Question 1

The most important treatment for dengue fever is?

Accepted Answer

Answer reason: Dengue fever has no specific curative antiviral therapy in routine practice; management is primarily supportive. The key life-threatening issue is plasma leakage leading to hypovolemia and shock, so careful fluid replacement and monitoring are central to treatment. Antibiotics are not indicated unless there is a secondary bacterial infection. Blood transfusion is reserved for significant hemorrhage or severe anemia and is not the primary treatment.
Category reason: This question tests appropriate clinical management of a viral illness with risk of hemodynamic instability, emphasizing supportive interventions and prevention of shock—an NCLEX-style focus on managing physiological adaptation to acute disease.

Question 2

A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

Accepted Answer

Answer reason: Using ABCs and physiologic priority, impaired circulation is most urgent. Hypothyroidism can cause significant bradycardia and reduced myocardial contractility, which can lower cardiac output and compromise tissue perfusion. While hypothermia is a concern (e.g., wearing two sweaters), the client’s presented critical objective finding is bradycardia (pulse 52) consistent with decreased cardiac output risk. Mobility and thought-process changes are less immediately life-threatening than compromised cardiac output.
Category reason: This is a nursing-priority question asking which nursing diagnosis is highest priority in a clinical scenario, requiring nursing judgment rather than recalling isolated biomedical facts; therefore it fits NCLEX Physiological Adaptation (Alterations in Body Systems).

Question 3

A nurse is assessing a patient with a suspected stroke (CVA). Which symptom suggests a left-sided stroke?

Accepted Answer

Answer reason:  C) Right-sided weakness and aphasia Left cerebral hemisphere strokes typically cause contralateral (right-sided) motor weakness due to crossing of corticospinal tracts. In most individuals, the left hemisphere is dominant for language, so aphasia is a classic left-sided stroke finding. The other options point more toward right hemisphere (impulsivity/poor judgment) or posterior circulation/cerebellar involvement (diplopia, loss of coordination) rather than a left hemispheric stroke pattern.
Category reason: This item tests nursing recognition of stroke lateralization based on assessment findings (neurologic deficits) to guide clinical judgment, which fits Physiological Adaptation—Alterations in Body Systems.

Question 4

A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for?

Accepted Answer

Answer reason: Moderate pain that worsens on inspiration. Pleuritic chest pain results from inflammation of the pleura and is characteristically sharp and worsened by deep breathing, coughing, or movement because these actions stretch the inflamed pleural surfaces. In pneumonia, pleural involvement can produce this classic inspiratory worsening pattern. The other options are more consistent with non-pleuritic etiologies (e.g., constant aching, severe midsternal cardiac/mediastinal pain, or musculoskeletal pain from coughing).
Category reason: This item tests nursing assessment/clinical recognition of a respiratory complication pattern (pleuritic pain characteristics) in a patient with pneumonia, fitting NCLEX-focused evaluation of alterations in body systems.

Question 5

A premature neonate with respiratory distress syndrome( RDS) is receiving oxygen therapy. Which finding indicates worsening respiratory distress?

Accepted Answer

Answer reason: Nasal flaring and grunting Nasal flaring and grunting are classic signs of increased work of breathing in neonates and indicate the infant is struggling to maintain adequate ventilation and oxygenation. Grunting represents an attempt to maintain positive end-expiratory pressure to keep alveoli open, which can worsen as RDS progresses. In contrast, a heart rate of 140 bpm and capillary refill of 2 seconds are within expected limits for a neonate, and an SpO2 of 96% suggests adequate oxygenation at that moment.
Category reason: This question tests recognition of clinical signs indicating deterioration and requires nursing judgment during ongoing respiratory support, which fits patient status assessment within Physiological Adaptation.

Question 6

Which order is most appropriate for a client with severe COPD exacerbation and chronic CO2 retention?

Accepted Answer

Answer reason: B. Titrate O2 to keep SpO2 88–92% via nasal cannula In chronic CO2 retainers (often severe COPD), the safest oxygen strategy is controlled supplementation targeting SpO2 88–92% to correct hypoxemia while reducing the risk of worsening hypercapnia. A non-rebreather aiming for 99–100% can precipitate CO2 retention via V/Q mismatch and the Haldane effect. Withholding oxygen until SpO2

Question 7

A client with myocardial infarction is developing cardiogenic shock. Which potential condition would the nurse anticipate and monitor the client for to detect cardiogenic shock?

Accepted Answer

Answer reason: Ventricular dysrhythmias Cardiogenic shock after an MI results from severely impaired myocardial contractility and electrical instability, making life-threatening ventricular dysrhythmias (e.g., VT/VF) a key complication to anticipate and monitor for. These dysrhythmias can rapidly worsen cardiac output and tissue perfusion, accelerating shock. Pulsus paradoxus is more associated with tamponade/severe asthma, while cardiogenic shock typically shows hypotension (not rising diastolic BP) and elevated filling pressures (CVP often rises rather than falls).
Category reason: This item asks what complication a nurse should anticipate and monitor for in a patient scenario (MI progressing to cardiogenic shock), emphasizing clinical surveillance for acute deterioration, which fits NCLEX Physiological Adaptation.

Question 8

A client is admitted with a head injury. The nurse identifies that the client's urinary retention catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause?

Accepted Answer

Answer reason: Inadequate ADH secretion Head injury can disrupt the hypothalamus or posterior pituitary, decreasing ADH release and causing central diabetes insipidus. Low ADH leads to inability to concentrate urine, producing large volumes of dilute (clear, colorless) urine. Increased serum glucose would cause osmotic diuresis but urine is typically not described as purely colorless and would be associated with hyperglycemia findings. Excess IV fluids could increase output but does not specifically explain markedly dilute polyuria after head trauma as well as ADH deficiency does.
Category reason: This item tests nursing recognition of a common complication of head injury (central diabetes insipidus) and interpretation of urine output to identify the physiologic alteration causing it, which aligns with Physiological Adaptation/Alterations in Body Systems.

Question 9

A patient is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse implement to ensure the patient maintains adequate oxygenation?

Accepted Answer

Answer reason: B. Encourage pursed-lip breathing. Pursed-lip breathing prolongs exhalation, helps prevent airway collapse, and reduces air trapping, which improves ventilation and oxygenation in COPD. Routine oxygen at 4 L/min can worsen hypercapnia in some COPD patients and should be titrated to target saturation. Supine positioning can impair chest expansion and worsen dyspnea; upright/tripod positioning is preferred. High-carbohydrate diets increase CO2 production and can increase the ventilatory demand in COPD.
Category reason: This is a nursing intervention question focused on maintaining oxygenation and managing respiratory compromise in a patient with COPD, which requires clinical nursing judgment and patient-care actions (NCLEX).

Question 10

The nurse is caring for a client receiving morphine sulfate intravenously for pain. Because morphine sulfate has been prescribed for this client, which nursing action should be included in the plan of care?

Accepted Answer

Answer reason: Encourage the client to cough and deep breathe. IV morphine can cause respiratory depression and decreased cough reflex, increasing the risk of atelectasis and retained secretions. Encouraging coughing and deep breathing promotes lung expansion and helps maintain adequate ventilation/oxygenation. The other options are not primary or specific interventions for morphine’s most significant immediate risk (respiratory compromise).
Category reason: This is a nursing care planning question focused on monitoring and interventions to prevent complications from an opioid (respiratory depression), which requires nursing judgment and patient-care actions, fitting NCLEX patient care.

Question 11

You have a patient that might have a urinary tract infection (UTI). Which statement by the patient suggests that a UTI is likely?

Accepted Answer

Answer reason: "It burns when I pee." Dysuria (burning with urination) is a classic symptom of a lower urinary tract infection due to inflammation/irritation of the urethra and bladder mucosa. While increased frequency can occur, it is less specific than burning pain. Going hours without urge suggests decreased output or retention rather than infection, and sweet-smelling urine is more suggestive of glycosuria/diabetes than UTI.
Category reason: This is a patient-care recognition question requiring nursing clinical judgment to identify a likely UTI symptom, fitting NCLEX-style assessment of alterations in the urinary system.

Question 12

Nurse Nancy is assessing a child with pyloric stenosis; she is likely to note which of the following?

Accepted Answer

Answer reason: Projectile vomiting Pyloric stenosis causes gastric outlet obstruction, leading to progressively worsening, non-bilious projectile vomiting after feeds in infants. The forceful emesis is due to increased gastric peristalsis against the narrowed pylorus and can result in dehydration and electrolyte disturbances. “Currant jelly” stools are more typical of intussusception, while steatorrhea suggests fat malabsorption and regurgitation is more consistent with uncomplicated reflux.
Category reason: This item tests recognition of a pediatric disorder’s clinical manifestation (a nursing assessment finding) to guide clinical judgment, which fits NCLEX Physiological Adaptation—Alterations in Body Systems.

Question 13

A nurse is caring for a client admitted with pneumonia who is receiving IV antibiotics. The client’s morning lab values are: • WBC: 15,200/mm³ • Temperature: 101.8°F (38.8°C) • SpO₂: 88% on room air • RR: 28/min Which action should the nurse take first?

Accepted Answer

Answer reason: Apply 2L oxygen via nasal cannula The client is hypoxemic (SpO₂ 88% on room air) and tachypneic, so airway/breathing take priority (ABCs). Immediate oxygen supplementation is the fastest nursing intervention to improve oxygenation and reduce respiratory distress in pneumonia. Fever control, fluids, and notifying the provider are important, but they do not address the most urgent threat—impaired gas exchange.
Category reason: This is a priority nursing action question requiring ABC-based clinical judgment to address acute respiratory compromise in a patient with pneumonia, fitting Physiological Adaptation (Alterations in Body Systems).

Question 14

True or False: Patients with COPD should receive high-flow oxygen.?

Accepted Answer

Answer reason: False In COPD, oxygen should be titrated to a target saturation (commonly 88–92%) rather than routinely giving high-flow oxygen. Excessive oxygen can worsen ventilation-perfusion mismatch and may precipitate CO2 retention and respiratory acidosis in susceptible patients. The safer nursing approach is controlled oxygen therapy (e.g., Venturi mask) with close monitoring of SpO2 and clinical status, and ABGs when indicated.
Category reason: This item tests a nursing decision about safe oxygen administration and monitoring in a patient with a chronic respiratory condition, aligning with Physiological Adaptation (Alterations in Body Systems).

Question 15

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?

Accepted Answer

Answer reason: I will place my child in a closed bathroom and allow my child to inhale steam from the running water. Hot steam in a closed bathroom is not recommended because it poses burn and scald risks and can worsen respiratory distress if the child becomes agitated. For croup, cool mist or exposure to cool/humid air is typically preferred to reduce upper-airway inflammation and improve stridor. Teaching should reinforce safer measures (cool-mist humidifier, cool night air) and prompt evaluation if significant respiratory distress persists.
Category reason: This question tests nursing caregiver teaching and appropriate home interventions for an acute respiratory episode (croup), which is a patient-care decision about managing an alteration in the respiratory system.

Question 16

A 10-year-old child with sickle cell disease presents to the emergency department with severe pain in the arms and legs. Which of the following is the priority intervention?

Accepted Answer

Answer reason: C. Give IV fluids and pain management This presentation is most consistent with a vaso-occlusive pain crisis, where priority care focuses on rapid analgesia and hydration to reduce blood viscosity and improve perfusion. IV fluids and prompt pain management address the immediate, severe symptom and help limit progression of ischemia. Antibiotics are prioritized when infection/fever is suspected, and transfusion is reserved for specific complications (e.g., acute chest syndrome, stroke, severe anemia) rather than uncomplicated pain crisis. Warm compresses can be adjunctive but are not the primary priority intervention.
Category reason: This is a patient-care prioritization question about the immediate nursing/ED management of a sickle cell vaso-occlusive crisis, which fits NCLEX Physiological Adaptation (alterations requiring urgent intervention).

Question 17

A nurse is caring for a client admitted with pneumonia who is receiving IV antibiotics. The client's morning lab values are: • WBC: 15,200/mm3 • Temperature: 101.8 °F (38.8 °C) • SpO2: 88% on room air • RR: 28/min?

Accepted Answer

Answer reason: Apply 2L oxygen via nasal cannula SpO2 of 88% on room air with tachypnea indicates acute hypoxemia and impaired gas exchange, which is the most immediate threat to life. Applying low-flow supplemental oxygen is an appropriate first nursing intervention to improve oxygenation while further assessment and treatments continue. Fever control, fluids, and notifying the provider are important, but they do not address the immediate airway/breathing problem as quickly as oxygen administration.
Category reason: This item tests prioritization of an immediate nursing intervention for respiratory compromise (hypoxemia) in pneumonia, which is a patient-care decision under Physiological Adaptation.

Question 18

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following interventions is the highest priority for this client?

Accepted Answer

Answer reason: Administering oxygen therapy as prescribed. This is the most immediate intervention supporting airway and breathing, which are prioritized over activity, education, and stress management. Clients with COPD are at risk for hypoxemia and increased work of breathing; prescribed oxygen helps maintain adequate oxygenation and reduce respiratory distress. Ambulation, smoking cessation teaching, and relaxation are important but are secondary once oxygenation and ventilation needs are addressed. Oxygen should be administered exactly as ordered and titrated/monitored to avoid worsening hypercapnia in CO2 retainers.
Category reason: This question tests priority nursing intervention for a client with a respiratory disorder, requiring nursing judgment to address an actual physiological need (oxygenation) first, which fits Physiological Adaptation/Alterations in Body Systems.

Question 19

Transient Tachypnea of the Newborn (TTN) A C-section newborn has respiratory rate of 72 bpm, mild retractions, and nasal flaring. What is the best intervention?

Accepted Answer

Answer reason: The findings (tachypnea, mild retractions, nasal flaring) indicate increased work of breathing and impaired gas exchange consistent with TTN, where supportive care is the priority. Providing supplemental oxygen treats hypoxemia while the excess lung fluid is reabsorbed. Suctioning is only helpful if airway obstruction from secretions is present, and chest compressions are reserved for severe bradycardia with poor perfusion. Feeding should be deferred until respiratory status stabilizes to reduce aspiration risk and worsening respiratory effort.
Category reason: This question asks for the safest immediate nursing intervention for a newborn showing respiratory distress, which is a patient-care decision under Physiological Adaptation related to acute alterations in respiratory function.

Question 20

What assessment finding would the nurse expect in a client with a herniated lumbar disc?

Accepted Answer

Answer reason: C. Numbness radiating down the leg A lumbar disc herniation commonly compresses a nerve root, producing radicular symptoms (sciatica) such as pain, paresthesia, and sensory loss that travels down the affected leg in a dermatomal pattern. Upper motor neuron signs like hyperreflexia or a positive Babinski are more consistent with central nervous system tract involvement rather than an isolated lumbar nerve root compression. Forward flexion may relieve symptoms more typically in spinal stenosis, while disc herniation often worsens with activities that raise intradiscal pressure (e.g., coughing, sneezing, sitting).
Category reason: This question tests recognition of expected clinical assessment findings from a musculoskeletal/neurologic disorder and requires applying pathophysiology to patient assessment, fitting Physiological Adaptation—Alterations in Body Systems.

Question 21

A nurse notes shortening and external rotation of the leg in a post-fall elderly client. What condition is suspected?

Accepted Answer

Answer reason: C. Hip fracture Shortening with external rotation after a fall is classic for a proximal femur/hip fracture due to muscle spasm and displacement of the fracture fragments. Older adults are at high risk because osteoporosis makes low-energy falls sufficient to fracture the femoral neck or intertrochanteric region. Knee dislocation more typically presents with gross knee deformity and instability, and pelvic fractures are more associated with pelvic pain/instability and may involve high-energy mechanisms. Prompt immobilization, pain control, and evaluation for neurovascular compromise are priorities due to risks of bleeding and complications.
Category reason: This item tests nursing recognition of a characteristic post-fall musculoskeletal finding to suspect a specific injury, which is patient-assessment–focused clinical judgment under Physiological Adaptation.

Question 22

The nurse is caring for a client newly diagnosed with hyperthyroidism. Which nursing diagnosis takes priority?

Accepted Answer

Answer reason: Hyperthyroidism increases metabolic demand and sensitizes the heart to catecholamines, leading to tachycardia and possible dysrhythmias and high-output heart failure. These cardiovascular effects can quickly become life-threatening and therefore take priority over longer-term concerns like nutrition changes, constipation risk, or body image. Prioritizing perfusion and hemodynamic stability aligns with ABCs and physiologic safety priorities in early management.
Category reason: This is a nursing-priority question requiring clinical judgment to select the most urgent nursing diagnosis based on potential complications, fitting Physiological Adaptation focused on body-system alterations.

Question 23

A client with pneumonia has thick secretions. What intervention should the nurse prioritize?

Accepted Answer

Answer reason: D. Elevate the head of the bed. Airway and breathing support are the immediate priority in pneumonia, and positioning improves ventilation and helps mobilize secretions for easier expectoration. Upright positioning also reduces the work of breathing and optimizes oxygenation. Limiting fluids can worsen secretion thickness, and cough suppressants can impair secretion clearance. Chest physiotherapy may help later, but first prioritize an intervention that rapidly improves breathing mechanics and gas exchange.
Category reason: This is a patient-care prioritization question focused on an immediate nursing intervention to support oxygenation/ventilation in a client with pneumonia, which fits NCLEX Physiological Adaptation (alterations in respiratory function).

Question 24

A nurse is assessing a client with chronic heart failure. Which assessment finding requires immediate intervention?

Accepted Answer

Answer reason: These findings suggest pulmonary congestion/edema from worsening left-sided heart failure, which can rapidly compromise oxygenation and progress to acute respiratory distress. This requires prompt intervention such as positioning, oxygen as needed, rapid focused assessment, and notifying the provider for urgent diuresis/therapy escalation. The other findings are either expected in chronic heart failure or not immediately dangerous in isolation.
Category reason: This question tests nursing judgment to recognize a potentially life-threatening decompensation in heart failure requiring urgent action, which aligns with Physiological Adaptation (alterations in body systems).

Question 25

A client is admitted with hypothyroidism. Which of the following would be a priority nursing intervention?

Accepted Answer

Answer reason: C. Monitor for bradycardia and hypotension Hypothyroidism lowers metabolic rate and can depress cardiovascular function, leading to decreased heart rate, reduced contractility, and low blood pressure. These changes can compromise perfusion and represent immediate physiologic risk, making close monitoring a priority. The other options address longer-term management (diet), comfort measures (temperature), or activity promotion, but do not take precedence over detecting potentially unstable vital-sign changes.
Category reason: This item asks for a priority nursing intervention focused on monitoring and preventing physiologic instability in a client with an endocrine disorder, which aligns with NCLEX patient-care decision-making under Physiological Adaptation.

Question 26

A client with hypertrophic cardiomyopathy reports dizziness after exercise. What is the most appropriate nurse instruction?

Accepted Answer

Answer reason: Exertion can worsen left ventricular outflow tract obstruction in hypertrophic cardiomyopathy by increasing contractility and reducing ventricular filling time, leading to decreased cardiac output and dizziness/syncope risk. Avoiding strenuous activity reduces the likelihood of exercise-triggered hypotension and malignant arrhythmias, including sudden cardiac death. Other measures like increasing fluids or leg elevation may help transient hypotension but do not address the primary safety risk associated with exertional symptoms in this condition.
Category reason: This question asks for the safest nursing instruction/intervention for a client experiencing exertional symptoms with a cardiac condition, which is nursing judgment about physiologic adaptation and preventing complications.

Question 27

A nurse is caring for a client who has sustained a chest injury and suffered a flail chest. Which most distinctive sign of flail chest should the nurse assess for?

Accepted Answer

Answer reason: Flail chest occurs when a segment of ribs is fractured in multiple places, creating a free-floating section of the chest wall. This segment moves inward during inspiration and outward during expiration, the classic paradoxical motion that distinguishes flail chest from other thoracic injuries. Dyspnea, cyanosis, and hypotension can occur but are nonspecific and may be seen with many causes of impaired ventilation, shock, or hypoxemia. Identifying paradoxical movement helps prompt urgent respiratory support and close monitoring for respiratory failure.
Category reason: This is a patient-care assessment question requiring recognition of a life-threatening traumatic thoracic condition and the key clinical sign a nurse should monitor, fitting NCLEX Physiological Adaptation (Alterations in Body Systems).

Question 28

True or False Nurses should always administer oxygen to patients with chronic obstructive pulmonary disease (COPD).?

Accepted Answer

Answer reason: Oxygen is administered based on assessment and target oxygen saturation, not automatically for all COPD patients. Some individuals with chronic CO2 retention can develop worsening hypercapnia with excessive supplemental oxygen due to ventilation-perfusion mismatch and the Haldane effect, so therapy should be titrated (often targeting SpO2 about 88–92% unless otherwise ordered). If a COPD patient is hypoxemic, oxygen is appropriate, but it must be carefully monitored with pulse oximetry and clinical status (and ABGs when indicated).
Category reason: This item tests nursing judgment about safe oxygen therapy and monitoring in a respiratory disorder, focusing on managing physiologic adaptation to COPD rather than foundational anatomy alone.

Question 29

The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be..?

Accepted Answer

Answer reason: B. Maintain the patient in an orthopneic position as needed Positioning in orthopnea (upright/tripod/high Fowler’s) decreases venous return and improves diaphragmatic excursion, which can quickly reduce work of breathing and improve ventilation. It is an immediate, noninvasive nursing intervention that can be implemented safely while further assessment and therapies are arranged. Strict bed rest is not necessary for all cases and can worsen deconditioning, and a fixed low FiO2 order (24% Venturi) may be inadequate and is not the first nursing measure without assessment of oxygenation. Scheduling rest between activities helps energy conservation but does not address acute dyspnea as promptly as optimizing positioning.
Category reason: This is a nursing intervention question focused on immediate bedside management of a patient with dyspnea, which requires clinical nursing judgment and prioritizing actions to support physiologic adaptation.

Question 30

A child is admitted to the emergency department with dyspnea related to bronchospasm. The nurse should place the client in which of the following positions?

Accepted Answer

Answer reason: Upright positioning maximizes lung expansion, improves diaphragmatic excursion, and reduces work of breathing, which is critical during bronchospasm. It also helps optimize ventilation by reducing abdominal pressure on the diaphragm and promoting better air entry. Side-lying, prone, and supine positions can limit chest expansion and may worsen dyspnea in an acutely short-of-breath child.
Category reason: This is a nursing intervention question focused on immediate positioning to improve respiratory status in an acute emergency presentation, which requires patient-care judgment rather than recall of basic science.

Question 31

The status of a patient in labor who experienced hypotonic uterine dysfunction is monitored by the nurse. The nurse interprets that which finding would least likely be consistent with this type of dysfunctional labor?

Accepted Answer

Answer reason: Hypotonic uterine dysfunction is characterized by weak, infrequent, or poorly coordinated contractions, typically after an initial period of normal labor progress. As a result, contractions may become less effective or even stop during the active phase, leading to slowed cervical change. Painful, frequent contractions with poor progress is more consistent with hypertonic uterine dysfunction rather than hypotonic patterns. Therefore this finding is least likely with hypotonic uterine dysfunction.
Category reason: This item tests nursing interpretation of labor patterns and dysfunctional labor findings to guide monitoring and management, which is a patient-care clinical judgment task rather than foundational biomedical science.

Question 32

A nurse assesses a neonate and notes cool extremities, acrocyanosis, and a temperature of 35.8°C (96.4°F). What is the priority nursing intervention?

Accepted Answer

Answer reason: The findings indicate neonatal cold stress/hypothermia, which increases oxygen and glucose consumption and can rapidly lead to hypoglycemia, metabolic acidosis, and respiratory distress. The first priority is to stabilize thermoregulation using a controlled external heat source to reduce ongoing heat loss and physiologic strain. Feeding may be needed after warming is initiated and the infant is stable, but it does not correct the immediate problem of heat loss. Bathing can worsen heat loss, and cold compresses would further aggravate hypothermia.
Category reason: This is a patient-care prioritization question requiring immediate nursing intervention to correct neonatal hypothermia and prevent physiologic deterioration, which fits NCLEX-focused clinical judgment.

Question 33

Thermoregulation in Newborns A nurse is caring for a newborn who is 4 hours old and has a temperature of 35.4°C (95.7°F). Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: A temperature of 35.4°C indicates neonatal hypothermia requiring immediate active rewarming to prevent hypoglycemia, metabolic acidosis, and respiratory distress. A radiant warmer provides controlled, rapid external heat and allows close monitoring, making it the safest first intervention. Waiting to recheck delays treatment, and simply adding blankets/hat is passive warming that may be insufficient at this low temperature. The provider can be notified after initiating stabilization measures.
Category reason: This question tests the nurse’s immediate priority intervention to correct an abnormal newborn vital sign (hypothermia), which is a patient-care decision under Physiological Adaptation.

Question 34

The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?

Accepted Answer

Answer reason: Anginal pain classically presents as substernal, deep, pressure-like chest discomfort due to myocardial ischemia. Pain that worsens with deep breathing or sitting up suggests pleuritic or musculoskeletal/pericardial etiologies rather than ischemia. Epigastric or “stomach area” pain can occur with cardiac ischemia, but the most typical and specific description for acute angina is retrosternal chest pain.
Category reason: This item asks the nurse to interpret a patient’s symptom description to identify acute angina, which is a clinical assessment and recognition of an alteration in a body system requiring nursing judgment.

Question 35

A patient with a fever of 101.5°F, productive cough, and shortness of breath is reported. What is the priority diagnosis?

Accepted Answer

Answer reason: Shortness of breath with a productive cough and fever suggests a lower respiratory process (e.g., pneumonia) that can interfere with alveolar ventilation and oxygenation. Using ABC priorities, breathing problems that threaten oxygen delivery take precedence over potential/secondary problems. “Risk for infection” is not the priority because infection is already likely present, and “acute pain” and “activity intolerance” are not as immediately life-threatening as compromised respiration.
Category reason: This item asks the nurse to choose the highest-priority nursing diagnosis based on acute respiratory symptoms, which requires clinical judgment using ABCs rather than testing isolated biomedical facts.

Question 36

A nurse is caring for a client with a new diagnosis of heart failure. The client reports dyspnea and fatigue. Which intervention should the nurse perform?

Accepted Answer

Answer reason: This position decreases venous return (preload) and allows maximal lung expansion, which helps relieve shortness of breath associated with fluid congestion in heart failure. It is an immediate, noninvasive intervention that can rapidly improve ventilation and reduce work of breathing while further assessments and therapies are initiated. Encouraging fluids can worsen volume overload, and starting a beta-blocker is not an immediate symptom-relief action and may be unsafe if the client is acutely decompensated. Oxygen may be needed depending on oxygen saturation, but positioning is a universally appropriate first supportive measure for dyspnea.
Category reason: The question asks for the best immediate nursing intervention to relieve dyspnea and fatigue in a client with heart failure, emphasizing clinical judgment and supportive care for an acute physiologic problem, which aligns with Physiological Adaptation/Alterations in Body Systems.

Question 37

A nurse is caring for a client with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which instruction should the nurse include in the teaching plan?

Accepted Answer

Answer reason: This technique prolongs exhalation, reduces air trapping, and improves ventilation in COPD, helping decrease dyspnea during flare-ups. Oxygen is often prescribed for hypoxemia and should not be avoided when indicated. Increased sodium can worsen fluid retention and is not a standard COPD teaching point, and bed rest can contribute to deconditioning and reduced respiratory muscle endurance.
Category reason: The question tests a nursing teaching/intervention for managing COPD symptoms, which is a patient-care decision rather than basic biomedical recall, fitting NCLEX Physiological Adaptation.

Question 38

A patient with congestive heart failure (CHF) is experiencing dyspnea. What is the priority nursing intervention?

Accepted Answer

Answer reason: Dyspnea in CHF reflects impaired oxygenation from pulmonary congestion and possible edema, making airway and breathing the immediate priority. Supplemental oxygen increases the fraction of inspired oxygen and helps improve tissue oxygen delivery while other measures (e.g., positioning, diuretics, monitoring) are initiated. Ambulation increases oxygen demand and can worsen respiratory distress. Increasing fluids can exacerbate volume overload, and a heating pad does not address the acute respiratory problem.
Category reason: This question asks for the priority nursing intervention for an acutely symptomatic patient (dyspnea in CHF), requiring nursing judgment focused on immediate physiologic stability rather than recall of basic science facts.

Question 39

A patient with pneumonia has a respiratory rate of 28 breaths/min. What is the priority nursing action?

Accepted Answer

Answer reason: A respiratory rate of 28/min indicates tachypnea and increased work of breathing, suggesting impaired gas exchange risk in pneumonia. Using ABCs, supporting oxygenation is the most immediate life-sustaining intervention while further assessment and treatments are arranged. Oxygen can quickly improve hypoxemia and reduce physiologic stress, whereas fluids and antibiotics are important but less immediately stabilizing. Vital signs are useful, but in a patient already showing respiratory compromise, initiating oxygen is a priority while continuing ongoing assessment.
Category reason: This is a nursing priority/intervention question using ABCs to decide immediate action for a patient with respiratory compromise, which fits NCLEX-style clinical judgment under Physiological Adaptation.

Question 40

A nurse is assessing a client with suspected heart failure. The client reports dyspnea and bilateral leg edema. Which intervention should the nurse prioritize to address clinical judgment needs? Select only one?

Accepted Answer

Answer reason: This is the fastest, lowest-risk nursing action to improve ventilation by maximizing lung expansion and decreasing venous return, which can reduce pulmonary congestion in suspected heart failure. It addresses the priority problem of dyspnea immediately while further assessment and orders are pursued. Oxygen may be needed, but positioning is an immediate independent intervention and should be initiated at once. Increased fluids can worsen volume overload, and initiating a beta-blocker “immediately” is not an appropriate urgent bedside response to acute dyspnea and requires provider evaluation.
Category reason: This question tests immediate nursing prioritization and an independent intervention to stabilize a client with acute cardiopulmonary symptoms, which aligns with Physiological Adaptation focused on managing alterations in body systems.

Question 41

A client with heart failure reports sudden shortness of breath. The nurse notes a respiratory rate of 28/min and crackles in both lung bases. What is the nurse's next action?

Accepted Answer

Answer reason: The findings suggest acute pulmonary congestion from worsening heart failure, where the immediate priority is to reduce preload and relieve fluid overload. A loop diuretic (e.g., furosemide) promotes rapid diuresis, decreasing pulmonary capillary pressure and improving dyspnea and crackles. Lying supine can worsen orthopnea and gas exchange, and deep-breathing exercises do not treat the underlying fluid overload. An ECG may be indicated to evaluate triggers, but it does not address the urgent respiratory compromise as directly as prompt diuresis.
Category reason: This question asks for the nurse’s immediate next intervention in an acute clinical change (sudden dyspnea with crackles) requiring nursing judgment and action, fitting NCLEX Physiological Adaptation.

Question 42

Scenario: 2 hours after abdominal surgery, the patient is drowsy and O2 saturation is 89% on room air. What is the nurse’s priority?

Accepted Answer

Answer reason: Low oxygen saturation shortly after abdominal surgery most commonly reflects hypoventilation and atelectasis from anesthesia, pain, and shallow breathing. The immediate priority is to improve ventilation and alveolar recruitment with deep-breathing/coughing and incentive spirometry to prevent worsening hypoxemia and postoperative pulmonary complications. Increasing IV fluids does not correct oxygenation, and giving a sedative could further depress respirations. Allowing the patient to rest delays needed airway/breathing intervention when saturation is already low.
Category reason: This is a patient-care priority question requiring nursing intervention to address an acute postoperative oxygenation problem, which fits NCLEX Physiological Adaptation (Alterations in Body Systems).

Question 43

Carol is 15 months old and weighs 5.5 kg and is in her initial visit. Her mother says that Carol is not eating well and unable to breastfeed, he has no vomiting, has no convulsion and not abnormally sleepy or difficult to awaken. Her temperature is 38.9 deg C. Using integrated management of childhood illness or IMCI strategy, if you were the nurse in charge Carol, how will you classify her illness?

Accepted Answer

Answer reason: D. severe malnutrition A 15-month-old weighing 5.5 kg is profoundly underweight and strongly suggests severe acute malnutrition by IMCI/WHO weight-for-age screening thresholds. The stem explicitly rules out IMCI general danger signs (no convulsions, not abnormally sleepy/difficult to awaken; no vomiting) and provides no respiratory signs to support severe pneumonia. Fever alone (38.9°C) does not meet criteria for “very severe febrile disease” without IMCI danger signs or specific risk indicators; the most critical classification is severe malnutrition requiring urgent nutritional and medical management.
Category reason: This item asks the nurse to classify an infant’s condition using IMCI based on clinical assessment findings and anthropometrics, which is a patient-care decision about a physiologic condition rather than testing basic biomedical mechanisms.

Question 44

A nurse is caring for a patient with heart failure. Which assessment finding indicates fluid overload?

Accepted Answer

Answer reason: Fluid overload in heart failure leads to pulmonary congestion as increased hydrostatic pressure forces fluid into the alveoli and interstitium. This produces inspiratory crackles/rales on auscultation and may be accompanied by dyspnea and decreased oxygenation. Hypotension and warm skin are not typical primary indicators of volume overload (warm skin suggests vasodilation; hypotension may indicate shock or over-diuresis). A bounding pulse can occur in high-output states but is less specific than pulmonary crackles for fluid overload in heart failure.
Category reason: This is a nursing assessment question requiring recognition of a clinical finding (lung crackles) that signals a complication of heart failure, aligning with Physiological Adaptation and alterations in cardiopulmonary function.

Question 45

A nurse is caring for a patient with pericardial effusion. Which sign indicates development of cardiac tamponade?

Accepted Answer

Answer reason: Cardiac tamponade occurs when rising pericardial pressure restricts ventricular filling, reducing stroke volume and cardiac output. One classic manifestation is Beck’s triad: hypotension, jugular venous distention, and distant/muffled heart sounds due to fluid dampening sound transmission. Bounding pulses and widened pulse pressure are more consistent with hyperdynamic states (e.g., aortic regurgitation) rather than tamponade, and bradycardia is not a typical early finding (tachycardia is more expected as compensation).
Category reason: This item asks the nurse to recognize a life-threatening complication of pericardial effusion based on patient assessment findings, which is a clinical judgment task within Physiological Adaptation focused on body-system alteration and emergent deterioration.

Question 46

A client post-myocardial infarction suddenly develops S3 heart sound, crackles in lungs, and dyspnea. What is the likely cause?

Accepted Answer

Answer reason: An S3 in an adult after MI suggests acute ventricular dysfunction with volume overload. Pulmonary crackles and dyspnea indicate pulmonary congestion/edema from elevated left-sided filling pressures and backup of blood into the pulmonary circulation. Pulmonary embolism more typically causes sudden pleuritic chest pain, tachycardia, and hypoxemia without an S3 and diffuse crackles, while tamponade classically presents with hypotension, muffled heart sounds, and JVD; pneumonia is usually infectious with fever and focal findings.
Category reason: This item tests recognition of acute post-MI clinical deterioration (S3, pulmonary crackles, dyspnea) and the most likely pathophysiologic complication requiring nursing/clinical judgment, fitting Physiological Adaptation—Alterations in Body Systems rather than foundational science.

Question 47

A pregnant client in her third trimester becomes hypotensive while lying flat. What is the correct action?

Accepted Answer

Answer reason: In late pregnancy, the enlarged uterus can compress the inferior vena cava when supine, reducing venous return and cardiac output (supine hypotensive syndrome). Left lateral positioning displaces the uterus off the vena cava (and aorta), rapidly improving preload and blood pressure. Elevating legs or Trendelenburg does not relieve the primary cause and may worsen respiratory mechanics, while high Fowler’s may further reduce venous return.
Category reason: This question tests an immediate nursing intervention to correct a pregnancy-related hemodynamic complication, requiring patient-care judgment rather than pure physiology recall.

Question 48

Best position for a client experiencing a severe asthma attack:

Accepted Answer

Answer reason: This position maximizes lung expansion by decreasing abdominal pressure on the diaphragm and improving ventilation. It also helps optimize accessory muscle use and reduces work of breathing during acute bronchospasm. Supine and Trendelenburg worsen diaphragmatic excursion and can increase dyspnea, while side-lying is less effective for rapidly improving chest expansion in a severe attack.
Category reason: This question tests an immediate nursing intervention (positioning) to support breathing during an acute respiratory compromise, which requires patient-care judgment rather than foundational biomedical recall.

Question 49

A client who had a thyroidectomy complains of tingling in lips and fingertips. What is the likely cause?

Accepted Answer

Answer reason: Perioral and fingertip tingling after thyroidectomy is a classic early sign of acute low calcium due to inadvertent injury or removal of the parathyroid glands, leading to decreased PTH and neuromuscular irritability. Hypocalcemia can progress to tetany (e.g., Chvostek and Trousseau signs) and laryngospasm if untreated, making it a priority postoperative complication to recognize. Hemorrhage would more likely present with neck swelling, airway compromise, and hemodynamic changes; hypoxia with dyspnea/low SpO2; and hypertension is not a typical cause of these paresthesias in this context.
Category reason: This question tests recognition of a common postoperative complication after thyroid surgery and its clinical manifestation, requiring nursing assessment and prompt identification of a system alteration rather than recalling isolated basic science facts.

Question 50

A nurse is caring for a client with Raynaud's disease. Which instruction is appropriate?

Accepted Answer

Answer reason: Nicotine causes peripheral vasoconstriction, which can trigger or intensify the episodic digital ischemia seen in Raynaud’s. Education focuses on avoiding vasoconstrictive triggers (cold exposure, stress, stimulants) and promoting measures that keep extremities warm. The other choices worsen vasospasm or reduce perfusion (no gloves in cold, cold water exposure, and dependent positioning).
Category reason: This item tests patient teaching to prevent symptom exacerbations in a vascular disorder, requiring nursing judgment about safe self-care measures and trigger avoidance.

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