Question 1

A nurse is caring for a client who has full-thickness burns all over 75% of his body. which of the following methods is appropriate to accurately monitor the cardiovascular system?

Accepted Answer

Answer reason: With massive full-thickness burns, patients can develop severe fluid shifts and burn shock, making noninvasive measures like cuff BP or palpated pulse pressure unreliable. Pulmonary artery pressure monitoring (via a PA catheter) provides the most accurate, detailed hemodynamic data to assess cardiovascular status and guide fluid resuscitation (e.g., preload and cardiac output trends). Central venous pressure is less comprehensive and can be misleading because it does not reliably reflect left-sided filling pressures or cardiac output. Therefore, monitoring pulmonary artery pressure is the best method among the options for accurate cardiovascular monitoring in this high-risk burn patient.
Category reason: The question tests the nurse’s choice of an appropriate hemodynamic monitoring method to assess cardiovascular status in a critically ill burn patient, which is a system-specific assessment used to reduce risk and detect complications.

Question 2

A nurse notes that when she took an oral temp on her patient, it was much higher than the baseline in the patient's chart. What factor could have influenced the discrepancy?

Accepted Answer

Answer reason: Temperature readings vary by measurement route; axillary temperatures are typically lower than oral temperatures, so switching from axillary (baseline) to oral (subsequent) can make the later value appear “much higher” even without true fever. Physical activity from therapy can raise temperature, but the stem contrasts route-specific discrepancy more directly and reading a book is not a meaningful confounder. Ingesting iced tea would tend to lower an immediate oral temperature, not raise it. Smoking more commonly elevates oral temperature near the mouth, which would make the baseline higher rather than explain a higher subsequent oral reading.
Category reason: This item tests nursing assessment accuracy and interpretation of vital signs, specifically how different routes of temperature measurement affect readings, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 3

A hospitalized patient complains of abdominal pain that ranks 9 on a scale of 1 to 10. After obtaining the pain rating, what is the nurse's next best step?

Accepted Answer

Answer reason: After establishing intensity, the nurse should complete a focused pain assessment (location, quality, radiation, onset, duration, aggravating/relieving factors, associated symptoms) to guide safe, appropriate interventions. A high pain score does not by itself identify the cause (e.g., peritonitis, obstruction) or the best therapy, and assessment findings may reveal red flags requiring urgent provider notification. Vital signs and last analgesic timing are helpful adjuncts but do not replace a full pain assessment. Administering medication may be appropriate after assessment and safety checks, but the next step is to further assess by having the client describe the pain.
Category reason: The question tests nursing judgment about the immediate next assessment action for a symptomatic hospitalized patient, which is a patient-care decision rather than foundational biomedical knowledge. It fits best under System-Specific Assessments because it focuses on completing an appropriate pain assessment before interventions.

Question 4

Which nursing intervention is a priority for a client in a cast who reports increasing pain and tightness in the affected limb?

Accepted Answer

Answer reason: Increasing pain and tightness in a casted limb raises concern for impaired circulation or developing compartment syndrome. The priority nursing action is to immediately assess neurovascular status (pain, pallor, pulses, paresthesia, paralysis, capillary refill) to detect compromised perfusion and guide urgent escalation. Analgesics could mask worsening ischemic pain, and elevation above the heart may further reduce arterial flow if perfusion is already threatened. Gentle finger movement is supportive but does not address the priority of identifying a limb-threatening complication.
Category reason: This is a nursing-priority question focused on recognizing and assessing a potential complication of casting (neurovascular compromise/compartment syndrome), which fits NCLEX patient-care judgment under system-specific assessments.

Question 5

A 70-year-old, female patient is having her yearly evaluation. The adult-gerontology primary care nurse practitioner gives which physical examination finding the highest priority for immediate treatment?

Accepted Answer

Answer reason: In a postmenopausal woman, an ovary is typically not palpable; a palpable ovary is an abnormal finding that raises concern for an adnexal mass, including possible ovarian malignancy, and warrants prompt evaluation. This finding has higher risk potential than benign age-related vaginal atrophy or pelvic organ prolapse. A cystocele and a pessary in place generally require routine management unless there are acute complications (e.g., urinary retention, ulceration, infection), which are not described. Therefore, the palpable ovary is the highest priority for immediate treatment/workup.
Category reason: The question asks the clinician to prioritize which assessment finding requires immediate attention due to potential serious complications (e.g., malignancy), which aligns with nursing/primary care clinical judgment in system-specific assessment and risk reduction.

Question 6

Which site is best for assessing skin turgor in an elderly patient?

Accepted Answer

Answer reason: In older adults, decreased subcutaneous fat and loss of skin elasticity make skin on the hands less reliable for hydration assessment, often showing tenting even when hydration is adequate. The forehead or sternum provides a better assessment site because these areas are less affected by age-related peripheral skin changes. Therefore, checking turgor over the forehead or sternum is the most accurate option for an elderly patient. This helps reduce false-positive signs of dehydration.
Category reason: The question tests a nursing physical assessment technique (choosing the most accurate site to assess skin turgor in an elderly patient), which fits System-Specific Assessments under Reduction of Risk Potential.

Question 7

Most reliable method to assess dehydration in infants:

Accepted Answer

Answer reason: In infants, the most reliable indicator of hydration status is change in body weight because it directly reflects net fluid loss or gain over a short period. Signs like sunken fontanelle or crying without tears can be subjective and influenced by factors other than dehydration. Urine output is useful but may be delayed or affected by renal concentrating ability and recent intake. Therefore, percentage of weight loss best quantifies dehydration severity.
Category reason: The question tests how to clinically assess dehydration severity in an infant, which is a nursing assessment and monitoring priority rather than a pure anatomy/physiology fact.

Question 8

Nurse Laura is assisting a client with Alzheimer's disease in performing activities of daily living. She notices the client attempting to use a toothbrush to brush her hair. The nurse recognizes that the client is demonstrating?

Accepted Answer

Answer reason: Using a toothbrush to brush hair reflects an inability to correctly perform a learned purposeful task and/or misuse objects despite having the physical ability to do the action, which is characteristic of apraxia. Apraxia commonly occurs in Alzheimer’s disease and affects the sequencing and execution of ADLs. Agnosia is failure to recognize objects, anomia is difficulty naming objects, and aphasia is impaired language comprehension or expression—none best explain the incorrect tool use during an ADL.
Category reason: This item tests nursing assessment/recognition of a neurologic cognitive deficit (apraxia) in an Alzheimer’s client to guide safe, appropriate assistance with ADLs, which fits system-specific assessment under Reduction of Risk Potential.

Question 9

Nurse Anderson is assessing Mrs. Green, a patient with peripheral edema. To accurately evaluate the extent of the edema, what method should Nurse Anderson use?

Accepted Answer

Answer reason: The standard bedside method to evaluate the extent of peripheral edema is to assess for pitting by pressing a finger into the swollen area and noting the depth and persistence of the indentation (graded 1+ to 4+). This provides a direct, objective measure of fluid accumulation and allows consistent tracking over time. Limb circumference can be helpful for monitoring trends but does not specifically quantify pitting severity and can vary with measurement technique. Discoloration/temperature and patient rating are important assessments but do not accurately quantify edema severity.
Category reason: This item tests a nursing assessment technique used to evaluate a patient finding (peripheral edema), which aligns with system-specific physical assessment within Reduction of Risk Potential.

Question 10

Nurse Taylor is assessing Mr. Henderson, a patient admitted with left-sided congestive heart failure. She needs to evaluate him for any signs of edema. Which area should Nurse Taylor examine?

Accepted Answer

Answer reason: In left-sided heart failure, fluid backs up into the pulmonary circulation causing pulmonary congestion, but patients may also have dependent peripheral edema due to overall fluid retention and reduced cardiac output. Dependent edema is best assessed in the most gravity-dependent areas in an ambulatory patient, typically the ankles, lower legs, and feet. The sacrum is more relevant for edema assessment in bedbound patients, while hands and abdomen are less typical primary sites for dependent edema in this context.
Category reason: This question tests a nursing assessment decision—where to inspect for dependent edema in a patient with heart failure—making it a system-specific physical assessment within Reduction of Risk Potential.

Question 11

A client with type 2 diabetes is sweating, anxious, and confused. What is the nurse’s immediate action?

Accepted Answer

Answer reason: Sweating, anxiety, and confusion in a diabetic client are classic signs of hypoglycemia, which can rapidly progress to seizures or coma if unrecognized. The nurse’s immediate priority is to assess by checking the blood glucose to confirm the suspected cause and guide urgent treatment. Administering insulin could worsen hypoglycemia, and notifying the provider delays needed bedside assessment. Offering a snack is an intervention, but assessment of glucose is the safest immediate first action to direct correct management.
Category reason: This is a patient-care priority question focused on immediate nursing assessment and safety in a symptomatic diabetic client, which aligns with NCLEX clinical judgment and system-specific assessment.

Question 12

A 36-hour-old term infant has not passed meconium. What should the nurse assess for?

Accepted Answer

Answer reason: Failure to pass meconium within the first 24–48 hours in a term newborn is a red flag for lower gastrointestinal obstruction. Key causes include Hirschsprung disease (aganglionosis causing functional obstruction) and anorectal malformations such as an imperforate anus. These require prompt focused assessment of abdominal distention, feeding intolerance/vomiting, and inspection of the anus for patency. The other options are not the most direct or common assessment priorities for delayed meconium passage.
Category reason: The stem asks what the nurse should assess for in response to an abnormal newborn finding (no meconium by 36 hours), which is a nursing clinical judgment focused on recognizing potential complications via targeted assessment.

Question 13

Which scale is used to assess head injury consciousness?

Accepted Answer

Answer reason: The Glasgow Coma Scale (GCS) is the standard bedside tool to quantify level of consciousness after head injury by scoring eye opening, verbal response, and motor response. It helps detect neurologic deterioration and guides urgency of interventions and monitoring. Braden assesses pressure-injury risk, Morse assesses fall risk, and Apgar evaluates newborn status immediately after birth, so they do not measure head-injury consciousness.
Category reason: The question tests selection of the correct nursing assessment tool to evaluate neurologic status (level of consciousness) in a head-injury context, which fits system-specific assessment under Reduction of Risk Potential.

Question 14

What is the primary purpose of auscultating the lungs in a patient with pneumonia?

Accepted Answer

Answer reason: Auscultating the lungs in pneumonia is primarily done to identify abnormal breath sounds such as crackles, bronchial breath sounds, diminished sounds, or wheezes that reflect consolidation and airway secretions. These findings help the nurse assess severity, monitor response to antibiotics and airway clearance measures, and detect worsening ventilation (e.g., developing atelectasis). Oxygen level assessment is done with pulse oximetry/ABGs, not auscultation. Heart rate and overall fluid status are assessed by other specific assessments rather than lung auscultation as the primary goal.
Category reason: The question tests a nursing assessment skill (lung auscultation) used to evaluate respiratory status and complications in a patient with pneumonia, which aligns with system-specific patient assessment within Reduction of Risk Potential.

Question 15

Which is the earliest sign of increased intracranial pressure?

Accepted Answer

Answer reason: The earliest and most sensitive indicator of increasing intracranial pressure is a change in level of consciousness (e.g., restlessness, confusion, decreased responsiveness) because cerebral perfusion is affected early. Headache is common but less reliable and may be subjective or absent in some patients. Papilledema typically develops later with sustained ICP elevation and is not an early change. Bradycardia is part of Cushing’s triad and is a late sign indicating significant ICP elevation and impending herniation risk.
Category reason: This item tests nursing assessment and early recognition of neurologic deterioration (ICP rise) using clinical findings, which fits system-specific assessment under Reduction of Risk Potential.

Question 16

Which time is best for checking orthostatic BP?

Accepted Answer

Answer reason: Orthostatic (postural) blood pressure assessment is specifically performed by comparing BP and pulse after changing positions, classically from supine (lying) to standing, to detect orthostatic hypotension. The clinically relevant “time” is immediately upon standing and again after about 1–3 minutes, because a significant drop occurs with the postural change. Times like after lunch, before sleep, or after exercise do not define orthostatic measurements and introduce confounders (postprandial or exertional effects). Therefore, measuring from lying to standing best captures the orthostatic response.
Category reason: This question tests a nursing assessment technique (how to assess orthostatic hypotension) to identify risk for dizziness/falls and hemodynamic instability, which aligns with system-specific assessment under Reduction of Risk Potential.

Question 17

Which of the following findings would indicate worsening of a client’s asthma?

Accepted Answer

Answer reason: A decreasing peak expiratory flow rate (PEFR) reflects increasing airflow obstruction and bronchospasm, which is a key objective marker of worsening asthma. PEFR trends often decline before severe clinical deterioration becomes obvious, so it is used to gauge severity and guide action plans. Inspiratory wheezes can occur but are less specific and may vary; worsening asthma more reliably shows reduced expiratory flow. Increased oxygen saturation would not indicate worsening, and a decreased respiratory rate is not a typical early sign of asthma exacerbation.
Category reason: This question tests recognition of a worsening respiratory condition using an objective assessment parameter (peak expiratory flow), which aligns with nursing system-specific assessment to detect complications or deterioration.

Question 18

A nurse is assessing a newborn who was born at 39 weeks of gestation. Which of the following findings should the nurse report to the provider?

Accepted Answer

Answer reason: A sunken anterior fontanelle in a term newborn is an abnormal finding that can indicate dehydration or hypovolemia and warrants prompt provider notification and further assessment (e.g., intake, output, weight loss, mucous membranes). In contrast, edema over the occiput (caput succedaneum) and overriding sutures are common, benign findings after vaginal birth and typically resolve spontaneously. A head circumference of 35 cm is within the expected normal range for a term newborn (about 32–37 cm). Therefore, the sunken fontanelle is the finding to report.
Category reason: The question centers on interpreting newborn assessment findings and identifying which requires provider notification, which is a nursing clinical judgment about patient status and risk.

Question 19

Which step of the nursing process involves gathering information about the patient's health status, including both subjective and objective data?

Accepted Answer

Answer reason: Assessment is the first step of the nursing process and is where the nurse collects subjective data (what the patient reports) and objective data (measurable/observed findings such as vital signs and physical exam results). This comprehensive data collection forms the basis for identifying nursing diagnoses and planning care. Planning, implementation, and evaluation occur after assessment and depend on the accuracy and completeness of the assessment findings.
Category reason: The question tests nursing process knowledge focused on performing patient assessment and data collection, which aligns with NCLEX nursing care and system-specific assessments rather than biomedical science content.

Question 20

The nurse is completing an abdominal exam. After inspecting the abdomen, which assessment skill is the nurse going to perform next?

Accepted Answer

Answer reason: Abdominal assessment follows the sequence IAPP: inspection, auscultation, percussion, then palpation. Auscultation is performed before percussion and palpation because manipulating the abdomen can stimulate or alter bowel sounds, leading to inaccurate findings. Therefore, immediately after inspection, the nurse should auscultate bowel sounds and vascular sounds.
Category reason: This item tests correct nursing assessment technique and sequencing during a physical exam, which is a patient-care clinical skill within System-Specific Assessments.

Question 21

What should be included in the nursing care plan for a client with diabetes insipidus?

Accepted Answer

Answer reason: Diabetes insipidus causes inadequate ADH effect, leading to large volumes of dilute urine and high risk for dehydration, hypovolemia, and hypernatremia. Strict intake and output monitoring is essential to quantify polyuria, guide fluid replacement, and evaluate response to therapies such as desmopressin. Urine ketones and frequent glucose checks are associated with diabetes mellitus, not diabetes insipidus. Hourly blood pressure may be used if the client is unstable, but the core care-plan assessment for DI is accurate I&O tracking.
Category reason: The item asks what nursing monitoring/intervention should be included in a care plan for a specific condition (diabetes insipidus), focusing on assessing fluid balance and preventing complications, which fits NCLEX System-Specific Assessments under Reduction of Risk Potential.

Question 22

A nurse is planning to assess the corneal reflex on an unconscious client. Which of the following is the safest stimulus to touch the client's cornea?

Accepted Answer

Answer reason: The corneal reflex is assessed by lightly touching the cornea with a sterile wisp of cotton to minimize the risk of abrasion. Cotton buds and tongue depressors are too rigid and increase the chance of corneal injury. A sterile glove is not an appropriate stimulus and could apply excessive pressure and introduce contamination. Using a gentle wisp of cotton is the standard, safest approach for corneal stimulation.
Category reason: This question tests safe performance of a focused neurologic/eye assessment technique (corneal reflex) and the best nursing action to minimize patient harm, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 23

The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?

Accepted Answer

Answer reason: Vitamin B12 deficiency commonly causes megaloblastic anemia and can present with glossitis, characterized by a sore, smooth, beefy-red tongue. Therefore, inspecting the oral mucosa and tongue is a targeted physical assessment finding linked to B12 deficiency. Petechiae is more suggestive of thrombocytopenia, and splenomegaly is not a classic primary finding of B12 deficiency. Blood pressure is a routine vital sign but is not specifically targeted to identifying manifestations of B12 deficiency.
Category reason: The question asks what physical assessment finding the nurse should focus on for a specific condition, which is a nursing assessment task and aligns with System-Specific Assessments under Reduction of Risk Potential.

Question 24

It is 4pm and you are the nurse on the floor and the patient has been admitted to you from the ER. The vital signs follow: HR 122, BP 145/82, SpO2 87% on room air, RR: 24, Temperature: 98. The patient denies any pain. Based on the above vital signs, what is your priority concern?

Accepted Answer

Answer reason: An oxygen saturation of 87% on room air indicates hypoxemia and impaired oxygenation, which is an immediate threat to life. Airway and breathing take priority over circulation and blood pressure abnormalities. Tachycardia and increased respiratory rate may be compensatory responses to hypoxia, while the blood pressure is only mildly elevated and not an immediate concern.
Category reason: This question focuses on interpreting vital signs to identify the most critical system problem, specifically respiratory and oxygenation status, which falls under system-specific assessments.

Question 25

The Glasgow Coma Scale assesses:

Accepted Answer

Answer reason: The Glasgow Coma Scale (GCS) is a standardized neurologic assessment used to quantify level of consciousness by scoring eye opening, verbal response, and motor response. It helps trend neurologic status over time and detect deterioration in patients with head injury or other causes of altered mental status. It does not directly measure pain intensity, cardiac function, or oxygenation, although these can influence mental status.
Category reason: This item tests a nursing assessment tool used to evaluate neurologic status (eye, verbal, motor responses) as part of system-specific assessment and monitoring for complications.

Question 26

What is the first sign of hypoxia?

Accepted Answer

Answer reason: Early hypoxia commonly presents with subtle neurobehavioral changes such as restlessness, anxiety, irritability, or confusion due to decreased cerebral oxygenation. Cyanosis is a late sign and may be absent despite significant hypoxemia, especially in anemia or with poor perfusion. Bradycardia is typically a late and ominous finding (more often preceded by tachycardia). Chest pain can occur with cardiac ischemia but is not the earliest general sign of hypoxia.
Category reason: The question tests recognition of early clinical assessment findings indicating impaired oxygenation, which fits nursing-focused system-specific assessment and risk reduction rather than detailed pathophysiology.

Question 27

Which pain scale is commonly used to assess pain in pediatric patients who are non-verbal or unable to self-report?

Accepted Answer

Answer reason: For non-verbal or pre-verbal pediatric patients, the FLACC scale is commonly used because it relies on observable behaviors (Face, Legs, Activity, Cry, Consolability) rather than self-report. The Numeric Rating Scale and Visual Analog Scale require the patient to understand and communicate a rating, so they are not appropriate when the child cannot self-report. The Wong-Baker FACES scale is typically used when a child can point/choose a face to represent pain, which still requires some ability to self-report.
Category reason: This item tests selection of an appropriate pediatric pain assessment tool based on the child’s ability to communicate, which is a nursing assessment decision and fits System-Specific Assessments under Reduction of Risk Potential.

Question 28

Which of the following need to be performed before radial arterial cannulation to evaluate radial and ulnar arterial patency?

Accepted Answer

Answer reason: Before radial arterial cannulation, collateral circulation to the hand must be confirmed to reduce the risk of hand ischemia if the radial artery becomes occluded. Allen’s test specifically assesses patency of both the radial and ulnar arteries and adequacy of ulnar collateral flow. Angiography is invasive and not routinely required for this bedside screening. Capillary refill and Buerger’s test do not directly evaluate radial–ulnar collateral perfusion adequacy for cannulation safety.
Category reason: The item tests a pre-procedure bedside assessment to reduce risk of complications (hand ischemia) before an arterial line, which aligns with system-specific assessments under Reduction of Risk Potential.

Question 29

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

Accepted Answer

Answer reason: The finding described corresponds to Kernig's sign, a meningeal irritation sign where pain/resistance prevents knee extension when the hip is flexed (often documented as difficulty extending or maintaining leg positioning with hip flexion). Kernig’s and Brudzinski’s signs are classic assessment findings that support suspicion of meningitis in a child with compatible symptoms. The other options are not primarily associated with meningeal signs on physical exam. Prompt recognition is important because bacterial meningitis can rapidly progress and requires urgent evaluation and treatment.
Category reason: This question tests nursing recognition of a specific neurological physical assessment finding (a meningeal sign) and linking it to a likely condition, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 30

The nurse is assessing a patient who came in for a hearing examination. Which of the following tests or tools may the nurse use to assess CN VIII, the acoustic nerve?

Accepted Answer

Answer reason: Cranial nerve VIII (acoustic/vestibulocochlear nerve) is assessed with bedside hearing tests using a tuning fork, including the Weber test. The Weber helps screen for conductive versus sensorineural hearing loss by assessing lateralization of sound. Rosenbaum chart tests near vision (CN II), Romberg evaluates balance/proprioception (often CN VIII function indirectly but is not a primary hearing test), and tonometry measures intraocular pressure for glaucoma risk.
Category reason: This item tests selection of an appropriate bedside assessment tool to evaluate a specific cranial nerve during a patient examination, which fits system-specific nursing assessments.

Question 31

Which of the following steps is the final step that is used during the physical assessment of the abdomen?

Accepted Answer

Answer reason: In abdominal assessment, the sequence is inspection, auscultation, percussion, then palpation to avoid altering bowel sounds before listening. Palpation is performed last, beginning with light palpation to assess tenderness and superficial structures. Deep palpation is the final step because it can elicit pain and is more intrusive, so it should follow inspection, auscultation, and percussion. Among the choices, deep palpation is therefore the last step.
Category reason: This item tests the correct nursing physical assessment sequence for the abdomen, which is a patient assessment skill rather than foundational anatomy/physiology content. That places it under system-specific nursing assessments in Reduction of Risk Potential.

Question 32

During a routine physical examination, a firm mass is palpated in the right breast of a 35-year-old woman. Which of the following findings or client history would suggest cancer of the breast as opposed to fibrocystic disease?

Accepted Answer

Answer reason: Early menarche increases lifetime estrogen exposure, which is a well-established risk factor for breast cancer. Fibrocystic breast changes more often cause breast tenderness and nodularity that fluctuates with the menstrual cycle, and a key differentiator is cyclic change in mass size rather than a persistent firm mass. Increased vascularity and anovulatory cycles are not as classic or specific for breast cancer compared with the strong epidemiologic association of early menarche.
Category reason: The question asks the nurse to distinguish breast cancer risk/history features from benign fibrocystic changes based on assessment and risk-factor recognition, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 33

A diabetic client becomes confused and diaphoretic. The nurse suspects hypoglycemia. What is the initial action?

Accepted Answer

Answer reason: Confusion and diaphoresis are classic signs of hypoglycemia, and the nurse’s first step is to rapidly assess and confirm with a point-of-care glucose check. This guides immediate treatment decisions and helps distinguish hypoglycemia from other urgent causes of altered mental status. Calling the provider or documenting delays time-sensitive care. D50 IV is a treatment typically reserved for severe hypoglycemia when the patient cannot safely take oral glucose and usually after verification per protocol.
Category reason: This item tests a nurse’s immediate assessment and first action in response to suspected hypoglycemia, which is a patient-care decision focused on system-specific assessment and complication risk reduction.

Question 34

The Glasgow Coma Scale is used to assess?

Accepted Answer

Answer reason: The Glasgow Coma Scale (GCS) is a standardized neurologic assessment tool used to quantify level of consciousness by scoring eye opening, verbal response, and motor response. It helps clinicians track neurologic status over time and identify deterioration (e.g., after head injury). Cardiac output, blood pressure, and oxygen saturation are assessed with other monitoring methods, not the GCS.
Category reason: This question tests a nursing assessment tool used to evaluate neurologic status (level of consciousness), which fits System-Specific Assessments under Reduction of Risk Potential.

Question 35

Skin turgor test is used to assess :;????

Accepted Answer

Answer reason: Skin turgor (pinching the skin and observing how quickly it returns) is a bedside assessment of tissue elasticity that correlates with extracellular fluid volume. Poor/“tenting” turgor commonly indicates dehydration or hypovolemia, especially when paired with other findings like dry mucous membranes and decreased urine output. It does not directly measure pain, level of consciousness, or presence of infection. Therefore, it is used to assess hydration status.
Category reason: This item tests a nursing physical assessment technique used to identify risk for fluid volume deficit, which fits within System-Specific Assessments under Reduction of Risk Potential.

Question 36

A nurse is caring for a client who is complaining of RUQ pain. Which sign should the nurse look for to indicate potential cholecystitis?

Accepted Answer

Answer reason: Murphy's sign is a classic physical exam finding for acute cholecystitis: palpation of the right upper quadrant during inspiration causes a sudden halt in inspiration due to pain. RUQ pain with a positive Murphy’s sign supports gallbladder inflammation. In contrast, Cullen’s and Grey-Turner signs indicate retroperitoneal/abdominal bleeding (often pancreatitis), and Battle’s sign is associated with basilar skull fracture.
Category reason: The question tests a nurse’s focused assessment finding to identify a potential complication/condition (cholecystitis) in a client with RUQ pain, which fits system-specific assessment under Reduction of Risk Potential.

Question 37

A nurse is attempting to assess lung sounds on a 3-year-old with a history of asthma. Which is the best method to encourage the child to take a deep breath?

Accepted Answer

Answer reason: For a 3-year-old, a play-based approach is the most effective way to elicit cooperation for respiratory assessment. Blowing bubbles promotes slow, controlled breathing with deeper inspirations between blows, improving the quality of lung sound auscultation. An incentive spirometer is typically not developmentally appropriate for most toddlers, and blowing out a candle or cotton balls is less engaging/standardized and may not sustain repeated deep breaths.
Category reason: This item focuses on how a nurse performs a respiratory assessment in a young child using age-appropriate techniques, which is a patient-care/system assessment decision rather than testing anatomy or physiology facts.

Question 38

A client who sustained a head injury has an intracranial pressure (ICP) monitor reading of 12 mm Hg. Which action should the nurse take?

Accepted Answer

Answer reason:  Continue to assess. An ICP of 12 mm Hg is within the normal adult range (about 5–15 mm Hg), so no acute intervention is indicated based on this value alone. The nurse should continue close neurologic monitoring and trending of ICP along with other indicators (e.g., mental status, pupils, CPP). Notifying the provider or giving mannitol is generally reserved for elevated ICP or clinical deterioration. Maintaining a supine position is not recommended in head injury because head-of-bed elevation (unless contraindicated) helps promote venous drainage and reduce ICP.
Category reason: This is a patient-care decision based on interpreting a monitored physiologic parameter (ICP) and choosing the safest nursing action, which aligns with system-specific assessment and monitoring to reduce risk of complications.

Question 39

A nurse completes an assessment on a newborn 12 hours after birth. The nurse contacts the healthcare provider for which finding?

Accepted Answer

Answer reason:  Respiratory rate of 72 breaths/min A normal newborn respiratory rate is typically about 30–60 breaths/min; 72/min is tachypnea and can indicate respiratory distress or underlying pathology requiring provider evaluation. Although acrocyanosis (blue hands/feet) can be normal in the first 24–48 hours and a temperature of 98.2 F is within normal range, persistent tachypnea is not expected. Accessory muscle use is also concerning for increased work of breathing, but this item is skipped due to SATA format.
Category reason: This item tests nursing assessment findings in a newborn and which require notifying the provider, which is a patient-care judgment consistent with System-Specific Assessments under Reduction of Risk Potential.

Question 40

A patient with a basilar skull fracture suddenly develops clear drainage from the nose. What is the nurse’s priority action?

Accepted Answer

Answer reason:  B. Test drainage for glucose Clear rhinorrhea after a basilar skull fracture suggests a cerebrospinal fluid (CSF) leak, which increases risk for meningitis and requires prompt identification and provider notification. Testing the drainage for glucose (and clinically, beta-2 transferrin when available) helps confirm CSF versus simple nasal secretions. Inserting an NG tube is contraindicated with basilar skull fracture due to risk of intracranial placement. Packing the nostril can obstruct drainage and increase intracranial pressure; the nurse should avoid occluding the leak and instead assess/confirm and escalate care.
Category reason: This is a priority nursing assessment and safety decision in an acute head-injury scenario, focused on recognizing and confirming a complication (suspected CSF leak) to reduce risk of infection and further harm.

Question 41

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first?

Accepted Answer

Answer reason: Auscultate the client's apical pulse and obtain a blood pressure. IV procainamide can cause hypotension and bradycardia due to its effects on cardiac conduction and contractility, and dizziness may signal decreased cerebral perfusion. The first nursing action is to assess immediate hemodynamic stability by checking apical pulse and blood pressure to identify a potentially dangerous adverse effect. Measuring the rhythm strip rate or obtaining a 12-lead ECG can follow, but they do not replace assessing perfusion and vital signs. Nitroglycerin is not indicated for dizziness after procainamide and could worsen hypotension.
Category reason: This is a patient-care prioritization question about the first nursing intervention after an IV antiarrhythmic causes a symptom, focusing on immediate assessment for complications (hemodynamic instability), which aligns with System-Specific Assessments.

Question 42

A patient at 28 weeks gestation reports severe headaches and blurred vision. The nurse’s priority action is to?

Accepted Answer

Answer reason: Assess the patient’s blood pressure. Severe headache and blurred vision at 28 weeks are warning signs of preeclampsia, which can rapidly progress to seizures (eclampsia) and other maternal-fetal complications. The priority nursing action is an immediate, focused assessment to identify hypertension because it drives urgent escalation of care and determines next interventions. Other actions (e.g., acetaminophen, DTR check, NST) may be appropriate after assessing and addressing potential severe hypertension.
Category reason: This is a priority nursing assessment decision in a pregnancy complication scenario, requiring immediate evaluation for a potentially life-threatening condition (preeclampsia), which fits System-Specific Assessments under Reduction of Risk Potential.

Question 43

The nurse is assessing a newborn infant with an upper respiratory tract infection. The nurse conducts a respiratory assessment and notes a respiratory rate of 55 breaths per minute. Which action is the most appropriate?

Accepted Answer

Answer reason: Reassess after the infant settles down. A newborn’s normal respiratory rate is about 30–60 breaths/min, so 55/min can be a normal finding, especially if the infant is crying, agitated, or febrile. The safest first step is to reassess when the infant is calm and ensure the rate is measured accurately (full minute) while also observing for signs of respiratory distress (retractions, grunting, nasal flaring, cyanosis). Administering oxygen or notifying the provider is not indicated solely for a normal-range rate without distress, and documenting alone does not address verification of the assessment finding.
Category reason: This item tests the nurse’s clinical assessment judgment and appropriate follow-up action for a pediatric respiratory vital sign, which aligns with system-specific assessment and monitoring for potential complications.

Question 44

Suitable site to check pulse in newborn?

Accepted Answer

Answer reason: Apical In newborns, the apical pulse is the most accurate and reliable method for assessing heart rate because peripheral pulses can be weak and difficult to palpate. Carotid palpation is generally avoided in infants due to risk of vagal stimulation and difficulty in technique. Femoral and pedal pulses may be inconsistent in newborns and are more commonly used for specific assessments (e.g., coarctation screening) rather than routine pulse counting.
Category reason: This question tests the correct nursing assessment site for measuring a newborn’s pulse (a patient assessment technique), which fits System-Specific Assessments under Reduction of Risk Potential.

Question 45

A primigravida at 37 weeks gestation presents with complaints of a sudden gush of fluid per vagina. Which of the following is the most appropriate initial assessment?

Accepted Answer

Answer reason: CHECK FETAL HEART RATE A sudden gush of fluid at term suggests rupture of membranes, and the priority initial assessment is fetal status because cord prolapse or fetal distress can occur immediately. Checking the fetal heart rate promptly identifies bradycardia or recurrent decelerations that require urgent intervention. A digital vaginal exam is avoided initially because it increases infection risk after membrane rupture unless delivery is imminent or needed for urgent assessment. Oxytocin or bed rest are interventions that may be considered later based on maternal-fetal assessment findings and labor status.
Category reason: This is a patient-care prioritization question in an obstetric scenario, requiring the nurse/midwife to choose the safest first assessment to detect complications after suspected rupture of membranes, which aligns with NCLEX nursing assessment and risk reduction.

Question 46

The nurse caring for an infant with bronchiolitis is monitoring for signs of dehydration. The nurse monitors which method as reliable for determining fluid loss?

Accepted Answer

Answer reason: Body weight. Daily weight is the most reliable objective measure of fluid status in infants because small changes in weight closely reflect changes in total body water. Intake and output can be inaccurate due to insensible losses and difficulties measuring exact amounts in infants. Skin turgor is less reliable in infants because baseline skin elasticity and subcutaneous fat can vary, making assessment subjective.
Category reason: This item tests nursing assessment of dehydration and the most accurate method to monitor fluid loss in an infant, which aligns with System-Specific Assessments under Reduction of Risk Potential.

Question 47

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?

Accepted Answer

Answer reason: Increased specific gravity of the urine. Long-term diuretic use increases renal excretion of water, which can lead to relative dehydration and more concentrated urine. Concentrated urine is reflected by an increased urine specific gravity. The other options suggest fluid overload (gurgling respirations), expected diuretic effect would lower rather than raise blood pressure, and hemoconcentration (not decreased hematocrit) is more consistent with fluid loss.
Category reason: This question tests recognition of expected assessment findings (urine concentration) related to a common therapy (diuretics), which is primarily a nursing patient-monitoring/surveillance task rather than pure foundational science.

Question 48

Which finger is best for GRBS checkup?

Accepted Answer

Answer reason: Ring For capillary blood glucose (GRBS) testing, the side of the fingertip is used, and the middle or ring finger is generally preferred because they are less calloused and typically less painful than the index finger (which is used more often) and safer than the little finger (smaller, closer to bone). Avoiding the index finger also helps preserve sensation/function used most in daily tasks. Using an appropriate finger reduces pain and improves the likelihood of obtaining an adequate blood sample.
Category reason: This question tests a bedside technique choice for performing a capillary blood glucose assessment, which is a system-specific nursing assessment decision rather than foundational biochemistry.

Question 49

A nurse is assessing a client with peripheral arterial disease (PAD) and arterial ulceration of the lower extremities. Which of the following findings would be consistent with the diagnosis?

Accepted Answer

Answer reason: Atrophic skin of the affected area. Peripheral arterial disease causes chronic tissue ischemia, leading to thin, shiny, hairless (atrophic) skin and diminished perfusion to the lower extremities. Arterial ulcers are typically “punched-out,” painful, and associated with cool skin and poor capillary refill rather than edema. Findings like significant edema and ulcers at the medial ankle are more characteristic of venous insufficiency.
Category reason: This is a nursing assessment question requiring recognition of clinical findings consistent with PAD/arterial ulcers, aligning with system-specific assessment under Reduction of Risk Potential.

Question 50

A client with diabetes reports feeling shaky and sweaty. Which action should the nurse take first?

Accepted Answer

Answer reason: Check blood glucose level Shakiness and sweating in a client with diabetes are classic symptoms of hypoglycemia, which is an immediate safety risk. The nurse’s first action is to assess by checking a bedside blood glucose to confirm and quantify the problem before intervening. Administering insulin could worsen hypoglycemia, and a high-protein snack is not the first-line immediate treatment (fast-acting carbohydrate is), while calling the provider is delayed until assessment and initial treatment are underway.
Category reason: This item tests the nurse’s priority first action in response to acute symptoms by performing an immediate physiologic assessment (blood glucose), which aligns with System-Specific Assessments under Reduction of Risk Potential.

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