Question 1

The nurse must assign a room to a client with scabies. Which of the following options would be the best choice for this client?

Accepted Answer

Answer reason: Scabies is transmitted through direct skin-to-skin contact and requires contact precautions. A private room is preferred to prevent transmission to other clients. Negative-pressure rooms are reserved for airborne infections and are not indicated for scabies.
Category reason: This question tests appropriate transmission-based precautions and room assignment to prevent infection spread, which falls under Infection Control.

Question 2

Nurses must protect themselves and clients from dangerous shocks by keeping their hands dry when manipulating machinery, mopping spilled fluid, ensuring that all plugs are grounded and reporting any equipment damage is called?

Accepted Answer

Answer reason: Keeping hands dry, mopping spills, ensuring grounded plugs, and reporting equipment damage are measures to prevent electrical shock—i.e., electrical safety.
Category reason: This is a nursing safety question about preventing accidents and injuries in the care environment, fitting Safety and Infection Control: Accident-Error Prevention.

Question 3

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

Accepted Answer

Answer reason: Pruritus with hepatitis is worsened by dry skin. Emollients help moisturize and reduce itching. Hot water and frequent showers dry the skin, and powder can irritate, so the best option is to add oil/emollient to the bath water.
Category reason: This is a nursing comfort and skin-care intervention to relieve itching without medications, fitting Basic Care and Comfort: Non-Pharmacological Comfort Interventions.

Question 4

What is the most important client teaching for a client with inflammatory arthritis who takes prednisone and is scheduled for elective surgery?

Accepted Answer

Answer reason: Chronic prednisone suppresses immune response and can mask infection, increasing postoperative infection risk. Teaching to recognize infection signs is the highest priority for safety.
Category reason: This focuses on preventing and recognizing infection risks in a perioperative client, which falls under Safety and Infection Control: Infection Control.

Question 5

All the flowing are essential standard precautions used in the care of all patients irrespective of whether they are diagnosed infectious or not, except one?

Accepted Answer

Answer reason: Standard precautions include hand hygiene, use of PPE, aseptic technique, and proper sharps and waste disposal. "Improper" sharps and waste disposal is unsafe and therefore the exception.
Category reason: The item tests knowledge of standard precautions for infection control and safe handling of materials, which is part of Safety and Infection Control.

Question 6

Ask the client to stand with feet together and arms at sides and eyes open then with eyes closed for 20 second. This test is performed for?

Accepted Answer

Answer reason: The described maneuver is the Romberg test, which evaluates balance/equilibrium (vestibular and proprioceptive function). Air and bone conduction are assessed by Rinne/Weber tests.
Category reason: This is a nursing assessment technique used to evaluate a client’s neurologic system, fitting System-Specific Assessments under Reduction of Risk Potential.

Question 7

The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet?

Accepted Answer

Answer reason: Coconut oil is high in saturated fat, which raises LDL cholesterol; unsaturated oils like safflower, sunflower, and canola are preferred for a low-cholesterol diet.
Category reason: This is a nursing nutrition teaching question about appropriate dietary choices, fitting Basic Care and Comfort: Nutrition and Oral Hydration.

Question 8

The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother's lap. Which should the nurse do first?

Accepted Answer

Answer reason: With infants, perform the least disturbing assessments first while the child is quiet; auscultate heart and lungs before manipulative steps like ear exam or abdominal palpation.
Category reason: This concerns adapting physical assessment techniques to an infant's developmental stage, fitting Growth and Development within Health Promotion and Maintenance.

Question 9

Which client should the nurse see first in the emergency department after a weather disaster?

Accepted Answer

Answer reason: The client with diaphoresis and chest pain suggests myocardial ischemia, a life-threatening priority requiring immediate care. Musculoskeletal injuries are stable and can safely wait.
Category reason: This question assesses recognition of life-threatening presentations and triage priority after mass casualty, which belongs to the “Triage” category.

Question 10

Which action should the nurse avoid when administering a soap suds enema?

Accepted Answer

Answer reason: For a soap suds enema, add a small amount of mild (e.g., castile) soap to warm water and mix gently. Injecting suds (foam) directly introduces air into the system, causing discomfort and cramping. The other actions are appropriate.
Category reason: This is a nursing care procedure related to bowel elimination and comfort measures, which falls under Basic Care and Comfort: Elimination.

Question 11

The nurse is caring for a 20 lbs (9 kg) six month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which of the following should be reported to the physician IMMEDIATELY?

Accepted Answer

Answer reason: Oliguria while receiving IV fluids containing potassium suggests impaired renal perfusion/function; potassium is contraindicated without adequate urine output due to risk of hyperkalemia. This requires immediate notification. The other findings are less urgent.
Category reason: The priority decision rests on safe medication/IV therapy management—recognizing a contraindication to potassium administration and responding to potential adverse effects.

Question 12

Planning cycle includes:

Accepted Answer

Answer reason: The planning cycle typically involves situation analysis, resource assessment, and evaluation; therefore all listed components are part of the cycle.
Category reason: This addresses management processes and resource considerations within nursing care delivery, fitting Management of Care—Resource Management.

Question 13

For treatment of class III dog bite, all of these are correct EXCEPT?

Accepted Answer

Answer reason: Category III bites require immediate wound washing, rabies vaccine (ARV), and rabies immunoglobulin. Primary closure is generally avoided initially; suturing, if needed, is delayed after proper cleansing and prophylaxis. Therefore immediate stitching is the incorrect step.
Category reason: This is a clinical management question about wound care and post‑exposure prophylaxis for a dog bite, fitting Safety and Infection Control.

Question 14

You identify that a polytrauma patient has developed acute respiratory distress syndrome when?

Accepted Answer

Answer reason: Early ARDS presents with acute dyspnea and tachypnea; a marked increase in respiratory rate is an early indicator of respiratory distress. Cyanosis is a late sign, crackles are nonspecific, and hypotension reflects hemodynamic instability rather than ARDS itself.
Category reason: This is a clinical recognition/assessment question about identifying signs of a respiratory complication, fitting NCLEX Physiological Integrity under Reduction of Risk Potential: System-Specific Assessments.

Question 15

A client discharged to home on parenteral nutrition (PN) should have which parameters most closely monitored during home care visits?

Accepted Answer

Answer reason: Home PN requires close monitoring for catheter-related infection (fever) and for nutritional/fluid status (weight).
Category reason: This is nursing management of a client receiving total parenteral nutrition, which falls under Pharmacological and Parenteral Therapies.

Question 16

Which diagnostic tool is most commonly used to determine location of myocardial damage?

Accepted Answer

Answer reason: ECG lead patterns localize myocardial ischemia/infarction (e.g., inferior vs anterior wall) via ST changes/Q waves. Enzymes indicate presence, not location; echo shows wall-motion but is not the most commonly used; catheterization visualizes coronaries but is invasive and not the standard for localizing myocardial damage.
Category reason: The question asks which diagnostic test is used to identify the location of myocardial damage, aligning with nursing knowledge of diagnostic tests under Reduction of Risk Potential.

Question 17

The nurse is performing discharge teaching for a client after cardiac catheterization. Which statement by the client indicates a need for further teaching?

Accepted Answer

Answer reason: Bleeding after cardiac catheterization requires firm manual pressure and medical assistance, not cold therapy.
Category reason: Therapeutic Procedures address post-procedural care to prevent vascular complications.

Question 18

The nurse who is caring for a client with cancer notes a WBC of 500 on the laboratory results. Which intervention would be most appropriate to include in the client’s plan of care?

Accepted Answer

Answer reason: A WBC of 500 indicates severe neutropenia with high infection risk. The priority intervention is to reduce exposure to pathogens by avoiding crowds and sick individuals. Option A cites hypothermia (incorrect rationale), and C/D address bleeding risk rather than infection.
Category reason: This focuses on infection-prevention measures for an immunocompromised client, which belongs to Safety and Infection Control under the NCLEX framework.

Question 19

Which action by a nurse would be considered an act of euthanasia?

Accepted Answer

Answer reason: Euthanasia involves intentionally causing or allowing death. Knowingly allowing a client to take lethal overmedication without intervening is an act of omission that hastens death. DNR orders, following advance directives, and facilitating power of attorney are legal/ethical actions, not euthanasia.
Category reason: The item addresses legal-ethical responsibilities of the nurse in end-of-life care, fitting NCLEX Management of Care: Legal Rights-Responsibilities.

Question 20

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should?

Accepted Answer

Answer reason: Chewing can trigger severe facial pain in trigeminal neuralgia, so soft, high-calorie foods in small, frequent meals meet caloric needs while minimizing jaw movement. Raw fruits/vegetables and meats require more chewing; sitting in a chair does not address pain-limited intake.
Category reason: This addresses nursing measures for feeding and nutrition support to maintain intake and comfort, which falls under Basic Care and Comfort: Nutrition and Oral Hydration.

Question 21

Which of the following describes the use of a decision grid for decision-making?

Accepted Answer

Answer reason: A decision grid visually organizes options against multiple criteria and assigns weight or values, making it a structured quantitative decision tool.
Category reason: Decision grids are widely used in evaluating processes and system choices, fitting the Process Improvement leaf category.

Question 22

The physician has ordered an iodine solution for a client scheduled to undergo a thyroidectomy. When administering this medication the nurse should?

Accepted Answer

Answer reason: Strong iodine solutions (e.g., Lugol's) should be diluted in fruit juice or other liquids and given with meals to mask taste and reduce GI irritation. Milk and antacids are not indicated; using only a straw does not address irritation or taste.
Category reason: This is a nursing medication-administration technique for a preoperative iodine solution, fitting Pharmacological and Parenteral Therapies under NCLEX.

Question 23

The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via a tracheostomy mask. Assessment reveals a respiratory rate of 40 and an O2 saturation of 88%. The client is restless. Which initial nursing action is most indicated?

Accepted Answer

Answer reason: Tachypnea, restlessness, and an O2 saturation of 88% indicate acute hypoxia. With a tracheostomy, the most immediate action is to ensure airway patency by suctioning secretions before notifying the provider or rechecking values.
Category reason: This scenario requires an immediate airway intervention—tracheal suctioning—classified as a therapeutic procedure used to reduce the risk of complications from hypoxia.

Question 24

The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. The BEST response focuses on?

Accepted Answer

Answer reason: Chiropractic care centers on diagnosing and treating illness through spinal adjustments/manipulation; the other options describe different complementary or rehabilitative modalities.
Category reason: This is community health teaching about a complementary therapy, fitting Health Promotion-Disease Prevention within Health Promotion and Maintenance.

Question 25

During which stage of labor is the placenta delivered?

Accepted Answer

Answer reason: The third stage of labor begins after the birth of the baby and ends with delivery of the placenta.
Category reason: This tests knowledge of intrapartum obstetric care, which is categorized under Health Promotion and Maintenance -> Growth and Development -> Ante-Intra-Postpartum Care.

Question 26

The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for?

Accepted Answer

Answer reason: Quinidine is a class IA antiarrhythmic that prolongs the action potential and QT interval, increasing risk of torsades de pointes. Therefore the nurse should monitor for QT prolongation rather than P-wave peaking, ST elevation, or isolated T-wave inversion.
Category reason: This is a clinical pharmacology monitoring question about an antiarrhythmic’s adverse ECG effect, fitting Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 27

Infants should be restrained in a car seat in a semi-reclined position facing the rear of the car until they weigh?

Accepted Answer

Answer reason: Rear-facing car seats provide optimal head and neck protection for infants. Standard pediatric safety guidance recommends that infants remain rear-facing until at least 20 pounds (and typically at least 1 year old), because their cervical spine cannot yet tolerate forward-facing forces.
Category reason: This item focuses on the proper use of child safety equipment to prevent injury, which fits the Safety Devices leaf category.

Question 28

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

Accepted Answer

Answer reason: Pheochromocytoma causes excess catecholamines, predisposing to hypertensive crises and dysrhythmias. An irregular heart rate indicates a potential dysrhythmia, whereas the other findings are within normal limits.
Category reason: This is a nursing assessment question identifying a complication risk in a patient with a disorder, fitting Reduction of Risk Potential: Potential for Complications.

Question 29

During the "tension building" phase of a violent relationship, the battered victim may experience what feelings at the unreasonable demand of the batterer?

Accepted Answer

Answer reason: In the tension-building phase of the cycle of violence, victims often internalize anger and feel powerless and depressed, leading to a sense of helplessness.
Category reason: This addresses psychological responses and dynamics within intimate partner violence, which fall under Psychosocial Integrity and Abuse-Neglect.

Question 30

For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by skin folds?

Accepted Answer

Answer reason: Separating skin folds with towels reduces pressure, friction, and moisture accumulation in intertriginous areas, directly addressing skin-fold pressure risk. The other options do not relieve the localized pressure caused by the folds.
Category reason: This asks for a nursing skin-care intervention to prevent skin breakdown in an obese patient, which fits under Basic Care and Comfort, specifically Personal Hygiene measures for skin integrity.

Question 31

One week after the discharge of a postpartum client, the client's husband calls and says, “Is it normal for my wife to cry at the drop of a hat?” The nurse's best initial response would be:

Accepted Answer

Answer reason: This open-ended question encourages discussion and assessment without minimizing the client’s experience or assigning blame.
Category reason: Therapeutic Communication supports client and family expression to identify emotional or behavioral concerns.

Question 32

The nurse uses a variety of therapeutic communication skills when working with patients. Which of the following is a therapeutic goal that can be accomplished through the use of therapeutic communication skills?

Accepted Answer

Answer reason: Therapeutic communication primarily facilitates assessment of the client’s feelings, thoughts, and perceptions; it is exploratory rather than directive. Option B reflects this goal, whereas the others are nurse-directed actions.
Category reason: The item addresses use of therapeutic communication in patient interactions, which is a Psychosocial Integrity topic under Coping and Adaptation: Therapeutic Communication.

Question 33

Which is a nontherapeutic communication technique?

Accepted Answer

Answer reason: Sympathy conveys pity and shifts the focus to the nurse’s feelings, which hinders patient-centered communication. Focusing, clarifying, and summarizing are therapeutic techniques that facilitate understanding.
Category reason: The item asks the nurse to identify appropriate communication techniques used with patients, which falls under Therapeutic Communication in Psychosocial Integrity.

Question 34

The physician's orders for a client with acute pancreatitis include the following: strict NPO and a nasogastric tube to low intermittent suction. The nurse recognizes that withholding oral intake will?

Accepted Answer

Answer reason: NPO with NG suction minimizes GI stimulation that triggers pancreatic secretion, thereby reducing pancreatic enzyme release. It does not affect insulin needs, does not fully prevent gastric acid secretion, and pain medication is still required.
Category reason: The item requires an understanding of how NPO and NG suction modify the physiological response in acute pancreatitis to limit autodigestion, aligning with disease pathophysiology within Physiological Adaptation.

Question 35

The nurse is assessing the lungs of a patient with asthma. What should the nurse most likely hear?

Accepted Answer

Answer reason: Asthma causes airway narrowing and bronchospasm, producing high-pitched expiratory wheezes. Crackles suggest fluid; a pleural rub indicates pleural inflammation; vascular/vesicular sounds are normal.
Category reason: Identifying expected lung sounds for a respiratory condition is a system-specific assessment of the respiratory system, fitting under System-Specific Assessments in Reduction of Risk Potential.

Question 36

What is the purpose of a nurse providing appropriate feedback?

Accepted Answer

Answer reason: In therapeutic communication, feedback aims to provide the client with clear, specific, nonjudgmental information that enhances awareness and guides self-evaluation, not to give advice or judge behavior.
Category reason: The item tests understanding of therapeutic communication in nurse–client interactions, which belongs to Psychosocial Integrity under Coping and Adaptation.

Question 37

A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. The MOST important reason for this assessment is to prevent?

Accepted Answer

Answer reason: Excess oxygen in premature infants can cause retinal vaso-obliteration and neovascularization leading to retinopathy of prematurity; careful monitoring of oxygen concentration helps prevent this complication.
Category reason: This asks about a nursing monitoring action to prevent a therapy-related complication in a vulnerable population, which fits Reduction of Risk Potential: Potential for Complications.

Question 38

Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?

Accepted Answer

Answer reason: Certain antibiotics reduce the effectiveness of oral contraceptives; clients should use a backup method. Weight gain and menstrual flow changes are common, non-urgent effects, and the missed-pill instruction given is incorrect.
Category reason: This is medication teaching about a drug interaction and precautions, which falls under Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications.

Question 39

You are the RN of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant, a nursing student, and yourself. To whom is it appropriate to assign complete care for a new admission?

Accepted Answer

Answer reason: A new admission requires initial assessment and clinical judgment, which cannot be delegated to an LPN/LVN, UAP, or student; the RN must provide the complete care initially.
Category reason: This asks about appropriate delegation/assignment of tasks within the health care team, which is Management of Care—Delegation.

Question 40

The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough?

Accepted Answer

Answer reason: A coughing client represents a droplet-spread risk; a mask is required.
Category reason: PPE selection for droplet precautions falls under Standard Precautions-Transmission-Based Precautions.

Question 41

The patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. When teaching about this medication, the nurse would include?

Accepted Answer

Answer reason: Metronidazole has a disulfiram-like reaction with alcohol; patients must avoid alcoholic beverages and products containing alcohol. The drug should be completed as prescribed, may be taken with food to reduce GI upset, and photosensitivity is not a key concern.
Category reason: This is medication teaching focusing on an important contraindicated interaction, which falls under Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 42

For which condition is digoxin used?

Accepted Answer

Answer reason: Digoxin, a cardiac glycoside, increases myocardial contractility and helps manage symptoms of heart failure and certain arrhythmias. Among the options, heart failure is correct.
Category reason: This asks about the indication and expected action of a medication, fitting NCLEX Pharmacological and Parenteral Therapies: Expected Actions-Outcomes.

Question 43

The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting for performing tracheostomy suctioning on the adult client is?

Accepted Answer

Answer reason: For adult tracheal suctioning, the recommended negative pressure is approximately 80–120 mmHg to effectively clear secretions while minimizing mucosal trauma.
Category reason: This is a nursing procedure parameter for a therapeutic intervention (airway suctioning), fitting Reduction of Risk Potential: Therapeutic Procedures.

Question 44

________ assist a low vision patient.

Accepted Answer

Answer reason: A typoscope is a low-vision aid that helps patients read by masking surrounding text and reducing glare, allowing focus on a single line. An anomaloscope is used to test color vision deficiencies, not to assist with low vision tasks. A periscope is for viewing over obstacles, and an orthoscope is not a standard low-vision assistive device. Therefore, the best choice is a typoscope.
Category reason: Selecting an assistive device for a patient with low vision is a nursing care intervention aimed at supporting basic functioning, fitting under Basic Care and Comfort → Assistive Devices.

Question 45

Which of the following Nursing diagnosis is INCORRECT?

Accepted Answer

Answer reason: Risk diagnoses should use the label "Risk for," and the etiology should be patient-related risk factors (e.g., confusion, impaired mobility), not an environmental omission like lack of side rails. Therefore option B is an incorrect nursing diagnosis.
Category reason: The question focuses on safe use/consideration of side rails and accurate risk-for-injury diagnosis, which falls under Safety and Infection Control—Safety Devices.

Question 46

The nurse is caring for a client with Parkinson's disease. The client spends more than one hour dressing for scheduled therapies. The most appropriate action for the nurse is to?

Accepted Answer

Answer reason: Clients with Parkinson's should be allowed extra time to perform ADLs to promote independence; hurrying increases stress and worsens motor function.
Category reason: This is a nursing care decision about assisting with an ADL (dressing) for a client with mobility impairment, fitting Basic Care and Comfort: Mobility-Immobility.

Question 47

A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?

Accepted Answer

Answer reason: Burning poison ivy releases urushiol in the smoke, which can cause widespread exposure and dermatitis. The other options do not involve significant urushiol exposure; poison ivy is not spread person-to-person.
Category reason: This focuses on preventing environmental exposure to a toxic irritant, aligning with Safety and Infection Control under Handling Hazardous Materials.

Question 48

The nurse is caring for a client who has sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

Accepted Answer

Answer reason: In the emergent phase after burns, plasma loss and capillary leakage cause hypovolemia and hemoconcentration, leading to elevated hematocrit. Patients typically have tachycardia, hypotension, and decreased urine output.
Category reason: This tests expected physiological changes and fluid shifts in acute burns, aligning with Physiological Adaptation—Fluid and Electrolyte Imbalances.

Question 49

First vaccine for newborn baby______?

Accepted Answer

The Hepatitis B vaccine is routinely administered at birth, usually within the first 24 hours of life. This early “birth dose” is critical because it helps prevent perinatal transmission of the Hepatitis B virus from mother to infant. Newborns infected with hepatitis B have a very high risk of developing chronic infection, which can later lead to Cirrhosis or Hepatocellular Carcinoma. Administering the vaccine immediately after birth significantly reduces this risk and is recommended by global health authorities such as the World Health Organization and the Centers for Disease Control and Prevention. Therefore, the hepatitis B vaccine is considered the first routine immunization given to a newborn.

Question 50

Which of the following BEST describes strategies that help build personal power in an organization?

Accepted Answer

Answer reason: Building personal power is best achieved through positive influence and relationships—networking, mentoring, and coalition building—rather than relying on tenure, confrontation, or appearance.
Category reason: The item focuses on leadership behaviors involving collaboration and building professional networks, aligning with Management of Care under Collaborative Care.

Question 51

As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?

Accepted Answer

Answer reason: Neuroblastoma commonly presents with an abdominal mass and increasing abdominal girth; parents noticing clothes tighter across the abdomen suggests this. The other options are nonspecific or less characteristic.
Category reason: This is a clinical nursing scenario requiring identification of a significant assessment finding related to a diagnosis, fitting NCLEX Reduction of Risk Potential: System-Specific Assessments.

Question 52

A four year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do FIRST?

Accepted Answer

Answer reason: During an active seizure, the first priority is safety—remove nearby hard objects to prevent injury. Do not place items in the mouth or move the child unnecessarily; medications may follow once safety is ensured.
Category reason: This tests immediate safety actions to prevent injury during a seizure, which fits Safety and Infection Control under Accident-Error Prevention.

Question 53

In what order should the nurse prioritize assessment of four clients: an 85-year-old with bacterial pneumonia and high fever, a 60-year-old postoperative thoracotomy client with chest tubes requesting pain medication, a 35-year-old with suspected tuberculosis and cough, and a 56-year-old with emphysema due for bronchodilator with no respiratory distress?

Accepted Answer

Answer reason: Prioritize by ABCs and acuity: the elderly client with bacterial pneumonia and high fever is at highest risk for respiratory compromise; next is the postoperative thoracotomy client with chest tubes needing pain control to support ventilation; the suspected TB client is stable and seen after isolation measures are initiated; the emphysema client without distress and only due for a bronchodilator is last.
Category reason: This is a prioritization/triage decision about order of client assessment, which falls under Management of Care: Establishing Priorities.

Question 54

Which of the following is NOT a phase of a home visit?

Accepted Answer

Answer reason:
Standard community-health home-visit phases include: (1) initiation/initiative, (2) pre-visit activities, (3) activities during the home visit, (4) termination, and (5) post-visit activities. “Orientation” is not included as a phase in the home-visit process, making it the correct answer.
Category reason:
This question addresses structured steps in planning, conducting, and evaluating client care in the home-care setting. This aligns with care coordination and structured processes under **Case Management**, a leaf category within Management of Care.

Question 55

A burn client's care plan indicates an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?

Accepted Answer

Answer reason: Minimal bacteria on a wound culture indicates absence of active local infection, supporting the expected outcome. The other findings—cloudy foul-smelling urine, elevated WBC count, and fever—suggest infection.
Category reason: The item asks the nurse to recognize assessment findings that indicate absence of infection, which falls under Safety and Infection Control, specifically Infection Control.

Question 56

The nurse has just received the change-of-shift report. The nurse should give priority to assessing the client with?

Accepted Answer

Answer reason: Chest tube drainage >100 mL/hr after thoracotomy suggests active hemorrhage and requires immediate assessment. The other findings are expected or less urgent: low-grade fever post-cholecystectomy, urinary urgency after TURP, and diminished hearing after stapedectomy due to packing.
Category reason: This is a prioritization decision about which postoperative client to assess first, fitting NCLEX Management of Care under Establishing Priorities (Triage).

Question 57

The nurse is caring for a client with a pneumothorax. The nurse expects the client to have a chest tube inserted because?

Accepted Answer

Answer reason: In a pneumothorax, air in the pleural space raises intrathoracic pressure and collapses the lung. A chest tube removes this air, re-establishing normal negative intrathoracic pressure and allowing lung re-expansion. The other options are incorrect regarding cause, indication, or effect on pressure.
Category reason: This asks for the nursing rationale for a therapeutic procedure (chest tube) to treat pneumothorax, fitting Physiological Integrity > Reduction of Risk Potential > Therapeutic Procedures.

Question 58

What is paracetamol used for?

Accepted Answer

Answer reason: Paracetamol (acetaminophen) is an analgesic and antipyretic used to relieve pain and reduce fever; it is not used for diabetes.
Category reason: The question asks for the therapeutic use of a medication, which fits Pharmacological and Parenteral Therapies—Expected Actions-Outcomes.

Question 59

An unconscious client with multiple injuries arrives in the emergency department; which nursing intervention receives the highest priority?

Accepted Answer

Answer reason: Follow ABCs in trauma; airway is the first priority for an unconscious patient to prevent hypoxia and death.
Category reason: This tests prioritization of nursing actions in an emergency, which falls under Management of Care—Establishing Priorities (Triage).

Question 60

A client with type 2 diabetes is prescribed metformin. What is the primary action of metformin?

Accepted Answer

Answer reason: Metformin primarily improves peripheral insulin sensitivity and reduces hepatic gluconeogenesis. It does not increase insulin secretion or stimulate hepatic glucose release; decreased intestinal absorption is minimal.
Category reason: The question asks about the mechanism of action of a medication, which falls under Pharmacological and Parenteral Therapies: Expected Actions-Outcomes.

Question 61

An adolescent client hospitalized with anorexia nervosa is described by her parents as "the perfect child." When planning care for the client, the nurse should:

Accepted Answer

Answer reason: Clients with anorexia nervosa often have an overcontrolled, perfectionistic personality; activities that promote self-identity and autonomy aid recovery.
Category reason: Mental Health Concepts includes therapeutic interventions to promote psychological adaptation and self-concept development.

Question 62

A client diagnosed with dependent personality disorder states, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate?

Accepted Answer

Answer reason: Avoid giving advice, asking "why," or inducing guilt. Exploring options supports autonomy and uses therapeutic communication for a client with dependent personality disorder.
Category reason: The item tests therapeutic communication strategies in a mental health scenario, fitting Psychosocial Integrity > Coping and Adaptation > Therapeutic Communication.

Question 63

What is the primary reason for administering mannitol to a patient with increased intracranial pressure (ICP)?

Accepted Answer

Answer reason: Mannitol is an osmotic diuretic that creates an osmotic gradient, drawing water from brain tissue into the intravascular space to reduce cerebral edema and ICP. Increased urine output is a secondary effect and it does not reduce CSF production.
Category reason: This tests the expected action and therapeutic outcome of a medication used in patient care, fitting Pharmacological and Parenteral Therapies.

Question 64

A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occur with aging?

Accepted Answer

Answer reason: Normal aging leads to decreased bladder capacity and weakened urethral sphincter tone/reflexes. Incontinence is not a normal consequence of aging, decreased frequency is incorrect (frequency often increases), and bladder stones are not a typical age-related change.
Category reason: The item asks about normal physiologic changes with aging affecting elimination, fitting Health Promotion and Maintenance under Growth and Development: Aging Process.

Train with a large NCLEX question bank and jump into a full exam-style simulator

NCLEX Master Full-Length Exam – 125-Question Practice Test