Question 1

Which activity is compromised in a newborn baby with cleft lip?

Accepted Answer

Answer reason: Cleft lip prevents the infant from creating an adequate seal on the nipple, leading to ineffective sucking; swallowing, breathing, and facial expression are less directly impaired by an isolated cleft lip.
Category reason: This pertains to a newborn congenital condition affecting feeding, a topic within Newborn Care under Growth and Development.

Question 2

Which medication is considered safe for treating nausea and vomiting during pregnancy?

Accepted Answer

Answer reason: Metoclopramide (a dopamine antagonist) has extensive safety data in pregnancy and is recommended as a second-line agent for nausea and vomiting of pregnancy after pyridoxine/doxylamine. Codeine is an opioid and not indicated for nausea, with maternal and fetal risks. Ibuprofen is contraindicated especially later in pregnancy due to risks such as premature ductus arteriosus closure. Ondansetron may be used when others fail but has mixed safety data in early pregnancy; metoclopramide is generally preferred.
Category reason: This item asks about the safe selection of a medication during pregnancy, which falls under Pharmacological and Parenteral Therapies—specifically evaluating contraindications and safety profiles.

Question 3

After a lengthy labor, a primigravid client delivers a healthy newborn boy with a moderate amount of skull molding. Which of the following would the nurse include when explaining this condition to the parents?

Accepted Answer

Answer reason: Newborn skull molding from passage through the birth canal is common after prolonged labor and typically resolves spontaneously within 24–48 hours. It is not typical of breech births, is not an indication for surgery, and the other statements are not accurate.
Category reason: The item concerns normal newborn physical findings and parent education, which falls under Health Promotion and Maintenance—Newborn Care.

Question 4

The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which of the following client complaints calls for IMMEDIATE nursing action?

Accepted Answer

Answer reason: Diaphoresis and tremors indicate acute hypoglycemia, which can rapidly progress to seizures or coma and requires immediate intervention. The other complaints reflect chronic issues (neuropathy), hyperglycemia symptoms, or a localized injection-site problem and are less urgent.
Category reason: The item asks the nurse to recognize and prioritize an acute complication (hypoglycemia) requiring urgent response, fitting Physiological Adaptation: Medical Emergencies.

Question 5

A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be MOST useful in counseling the parent?

Accepted Answer

Answer reason: Normal developmental dysfluency (stuttering) commonly occurs in preschool-aged children as language outpaces motor speech skills; therefore the child’s age is the most useful data for counseling.
Category reason: This addresses normal child developmental patterns and counseling parents about typical behaviors, fitting Growth and Development: Developmental Stages and Transitions.

Question 6

The charge nurse is assigning staff for the day. The staff consists of an RN, an LPN, and two certified nursing assistants. Which client assignment should be given to the nursing assistants?

Accepted Answer

Answer reason: Stable, predictable needs (e.g., basic hygiene, turning) can be delegated to CNAs with appropriate RN supervision.
Category reason: Choosing who should care for which client is an assignment decision.

Question 7

A patient on paroxetine (Paxil) reports feeling 'wired' and unable to sleep; which nursing intervention is most appropriate?

Accepted Answer

Answer reason: Paroxetine (an SSRI) can cause activation and insomnia. The safest immediate nursing intervention is to promote sleep hygiene with relaxing activities before bedtime. Taking it at bedtime could worsen insomnia, dose changes require provider direction, and documentation alone does not address the patient’s problem.
Category reason: This focuses on nursing measures to promote sleep and comfort for a patient experiencing insomnia, fitting Basic Care and Comfort: Rest and Sleep.

Question 8

Nurse Renor is about to perform Romberg’s test to zakir. To ensure the latter’s safety, which intervention should nurse Renor implement?

Accepted Answer

Answer reason: During the Romberg test the client stands with feet together and eyes closed, increasing fall risk. The nurse should stand close to guard and prevent a fall.
Category reason: This is a nursing safety intervention to prevent client injury during a balance assessment, fitting Safety and Infection Control: Accident-Error Prevention.

Question 9

During history taking if a clinician asks a patient, "What do you feel is causing your problem?" The clinician wants to check?

Accepted Answer

Answer reason: Asking what the patient believes is causing their problem evaluates their awareness and understanding of their illness, which is assessment of insight.
Category reason: This is a psychiatric mental status assessment concept (insight), fitting Psychosocial Integrity under Mental Health Concepts.

Question 10

A 25-year-old man is in an acute manic episode. The nurse knows that which client behavior would be MOST characteristic of mania?

Accepted Answer

Answer reason: Classic manic features include elevated or euphoric mood, increased activity/agitation, grandiosity, and poor concentration/distractibility. These are best captured by option 1.
Category reason: The item assesses recognition of behaviors associated with mania in bipolar disorder, a psychiatric condition under Mental Health Disorders: Mood Disorders.

Question 11

How many people does one ASHA render services to?

Accepted Answer

Answer reason: Under the National Rural Health Mission, the standard norm is one ASHA for approximately 1,000 people (about 500 in tribal or hard-to-reach areas). Therefore, 1,000 is the best answer.
Category reason: This asks about staffing allocation standards for community health workers, which align with managing healthcare resources in the care environment.

Question 12

The nurse gives an inaccurate dose of medication to a client. After assessing the client, the nurse files an incident report, notifies the supervisor, and calls the physician. The nurse understands that the:

Accepted Answer

Answer reason: Incident reports exist to improve safety systems—not to punish staff.
Category reason: The question aligns with the Error Reporting leaf category in Quality Improvement.

Question 13

Crackles are commonly seen in which condition?

Accepted Answer

Answer reason: Crackles (rales) result from fluid in the alveoli and are classically heard in pulmonary edema; asthma and emphysema more often produce wheezes or diminished sounds, and hypoventilation does not typically cause crackles.
Category reason: Identifying abnormal lung sounds associated with a condition is part of system-specific assessment within Reduction of Risk Potential.

Question 14

The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for a 47-year-old woman. The nurse in the outpatient clinic teaches the client about the medication. The nurse should encourage the client to make sure her diet has adequate?

Accepted Answer

Answer reason: Lithium and sodium compete for renal reabsorption; low sodium intake increases lithium reabsorption and risk of toxicity. Teach the client to maintain adequate, consistent sodium intake.
Category reason: This is medication teaching to prevent adverse drug effects, fitting Pharmacological and Parenteral Therapies—Adverse Effects-Contraindications.

Question 15

A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to?

Accepted Answer

Answer reason: Prone positioning promotes hip and knee extension and helps prevent or reduce knee flexion contractures. The other positions encourage joint flexion or malalignment.
Category reason: This is a nursing intervention about patient positioning to prevent contractures, which falls under Basic Care and Comfort: Mobility-Immobility.

Question 16

Which medication would a client with cocaine addiction most likely be placed on?

Accepted Answer

Answer reason: Amantadine, a dopaminergic agent, has been used to reduce cocaine withdrawal symptoms and cravings. Methadone treats opioid dependence, disulfiram treats alcohol use disorder, and THC is not used to treat cocaine addiction.
Category reason: This addresses medication management for a substance use disorder, fitting the mental health domain under substance use dependence.

Question 17

Which example of a therapeutic communication technique would be effective in the planning phase of the nursing process?

Accepted Answer

Answer reason: Planning involves setting goals and selecting strategies. Proposing the use of previously discussed coping skills reflects planning an intervention.
Category reason: The item asks about choosing a therapeutic communication technique appropriate for a phase of the nursing process, which fits Psychosocial Integrity—Therapeutic Communication.

Question 18

To assess an immobilized patient, focus on the following, except:

Accepted Answer

Answer reason: Mobility assessment focuses on range of motion, activity tolerance, and body alignment. Psychological condition is important, but not a direct component of assessing mobility itself, making it the exception.
Category reason: This concerns assessing a patient's mobility and physical positioning during care, which falls under Basic Care and Comfort: Mobility-Immobility.

Question 19

Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?

Accepted Answer

Answer reason: Postpartum nurses care for women’s health and gynecologic postoperative patients; a hysterectomy patient is appropriate overflow. The other options include males (not appropriate for a postpartum unit) or an infectious GI illness that would risk mothers/newborns.
Category reason: This question requires choosing appropriate unit placement/assignment of clients during high census, which is part of Management of Care—Assignment.

Question 20

Precautions apply during the measurement of blood pressure.

Accepted Answer

Answer reason: During blood pressure measurement, the manometer should be positioned at eye level for an accurate reading, with the patient seated and the arm at heart level.
Category reason: The item involves correct technique for measuring a diagnostic vital sign, fitting Diagnostic Tests under Reduction of Risk Potential.

Question 21

Which client should the charge nurse assign to a nurse with postpartum care experience who is reassigned to a medical-surgical care area?

Accepted Answer

Answer reason: Float/postpartum nurse should receive the most stable client. Trauma with facial injury, heatstroke, and systemic latex reaction can be emergent/unstable. Scleroderma with Raynaud phenomenon is a chronic, stable condition appropriate for reassignment.
Category reason: This is a staffing and assignment decision to ensure safe client care, which falls under Management of Care: Assignment.

Question 22

In which situation would the nurse understand that implied consent is given?

Accepted Answer

Answer reason: Implied consent applies in emergencies when immediate treatment is necessary and explicit consent may not be obtainable. Suturing an ED laceration falls under emergency care, whereas anesthesia and delivery require explicit informed consent.
Category reason: The item addresses legal/ethical aspects of obtaining consent, which is part of Management of Care under Safe and Effective Care Environment.

Question 23

What is the name of the mental disorder in which a patient becomes self-critical and believes that he is a criminal?

Accepted Answer

Answer reason: Self-accusatory, excessive guilt with beliefs of being a criminal is characteristic of guilt delusion, seen in psychotic depression.
Category reason: Identifying a specific type of delusion is part of psychiatric disorders, fitting Psychosocial Integrity: Mental Health Disorders—Psychotic Disorders.

Question 24

An important goal in the development of a therapeutic in-patient milieu is?

Accepted Answer

Answer reason: The therapeutic milieu provides a safe, structured environment that serves as a testing ground for practicing new, adaptive behaviors while promoting personal responsibility. The other options misstate goals: it is not primarily businesslike, rules are not determined solely by clients, and appropriate expression of feelings like anger should be allowed, not discouraged.
Category reason: This focuses on milieu therapy and behavior-shaping strategies in psychiatric nursing, fitting Psychosocial Integrity under Behavioral Interventions.

Question 25

A PRIORITY goal of involuntary hospitalization of the severely mentally ill client is?

Accepted Answer

Answer reason: Involuntary hospitalization is primarily for safety—when a person is a danger to self or others or gravely disabled. Protection from harm is the immediate priority; symptom elimination and return to independent functioning are longer-term goals.
Category reason: This is a psychiatric nursing priority about patient safety in involuntary admission, fitting Psychosocial Integrity under Mental Health Concepts.

Question 26

If the client is female and the doctor is male, and the patient is about to undergo a vaginal and cervical examination, why is it necessary to have a female nurse in attendance?

Accepted Answer

Answer reason: The presence of a female nurse protects client dignity, prevents misunderstanding, and upholds ethical standards.
Category reason: Legal-Ethical includes maintaining privacy, professional conduct, and patient rights during care.

Question 27

The graduate nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority?

Accepted Answer

Answer reason: For organ donor maintenance, the priority is ensuring adequate perfusion; thus maintaining sufficient blood pressure comes first. Other targets are inappropriate (300 mL/hr urine is excessive, 33°F is impossible/typo for C°, and Hct

Question 28

In which color container should infected and soiled dressings be discarded?

Accepted Answer

Answer reason: Infected and soiled dressings are considered soiled biomedical waste and should be placed in yellow bags/containers designated for infectious, blood- or body fluid–contaminated materials.
Category reason: This concerns proper disposal of biohazardous materials, a safety practice under Safety and Infection Control: Handling Hazardous Materials.

Question 29

The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

Accepted Answer

Answer reason: Roast beef provides heme iron, the most readily absorbed form, making this meal highest in iron compared with the others that have lower or nonheme sources.
Category reason: The item asks the nurse to choose an appropriate diet for iron-deficiency anemia, which is a patient care nutrition intervention under Basic Care and Comfort: Nutrition and Oral Hydration.

Question 30

While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is MOST important for the nurse to teach them to?

Accepted Answer

Answer reason: Phenytoin commonly causes gingival hyperplasia; emphasize meticulous oral hygiene and regular dental care. The other options are incorrect or unrelated to phenytoin therapy.
Category reason: The item focuses on client education about a medication’s adverse effect and appropriate nursing teaching, which falls under Pharmacological and Parenteral Therapies: Adverse Effects-Contraindications.

Question 31

Following surgery for placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The BEST response by the nurse would be to explain that the incision was made in order to?

Accepted Answer

Answer reason: A VP shunt drains cerebrospinal fluid from the ventricles to the peritoneal cavity. A small abdominal incision is needed to pass the distal catheter into the peritoneum.
Category reason: This is a nursing scenario explaining the purpose of a surgical device (VP shunt), aligning with patient care related to therapeutic procedures, which falls under Reduction of Risk Potential.

Question 32

A client is prescribed levothyroxine for hypothyroidism. What is the primary therapeutic effect of levothyroxine?

Accepted Answer

Answer reason: Levothyroxine is synthetic T4 used to replace deficient thyroid hormone in hypothyroidism; its primary effect is to increase circulating thyroid hormone levels.
Category reason: The item asks for the expected therapeutic action of a prescribed medication, which falls under Pharmacological and Parenteral Therapies: Expected Actions-Outcomes.

Question 33

After receiving handoff shift report, which patient should the nurse assess first?

Accepted Answer

Answer reason: Use ABCs. An SpO2 of 89% indicates hypoxemia and potential inadequate oxygenation requiring immediate assessment and intervention. The loose bandage is nonurgent, reddish-orange urine with rifabutin is expected, and dyspnea after inhaler use is concerning but lacks objective evidence of hypoxemia compared with the 89% saturation.
Category reason: This is a prioritization question about which patient to assess first, which falls under Management of Care—Triage.

Question 34

What is the primary action of metoclopramide prescribed for a patient diagnosed with GERD?

Accepted Answer

Answer reason: Metoclopramide is a prokinetic dopamine antagonist that increases gastric motility and emptying and enhances lower esophageal sphincter tone, helping GERD. It does not reduce or neutralize acid or coat the esophagus.
Category reason: The item asks for the expected action of a medication used in patient care, which falls under Pharmacological and Parenteral Therapies—Expected Actions-Outcomes.

Question 35

The nurse is providing discharge instructions for a client with an implantable permanent pacemaker. What discharge instruction is an essential part of the plan?

Accepted Answer

Answer reason: Pacemaker clients should check their pulse regularly to monitor device function and report abnormalities. Microwaves and commercial air travel are safe, and complete avoidance of shoulder movement is incorrect; only arm elevation above the shoulder is limited initially.
Category reason: This is post–pacemaker teaching to monitor device function and prevent complications related to a therapeutic procedure and fits Reduction of Risk Potential under Therapeutic Procedures.

Question 36

The nurse is performing a physical assessment on an infant with roseola. Which of the following characteristics of the skin lesions would the nurse expect to find?

Accepted Answer

Answer reason: Roseola (HHV-6) presents with a blanching rose-pink macular rash that begins on the trunk and may spread. Option A describes varicella, C describes erythema infectiosum, and D describes measles.
Category reason: This is a nursing assessment finding for a pediatric infectious illness, fitting Reduction of Risk Potential: System-Specific Assessments.

Question 37

The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?

Accepted Answer

Answer reason: Weak or absent femoral pulses suggest possible coarctation of the aorta or other congenital cardiac defects. Harlequin sign and acrocyanosis are common benign newborn findings; circumoral pallor is nonspecific.
Category reason: This tests recognition of normal vs abnormal newborn assessment findings in routine neonatal care, fitting Health Promotion and Maintenance: Newborn Care.

Question 38

The nurse is caring for a client with a history of falls. What safety intervention is essential for preventing falls in this client?

Accepted Answer

Answer reason: Adequate lighting reduces tripping hazards and improves visibility, a key fall-prevention measure. Slip-on shoes are unstable, restraints increase injury risk, and independent ambulation is unsafe for a high fall-risk client.
Category reason: This addresses fall-prevention measures in patient care, which is a Safety and Infection Control—Accident-Error Prevention topic.

Question 39

A client with cancer is to undergo an intravenous pyelogram. The nurse should?

Accepted Answer

Answer reason: For an IVP, the bladder should be emptied just before imaging to avoid obscuring urinary tract views. Fluids are encouraged after the study to flush the dye. CNS meds are not held, and pelvic shielding would obscure the area being imaged.
Category reason: This asks for the correct nursing action in preparation for a diagnostic imaging test (IVP), which falls under Diagnostic Tests within Reduction of Risk Potential.

Question 40

The nurse is working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse?

Accepted Answer

Answer reason: Thoracotomy patients are high-risk for respiratory complications and require full RN assessment.
Category reason: Assigning high-acuity clients is part of Management of Care: Assignment.

Question 41

Waste from laboratory cultures and specimens of micro organisms are discarded in-?

Accepted Answer

Answer reason: Biomedical waste from microbiology labs (cultures, stocks, and specimens of microorganisms) is segregated into the yellow bag for incineration/treatment. Red is for contaminated recyclables, blue for glassware, and black for general waste.
Category reason: The item concerns proper segregation of infectious biomedical waste, a safety and infection-control responsibility in clinical settings.

Question 42

What is the primary purpose of an AV shunt in a patient with renal failure?

Accepted Answer

Answer reason: An AV shunt (fistula or graft) creates high-flow vascular access specifically for hemodialysis; it is not used to raise blood pressure, give routine medications, or improve limb circulation.
Category reason: The question addresses the purpose of a dialysis access device, which is part of patient care involving therapeutic procedures under Reduction of Risk Potential.

Question 43

What is the key dietary advice given for patients with esophageal reflux disease?

Accepted Answer

Answer reason: GERD management includes avoiding substances that relax the lower esophageal sphincter or increase acid/bloating, such as caffeine, alcohol/beer, tobacco, milk for some patients, and carbonated beverages.
Category reason: This is patient education about diet to manage a GI condition, fitting Basic Care and Comfort: Nutrition and Oral Hydration.

Question 44

Which of the following clinical presentations would a nurse expect while assessing a patient with placental abruption?

Accepted Answer

Answer reason: Placental abruption causes painful uterine tenderness and hypertonicity with a rigid, board-like abdomen due to concealed bleeding. Leg edema is nonspecific (more typical of preeclampsia), external bleeding may be minimal, and PROM is unrelated.
Category reason: This is an obstetric assessment scenario about expected findings in placental abruption, fitting Ante-Intra-Postpartum Care within NCLEX.

Question 45

When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by?

Accepted Answer

Answer reason: In sickle cell disease, hemolysis shortens RBC lifespan dramatically, and bone marrow production cannot keep up, causing anemia. This is not due to iron deficiency or inability of cells to regenerate.
Category reason: The item asks about disease mechanism causing anemia in sickle cell disease, aligning with Physiological Adaptation—Pathophysiology within NCLEX.

Question 46

The nurse is caring for a client who was recently admitted to the hospital for complications related to Influenza A. To prevent infection transmission, which personal protective equipment (PPE) should be worn when entering the client’s room?

Accepted Answer

Answer reason: Influenza A is transmitted primarily by droplets. Droplet precautions require a surgical (face) mask within 3 feet of the patient; N95 respirators are reserved for airborne pathogens like tuberculosis.
Category reason: The question tests knowledge of transmission-based precautions for communicable diseases, which is a key component of Infection Control.

Question 47

In which of the following clients is a rectal temperature most usually contraindicated?

Accepted Answer

Answer reason: Rectal temperatures can stimulate the vagus nerve and precipitate bradycardia or dysrhythmias, which is especially risky after myocardial infarction. The other conditions are not standard contraindications.
Category reason: This is a nursing safety question about avoiding a harmful assessment technique, fitting Safety and Infection Control under the NCLEX framework.

Question 48

A community health nurse should be resourceful and meet the needs of the client. A villager asks him, "Can you test my urine for glucose?" Which of the following techniques allows the nurse to test a client’s urine for glucose without the need for intricate instruments?

Accepted Answer

Answer reason: Benedict's test detects reducing sugars, like glucose, in urine using Benedict's reagent and heat. Acetic acid testing is for protein, and nitrazine or litmus papers assess pH, not glucose.
Category reason: This asks the nurse to choose the appropriate bedside method for detecting glucose in the urine, which aligns with selecting and understanding diagnostic tests.

Question 49

The nurse is training a group of Certified Nursing Assistants (CNAs) about hand hygiene. Which of the following statements indicate that CNAs need further instructions from the nurse?

Accepted Answer

Answer reason: Gloves do not replace hand hygiene; hands must be cleaned before and after glove use. Statement A shows a misunderstanding.
Category reason: This question evaluates knowledge of proper hygiene under Standard Precautions.

Question 50

A client is prescribed levothyroxine for hypothyroidism. What is the primary nursing consideration during levothyroxine therapy?

Accepted Answer

Answer reason: Levothyroxine dosing is guided by TSH and free T4 values; monitoring thyroid function tests evaluates therapeutic effectiveness and prevents over- or under-replacement.
Category reason: This asks about nursing management of a medication and monitoring for therapeutic effect, fitting Pharmacological and Parenteral Therapies: Expected Actions-Outcomes.

Question 51

During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: Immunocompromised clients exposed to measles should receive immune globulin within 6 days to prevent or modify disease. Antibiotics do not treat measles, there is no specific antiviral therapy, and isolation alone is not the priority intervention.
Category reason: This is a nursing decision about post-exposure management and transmission prevention for an infectious disease, fitting Safety and Infection Control.

Question 52

The nurse is obligated to follow a physician’s order unless?

Accepted Answer

Answer reason: Nurses must question and refuse to carry out orders that are erroneous, violate policy, or could harm the client. Verbal, illegible, or untranscribed orders require clarification/transcription but are not automatic grounds to refuse once clarified.
Category reason: The item addresses the nurse’s legal responsibilities when carrying out provider orders, which falls under Management of Care—Legal Rights-Responsibilities.

Question 53

Which of the following should be obtained from a client PRIOR to having electroconvulsive therapy?

Accepted Answer

Answer reason: Pre-ECT preparation includes obtaining spinal x-rays to identify vertebral pathology and reduce fracture risk during the induced seizure.
Category reason: This is a nursing pre-procedure safety measure for a therapeutic intervention (ECT), fitting Reduction of Risk Potential: Therapeutic Procedures.

Question 54

The appropriate position for abdominal assessment is?

Accepted Answer

Answer reason: Abdominal assessment is best done with the client lying supine and the abdominal muscles relaxed; arms should be at the sides or folded across the chest. High Fowler or prone positions tense or misposition the abdomen.
Category reason: This asks about proper patient positioning for an abdominal physical assessment, which falls under system-specific nursing assessments within Reduction of Risk Potential.

Question 55

When obtaining the nursing history of a client who has diabetes mellitus, which early symptom of renal insufficiency should the nurse assess?

Accepted Answer

Answer reason: Early renal insufficiency impairs the kidney’s ability to concentrate urine, leading to polyuria and often nocturia. Oliguria occurs in later stages; dysuria suggests infection; hematuria is not a typical early finding.
Category reason: The item asks the nurse to identify an assessment finding indicating renal dysfunction, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 56

What is the correct head position during active epistaxis?

Accepted Answer

Answer reason: During a nosebleed the head should be tilted slightly forward to prevent blood from flowing into the throat and risking aspiration; leaning back or upward is contraindicated.
Category reason: This is a nursing intervention about patient positioning to prevent complications, which fits Basic Care and Comfort.

Question 57

A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history-taking the nurse first asks the client about a recent history of:

Accepted Answer

Answer reason: Acute poststreptococcal glomerulonephritis commonly follows a recent group A streptococcal infection of the throat or skin; assessing for this history is most relevant.
Category reason: The item tests knowledge of the disease cause and clinical reasoning about a renal disorder, fitting Physiological Adaptation—Pathophysiology.

Question 58

The client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. The nurse is aware that Pitocin is working if the fundus is?

Accepted Answer

Answer reason: Oxytocin increases uterine tone and contraction postpartum; effective therapy results in a firm, midline fundus. Deviation suggests bladder distention, and a boggy uterus indicates atony.
Category reason: This evaluates the expected therapeutic effect of a medication (oxytocin) on postpartum uterine tone, which falls under Pharmacological and Parenteral Therapies: Expected Actions-Outcomes.

Question 59

The nurse admits a hypertensive client who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the MOST important information for the nurse to assess?

Accepted Answer

Answer reason: Diltiazem can cause dizziness from hypotension/bradycardia; the priority assessment is whether the client is taking the medication as prescribed (timing/dose) to rule out dosing errors or inappropriate timing contributing to symptoms.
Category reason: This is a nursing scenario focused on safe medication use and assessment of adherence with a prescribed antihypertensive, fitting Pharmacological and Parenteral Therapies—Medication Administration.

Question 60

The nurse caring for a client scheduled for an angiogram should prepare the client for the procedure by telling him to expect?

Accepted Answer

Answer reason: During angiography, injection of iodinated contrast commonly causes a transient warm or flushed sensation; the other options are not expected normal effects.
Category reason: This involves pre-procedure patient teaching for a diagnostic test (angiography), fitting Reduction of Risk Potential: Diagnostic Tests.

Question 61

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping out of windows. Which client should be transported first?

Accepted Answer

Answer reason: In mass-casualty triage, airway compromise or inhalation injury takes priority. Rapid respirations and cough suggest possible airway burns requiring urgent care.
Category reason: The scenario tests knowledge of emergency triage principles for prioritizing care, classified under “Triage.”

Question 62

A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department; which order should the nurse do first?

Accepted Answer

Answer reason: Within 1 hour of acetaminophen ingestion, activated charcoal is the first-line treatment to absorb the drug and prevent further hepatic injury. Acetylcysteine is the antidote but is given after gastric decontamination and confirmation of serum levels.
Category reason: The question evaluates emergency nursing response to a toxic ingestion, aligning with “Medical Emergencies” under Physiological Adaptation.

Question 63

A 16-year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and has signed the consent form for treatment. What would be the appropriate initial action by the nurse?

Accepted Answer

Answer reason: A legally married minor is an emancipated minor and has the legal capacity to consent to treatment; therefore the nurse should proceed to assess and treat as an adult without seeking parental or spouse consent.
Category reason: This concerns legal capacity for consent and the nurse’s actions regarding informed consent, which falls under Management of Care: Informed Consent.

Question 64

A client is prescribed enalapril for heart failure. What is the primary action of enalapril?

Accepted Answer

Answer reason: Enalapril is an ACE inhibitor that blocks conversion of angiotensin I to angiotensin II, reducing vasoconstriction and aldosterone. That is its primary action.
Category reason: Asks for the mechanism of action of a medication, which fits Pharmacological and Parenteral Therapies: Expected Actions-Outcomes.

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