Question 1

The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30 mcg/mL. What is the appropriate nursing action?

Accepted Answer

Answer reason: Therapeutic phenytoin level is 10–20 mcg/mL; 30 mcg/mL indicates toxicity risk. The nurse should hold the dose and notify the provider.
Category reason: The item requires interpreting a drug level and taking action to prevent medication toxicity, which fits Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 2

While performing high-quality CPR on an adult, what action should you ensure is being accomplished?

Accepted Answer

Answer reason: Adult high-quality CPR requires a compression depth of at least 2 inches (5–6 cm). Other options are incorrect: rate should be 100–120/min (not 90–120), hand placement is the lower half of the sternum (not upper third), and chest should fully recoil rather than a measured 1 inch.
Category reason: This is an emergency resuscitation technique question concerning immediate life-saving care during cardiac arrest, fitting Physiological Adaptation—Medical Emergencies.

Question 3

The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritus. Which would be the most appropriate nursing intervention?

Accepted Answer

Answer reason: Hepatitis-related pruritus is eased by skin lubrication and cool/tepid bathing. Adding an emollient (baby oil) to bath water moisturizes the skin and reduces itching, whereas hot water and powders dry and irritate the skin.
Category reason: This asks for a nursing comfort/skin-care intervention to relieve itching, which falls under Basic Care and Comfort: Non-Pharmacological Comfort Interventions.

Question 4

A client being treated with warfarin has a prothrombin time of 120 seconds; which nursing intervention is most important to include in the care plan?

Accepted Answer

Answer reason: A PT of 120 seconds indicates severe over-anticoagulation with high hemorrhage risk. The priority nursing intervention is to assess for abnormal bleeding; dosage should not be increased.
Category reason: This scenario focuses on managing a medication’s adverse effects (warfarin-induced bleeding risk) and appropriate nursing interventions, fitting Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 5

During initial neonatal resuscitation immediately after birth, which action is addressed first?

Accepted Answer

Answer reason: Newborns are at high risk for heat loss immediately after birth. Initial neonatal resuscitation begins with thermal management, including drying and warming, before airway and breathing interventions.
Category reason: This is a clinical emergency protocol (neonatal resuscitation) focusing on immediate life-saving steps, fitting Physiological Adaptation: Medical Emergencies.

Question 6

A 28-month-old child with severe diarrhea is admitted. On assessment, the child is febrile, has dry lips, and is irritable. What is the nurse’s first priority upon admission?

Accepted Answer

Answer reason: Answer reason: In a toddler with signs of acute dehydration, the nurse’s first priority is a rapid bedside assessment to determine dehydration severity. Skin turgor provides immediate clinical information and guides urgent fluid management decisions. Weight measurement is important but is not the first priority in an acute setting.
Category reason: This question addresses System-Specific Assessments, emphasizing targeted evaluation of body systems—in this case, fluid balance and circulatory function—to identify urgent physiological needs.

Question 7

Which activity is not recorded by a pulse oximeter?

Accepted Answer

Answer reason: A pulse oximeter provides pulse rate and peripheral oxygen saturation (SpO2). It does not record or display ECG rhythm or changes.
Category reason: Identifying what a monitoring device measures relates to understanding diagnostic monitoring equipment, fitting Reduction of Risk Potential: Diagnostic Tests.

Question 8

Which of the following is the FIRST priority in preventing infections when providing care for a client?

Accepted Answer

Answer reason: Hand hygiene is the primary and most effective first-line measure for preventing infection; PPE and barriers are adjuncts and situation-dependent.
Category reason: The item addresses infection prevention using standard precautions, which is part of Safety and Infection Control.

Question 9

A client has ataxia following a cerebral vascular accident. The nurse should?

Accepted Answer

Answer reason: Ataxia causes poor coordination and balance after stroke, creating a high fall risk. The priority is to supervise ambulation. The other options address issues like fluid balance or communication deficits, not ataxia.
Category reason: This is a nursing safety intervention to prevent falls in a post-stroke client, fitting Safety and Infection Control: Accident-Error Prevention.

Question 10

A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year-old. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: For a school-age child, provide honest, developmentally appropriate information about procedures to reduce anxiety and build trust. Restraints are last resort and parents need not be forced to leave.
Category reason: The item tests therapeutic communication and patient education during a clinical procedure, which fits Psychosocial Integrity: Coping and Adaptation—Therapeutic Communication.

Question 11

The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?

Accepted Answer

Answer reason: During chest physiotherapy, percussion should be applied only over lung fields within the rib cage to mobilize secretions and avoid injury to abdominal organs, spine, and kidneys. Coughing is encouraged, therapy is scheduled before meals or 1–2 hours after, and positioning varies by lobe—not always prone.
Category reason: This is a nursing intervention question about performing a therapeutic respiratory procedure safely, fitting NCLEX Physiological Integrity > Reduction of Risk Potential > Therapeutic Procedures.

Question 12

Why should nurse Jamie explain to the male client that self-monitoring of blood glucose is preferred over urine glucose testing?

Accepted Answer

Answer reason: Blood glucose self-monitoring directly measures current blood glucose, unlike urine tests which reflect past levels and depend on renal threshold and hydration, making SMBG more accurate and reliable.
Category reason: The item compares monitoring methods and patient teaching about glucose testing, which relates to using and interpreting diagnostic tests.

Question 13

Which family member exposed to TB is at highest risk for contracting the disease?

Accepted Answer

Answer reason: Elderly individuals have decreased immune function, placing them at higher risk of contracting and progressing to active tuberculosis compared with healthy adults and adolescents.
Category reason: This question concerns susceptibility to an infectious disease and recognizing high‑risk groups, which fits Safety and Infection Control under Infection Control.

Question 14

The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?

Accepted Answer

Answer reason: First assess the nurse’s immunity to varicella. If she has had chickenpox (or is immune), risk to an immunocompromised leukemia client is minimal; if not, reassignment is needed. Assessment precedes intervention.
Category reason: This scenario addresses preventing infectious disease transmission to an immunocompromised client, fitting Safety and Infection Control: Infection Control.

Question 15

When an infant's head is turned to the right side, causing the leg and arm on the right side to extend and the leg and arm on the left side to flex, what type of reflex is this?

Accepted Answer

Answer reason: Turning the infant’s head to one side causing extension of the arm and leg on the same side with flexion of the opposite limbs describes the asymmetric tonic neck reflex.
Category reason: Assessment of primitive newborn reflexes is part of Growth and Development within Newborn Care.

Question 16

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

Accepted Answer

Answer reason: For magnesium sulfate in preeclampsia, use an infusion pump, maintain a quiet, dark environment, and monitor urine output with a Foley to prevent toxicity. There is no reason to avoid BP checks in one arm; frequent BP monitoring is required. Thus, placing a sign not to check BP in the left arm shows a misunderstanding.
Category reason: This question focuses on recognizing correct and incorrect nursing actions during magnesium sulfate administration, fitting Pharmacological and Parenteral Therapies: Medication Administration.

Question 17

The best definition of a tort is:

Accepted Answer

Answer reason: A tort is a civil wrong, such as negligence or malpractice, committed against an individual or their property rather than the state. It allows for compensation through civil court rather than criminal punishment. Understanding torts helps nurses prevent liability and uphold professional responsibility in practice.
Category reason: Falls under Legal Rights-Responsibilities, as it addresses nurses’ legal accountability and the principles governing civil obligations in healthcare.

Question 18

Which of the following is the most important initial care when chemical burn is suspected?

Accepted Answer

Answer reason: For chemical burns, the priority is immediate copious irrigation with water for 20–30 minutes to dilute and remove the chemical and limit tissue damage. Other actions are secondary.
Category reason: This addresses first-aid management of exposure to hazardous chemicals, fitting Safety and Infection Control: Handling Hazardous Materials.

Question 19

If a very active 2 year-old client pulls his tunneled central venous catheter out, what INITIAL nursing action is appropriate?

Accepted Answer

Answer reason: Immediate priority is to control bleeding and prevent air embolism by applying direct pressure to the venous entry site. The other actions are secondary.
Category reason: This addresses urgent management of a central venous access device complication, which falls under Pharmacological and Parenteral Therapies: Central Venous Access Devices.

Question 20

The client has elected to receive epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would?

Accepted Answer

Answer reason: Epidural anesthesia can cause hypotension due to sympathetic blockade. The priority intervention in a laboring client is positioning in the left lateral position to improve venous return and uteroplacental perfusion. IV fluids are supportive but secondary.
Category reason: This item addresses the management of an acute hypotensive reaction following anesthesia, requiring priority nursing intervention for an unexpected response to therapy.

Question 21

Occurrence of the Oedipus complex is commonly seen in which age and gender group?

Accepted Answer

Answer reason: The Oedipus complex is part of Freud’s phallic stage, typically occurring in boys around ages 3–6; the closest option is boys 3–5 years.
Category reason: This concerns a developmental milestone from psychosexual theory, fitting Growth and Development under Developmental Stages and Transitions.

Question 22

Cross infection can occur through the following, except?

Accepted Answer

Answer reason: Fomites, contaminated food/drinks, and insects can transmit pathogens; autoclaving sterilizes and prevents transmission, so it is not a source of cross infection.
Category reason: This tests knowledge of infection transmission and prevention strategies, which belong to Safety and Infection Control in nursing practice.

Question 23

A client with multiple sclerosis has an order to receive Solu Medrol 200 mg IV push. The available dose is Solu Medrol 250 mg per mL. How much medication will the nurse administer?

Accepted Answer

Answer reason: Use dose-volume calculation: Volume = Desired/Have = 200 mg ÷ 250 mg/mL = 0.8 mL.
Category reason: This asks for calculating the IV medication volume to administer, which is a dosage calculation under Pharmacological and Parenteral Therapies.

Question 24

The early neonatal period is up to how many days of life?

Accepted Answer

Answer reason: The early neonatal period is defined as the first week of life (0–7 days).
Category reason: This asks about newborn developmental timeframes, which fits Health Promotion and Maintenance: Growth and Development (Newborn Care).

Question 25

What is the primary acid–base disturbance indicated by ABG results showing a pH of 7.50, PaCO2 of 25 mmHg, and HCO3− of 18 mEq/L?

Accepted Answer

Answer reason: pH > 7.45 indicates alkalemia; PaCO2 is low (25 mm Hg), pointing to a primary respiratory alkalosis. The decreased HCO3− reflects renal compensation.
Category reason: This is an interpretation of acid–base balance using ABG values, a core concept within fluid–electrolyte and acid–base regulation in Physiological Adaptation.

Question 26

A client who had major abdominal surgery is having delayed healing of the wound. Which laboratory test result would most closely correlate with this problem?

Accepted Answer

Answer reason: Hypoalbuminemia reflects poor protein nutrition, which impairs collagen synthesis and tissue repair, leading to delayed wound healing. Creatinine, calcium, and sodium levels do not directly account for impaired wound healing.
Category reason: This item requires interpreting lab abnormalities related to a postoperative complication, which fits Reduction of Risk Potential: Abnormal Laboratory Values.

Question 27

Which of the following is used to assess the level of consciousness?

Accepted Answer

Answer reason: The Glasgow Coma Scale assesses level of consciousness via eye, verbal, and motor responses. Apgar scores newborn status, tonometry measures intraocular pressure, and the Snellen chart tests visual acuity.
Category reason: This is a clinical assessment tool used in neurological evaluation, fitting NCLEX Reduction of Risk Potential: System-Specific Assessments.

Question 28

A client who has been drinking for 5 years states that he drinks when he gets upset about "things" such as being unemployed or feeling like life is not leading anywhere. The client is using alcohol as a way to deal with?

Accepted Answer

Answer reason: He reports drinking when upset by unemployment and life problems, indicating alcohol is being used as a maladaptive coping mechanism for stressors.
Category reason: The item addresses coping with stress and maladaptive stress management behaviors, which falls under Psychosocial Integrity—Coping and Adaptation.

Question 29

A client who is receiving chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which of the following nursing actions is the PRIORITY INITIAL assessment?

Accepted Answer

Answer reason: In a septic patient, the priority is rapid assessment to identify the source of infection so treatment can be initiated. Inspecting potential entry sites (e.g., central line, wounds) addresses this first. Reverse isolation and contact restriction are preventive, and changing the dressing is not the initial priority in active sepsis.
Category reason: This focuses on infection-source assessment and control measures in clinical care, fitting Safety and Infection Control within the NCLEX framework.

Question 30

A new mother tells the nurse that she is getting a new microwave so that her husband can help prepare the baby's feedings. The nurse should?

Accepted Answer

Answer reason: Microwaving infant bottles causes uneven heating and hot spots that can burn the infant and may degrade milk; parents should use safer methods like a warm water bath. Therefore, advise never to microwave bottles.
Category reason: This is parent education about safe infant feeding practices, which falls under Health Promotion and Maintenance for Newborn Care.

Question 31

The nurse is assigned to care for four clients. Which of the following should be assessed immediately after hearing the report?

Accepted Answer

Answer reason: Active vomiting in a client with a peptic ulcer signals possible perforation or GI bleeding and acute fluid-electrolyte imbalance, which is potentially life-threatening and requires immediate assessment.
Category reason: This is a prioritization question about which client to assess first, aligning with Management of Care—Triage.

Question 32

In a typical U.S. rural Primary Care Service Area (PCSA), approximately how many residents are served by one primary care provider?

Accepted Answer

Answer reason: According to HRSA population-to-provider ratios, rural primary care coverage areas often have one primary care provider serving approximately 3,000–3,500 residents. This estimate reflects real U.S. workforce distribution patterns and is used to identify regions at risk for provider shortages.
Category reason: This item belongs to “Health Promotion–Disease Prevention” because it addresses population-level access to primary care services, a core component of community health planning and preventive public health strategies.

Question 33

What is the first action the nurse should perform when providing care for a client diagnosed with pre-renal acute kidney injury?

Accepted Answer

Answer reason: Pre-renal AKI results from decreased renal perfusion, commonly due to hypotension or hypovolemia. The priority first action is to assess blood pressure to evaluate perfusion and guide urgent interventions. The other options are not immediate priorities and may address different causes (e.g., post-renal obstruction) or longer-term monitoring.
Category reason: This asks for the priority nursing assessment to reduce risk and monitor hemodynamic status in a client with AKI, fitting Reduction of Risk Potential: System-Specific Assessments.

Question 34

The nurse is discussing dietary intake with an adolescent who has acne. The MOST appropriate statement for the nurse is?

Accepted Answer

Answer reason: Evidence does not support specific dietary restrictions or additions for acne; the appropriate teaching is to maintain a well-balanced diet suitable for age.
Category reason: This is patient education about dietary habits and nutrition, which aligns with Basic Care and Comfort: Nutrition and Oral Hydration.

Question 35

A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of the following is a nursing PRIORITY?

Accepted Answer

Answer reason: Infant of a methadone-maintained mother with hyperactive Moro, tremors, and loose stool shows signs of neonatal abstinence; the priority is to assess for NAS to guide monitoring and treatment. Comfort measures or fluids may follow, and paregoric is not first-line and requires a provider order.
Category reason: This is a nursing priority question about assessing a newborn for withdrawal, which falls under Newborn Care within Health Promotion and Maintenance.

Question 36

Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?

Accepted Answer

Answer reason: Pregnant staff should not care for clients with internal radiation (radium implant) due to fetal radiation exposure risk. The other options do not pose a specific contraindication.
Category reason: This addresses safe staff assignment and protection from radiation exposure, which falls under Safety and Infection Control—Handling Hazardous Materials.

Question 37

A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler’s position, the nurse’s next action should be to?

Accepted Answer

Answer reason: Autonomic dysreflexia is usually triggered by noxious stimuli, most commonly bladder distention from a kinked or obstructed catheter. After elevating the head of bed, the priority is to remove the trigger—first check catheter patency and relieve bladder distention. Antihypertensives or provider notification follow if blood pressure remains elevated; oxygen is not the priority.
Category reason: This is a nursing management question about responding to a medical emergency (autonomic dysreflexia) and prioritizing immediate interventions, fitting Physiological Adaptation: Medical Emergencies.

Question 38

The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of?

Accepted Answer

Answer reason: Methylphenidate commonly suppresses appetite and can cause weight loss; encouraging high-calorie snacks helps maintain growth. It does not typically cause infection risk, photosensitivity, or oversedation (it is a stimulant, often causing insomnia).
Category reason: This is medication teaching focused on managing adverse effects of a prescribed drug, which falls under Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications.

Question 39

Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital the day before scheduled surgery. The nurse's preoperative goals for Mrs. M. would include?

Accepted Answer

Answer reason: Severe macular degeneration limits vision, so the key preoperative safety goal is orienting the patient to the room and ensuring safe maneuvering. Independent unit ambulation is unsafe, reading materials may be ineffective, and a bedpan is unnecessary without mobility limitations.
Category reason: This is a nursing scenario focused on patient safety and fall/accident prevention for a visually impaired preoperative client, which falls under Safety and Infection Control: Accident-Error Prevention.

Question 40

The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. The employee does not respond to the physician's complaints. The nurse manager's FIRST action should be?

Accepted Answer

Answer reason: When unprofessional behavior occurs in front of others, the nurse manager’s first responsibility is to immediately stop the behavior to protect staff, clients, and the care environment. Addressing the physician calmly and privately in the moment prevents escalation and maintains professionalism. Further discussion or reporting can occur afterward.
Category reason: This is a nursing management scenario involving interprofessional conflict resolution and protecting the care environment, which fits Management of Care—Collaborative Care.

Question 41

A patient receiving long-term therapy develops blue-gray discoloration of the skin and reports visual disturbances. Which medication is most likely responsible?

Accepted Answer

Answer reason: Amiodarone can cause blue-gray skin discoloration, corneal deposits, thyroid dysfunction, and pulmonary toxicity, especially with long-term use.

Category reason: Physiological Integrity → Pharmacological and Parenteral Therapies → Adverse Effects–Contraindications

Question 42

Personal barriers in effective communication do not include?

Accepted Answer

Answer reason: Language barriers are semantic/linguistic, not personal. Impatience and age are individual (person-related) factors, while rumors typically stem from interpersonal dynamics.
Category reason: The item addresses barriers to effective therapeutic communication, a core nursing interaction skill within Psychosocial Integrity.

Question 43

What is the first aid required in case of a deep wound while playing?

Accepted Answer

Answer reason: First aid priorities for deep wounds focus on controlling hemorrhage; apply direct pressure to stop bleeding before other actions.
Category reason: This addresses immediate first-aid response to an injury, which falls under Safety and Infection Control—Emergency Response Plans.

Question 44

Which adult client should the triage nurse assess first in the emergency department?

Accepted Answer

Answer reason: In triage, conditions that threaten airway, breathing, or circulation are addressed first. A persistent nosebleed represents active bleeding and a potential circulation risk, making this client the highest priority. The other clients are stable and can safely wait.
Category reason: This is a prioritization scenario in emergency triage, which falls under Management of Care: Triage in the NCLEX framework.

Question 45

The physician has ordered a thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should?

Accepted Answer

Answer reason: A thyroid scan uses a radiotracer; the nurse should screen for allergies/contraindications to the agent. Sedation, IV fluid bolus, and urinary catheterization are not required for this test.
Category reason: This is a nursing action related to preparing a client for a diagnostic test, which fits Reduction of Risk Potential: Diagnostic Tests.

Question 46

A nurse witnesses a client climbing over the side rails and falling out of bed onto the floor. Restraints had been ordered but were not in place. When the nurse completes the incident report, what information should the nurse note?

Accepted Answer

Answer reason: Incident reports should contain an objective, factual description of what was observed and of the actions taken. They should not assign blame, identify responsible staff beyond what is necessary for reporting, or include excuses.
Category reason: The item asks about the correct content when documenting an incident report, which pertains to reporting errors or events as part of the management of care and quality improvement processes.

Question 47

Which instrument is placed against a patient's chest to hear both lung and heart sounds?

Accepted Answer

Answer reason: A stethoscope is used for auscultation of heart and lung sounds by placing the diaphragm or bell against the chest.
Category reason: The question concerns a nursing assessment tool used to obtain heart and lung sounds, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 48

The client is admitted to the unit. A vaginal exam reveals that she is 3cm dilated. Which of the following statements would the nurse expect her to make?

Accepted Answer

Answer reason: At 3 cm the client is in the latent phase of labor, typically excited, talkative, and focused on the baby, not on pushing or intense concentration. Statements about pushing occur near complete dilation; irritability and intense focus are common in active/transition phases.
Category reason: This is an intrapartum assessment question about labor phases and expected client behavior, which falls under Ante-Intra-Postpartum Care.

Question 49

Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure? She says to her husband,?

Accepted Answer

Answer reason: During intracavitary (sealed-source) radiation, visitors must follow time–distance–shielding precautions; pregnant visitors should not enter. Option 2 reflects correct understanding. Option 3 is incorrect because sealed implants do not leave residual radiation once removed. Option 1 is irrelevant to the procedure, and option 4 suggests activity; the client will be on strict bed rest with minimal movement to prevent displacement.
Category reason: This is a nursing safety question about radiation precautions and visitor restrictions, which falls under Safety and Infection Control.

Question 50

The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnosis for this client?

Accepted Answer

Answer reason: Cyclosporine is an immunosuppressant that decreases T-cell function, increasing susceptibility to infections; thus the priority nursing diagnosis is risk for infection.
Category reason: This focuses on preventing infection in a patient receiving an immunosuppressant, which is part of Safety and Infection Control.

Question 51

To avoid pulling the urinary catheter, where should the nurse tape the catheter on the patient's leg?

Accepted Answer

Answer reason: Securing the Foley to the upper/inner thigh with slack minimizes traction on the urethra during movement, reducing risk of accidental pulling or urethral trauma.
Category reason: This addresses proper urinary catheter care and securement, a Basic Care and Comfort intervention under Elimination.

Question 52

Which statement by a client with dumping syndrome indicates the need for further teaching?

Accepted Answer

Answer reason: Management of dumping syndrome includes small frequent meals, fluids between meals, lying down after eating, and a diet high in protein with moderate-to-high fat and low carbohydrates. The statement advocating a low-fat diet is incorrect and indicates need for further teaching.
Category reason: This is patient education regarding dietary measures to manage symptoms, which falls under Basic Care and Comfort: Nutrition and Oral Hydration.

Question 53

The following is characteristic of normal mood and manner?

Accepted Answer

Answer reason: Normal mood and manner reflect appropriate affect and cooperative, pleasant interaction. Hostility, flattened affect, and unusual elation indicate potential mood or affect disturbances.
Category reason: Assesses recognition of normal versus abnormal affect and behavior, which fits Mental Health Concepts under Psychosocial Integrity.

Question 54

The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?

Accepted Answer

Answer reason: Option C provides a balanced meal with lean protein (baked chicken), fruits/vegetables, and a calcium source (yogurt) while limiting fried foods and sugary soda. Other options are high in fried/chip items, lack dairy, or include more caffeine/soda.
Category reason: This is patient teaching on prenatal nutrition, which falls under Health Promotion and Maintenance for Ante-Intra-Postpartum Care.

Question 55

A client with multiple sclerosis is prescribed baclofen. What is the primary purpose of baclofen in the management of multiple sclerosis?

Accepted Answer

Answer reason: Baclofen is a GABA-B agonist and skeletal muscle relaxant used primarily to reduce spasticity in conditions like multiple sclerosis; improvements in mobility or pain are secondary effects.
Category reason: This asks for the primary therapeutic effect of a medication, corresponding to the expected actions and outcomes of pharmacologic therapy.

Question 56

When is the safest time for a nurse to administer sertraline (Zoloft) to a client with depression?

Accepted Answer

Answer reason: Sertraline, an SSRI, can be activating and may cause insomnia; dosing in the morning reduces this risk. It is not given PRN, does not require an empty stomach, and bedtime dosing may worsen sleep disturbance.
Category reason: This is a nursing medication-administration question about appropriate timing for a psychotropic drug, fitting Pharmacological and Parenteral Therapies: Medication Administration.

Question 57

The nurse is caring for a pregnant woman with pregnancy induced hypertension receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do FIRST?

Accepted Answer

Answer reason: Findings suggest magnesium sulfate toxicity: hypotension, bradycardia, respiratory rate at 12, and oliguria (200 mL/8 h = 25 mL/h). The priority first action is to stop the infusion to prevent further toxicity, then notify the provider and prepare antidote if needed.
Category reason: This is a nursing intervention related to adverse effects of a medication and immediate action, fitting Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 58

You are the nurse performing education for a patient with AIDS at the community clinic. Which of the following statements is an example of appropriate teaching?

Accepted Answer

Answer reason: HIV is not transmitted through casual household contact such as shared dishes, showers, or toilets. Appropriate teaching emphasizes routine hygiene and standard precautions; cleaning dishes and utensils before reuse is correct.
Category reason: This is a nursing education scenario about infection prevention and standard precautions in the community, fitting Safety and Infection Control under the NCLEX framework.

Question 59

Which of the following characteristics defines nephrotic syndrome?

Accepted Answer

Answer reason: Nephrotic syndrome is characterized by massive proteinuria (>3.5 g/day), hypoalbuminemia, and lipiduria, often evidenced by fatty casts or “Maltese crosses” in the urine sediment.
Category reason: The item tests recognition of key renal pathophysiologic findings, fitting “Alterations in Body Systems.”

Question 60

The volume of SC medication must be no more than:

Accepted Answer

Answer reason: For subcutaneous injections, the recommended maximum volume is 1 mL to prevent tissue distension and ensure proper absorption.
Category reason: This item asks about the correct technique and limits for administering medications via the subcutaneous route, which falls under medication administration practices.

Question 61

A client with cancer of the prostate requests the urinal at frequent intervals but either does not void or voids in very small amounts. What does the nurse conclude is most likely the causative factor?

Accepted Answer

Answer reason: Prostate pathology can obstruct bladder outflow, causing urinary retention characterized by frequent urge with little or no urine. Dysuria is painful urination, suppression is failure of urine formation, and edema is unrelated.
Category reason: The item asks the nurse to identify a likely urinary problem based on symptoms, a genitourinary system assessment issue under Reduction of Risk Potential.

Question 62

Which assessment finding raises concern for a child with sickle cell anemia?

Accepted Answer

Answer reason: Frequent soda intake (often caffeinated) increases dehydration risk, which can precipitate vaso-occlusive crises in sickle cell disease. The other findings are generally acceptable: moderate sports participation, normal sleep, and occasional ibuprofen use.
Category reason: This item focuses on hydration and dietary choices to prevent complications, which aligns with Basic Care and Comfort: Nutrition and Oral Hydration.

Question 63

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes documentation of asterixis. How should the nurse assess for its presence?

Accepted Answer

Answer reason: Asterixis (flapping tremor), seen in hepatic encephalopathy, is elicited by asking the client to extend the arms with the wrists dorsiflexed and the fingers spread; brief, nonrhythmic lapses cause a flapping motion. Foot dorsiflexion assesses for Homan's sign; abdominal girth measures ascites; leaning forward is for cardiac assessment.
Category reason: This asks for the correct physical assessment technique to identify a neurologic sign associated with liver disease, fitting a focused, system-specific assessment.

Question 64

The physician has prescribed Coumadin (sodium warfarin) for a client having transient ischemic attacks. Which laboratory test measures the therapeutic level of Coumadin?

Accepted Answer

Answer reason: Warfarin therapy is monitored by PT/INR because it inhibits vitamin K–dependent clotting factors in the extrinsic pathway. PTT monitors heparin; bleeding time assesses platelets; clot retraction time is not used to monitor warfarin.
Category reason: The question concerns monitoring the therapeutic effect of a medication, which fits Pharmacological and Parenteral Therapies—Expected Actions-Outcomes.

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