statement by the parent indicates understanding?
A) “I will clean the umbilical cord with alcohol at every diaper change.”
B) “I should place my baby on their back to sleep.”
C) “My baby should drink water between feedings.”
D) “I will microwave the baby’s bottle to warm the milk.”
Answer: B) “I should place my baby on their back to sleep.”
Explanation: This reduces the risk of sudden infant death syndrome (SIDS).
A nurse is reinforcing teaching about osteoporosis prevention. Which recommendation is appropriate?
A) “Avoid weight-bearing exercises.”
B) “Increase calcium and vitamin D intake.”
C) “Drink carbonated sodas daily.”
D) “Reduce protein intake to prevent bone loss.”
Answer: B) “Increase calcium and vitamin D intake.”
Explanation: These nutrients are essential for bone health and preventing osteoporosis.
A nurse is reinforcing teaching about breastfeeding. Which statement indicates a need for further teaching?
A) “Breast milk provides immunity to my baby.”
B) “I will feed my baby on demand, at least every 2-3 hours.”
C) “I can store expressed breast milk in the refrigerator for up to one week.”
D) “I should ensure a proper latch for effective feeding.”
Answer: C) “I can store expressed breast milk in the refrigerator for up to one week.”
Explanation: Breast milk should be refrigerated for up to 4 days or frozen for longer storage.
A nurse is caring for a client with a tracheostomy. Which action is correct?
A) Use clean technique for suctioning
B) Suction no longer than 10-15 seconds
C) Inflate the cuff to maximum pressure
D) Provide oral fluids freely
Answer: B) Suction no longer than 10-15 seconds
Explanation: Prolonged suctioning can cause hypoxia.
A nurse is reinforcing teaching about car seat safety. Which instruction is appropriate?
A) “Use a forward-facing car seat until age 1.”
B) “The car seat should be placed in the back seat.”
C) “Place the baby in a seat with a loose harness for comfort.”
D) “Use a booster seat until the child is 2 years old.”
Answer: B) “The car seat should be placed in the back seat.”
Explanation: The safest position for a car seat is in the back seat.
A nurse is reinforcing teaching for a client prescribed albuterol. Which statement indicates understanding?
A) “I will use my inhaler before exercising.”
B) “I should take this medication on an empty stomach.”
C) “I should wait 5 minutes before using another inhaler.”
D) “I will use this medication for long-term asthma control.”
Answer: A) “I will use my inhaler before exercising.”
Explanation: Albuterol is a short-acting bronchodilator used for asthma prevention before activity.
A nurse is caring for a client who is receiving warfarin therapy. Which laboratory value should the nurse monitor?
A) Activated partial thromboplastin time (aPTT)
B) Prothrombin time (PT) and INR
C) Platelet count
D) Hemoglobin and hematocrit
Answer: B) Prothrombin time (PT) and INR
Explanation: PT and INR are used to monitor warfarin therapy and assess the risk of bleeding.
A nurse is caring for a client with tuberculosis (TB). Which infection control measure is appropriate?
A) Wear a surgical mask when entering the room
B) Place the client in a negative pressure room
C) Use contact precautions only
D) Have the client wear a surgical mask at all times
Answer: B) Place the client in a negative pressure room
Explanation: TB is airborne, requiring a negative pressure room and N95 respirator use.
A nurse is reinforcing teaching for a client with gastroesophageal reflux disease (GERD). Which statement indicates a need for further teaching?
A) “I should avoid eating late at night.”
B) “I will sleep with my head elevated.”
C) “I can drink coffee in moderation.”
D) “I should avoid spicy and fatty foods.”
Answer: C) “I can drink coffee in moderation.”
Explanation: Coffee increases stomach acid production and should be avoided in GERD.
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which oxygen delivery method is most appropriate?
A) Simple face mask at 10 L/min
B) Nasal cannula at 2 L/min
C) Non-rebreather mask at 15 L/min
D) Venturi mask at 12 L/min
Answer: B) Nasal cannula at 2 L/min
Explanation: High oxygen levels can suppress respiratory drive in COPD clients, so low-flow oxygen is preferred.
A nurse is reinforcing teaching for a client prescribed furosemide. Which instruction is appropriate?
A) “Increase your intake of potassium-rich foods.”
B) “Take the medication at bedtime.”
C) “Limit your fluid intake to avoid frequent urination.”
D) “Avoid foods high in sodium.”
Answer: A) “Increase your intake of potassium-rich foods.”
Explanation: Furosemide is a loop diuretic that can cause potassium loss, so intake should be increased.
A nurse is assisting in the care of a client receiving continuous enteral feedings. Which action is appropriate?
A) Position the client flat in bed
B) Flush the feeding tube every 8 hours
C) Check gastric residual before each feeding
D) Change the feeding bag every 48 hours
Answer: C) Check gastric residual before each feeding
Explanation: Checking residual prevents overfeeding and aspiration risk.
A nurse is reinforcing teaching about insulin administration. Which statement indicates correct understanding?
A) “I should inject insulin into the same spot every time.”
B) “I will rotate injection sites to prevent lipodystrophy.”
C) “I should store all insulin in the freezer.”
D) “I can mix long-acting insulin with regular insulin.”
Answer: B) “I will rotate injection sites to prevent lipodystrophy.”
Explanation: Rotating sites prevents tissue damage and ensures proper absorption.
A nurse is caring for a client with a urinary tract infection (UTI). Which symptom should be reported immediately?
A) Dysuria
B) Cloudy urine
C) Flank pain and fever
D) Frequent urination
Answer: C) Flank pain and fever
Explanation: These indicate possible pyelonephritis, which requires immediate medical attention.
A nurse is reinforcing teaching about alendronate for osteoporosis. Which instruction is appropriate?
A) “Take the medication at bedtime with a full glass of water.”
B) “Lie down after taking the medication to help absorption.”
C) “Take the medication on an empty stomach in the morning.”
D) “Avoid weight-bearing exercises while taking this medication.”
Answer: C) “Take the medication on an empty stomach in the morning.”
Explanation: Alendronate should be taken in the morning, on an empty stomach, with water, and the client should remain upright for 30 minutes.
A nurse is reinforcing teaching for a client prescribed levothyroxine. Which statement indicates understanding?
A) “I will take the medication with food every morning.”
B) “I will take the medication on an empty stomach before breakfast.”
C) “I should avoid all iodine-containing foods.”
D) “I can stop taking this medication once I feel better.”
Answer: B) “I will take the medication on an empty stomach before breakfast.”
Explanation: Levothyroxine is best absorbed on an empty stomach.
A nurse is assisting in a disaster response. Which client should be treated first using a mass casualty triage system?
A) Client with a minor hand laceration
B) Client with an open femur fracture and weak pulses
C) Client who is unresponsive with agonal breathing
D) Client with a sprained ankle
Answer: B) Client with an open femur fracture and weak pulses
Explanation: Clients with life-threatening but salvageable injuries are prioritized.
A nurse is caring for a client in the first stage of labor. Which finding should be reported to the provider immediately?
A) Cervical dilation of 5 cm
B) Contractions every 4 minutes
C) Persistent late decelerations on fetal monitoring
D) Client reports feeling rectal pressure
Answer: C) Persistent late decelerations on fetal monitoring
Explanation: Late decelerations indicate uteroplacental insufficiency and fetal distress.
A nurse is reinforcing teaching about seizure precautions. Which statement by the client requires further teaching?
A) “I should wear a medical alert bracelet.”
B) “I will take my medication even if I feel fine.”
C) “I should keep a soft object in my mouth during a seizure.”
D) “I will avoid alcohol and sleep deprivation.”
Answer: C) “I should keep a soft object in my mouth during a seizure.”
Explanation: Nothing should be placed in a client’s mouth during a seizure.
A nurse is reinforcing teaching for a client prescribed nitroglycerin. Which instruction is appropriate?
A) “Take one tablet every 5 minutes up to three times for chest pain.”
B) “Swallow the tablet whole with water.”
C) “Store the medication in a clear, open container.”
D) “Take the medication only when experiencing severe pain.”
Answer: A) “Take one tablet every 5 minutes up to three times for chest pain.”
Explanation: If pain persists after three doses, emergency medical services should be called.
A nurse is reinforcing teaching about a high-fiber diet. Which food is a good source of fiber?
A) White bread
B) Canned fruit
C) Brown rice
D) Whole milk
Answer: C) Brown rice
Explanation: Whole grains, fruits, and vegetables are high in fiber.
A nurse is caring for a client with pneumonia. Which intervention is the most effective in preventing complications?
A) Encourage bed rest to conserve energy
B) Encourage deep breathing and coughing exercises
C) Administer oxygen at 4 L/min continuously
D) Withhold fluids to prevent aspiration
Answer: B) Encourage deep breathing and coughing exercises
Explanation: Deep breathing and coughing help prevent atelectasis and mobilize secretions.
A client with a total hip replacement is being discharged. Which statement by the client indicates a need for further teaching?
A) “I will use a raised toilet seat.”
B) “I can cross my legs when sitting.”
C) “I will use an abduction pillow when sleeping.”
D) “I should avoid bending at the waist more than 90 degrees.”
Answer: B) “I can cross my legs when sitting.”
Explanation: Crossing legs increases the risk of hip dislocation.
A nurse is caring for a client receiving digoxin. Which finding should be reported immediately?
A) Heart rate of 55 beats per minute
B) Blood pressure of 120/80 mmHg
C) Respiratory rate of 18 breaths per minute
D) Potassium level of 4.0 mEq/L
Answer: A) Heart rate of 55 beats per minute
Explanation: Digoxin can cause bradycardia; hold the dose if the heart rate is below 60 bpm.
A nurse is reinforcing discharge teaching for a client with heart failure. Which statement indicates understanding?
A) “I should weigh myself daily.”
B) “I can drink unlimited fluids.”
C) “I should avoid potassium-rich foods.”
D) “I will stop taking my diuretic if I feel better.”
Answer: A) “I should weigh myself daily.”
Explanation: Daily weights help detect fluid retention early.
A nurse is reviewing dietary choices with a client on a low-sodium diet. Which food should the client avoid?
A) Fresh fruit salad
B) Grilled chicken breast
C) Canned soup
D) Steamed vegetables
Answer: C) Canned soup
Explanation: Canned soups are high in sodium and should be avoided.
A nurse is reinforcing teaching about metformin for a client with type 2 diabetes. Which instruction is correct?
A) “Take the medication on an empty stomach.”
B) “This medication may cause low blood sugar.”
C) “Stop taking the medication before a contrast dye procedure.”
D) “Monitor for weight gain while taking this medication.”
Answer: C) “Stop taking the medication before a contrast dye procedure.”
Explanation: Metformin should be held before contrast dye procedures to prevent lactic acidosis.
A nurse is monitoring a client with increased intracranial pressure (ICP). Which finding requires immediate intervention?
A) Blood pressure of 140/90 mmHg
B) Heart rate of 48 beats per minute
C) Respiratory rate of 18 breaths per minute
D) Temperature of 99°F (37.2°C)
Answer: B) Heart rate of 48 beats per minute
Explanation: Bradycardia with hypertension and irregular respirations (Cushing’s triad) indicates increased ICP.
A nurse is reinforcing teaching for a client taking prednisone. Which statement indicates a need for further teaching?
A) “I should not stop taking this medication suddenly.”
B) “I should take the medication with food.”
C) “I will avoid crowded places.”
D) “I can stop taking the medication when I feel better.”
Answer: D) “I can stop taking the medication when I feel better.”
Explanation: Steroids must be tapered gradually to prevent adrenal insufficiency.
A nurse is reinforcing dietary teaching for a client with iron-deficiency anemia. Which food is the best source of iron?
A) Chicken breast
B) Oranges
C) Spinach
D) White rice
Answer: C) Spinach
Explanation: Dark leafy greens like spinach are high in iron.
A nurse is assisting with a lumbar puncture. Which position should the client be placed in?
A) Supine with the head of the bed at 30 degrees
B) High Fowler’s position
C) Side-lying with the knees drawn to the chest
D) Prone with the arms extended
Answer: C) Side-lying with the knees drawn to the chest
Explanation: This position increases the space between vertebrae, allowing easier needle insertion.
A nurse is reinforcing teaching about nitroglycerin. Which side effect should the client expect?
A) Dry mouth
B) Headache
C) Bradycardia
D) Constipation
Answer: B) Headache
Explanation: Nitroglycerin causes vasodilation, which can lead to headaches.
A nurse is monitoring a client on heparin therapy. Which laboratory value should be monitored?
A) INR
B) Platelets
C) aPTT
D) Hemoglobin
Answer: C) aPTT
Explanation: Heparin effectiveness is monitored using aPTT.
A nurse is assisting in the care of a client with a chest tube. Which action is appropriate?
A) Clamp the chest tube routinely
B) Strip the chest tube frequently
C) Keep the drainage system below chest level
D) Empty the drainage chamber every shift
Answer: C) Keep the drainage system below chest level
Explanation: Keeping it below chest level prevents fluid from re-entering the pleural space.
A nurse is caring for a client with Addison’s disease. Which dietary choice is appropriate?
A) Low-sodium, low-potassium diet
B) High-sodium, low-potassium diet
C) High-sodium, high-potassium diet
D) Low-sodium, high-protein diet
Answer: B) High-sodium, low-potassium diet
Explanation: Addison’s disease causes sodium loss and potassium retention.
A nurse is reinforcing teaching for a client prescribed warfarin. Which food should the client limit?
A) Bananas
B) Green leafy vegetables
C) Yogurt
D) Apples
Answer: B) Green leafy vegetables
Explanation: These are high in vitamin K, which counteracts warfarin.
A nurse is caring for a client in the manic phase of bipolar disorder. Which intervention is most appropriate?
A) Encourage group therapy
B) Provide frequent snacks and hydration
C) Allow unlimited activity
D) Discourage movement
Answer: B) Provide frequent snacks and hydration
Explanation: Clients in mania may neglect nutrition and hydration.
A nurse is reinforcing teaching about a clear liquid diet. Which food is allowed?
A) Milk
B) Chicken broth
C) Orange juice with pulp
D) Scrambled eggs
Answer: B) Chicken broth
Explanation: Clear liquids include broth, gelatin, and clear juices.
A nurse is reinforcing discharge teaching for a client with a newly placed colostomy. Which statement indicates understanding?
A) “I will avoid drinking fluids to reduce stool output.”
B) “I will empty the pouch when it is half full.”
C) “I can take laxatives daily to keep my stool soft.”
D) “I will limit my diet to soft foods permanently.”
Answer: B) “I will empty the pouch when it is half full.”
Explanation: A full pouch may cause leakage.