Question 1

The chest tube drainage system has continuous bubbling in the water-seal chamber. When the nurse clamps different areas of the tube to find out where the bubbling stops, he is checking for?

Accepted Answer

Answer reason: Continuous bubbling in the water-seal chamber indicates an air leak; sequential clamping is used to locate the leak along the tubing or system.
Category reason: This involves the assessment and troubleshooting of a chest tube drainage system, which is nursing care related to managing a therapeutic procedure to reduce risk to the patient.

Question 2

An 18-year-old woman comes to the physician’s office for a routine prenatal checkup at 34 weeks gestation. Abdominal palpation reveals the fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal heart tone?

Accepted Answer

Answer reason: In ROA the fetus is in a cephalic (vertex) presentation with its back on the mother’s right anterior side. Fetal heart tones are best heard over the fetal back and, in vertex, below the umbilicus—thus below the umbilicus on the mother’s right.
Category reason: This tests obstetric assessment of fetal heart tone location, which falls under system-specific nursing assessments.

Question 3

You are caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should lead you to question the safety of this medication?

Accepted Answer

Answer reason: SSRIs are contraindicated with MAO inhibitors due to risk of serious reactions such as serotonin syndrome; a washout period is required.
Category reason: Focuses on medication safety and drug–drug contraindications, which fits Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 4

When assessing the lower extremities for arterial function, which intervention should the nurse perform?

Accepted Answer

Answer reason: Pedal pulse palpation directly evaluates arterial perfusion to the lower extremities. Allen’s test assesses upper-extremity (radial/ulnar) patency, pitting edema reflects venous/volume status, and Homans’ sign screens for DVT (venous).
Category reason: This is a nursing assessment task focusing on evaluating arterial circulation in the lower extremities, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 5

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?

Accepted Answer

Answer reason: In frostbite, tissue freezing causes pallor or white discoloration with waxy appearance and loss of sensation. These are key signs of impaired perfusion and nerve function.
Category reason: The question focuses on assessment findings for a localized circulatory and tissue injury, classified under “System-Specific Assessments.”

Question 6

Which of the following is considered an example of an intentional tort?

Accepted Answer

Answer reason: False imprisonment is an intentional tort involving unauthorized restraint. Malpractice and negligence are unintentional torts, and breach of duty is an element of negligence, not an intentional tort.
Category reason: This tests legal-ethical knowledge of client rights and nurse responsibilities, fitting Management of Care: Legal Rights-Responsibilities.

Question 7

Up to how many weeks is a medical abortion typically performed?

Accepted Answer

Answer reason: Medical abortion with mifepristone and misoprostol is most commonly provided in early pregnancy, typically up to about 8 weeks’ gestation; beyond this, its efficacy declines and the need for additional intervention increases.
Category reason: The item addresses the timing of a pregnancy-related intervention, fitting within obstetric care during the antepartum period.

Question 8

Which committee gave the concept of multipurpose workers?

Accepted Answer

Answer reason: The Kartar Singh Committee (1973) recommended the multipurpose worker scheme, integrating several vertical programs and creating male and female health workers at the subcenter level.
Category reason: This concerns health workforce planning and role design in care delivery, fitting Management of Care under Resource Management.

Question 9

You are caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor?

Accepted Answer

Answer reason: Levodopa can precipitate psychosis and hallucinations in Parkinson's patients, especially at higher doses; this is a known adverse effect and most likely contributor among the options.
Category reason: This asks the nurse to identify a medication causing an adverse effect (hallucinations), which falls under Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 10

Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is?

Accepted Answer

Answer reason: Home fall risk is primarily related to environmental hazards; adequate lighting is a key determinant to prevent trips and missteps. The other options are less directly related to immediate fall risk.
Category reason: This is a patient safety question about preventing falls in the home environment, which fits Safety and Infection Control under Accident-Error Prevention.

Question 11

Intra-arterial chemotherapy primarily benefits the client by delivering higher concentrations of medication directly to the malignant tumor. An additional benefit of intra-arterial chemotherapy is?

Accepted Answer

Answer reason: Regional intra-arterial delivery limits systemic exposure, reducing bone marrow suppression compared with systemic chemotherapy and thus helps prevent therapy-induced anemia.
Category reason: The question asks about the therapeutic benefit of a specific medication route and its expected outcome, fitting under Pharmacological and Parenteral Therapies: Expected Actions and Outcomes.

Question 12

Which of the following diagnostic tests is typically used to diagnose pneumonia?

Accepted Answer

Answer reason: Pneumonia is confirmed by imaging that shows infiltrates or consolidation; the standard test is a chest X-ray. ABGs assess oxygenation, and cultures identify pathogens but do not by themselves establish the diagnosis.
Category reason: The item asks which diagnostic test confirms a clinical condition, aligning with Reduction of Risk Potential: Diagnostic Tests.

Question 13

What is the name of the reflex observed when a 2-month-old infant is held upright with legs and feet touching a surface and appears to be walking?

Accepted Answer

Answer reason: The stepping reflex is seen when a young infant held upright with feet touching a surface makes alternating stepping motions, as if walking. Babinski involves toe fanning; Bauer crawling is prone-triggered; Push-to-Walk is not a standard neonatal reflex.
Category reason: This tests knowledge of primitive neonatal reflexes used in developmental assessment, fitting Growth and Development within Health Promotion and Maintenance.

Question 14

Which of the following nursing interventions is appropriate while caring for a child after a tonsillectomy and adenoidectomy?

Accepted Answer

Answer reason: Frequent swallowing can indicate postoperative bleeding after tonsillectomy/adenoidectomy. Using straws can dislodge clots, ice cream (dairy) increases mucus, and supine positioning increases aspiration risk.
Category reason: This is a postoperative nursing care intervention aimed at monitoring and preventing complications, fitting Reduction of Risk Potential.

Question 15

A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is?

Accepted Answer

Answer reason: With a suspected embedded foreign body, do not irrigate or attempt removal. Protect the eye and prevent ocular movement by shielding both eyes (e.g., paper cups) until specialist evaluation.
Category reason: This asks for the immediate nursing safety action for an eye injury, specifically use of a protective device to prevent further harm, which fits Safety and Infection Control: Safety Devices.

Question 16

After chest tube placement, it started to drain dark red secretions. It suggests...

Accepted Answer

Answer reason: Dark red drainage from a chest tube indicates blood in the pleural space, consistent with hemothorax. Pneumothorax is air, pyothorax is pus, and emphysema is air trapping in lung tissue.
Category reason: The item requires interpreting chest tube drainage, a system-specific assessment finding relevant to respiratory monitoring, which falls under Reduction of Risk Potential: System-Specific Assessments.

Question 17

What consistency do dalia, khichdi, suji kheer, upma, and custard have?

Accepted Answer

Answer reason: These items span soft and semi-solid consistencies: khichdi and upma are soft, while custard and suji kheer are semi-solid; thus they fit both categories.
Category reason: The question addresses diet consistency choices used in patient nutrition, which falls under Basic Care and Comfort: Nutrition and Oral Hydration.

Question 18

A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate FIRST action by the nurse?

Accepted Answer

Answer reason: Sudden deep throbbing leg pain suggests deep vein thrombosis. The priority is to prevent embolization by keeping the client on bed rest and notifying the provider; exercise or ambulation could dislodge the clot, and ice is not the first priority action.
Category reason: This is a nursing action prioritization question focused on preventing complications of a suspected DVT, fitting Physiological Integrity → Reduction of Risk Potential → Potential for Complications.

Question 19

Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?

Accepted Answer

Answer reason: Preschoolers/toddlers are highly mobile and curious, engage in oral exploration, and lack hazard awareness—making 4-year-olds the highest risk for accidental poisoning among the options.
Category reason: The question hinges on developmental stage differences and associated safety risks, which fits Health Promotion and Maintenance: Growth and Development—Developmental Stages and Transitions.

Question 20

Which client can best be assigned to the newly licensed nurse?

Accepted Answer

Answer reason: Newly licensed nurses should be assigned stable, predictable clients. Clients receiving chemotherapy, post–coronary bypass, or post-TURP require specialized skills and close monitoring. A client with diverticulitis is typically a stable medical patient appropriate for a new RN.
Category reason: This is an RN staffing/assignment decision about matching client acuity to nurse experience, which falls under Management of Care → Establishing Priorities → Assignment.

Question 21

What is the best method to confirm the placement of a nasogastric tube?

Accepted Answer

Answer reason: Radiographic verification is the gold standard for confirming NG tube placement and preventing misplacement or aspiration; methods such as auscultation or aspiration are unreliable.
Category reason: This focuses on safely verifying the placement of an NG tube, a therapeutic procedure, to reduce the risk of complications.

Question 22

Which of the following is an indication for oxygen therapy?

Accepted Answer

Answer reason: Cyanosis is a direct sign of hypoxemia and indicates the need for oxygen therapy. Anorexia is unrelated; anemia is not corrected by oxygen alone; pulmonary edema may require oxygen, but the clear indication among the options is cyanosis.
Category reason: Determining when to initiate oxygen therapy is a nursing care decision about a therapeutic intervention, fitting Pharmacological and Parenteral Therapies: Expected Actions-Outcomes.

Question 23

A client diagnosed with tuberculosis asks the nurse when he can return to work. The nurse should tell the client that?

Accepted Answer

Answer reason: Return to work is appropriate when the client is no longer infectious, typically evidenced by three consecutive negative sputum results after effective therapy. Feeling better or one week of treatment is insufficient; disability is not indicated.
Category reason: This concerns transmission-based precautions and criteria for ending infectiousness for TB, which falls under Safety and Infection Control.

Question 24

A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The nurse should emphasize immediate report of?

Accepted Answer

Answer reason: INH commonly causes peripheral neuropathy due to pyridoxine deficiency, presenting as tingling and numbness in the extremities and requiring prompt reporting. Visual halos suggest digoxin toxicity; photosensitivity is more typical of other antibiotics; confusion/lightheadedness are not the primary INH concern.
Category reason: This asks about a medication adverse effect requiring nursing teaching and reporting, aligning with NCLEX Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 25

Hydralazine (a vasodilator) can produce?

Accepted Answer

Answer reason: Hydralazine commonly causes reflex tachycardia and a drug-induced lupus-like syndrome; seizures, acute hepatitis, and aplastic anemia are not typical adverse effects.
Category reason: The item asks about medication side effects, fitting Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications.

Question 26

The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client?

Accepted Answer

Answer reason: Osteogenesis imperfecta causes fragile bones with high fracture risk; contact sports like football greatly increase injury risk and are contraindicated.
Category reason: This is a nursing safety question about preventing injury through activity restrictions, fitting Safety and Infection Control: Accident-Error Prevention.

Question 27

Which client should the nurse prioritize on a med-surg unit?

Accepted Answer

Answer reason: Petechiae in a septic client suggests DIC and impending hemodynamic instability—an immediate life-threatening complication. The ostomy leak is non-urgent, COPD with SpO2 90% may be baseline (target 88–92%), and a missed warfarin dose for DVT is not as emergent.
Category reason: This is a prioritization question determining which client to assess first, which falls under Management of Care—Establishing Priorities (Triage).

Question 28

A client is admitted with a suspected gastrointestinal bleed. What assessment finding indicates a potential complication of this condition?

Accepted Answer

Answer reason: A GI bleed can progress to hypovolemia and shock. Hallmark findings include hypotension and tachycardia with decreased urine output. Thus, hypotension indicates a serious complication.
Category reason: The item asks the nurse to recognize a complication of GI bleeding based on assessment findings, aligning with monitoring and identifying potential complications.

Question 29

Which nursing statement is a good example of the therapeutic communication technique of offering self?

Accepted Answer

Answer reason: Offering self involves making one’s presence available to support the client. Option B appropriately offers to accompany the patient, while A is giving advice, C is making an observation, and D violates professional boundaries.
Category reason: This tests therapeutic communication techniques used in mental health nursing, which falls under Psychosocial Integrity—Coping and Adaptation—Therapeutic Communication.

Question 30

The nurse notes that a postoperative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per the standing order. Following administration of the medication, the nurse should assess the client for?

Accepted Answer

Answer reason: Naloxone reverses opioid effects, including analgesia. After administration the client may experience an abrupt return of severe pain, so the nurse should assess for sudden, intense pain.
Category reason: This is a nursing scenario about monitoring expected effects after administering a medication, which falls under Pharmacological and Parenteral Therapies: Expected Actions-Outcomes.

Question 31

The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?

Accepted Answer

Answer reason: In acute diverticulitis, a low-residue diet is used and foods with small seeds are avoided because they can irritate or lodge in diverticula. Tomato and cucumber salad contains many seeds and roughage, so it should be avoided.
Category reason: This asks the nurse to choose appropriate dietary items for a patient condition, which falls under Basic Care and Comfort: Nutrition and Oral Hydration.

Question 32

A cancer patient receiving 30 mg oral morphine becomes nauseated; which IV morphine dosage should the nurse select to achieve the same pain-relieving effect?

Accepted Answer

Answer reason: Equianalgesic conversion: 10 mg IV morphine provides approximately the same analgesia as 30 mg oral morphine. Therefore select 10 mg IV.
Category reason: This is a medication dose-conversion question requiring pharmacologic calculation when changing routes, fitting Pharmacological and Parenteral Therapies – Dosage Calculation.

Question 33

The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should?

Accepted Answer

Answer reason: Heparin is an anticoagulant; after a subcutaneous injection the priority is to assess for bleeding/hematoma at the site. Do not aspirate or massage.
Category reason: This is a nursing action related to safe administration and immediate monitoring of a medication, fitting Pharmacological and Parenteral Therapies: Medication Administration.

Question 34

The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which post operative prescription should the nurse question and verify?

Accepted Answer

Answer reason: After gastric surgery the NG tube should not be irrigated or repositioned unless specifically directed by the surgeon because it can disrupt the anastomosis. Leg exercises, early ambulation, and coughing/deep breathing are appropriate to prevent postoperative complications.
Category reason: This is a nursing postoperative management question focused on preventing complications of a therapeutic procedure (NG tube after gastric surgery), which falls under Reduction of Risk Potential: Therapeutic Procedures.

Question 35

The nurse says to the client, 'You become very anxious when we start talking about your drinking.' Which of the following techniques is the nurse using?

Accepted Answer

Answer reason: The nurse neutrally describes an observed behavior (client becomes anxious) to increase awareness, which is the therapeutic technique of making an observation—not confronting, translating feelings, or verbalizing the implied.
Category reason: This is a therapeutic communication scenario involving appropriate nurse–client interaction, which falls under Psychosocial Integrity: Coping and Adaptation.

Question 36

If the school-age child is not given the opportunity to engage in tasks and activities he can carry through to completion, he is likely to develop feelings of?

Accepted Answer

Answer reason: In Erikson’s school-age stage (industry vs. inferiority), lack of opportunities to complete tasks and achieve competence leads to feelings of inferiority.
Category reason: This tests developmental psychology of the school-age child, fitting Health Promotion and Maintenance → Growth and Development → Developmental Stages and Transitions.

Question 37

A patient is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse include in the care plan for the client?

Accepted Answer

Answer reason: Acute pancreatitis requires pancreatic rest: keep the client NPO and use NG suction to reduce gastric contents and pancreatic stimulation. Other options address different conditions (variceal bleeding, ascites) or are appropriate later in recovery.
Category reason: This is a nursing intervention for an acute illness (pancreatitis), fitting Physiological Integrity—Physiological Adaptation: Alterations in Body Systems.

Question 38

A client arrives in the emergency room and is assessed by the nurse. The client is staggering, confused, and verbally abusive. The client complains of a headache from drinking alcohol and is asking for medication. The nurse explains to the client that the physician will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse obtains leather restraints and threatens to place the client in the restraints. With which of the following can the client legally charge the nurse as a result of the nursing action?

Accepted Answer

Answer reason: Threatening to place a client in restraints creates fear of harmful or offensive contact, which is assault. Battery requires actual touching; negligence and invasion of privacy do not apply.
Category reason: The item tests legal aspects of nursing practice and client rights (torts), which falls under Management of Care: Legal Rights-Responsibilities.

Question 39

When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse knows that which of the following instructions is BEST?

Accepted Answer

Answer reason: Early-morning deep cough yields the most concentrated lower-airway sputum and reduces saliva contamination, which is optimal for culture and sensitivity. Saving sputum for days is incorrect, pursed-lip breathing is unrelated, and collecting after a treatment is not standard for C&S.
Category reason: This asks about proper specimen collection technique for a diagnostic test (sputum C&S), which falls under Reduction of Risk Potential: Diagnostic Tests.

Question 40

Today's prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the APPROPRIATE nursing action?

Accepted Answer

Answer reason: Warfarin therapy prolongs PT/INR to a therapeutic range. A PT of 20 seconds with a lab normal of 10–14 indicates a therapeutic effect, not an emergency; no additional bleeding assessment beyond routine or physician notification is required.
Category reason: The item requires interpreting a laboratory value for a medicated client to determine appropriate nursing action, which fits Reduction of Risk Potential: Abnormal Laboratory Values.

Question 41

What is the first symptom that develops when a patient experiences cast compromise?

Accepted Answer

Answer reason: Early neurovascular compromise from a tight cast presents first with paresthesia (tingling). Cyanosis is a late sign, 'circulation' is not a symptom, and restlessness is nonspecific.
Category reason: This asks about early assessment findings indicating complication from a cast, aligning with nursing assessments to reduce risk of complications (System-Specific Assessments).

Question 42

What is the name of the first stool of a neonate?

Accepted Answer

Answer reason: The first stool passed by a newborn is called meconium. Sebum is skin oil, mucosa is a tissue lining, and lanugo (misspelled as Lenugo) is fine fetal hair.
Category reason: This tests knowledge of newborn characteristics and care, fitting Health Promotion and Maintenance under Growth and Development: Newborn Care.

Question 43

A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being "too sick to return to work." The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior?

Accepted Answer

Answer reason: Somatoform (somatic symptom) disorders involve physical symptoms that are unconsciously produced; they are not under voluntary control. This distinguishes them from malingering or factitious disorder.
Category reason: The question addresses understanding of a mental health disorder and related nursing considerations, fitting Psychosocial Integrity under Mental Health Concepts.

Question 44

Who give ethical approve of clinical trial of drug in Nepal?

Accepted Answer

Answer reason: In Nepal, ethical approval for health research and clinical trials is overseen by the Nepal Health Research Council (NHRC) through its Ethical Review Board. The NHRC is the statutory authority responsible for ensuring protection of research participants and adherence to ethical standards. The Department of Drug Administration regulates medicines and marketing authorization, not ethical review. Therefore, NHRC is the correct body for ethical approval.
Category reason: The item addresses regulatory and ethical responsibilities in conducting clinical trials, aligning with Management of Care under Legal Rights-Responsibilities.

Question 45

When working with a client with paranoid personality disorder, which approach would the nurse use?

Accepted Answer

Answer reason: Clients with paranoid personality disorder are suspicious and mistrustful; they respond best to a serious, straightforward, and professional manner rather than cheerful or overly friendly approaches.
Category reason: This is a therapeutic communication choice in a psychiatric nursing scenario, fitting Psychosocial Integrity—Coping and Adaptation—Therapeutic Communication.

Question 46

Vaginal examination is contraindicated in pregnancy in which situation?

Accepted Answer

Answer reason: Digital vaginal examination is contraindicated with placenta previa because it can disrupt the placenta and precipitate severe hemorrhage. The other options are not absolute contraindications.
Category reason: This is a patient-safety question about avoiding an assessment that could cause bleeding in pregnancy, aligning with Reduction of Risk Potential: preventing complications.

Question 47

A pregnant woman with upper RTI due to streptococcus bacteria has history of penicillin allergy. The suitable drug is?

Accepted Answer

Answer reason: Macrolides such as azithromycin are safe in pregnancy and cover streptococcal URIs. Amoxicillin is a penicillin (avoid with penicillin allergy). Doxycycline and chloramphenicol are contraindicated in pregnancy.
Category reason: This is a nursing pharmacology question selecting a safe medication considering contraindications (pregnancy and allergy), fitting Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 48

What precautions should be taken to protect from the coronavirus?

Accepted Answer

Answer reason: Covering the nose and mouth when sneezing follows respiratory hygiene to reduce droplet transmission. Garlic has no proven protective effect; antibiotics do not treat viral infections; washing specifically every hour is not evidence-based compared to performing hand hygiene as needed.
Category reason: The question addresses infection-prevention practices, which fall under Safety and Infection Control, specifically Standard Precautions.

Question 49

Which national U.S. program focuses on improving population health by setting measurable objectives for disease prevention and health promotion every decade?

Accepted Answer

Answer reason: The Healthy People initiative, led by the U.S. Department of Health and Human Services (HHS), establishes 10-year measurable objectives targeting major preventable health threats. It guides nationwide strategies to improve population health, reduce disparities, and promote evidence-based preventive care.
Category reason: This question addresses large-scale U.S. public health planning focused on prevention, risk reduction, and health promotion, which aligns directly with Health Promotion–Disease Prevention.

Question 50

Which action by the newly hired nurse administering medications via a double-lumen nasogastric tube with an air vent requires follow-up?

Accepted Answer

Answer reason: For a double-lumen (Salem sump) NG tube, the blue air-vent lumen should remain open to air and is not irrigated with water; irrigation can be done with air only if needed. The other actions are appropriate for NG medication administration.
Category reason: The item tests safe nursing actions for administering medications via an NG tube, which is part of Pharmacological and Parenteral Therapies: Medication Administration.

Question 51

The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated with morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opioid analgesics?

Accepted Answer

Answer reason: Naloxone is an opioid antagonist that reverses opioid-induced respiratory depression; it should be available when administering opioids. Ketorolac and aspirin are NSAIDs, and atropine is an anticholinergic, none of which reverse opioid effects.
Category reason: This tests safe pharmacologic management of opioid adverse effects, fitting Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 52

While assessing a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be MOST concerned about the mother's report that?

Accepted Answer

Answer reason: Wilms tumor commonly presents as a rapidly enlarging abdominal mass; increasing abdominal girth (tight clothing at the waist) is an early, specific warning sign and most concerning compared to nonspecific findings like weight loss, decreased urine noted by parent, or food preferences.
Category reason: This is a nursing assessment/priority concern in a pediatric client with suspected disease, fitting NCLEX Reduction of Risk Potential: System-Specific Assessments.

Question 53

The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in?

Accepted Answer

Answer reason: In Meniere's disease excess endolymphatic fluid accumulates in the inner ear. A low-sodium diet helps reduce fluid retention; therefore the client should avoid high-sodium foods.
Category reason: This is patient teaching about dietary modification for a condition, which falls under Basic Care and Comfort: Nutrition and Oral Hydration.

Question 54

The nurse is observing a client with an obsessive-compulsive disorder in an in-patient setting. Which of the following behaviors is consistent with this diagnosis?

Accepted Answer

Answer reason: Obsessive-compulsive disorder involves obsessions and compulsions, commonly repetitive checking or washing behaviors. Repeatedly checking a locked door is a classic compulsion.
Category reason: This is a clinical mental health recognition question about OCD symptoms, fitting Psychosocial Integrity under Mental Health Disorders—Anxiety Disorders.

Question 55

The 87 year-old women is brought to the emergency room for treatment of a fractured arm. On physical assessment the nurse notes old and new ecchymotic areas on the client's chest and legs. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which of the following is the most appropriate nursing response?

Accepted Answer

Answer reason: Elder abuse must be reported by the nurse as a mandated reporter. The nurse should inform the client of the legal obligation to report rather than promise confidentiality, discuss with the abuser, or blame the victim.
Category reason: This is a nursing legal/ethical responsibility scenario concerning mandated reporting and client rights, fitting Management of Care: Legal Rights-Responsibilities.

Question 56

Which part of the mind distinguishes right from wrong and acts as a censor of behavior?

Accepted Answer

Answer reason: The superego represents internalized morals and ideals, judging right from wrong and censoring behavior. The ego mediates reality; the id seeks pleasure; libido is psychic energy, not a mind part.
Category reason: This is a foundational mental health concept about Freud’s personality structure, fitting Psychosocial Integrity → Coping and Adaptation → Mental Health Concepts.

Question 57

The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which one of the following tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?

Accepted Answer

Answer reason: Education, assessment, and evaluation require RN judgment and cannot be delegated to UAP. Assisting with ambulation, feeding a stable patient, and collecting non-sterile specimens like sputum are within UAP scope.
Category reason: This is a nursing management question about what tasks can be delegated to UAPs, fitting NCLEX Management of Care—Delegation.

Question 58

If a nurse discovers fire in a client's room, what is the first action the nurse should take?

Accepted Answer

Answer reason: Follow RACE for fire: Rescue first. Move the client to safety before sounding alarms or attempting other actions. Opening windows can fuel the fire.
Category reason: This addresses emergency response actions for a fire in a healthcare setting, which falls under Safety and Infection Control—Emergency Response Plans.

Question 59

How much does head circumference increase from birth to 3 months?

Accepted Answer

Answer reason: During the first 3 months of life, head circumference increases rapidly at about 2 cm per month, then slows.
Category reason: The item tests normal infant growth parameters, which fall under the developmental stages and transitions in growth and development.

Question 60

When inspecting the abdomen, which of the following is not done?

Accepted Answer

Answer reason: For abdominal assessment, the client should void first and assume a dorsal recumbent position, with knees flexed and hips externally rotated, to relax the abdominal muscles. Straightening the knees tenses the abdomen, so it is not done.
Category reason: This item tests the correct technique and positioning for abdominal assessment, fitting system-specific assessment practices to reduce the risk of inaccurate findings.

Question 61

What should a nurse document in a patient's chart?

Accepted Answer

Answer reason: Objective assessment data, like vital signs, must be documented. The other choices describe unsafe practices (recapping a needle, injecting into a reddened area) or information to review, rather than being specifically charted as a new entry.
Category reason: The item focuses on proper legal documentation responsibilities in the medical record, which align with Management of Care under Legal Rights-Responsibilities.

Question 62

The nurse is teaching a client with Parkinson's disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to?

Accepted Answer

Answer reason: Prone lying without a pillow promotes spinal extension and counteracts the flexed posture of Parkinson's disease. The other positions encourage or do not correct flexion.
Category reason: This is patient positioning education to prevent complications of immobility/posture, fitting Basic Care and Comfort: Mobility-Immobility.

Question 63

The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for?

Accepted Answer

Answer reason: Calcium carbonate antacids commonly cause constipation and can lead to hypercalcemia or kidney stones. They do not cause diarrhea (magnesium salts do), and are not associated with hyperphosphatemia or hypomagnesemia.
Category reason: This asks the nurse to identify a key adverse effect to assess with a prescribed antacid, which falls under monitoring for medication side effects in Pharmacological and Parenteral Therapies.

Question 64

A client refuses to follow the physician's orders and leaves the hospital against medical advice (AMA). What risk is the client assuming?

Accepted Answer

Answer reason: Clients have the right to refuse treatment and leave AMA; by doing so they assume responsibility for the consequences to their health, not negligence or simple rule‑breaking.
Category reason: The item addresses client rights and legal implications of leaving AMA, fitting Management of Care under Client Rights.

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