Question 1

A client is admitted with exacerbation of heart failure. What is the priority nursing intervention?

Accepted Answer

Answer reason: In acute heart failure exacerbation, the priority is to rapidly reduce fluid overload and pulmonary congestion. Administering diuretics achieves this promptly; the other options are less immediate or not directly indicated.
Category reason: This is a nursing prioritization question about selecting the immediate pharmacologic intervention for heart failure, fitting Pharmacological and Parenteral Therapies—Expected Actions-Outcomes.

Question 2

The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the?

Accepted Answer

Answer reason: For accurate CVP measurement, the zero reference point is leveled with the right atrium at the phlebostatic axis (4th intercostal space at the mid-axillary line).
Category reason: This is a nursing procedure for accurate hemodynamic monitoring, fitting Reduction of Risk Potential—Therapeutic Procedures.

Question 3

Which client should the triage nurse see first when four clients present at the same time in the emergency department?

Accepted Answer

Answer reason: An infant with petechial rash, fever, and nuchal rigidity suggests meningococcal meningitis/sepsis, a rapidly life-threatening and contagious emergency that requires immediate assessment and intervention.
Category reason: The item asks the nurse to prioritize which client to see first in triage, which is an Establishing Priorities task under Management of Care.

Question 4

The nurse is teaching parents how to reduce risks in the home, the most important consideration is?

Accepted Answer

Answer reason: Safety teaching must be developmentally appropriate. The risks and necessary precautions differ dramatically between infants, toddlers, school-aged children, and adolescents, so the age of the children dictates what hazards and prevention strategies are most critical.
Category reason: Home safety education and injury prevention fall directly under “Accident-Error Prevention,” a leaf category within Safety and Infection Control.

Question 5

Which of the following medications is known to increase aPTT levels when taken concurrently?

Accepted Answer

Answer reason: APTT monitors the intrinsic pathway and is used to assess unfractionated heparin therapy; heparin increases aPTT. Warfarin is monitored with PT/INR, and aspirin/clopidogrel affect platelets without changing aPTT.
Category reason: This tests knowledge of the expected laboratory effect of a medication, fitting Pharmacological and Parenteral Therapies—Expected Actions-Outcomes.

Question 6

Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?

Accepted Answer

Answer reason: The ictal phase of a generalized tonic–clonic seizure is characterized by sudden loss of consciousness followed by tonic stiffening and clonic rhythmic muscle contractions.
Category reason: Identifying clinical manifestations of a seizure involves understanding the body’s physiological response to a neurological disorder, fitting Physiological Integrity → Physiological Adaptation → Pathophysiology.

Question 7

What is the Pap smear test used for?

Accepted Answer

Answer reason: Pap smear screens cervical cells for precancerous and cancerous changes, making it a test for cervical cancer detection. The other options are unrelated to its primary purpose.
Category reason: This asks about the purpose of a preventive screening test, which fits Health Promotion and Maintenance under Screenings and Immunizations.

Question 8

The nurse is planning care for a client with adrenal insufficiency. Which nursing diagnosis should receive priority?

Accepted Answer

Answer reason: Adrenal insufficiency (low cortisol and aldosterone) causes sodium and water losses leading to hypotension and dehydration. Preventing and treating fluid volume deficit is the immediate, life‑threatening priority over sleep, nutrition, or body image concerns.
Category reason: This is a prioritization decision for nursing care planning, which falls under Management of Care—Establishing Priorities (triage).

Question 9

This sign is positive in inflammatory processes of the gallbladder, such as cholecystitis?

Accepted Answer

Answer reason: Murphy's sign—arrest of inspiration during deep palpation of the right upper quadrant—is classic for cholecystitis. Rovsing's sign is for appendicitis, Homan's for DVT, and Hook's sign is not the recognized gallbladder test.
Category reason: Identifies a specific physical exam finding used in gastrointestinal assessment, aligning with System-Specific Assessments under Reduction of Risk Potential.

Question 10

The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?

Accepted Answer

Answer reason: Rivastigmine is a cholinesterase inhibitor. The most common adverse effects are gastrointestinal, particularly nausea and vomiting.
Category reason: The question asks for a common side effect of a medication, which aligns with pharmacological adverse effects in Pharmacological and Parenteral Therapies.

Question 11

A client is prescribed albuterol for asthma. What is the primary action of albuterol?

Accepted Answer

Answer reason: Albuterol is a short-acting beta2-adrenergic agonist that relaxes bronchial smooth muscle, producing bronchodilation. It is not a leukotriene antagonist, beta blocker, or primary anti-inflammatory agent.
Category reason: This asks for the expected pharmacologic action of a medication given to a client, which fits Pharmacological and Parenteral Therapies: Expected Actions-Outcomes.

Question 12

You're educating a patient how to use a peak flow meter to help monitor the status of their asthma. Which statement by the patient demonstrates they understand how to use the device?

Accepted Answer

Answer reason: Peak flow meters are for monitoring, not strengthening. Correct technique includes daily use at a consistent time and comparing results to the patient's personal best; blowing out hard and fast is required (not inhaling). Values ≥90% are in the green zone and do not require notifying the provider.
Category reason: This is patient teaching about using a monitoring device for asthma, which aligns with Physiological Integrity—Reduction of Risk Potential: Diagnostic Tests.

Question 13

The most common morbidity among schoolchildren is?

Accepted Answer

Answer reason: Dental caries and other dental problems are the most prevalent chronic conditions among school-age children globally, making dental ailments the commonest morbidity.
Category reason: The item concerns population health patterns and common pediatric conditions relevant to preventive care and screening in school-age children, fitting Health Promotion-Disease Prevention.

Question 14

Which of the following is MOST likely to ensure the safety of the nurse while making a home visit?

Accepted Answer

Answer reason: Constant situational awareness and leaving when unsafe cues appear is the most reliable action to ensure personal safety; absence of noted weapons or prior violence does not guarantee safety, and carrying devices helps but does not prevent harm if the situation is unsafe.
Category reason: The item addresses nurse personal safety strategies in the community/home setting, which falls under Safety and Infection Control—specifically Security Plans.

Question 15

What is the priority nursing diagnosis for a patient with Guillain-Barré Syndrome?

Accepted Answer

Answer reason: Guillain-Barré can rapidly progress to respiratory muscle weakness causing hypoventilation and hypoxia. By ABCs, airway/breathing take priority, making risk for impaired gas exchange the most urgent nursing diagnosis.
Category reason: This is a clinical prioritization question related to physiologic compromise (respiratory failure risk) in a disease process, fitting Physiological Adaptation: Alterations in Body Systems.

Question 16

The nurse asks the patient what he would like to talk about. This is an example of?

Accepted Answer

Answer reason: Asking the client what they would like to discuss invites the client to set the topic and lead the conversation, which is the therapeutic technique of using broad openings.
Category reason: The item tests knowledge of therapeutic communication strategies used in psychosocial nursing care, fitting Psychosocial Integrity under Therapeutic Communication.

Question 17

Priority intervention in patient of head injury is?

Accepted Answer

Answer reason: Use ABCs for trauma: ensure airway patency first in a head-injured patient to prevent hypoxia and aspiration.
Category reason: This asks for the first nursing priority in an acute patient scenario, which is a Management of Care priority-setting/triage concept.

Question 18

A client hospitalized for treatment of congestive heart failure is to be discharged with a prescription for Digitek (digoxin) 0.25mg daily. Which of the following statements indicates that the client needs further teaching?

Accepted Answer

Answer reason: Antacids decrease digoxin absorption and should not be taken concurrently; take digoxin at the same time daily and report visual changes. High-fiber foods can also reduce absorption, so they are not used to prevent toxicity.
Category reason: This is medication teaching about digoxin, focusing on drug interactions and adverse-effect prevention, which fits Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 19

A client is brought to the emergency department unresponsive, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. Which anticipated health care provider's prescription would the nurse immediately prepare to initiate?

Accepted Answer

Answer reason: HHS presents with profound dehydration; the immediate priority is aggressive fluid resuscitation with isotonic saline before insulin therapy. NPH insulin is inappropriate, bicarbonate is not indicated, and intubation is only needed if airway compromise is evident.
Category reason: This is an acute nursing intervention selecting the initial IV therapy for HHS, which falls under Pharmacological and Parenteral Therapies—Intravenous Therapy.

Question 20

Which position is given to the patient for a vaginal examination?

Accepted Answer

Answer reason: Vaginal examinations are performed with the patient in the lithotomy position, which provides optimal access with hips and knees flexed and feet supported.
Category reason: This asks about proper patient positioning for a procedure, which is part of nursing care and comfort measures under Basic Care and Comfort—Mobility/Immobility.

Question 21

Which of the following is true about verapamil?

Accepted Answer

Answer reason: Verapamil, a calcium-channel blocker, can cause hypotension due to vasodilation and negative inotropy. It is not indicated for wide-complex tachycardia or PEA, and is contraindicated in severe hypotension.
Category reason: Determining the true statement centers on the medication’s adverse effects and contraindications for clinical use, fitting pharmacologic adverse effects.

Question 22

A nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The most appropriate initial action by the nurse is which of the following?

Accepted Answer

Answer reason: Suspected impaired practice by a coworker should be reported following the chain of command. Notify the nursing supervisor immediately; do not call police/security unless there is a safety threat, and do not detain the coworker.
Category reason: The scenario concerns legal/ethical responsibilities and proper reporting of an impaired coworker, which falls under Management of Care: Legal Rights-Responsibilities.

Question 23

This statement is an example of what NON-therapeutic communication technique? Yawning when the client is speaking, looking at watch frequently, missing clients messages?

Accepted Answer

Answer reason: Yawning, checking the watch, and missing messages show inattentiveness and poor engagement—hallmarks of the non-therapeutic technique "failure to listen.
Category reason: The item evaluates therapeutic vs. non-therapeutic communication behaviors used in patient interactions, which falls under Psychosocial Integrity: Coping and Adaptation – Therapeutic Communication.

Question 24

What is the primary role of the pediatric nurse?

Accepted Answer

Answer reason: The core role of pediatric nursing centers on advocacy for the child and family, education to promote understanding and participation in care, and management and coordination of care. This best aligns with option B.
Category reason: The item asks about the nurse’s role and responsibilities, which fall within management of care and scope of practice considerations.

Question 25

The nurse is performing physical assessments on adolescents. The nurse would anticipate that females experience growth spurts?

Accepted Answer

Answer reason: Females typically enter puberty and reach peak height velocity earlier than males, with growth spurts occurring about two years sooner.
Category reason: The item addresses normal adolescent growth timing, a developmental milestone topic under Growth and Development.

Question 26

Which education points should the nurse prioritize for a patient with keratitis secondary to contact lens wear?

Accepted Answer

Answer reason: Adhering to the recommended replacement schedule reduces biofilm and microbial buildup on lenses, lowering keratitis risk. Tap water is unsafe for lenses; sleeping in lenses increases risk but only one priority is asked; the makeup statement is incorrect.
Category reason: This is patient education to prevent infection related to contact lens use, aligning with Safety and Infection Control.

Question 27

A client has been diagnosed to have chronic renal failure. Sodium polysterene sulfonate (exchange resin kayexalate) is prescribed. The action of the medication is that it releases?

Accepted Answer

Answer reason: Sodium polystyrene sulfonate (Kayexalate) is a cation-exchange resin that releases sodium and binds potassium in the gut, facilitating potassium excretion to treat hyperkalemia.
Category reason: The item tests knowledge of a medication’s mechanism of action, fitting Pharmacological and Parenteral Therapies—Expected Actions-Outcomes.

Question 28

A client with a diagnosis of depression says to the nurse, 'I've always been a failure.' Which therapeutic response should the nurse make?

Accepted Answer

Answer reason: Reflecting and encouraging elaboration is therapeutic. Option D restates the feeling and invites the client to explore, while A and B offer nontherapeutic reassurance and C minimizes the experience.
Category reason: This focuses on appropriate therapeutic communication with a depressed patient, which is part of Psychosocial Integrity under Coping and Adaptation.

Question 29

A client is prescribed sertraline for depression. What education should the nurse provide regarding sertraline?

Accepted Answer

Answer reason: SSRIs like sertraline carry a black box warning for increased suicidal thoughts, especially early in therapy. Patients should be taught to monitor and report suicidal ideation. Effects are not immediate, medication should not be stopped abruptly, and it does not need to be taken on an empty stomach.
Category reason: This is a nursing patient-education question about safe medication use and adverse effect monitoring, which falls under Pharmacological and Parenteral Therapies in NCLEX.

Question 30

What gauge needle is used for intradermal injections?

Accepted Answer

Answer reason: Intradermal injections (e.g., TB testing) use very fine needles, typically 25–27-gauge, to form a small bleb in the dermis. 20–25-gauge needles are used for IM injections, and 27–30-gauge needles are more typical for subcutaneous insulin injections.
Category reason: Selecting the correct needle gauge for an injection is part of safe medication administration in pharmacological and parenteral therapies.

Question 31

The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?

Accepted Answer

Answer reason: Edrophonium (Tensilon) can cause severe cholinergic effects such as bradycardia during testing; atropine sulfate is the antidote and must be on hand.
Category reason: This asks about safe medication management and having the antidote available for a diagnostic drug, fitting Pharmacological and Parenteral Therapies under Adverse Effects-Contraindications.

Question 32

According to the Ethiopia’s abortion Law, May 2005: Termination of pregnancy recognized by medical institution within the period permitted by the profession not punishable where?

Accepted Answer

Answer reason: Ethiopia’s 2005 abortion law allows termination for rape or incest, risk to the mother’s health/life, fetal deformity, physical or mental disability, and for minors; therefore all listed conditions apply.
Category reason: This tests knowledge of legal rights and conditions under which care (termination of pregnancy) is permissible, fitting Legal Rights-Responsibilities within Management of Care.

Question 33

Which of the following assignments by the RN would be appropriate for an LPN/LVN?

Accepted Answer

Answer reason: LPNs are assigned stable clients with predictable outcomes. A patient in traction with a fractured femur is stable and involves routine, ongoing care. The other options involve initial or discharge teaching or potentially unstable/new conditions, which require an RN.
Category reason: This is a delegation/assignment decision about which client an LPN can safely care for, fitting Management of Care under Establishing Priorities: Assignment.

Question 34

The nurse is caring for a client hospitalized with nephotic syndrome. Based on the client's treatment, the nurse should?

Accepted Answer

Answer reason: Clients with nephrotic syndrome are commonly treated with corticosteroids, which increase infection risk; limiting visitors helps reduce exposure. A low-protein diet is not indicated (protein losses require adequate intake), dialysis is not typical, and fluids are usually restricted due to edema.
Category reason: This is a nursing care decision focused on preventing infection in an immunosuppressed client, fitting Safety and Infection Control in the NCLEX framework.

Question 35

A nursing graduate is employed as a staff nurse in a local hospital. During orientation, the new graduate asks the nurse educator about the need to obtain professional liability insurance. The most appropriate response by the nurse educator is?

Accepted Answer

Answer reason: Employer policies primarily protect the institution and may not fully cover the nurse, especially for actions outside scope or employment. Nurses are advised to carry personal malpractice insurance to protect their own legal and financial interests.
Category reason: This asks about legal responsibilities and professional liability for nurses, which falls under Management of Care: Legal Rights-Responsibilities.

Question 36

A parent tells the nurse that their six year-old child who normally enjoys school, has not been doing well since his grandmother died two months ago. Which statement MOST accurately describes thoughts on death and dying at this age?

Accepted Answer

Answer reason: At about age 6, children often view death in magical and personified terms (e.g., a bogeyman). Irreversibility and personal mortality are better understood later; guilt attribution is more typical of preschoolers.
Category reason: The item assesses developmental understanding of death in a school-age child, fitting Growth and Development within Health Promotion and Maintenance.

Question 37

A client tells the RN she has decided to stop taking Sertraline (Zoloft) because she doesn't like the nightmares, sex dreams and obsessions she's experiencing since starting on the medication. An appropriate response is to caution the client that?

Accepted Answer

Answer reason: SSRIs like sertraline should not be stopped suddenly due to risk of discontinuation syndrome; clients should be cautioned to consult the provider for a taper. Other options are either generic or inappropriate.
Category reason: This is nursing teaching for safe medication use and discontinuation precautions, fitting Pharmacological and Parenteral Therapies—Medication Administration.

Question 38

The most appropriate means of rehydration of a 7-month-old with diarrhea and mild dehydration is?

Accepted Answer

Answer reason: For infants with mild dehydration from diarrhea, first-line therapy is oral rehydration solution (ORS). IV fluids are reserved for moderate to severe dehydration, lactose-free formula does not address acute rehydration, and the BRAT-type diet is not recommended as primary therapy.
Category reason: This addresses management of dehydration and fluid-electrolyte balance in a pediatric patient, fitting Physiological Adaptation: Fluid and Electrolyte Imbalances.

Question 39

Which medicine is administered sublingually?

Accepted Answer

Answer reason: Nitroglycerin tablets are given sublingually for rapid absorption and onset in acute angina; aspirin and clopidogrel are typically administered orally and not sublingually.
Category reason: This asks about the correct route for a medication, a nursing responsibility under Pharmacological and Parenteral Therapies: Medication Administration.

Question 40

The charge nurse on a surgical unit is making assignments for the day. There are two RNs, one LPN, and two unlicensed assistive personnel (UAPs). Which one of the following tasks could be assigned to the LPN?

Accepted Answer

Answer reason: LPNs can perform sterile/complex wound care such as irrigation and dressing changes. Ambulation and occult blood testing can be delegated to UAPs, while admitting a patient requires an RN for initial assessment.
Category reason: This is a delegation/assignment decision about which tasks are appropriate for an LPN versus UAPs or RNs, fitting Management of Care: Assignment.

Question 41

Which of the following is NOT a job responsibility of a nursing superintendent in the hospital?

Accepted Answer

Answer reason: Maintaining admission registers is a clerical/ward-level task handled by registration/ward staff, not the nursing superintendent. A superintendent’s role focuses on policy planning, organizational structure, and supervisory rounds.
Category reason: The question tests knowledge of role delineation and responsibilities within nursing administration, which aligns with Management of Care—Scope of Practice.

Question 42

When giving a report to the oncoming shift, which action by the nurse could be considered an invasion of the client's privacy?

Accepted Answer

Answer reason: Taking a client’s photo while asleep lacks consent and violates privacy/HIPAA. Sharing relevant health info with the oncoming nurse is need-to-know, and asking permission for student participation respects privacy; room number disclosure may be directory information per policy but is less clearly a violation.
Category reason: This concerns protecting patient privacy and confidentiality during care handoff, which falls under Management of Care: Confidentiality-Information Security.

Question 43

A client is admitted with symptoms of pseudomembranous colitis. Which finding is associated with Clostridium difficile?

Accepted Answer

Answer reason: C. difficile commonly causes profuse watery diarrhea that may contain mucus and blood due to colonic inflammation.
Category reason: Recognizing and managing infectious processes aligns with infection control.

Question 44

The nurse is caring for a client who has developed cardiac tamponade. Which of the following assessments would the nurse anticipate finding?

Accepted Answer

Answer reason: Cardiac tamponade increases intrapericardial pressure, impeding venous return and raising venous pressure, producing jugular venous distention. Tamponade typically causes narrowed (not widened) pulse pressure and tachycardia; a pleural friction rub reflects pleural/pericardial inflammation, not tamponade.
Category reason: This asks for expected assessment findings for a cardiovascular condition, fitting Reduction of Risk Potential: System-Specific Assessments.

Question 45

A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is?

Accepted Answer

Answer reason: Positive (definitive) signs of pregnancy include fetal heart tones, fetal movement felt by the examiner, and ultrasound visualization. Elevated hCG, uterine and breast changes are presumptive/probable, not definitive.
Category reason: This is an obstetric assessment question about determining a positive sign of pregnancy, which belongs to Ante-Intra-Postpartum Care under Health Promotion and Maintenance.

Question 46

Which is the most common clinical syndrome of OCD?

Accepted Answer

Answer reason: Contamination fears with compulsive washing are the most common presentation subtype of obsessive–compulsive disorder.
Category reason: The item assesses knowledge about OCD, a mental health disorder, fitting Psychosocial Integrity: Mental Health Disorders (Anxiety Disorders).

Question 47

In premature labor, which of the following medicines is useful for the newborn?

Accepted Answer

Answer reason: Antenatal corticosteroids, such as dexamethasone, accelerate fetal lung maturation and reduce neonatal respiratory distress and complications in preterm birth.
Category reason: The item asks for the drug intended to affect neonatal outcomes in preterm labor, focusing on the expected actions and outcomes of the medication.

Question 48

What is the period after childbirth called?

Accepted Answer

Answer reason: Postnatal refers to the period after birth. Antenatal/prenatal are before birth, and gestation is the pregnancy period.
Category reason: This is maternal-newborn terminology related to postpartum care, which falls under Ante-Intra-Postpartum Care in Health Promotion and Maintenance.

Question 49

The nurse is teaching a client with chronic obstructive pulmonary disease to use occasional pursed-lip breathing. What is the MAJOR reason for this?

Accepted Answer

Answer reason: Pursed-lip breathing creates back-pressure during exhalation (PEEP), prolonging expiration and helping keep small airways and alveoli from collapsing, which improves ventilation in COPD.
Category reason: This is a nursing intervention and patient teaching strategy to improve breathing comfort and function, fitting Basic Care and Comfort: Non-Pharmacological Comfort Interventions.

Question 50

What action by the nurse is most important when performing a dressing change using surgical aseptic technique?

Accepted Answer

Answer reason: In a sterile dressing change, the critical priority is maintaining sterility to prevent infection; the other actions are secondary.
Category reason: This tests sterile technique and prevention of infection during a procedure, which falls under Safety and Infection Control—Infection Control.

Question 51

A child is on CPAP and is hemodynamically stable. Which of the following is the best method of feeding the child?

Accepted Answer

Answer reason: On CPAP, oral feeding increases aspiration risk and infants often cannot coordinate suck–swallow–breathe. Since the child is hemodynamically stable, enteral nutrition via a tube is preferred; thus nasogastric feeding is the best option among those listed.
Category reason: This concerns choosing an appropriate feeding method for a patient, which falls under Basic Care and Comfort—Nutrition and Oral Hydration.

Question 52

The 5-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?

Accepted Answer

Answer reason: Enterobiasis (pinworms) causes nocturnal perianal irritation as female worms lay eggs around the anus, leading to rectal itching; the other symptoms are not characteristic.
Category reason: This is a patient-care question assessing recognition of a disease-specific symptom, fitting NCLEX Reduction of Risk Potential under System-Specific Assessments.

Question 53

Ben is diagnosed with a retinal detachment at the inner aspect of the right eye. Into which position would the nurse place the client?

Accepted Answer

Answer reason: Position the detached retinal area dependently so gravity helps appose the retina. A right-eye medial (inner) detachment is best positioned with the client on the left side, making the nasal retina dependent.
Category reason: This asks for appropriate patient positioning to prevent complications, which is a Basic Care and Comfort task under Mobility-Immobility.

Question 54

What is the reason for using an intradermal route instead of subcutaneous for certain medications?

Accepted Answer

Answer reason: Intradermal injections are used for tests like TB and allergy testing to provoke a localized immune reaction in the dermis. Absorption is slower and only very small volumes are used, so the other options are incorrect.
Category reason: Selecting the appropriate parenteral route is part of nursing medication administration within Pharmacological and Parenteral Therapies.

Question 55

Maintaining eye contact and receptive nonverbal communication describes which therapeutic communication technique?

Accepted Answer

Answer reason: Eye contact and receptive nonverbal cues are elements of active therapeutic listening, which conveys attention and understanding.
Category reason: This question asks about a therapeutic communication technique used by nurses to support patients, fitting the Therapeutic Communication category under Psychosocial Integrity.

Question 56

The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?

Accepted Answer

Answer reason: By 30 months, a toddler should be able to drink from an open cup; reliance on a sippy cup suggests a delayed self-feeding/oral-motor milestone. The other options reflect behaviors within normal variation for those ages.
Category reason: The item evaluates normal developmental milestones in toddlers, which falls under Health Promotion and Maintenance: Growth and Development—Developmental Stages and Transitions.

Question 57

A mentally competent client with end-stage liver disease continues drinking alcohol despite being warned of consequences. What action best illustrates the nurse's role as a client advocate?

Accepted Answer

Answer reason: Advocacy includes supporting the client’s autonomous, informed decisions—even if they are risky.
Category reason: This item involves respecting autonomy, which falls under Client Rights.

Question 58

The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?

Accepted Answer

Answer reason: Magnesium sulfate is renally excreted; decreased urine output increases risk for toxicity. Inserting a Foley allows accurate hourly monitoring of output to detect/avoid toxicity. The other actions do not address magnesium toxicity monitoring.
Category reason: This question focuses on nursing actions related to medication toxicity and monitoring for magnesium sulfate, which is part of Pharmacological and Parenteral Therapies—Adverse Effects-Contraindications.

Question 59

The nurse is caring for a client with a new order for Bupropion (Wellbutrin) for treatment of depression. The physician's order reads "175 mg. BID x 4 days". What is the appropriate action?

Accepted Answer

Answer reason: 175 mg BID is not a standard or safe initial dosing schedule for bupropion and 175 mg is not a usual tablet strength; the nurse should clarify the order before administration.
Category reason: This is a nursing decision about verifying a potentially unsafe medication order, which falls under Pharmacological and Parenteral Therapies: Medication Administration.

Question 60

Which of the following is NOT a principle of budgeting?

Accepted Answer

Answer reason: Effective budgeting in healthcare should be flexible to adapt to changing needs and resources. Being rigid contradicts budgeting principles, whereas the other options support effective resource allocation and oversight.
Category reason: The item addresses budgeting and allocation of resources, which is part of nursing management under Resource Management in the NCLEX Management of Care domain.

Question 61

An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which one of these questions by the charge nurse would be most appropriate when making delegation decisions?

Accepted Answer

Answer reason: Delegation requires verifying the UAP’s competency for assigned tasks. Reviewing the competency checklist objectively confirms skills, whereas experience length, prior unit tasks, or comfort are insufficient.
Category reason: This is a nursing management question about safe delegation and determining appropriate task assignment, which falls under Management of Care—Delegation.

Question 62

The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?

Accepted Answer

Answer reason: Chest tubes remove air, blood, and serous fluid from the pleural space to restore negative pressure and allow lung re-expansion, which is the primary rationale.
Category reason: This is a nursing intervention regarding the purpose of a chest tube, a therapeutic procedure to reduce risk and restore function, fitting Reduction of Risk Potential: Therapeutic Procedures.

Question 63

When suctioning a client's tracheostomy, the nurse should instill saline in order to?

Accepted Answer

Answer reason: Instilling sterile saline helps thin and loosen tracheal secretions, making them easier to remove with suction. It does not oxygenate, prevent aspiration, or primarily reduce discomfort.
Category reason: This is a nursing procedure about airway suctioning technique, which falls under Reduction of Risk Potential—Therapeutic Procedures.

Question 64

Which of the following takes priority in planning nursing care for a client?

Accepted Answer

Answer reason: Nursing care plans are individualized and prioritized based on the client’s assessed condition and needs; orders and policies guide care but do not supersede the client’s current status.
Category reason: This tests prioritization in planning care—a Management of Care concept under Establishing Priorities, emphasizing client-centered, ethical decision-making.

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