Question 1

Which of the following can be used to determine accurate ng tube placement?

Accepted Answer

Answer reason: pH of aspirate contents Checking pH of aspirate is an evidence-based bedside method to help verify NG tube placement because gastric contents are typically acidic (lower pH) compared with respiratory secretions. Auscultation of injected air (“whoosh test”) is unreliable and can be falsely reassuring even with malposition. Premeasured insertion length and patient comfort do not confirm correct gastric placement and cannot rule out pulmonary or esophageal placement. When available per policy, radiography is the gold standard for initial confirmation, but among the listed options pH testing is the best.
Category reason: This question tests a nursing safety assessment to reduce risk of complications (e.g., aspiration) by verifying NG tube placement, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 2

Crackles in the lungs are a normal finding in older adults.?

Accepted Answer

Answer reason: False Crackles (rales) are an abnormal lung sound that usually indicates fluid in the alveoli or small airways, such as with heart failure, pneumonia, or atelectasis. Although older adults can have age-related decreases in lung elasticity and cough effectiveness, adventitious sounds are not considered a normal age-related finding. Hearing crackles should prompt further assessment (e.g., oxygenation, respiratory effort, and possible underlying cardiopulmonary pathology) rather than being dismissed as normal aging.
Category reason: This item tests interpretation of an abnormal respiratory assessment finding and whether it represents risk for complications, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 3

The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication?

Accepted Answer

Answer reason: Speak in a normal tone Speaking in a normal tone helps clients with hearing impairment because shouting can distort speech sounds and make lip-reading and comprehension more difficult. Clear, normal-volume speech with good articulation and facing the client improves understanding without increasing background noise. Speaking loudly or directly into the ear is not recommended and may be perceived as rude or may worsen clarity of speech.
Category reason: This item tests a nursing communication approach for a client with a sensory impairment, which aligns with system-specific assessment and communication techniques used to reduce risk of misunderstanding and promote safe care.

Question 4

The nurse is handling a client who sustained electrical burn on the arm and wrist and is scheduled for a fasciotomy. After the procedure, the nurse should assess the affected extremity in which of the following EXCEPT?

Accepted Answer

Answer reason: All of the above. After a fasciotomy for an electrical burn, neurovascular checks of the affected extremity are essential, including sensation (neurologic status), color (perfusion/oxygenation), and distal circulation (pulses/capillary refill). These are all appropriate and expected postoperative assessments to detect complications such as compromised perfusion, ongoing compartment issues, or nerve injury. Therefore, there is no “EXCEPT” among A–C, making “All of the above” the best answer choice for the exception prompt as written.
Category reason: This is a postoperative nursing assessment question focused on monitoring for complications via extremity neurovascular checks (perfusion and nerve function), which fits System-Specific Assessments under Reduction of Risk Potential.

Question 5

The home care nurse visits a client with chronic obstructive pulmonary disease (COPD) who is on home oxygen at 2 L per minute. The client’s respiratory rate is 22 breaths per minute, and the client is complaining of increased dyspnea. The nurse should take which initial action?

Accepted Answer

Answer reason: Collect more information about the client’s respiratory status. The initial nursing action is assessment before intervention unless there is clear evidence of an immediate life-threatening emergency. Increased dyspnea with a mildly elevated RR (22/min) requires further evaluation such as work of breathing, lung sounds, SpO2 (if available), mental status, and oxygen equipment function before changing oxygen flow or calling EMS. Automatically increasing oxygen in COPD can be inappropriate without assessment, and reassurance without assessment is unsafe.
Category reason: This question tests a nursing priority decision about the first action in response to a client’s worsening respiratory complaint, emphasizing focused respiratory assessment (system-specific assessment) before interventions.

Question 6

Suitable site to check pulse in newborns?

Accepted Answer

Answer reason: Apical In newborns, the most accurate routine pulse assessment is the apical pulse, obtained by auscultation at the left 4th intercostal space at the midclavicular line. Peripheral pulses can be difficult to palpate reliably due to small vessel size and infant movement. Carotid palpation is generally avoided in infants because of vagal stimulation risk and difficulty. Femoral/pedal pulses are used for specific assessments (e.g., coarctation screening), not as the primary routine pulse site.
Category reason: This item tests a nursing assessment decision about the best site to measure a newborn’s pulse, which is a system-specific clinical assessment skill rather than foundational anatomy alone.

Question 7

True or False The radial pulse is always the most accurate site for assessing heart rate.?

Accepted Answer

Answer reason: False The radial pulse is not always the most accurate site for heart rate assessment; accuracy depends on the patient’s condition. In infants/young children and when rhythms are irregular, an apical pulse (auscultated at the PMI) is preferred for a more accurate rate. Radial pulses can be weak, difficult to palpate, or not reflect irregular rhythms reliably, so “always” makes the statement incorrect.
Category reason: This question tests selection of the appropriate assessment site for heart rate measurement, which is a nursing assessment skill under system-specific assessments.

Question 8

A client diagnosed with type 1 diabetes reports nausea and abdominal pain. Their blood glucose level is 320 mg/dL. What is the priority nursing action?

Accepted Answer

Answer reason: Assess urine for ketones Nausea and abdominal pain with marked hyperglycemia in a type 1 diabetic raises concern for diabetic ketoacidosis, which can rapidly become life-threatening. The immediate priority is to assess for ketosis to confirm impending/active DKA and guide urgent escalation of care (e.g., IV fluids, insulin infusion, electrolyte monitoring). Administering insulin may be required, but assessment for ketones is the critical first nursing action to identify the complication and ensure timely, safe treatment. A carbohydrate snack is inappropriate with hyperglycemia, and oral fluids may be helpful but does not address the need to rule out DKA.
Category reason: The item asks for the priority nursing action and focuses on assessment to detect a high-risk complication (DKA) in a symptomatic patient, which aligns with NCLEX-style clinical judgment and system-specific assessment.

Question 9

Which of the following is used to assess a patient’s level of consciousness?

Accepted Answer

Answer reason: Glasgow Coma Scale It is the standard bedside tool to quantify level of consciousness by scoring eye opening, verbal response, and motor response. This provides an objective way to trend neurologic status over time and helps detect deterioration, especially after head injury or with altered mental status. The other tools assess different risks/populations (APGAR for newborn transition, Braden for pressure injury risk, Morse for fall risk) rather than consciousness.
Category reason: This item tests selection of an appropriate nursing assessment instrument to evaluate neurologic status, fitting System-Specific Assessments under Reduction of Risk Potential.

Question 10

A nurse should assess a patient’s pain level only when they verbally report discomfort.?

Accepted Answer

Answer reason: False Pain should be assessed routinely and proactively as part of vital sign checks and ongoing reassessment, not only when the patient verbalizes it. Many patients may underreport or be unable to report pain due to sedation, cognitive impairment, language barriers, or critical illness. Nurses should use appropriate pain scales (including behavioral and physiologic indicators when needed) to detect pain early and evaluate response to interventions. Regular assessment reduces the risk of untreated pain and associated complications such as impaired mobility, delayed healing, and physiologic stress responses.
Category reason: This item tests nursing assessment judgment—when and how to assess pain in patients as part of ongoing monitoring—so it fits NCLEX-focused System-Specific Assessments under Reduction of Risk Potential.

Question 11

A newborn has a positive Ortolani sign. What is the nurse's best next step?

Accepted Answer

Answer reason: A positive Ortolani sign indicates possible developmental dysplasia of the hip, an abnormal finding that requires prompt medical evaluation and follow-up. Early recognition and treatment (e.g., positioning devices such as a Pavlik harness) reduce the risk of long-term complications like gait abnormalities and degenerative joint disease. The nurse’s priority is timely escalation/notification rather than reassurance or routine care measures. Tight swaddling can worsen hip positioning by forcing hip extension/adduction.
Category reason: This item tests recognition of an abnormal newborn musculoskeletal assessment finding and the appropriate nursing action to reduce risk through prompt reporting and evaluation, aligning with system-specific assessments under Reduction of Risk Potential.

Question 12

A nurse is checking the assessment findings and laboratory results of a child diagnosed with new-onset glomerulonephritis. Which finding should the nurse most likely expect to note?

Accepted Answer

Answer reason: Glomerulonephritis causes inflammation and damage to the glomerular capillaries, allowing red blood cells to leak into urine and produce gross hematuria. This classically appears as dark, smoky, or tea-colored urine in children with acute onset disease. Hypotension is less expected because fluid retention more commonly contributes to hypertension. Low serum potassium is not typical early; potassium may be normal or elevated if renal function worsens.
Category reason: This item asks the nurse to recognize an expected assessment finding in a specific renal disorder, focusing on clinical assessment cues rather than underlying biomedical mechanisms alone, which fits System-Specific Assessments.

Question 13

The nurse is assessing the patient’s head and neck. The nurse provides a glass of water and asks the patient to take a drink. Which structure is the nurse assessing?

Accepted Answer

Answer reason: Having the client swallow (water is often used) allows observation and palpation of thyroid movement and symmetry because the gland elevates with deglutition. This helps detect enlargement (goiter), nodules, or asymmetric rise that may suggest a mass. The other structures are not primarily assessed by asking the client to swallow during a head and neck exam.
Category reason: This is a nursing physical assessment technique used to evaluate a specific body system during the head and neck exam, aligning with System-Specific Assessments.

Question 14

Q.1396: The tympanic method is especially useful for —?

Accepted Answer

Answer reason: It is a rapid, minimally disruptive way to obtain a temperature without requiring patient cooperation, which is important when a client cannot follow instructions or safely hold an oral thermometer. It also avoids the need for positioning and prolonged contact needed for axillary/rectal methods, reducing struggle and potential injury. Ear wax can interfere with accuracy, and measurements after meals are more relevant to oral temperatures rather than tympanic readings.
Category reason: This item tests selection of an appropriate vital-sign measurement technique for a specific patient condition, which is a nursing assessment decision under system-specific assessments.

Question 15

Q. 932 A POST-OP PATIENT HAS NOT VOIDED IN 8 HOURS. THE YOU SHOULD DO FIRST?

Accepted Answer

Answer reason: An 8-hour period without voiding postoperatively raises concern for urinary retention, often related to anesthesia, opioids, or fluid shifts. The priority is to assess for retention (e.g., palpation/percussion of suprapubic area or bladder scan) to identify a potentially harmful complication before implementing interventions. Assessment findings then guide next steps such as noninvasive measures, bladder scanning, or provider notification for catheterization orders if indicated. Simply documenting as normal delays recognition of retention and its risks (pain, bladder overdistention, infection, renal complications).
Category reason: This is a nursing priority question about the first assessment/intervention for a postoperative complication risk (urinary retention), which fits NCLEX Physiological Integrity and specifically system-specific assessment to detect complications early.

Question 16

Which assessment findings should the nurse report promptly?

Accepted Answer

Answer reason: Oliguria (

Question 17

A client with heart failure has a weight gain of 3 pounds in 24 hours. What is the nurse's priority action?

Accepted Answer

Answer reason: B. Assess lung sounds A rapid 3-lb weight gain in 24 hours in heart failure suggests acute fluid retention with risk for pulmonary congestion. The nurse’s first priority is assessment for respiratory compromise (e.g., crackles, increased work of breathing) to identify immediate threats to oxygenation and guide urgent escalation. Interventions like diuretics or fluid restriction may be indicated but should follow focused assessment and any needed provider notification per protocol.
Category reason: This is a patient-care priority question requiring nursing judgment about immediate assessment and risk detection in a heart failure client, which aligns with system-specific assessment within Reduction of Risk Potential.

Question 18

After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?

Accepted Answer

Answer reason: A sudden elevation in blood pressure after suctioning can indicate increased intracranial pressure, pain, or sympathetic stimulation and requires prompt RN evaluation to prevent complications.
Category reason: This item tests recognition of abnormal assessment findings related to physiologic responses following an intervention, fitting the System-Specific Assessments leaf category.

Question 19

A nurse is caring for a postpartum client who had a cesarean birth. She reports calf pain and swelling in the right leg. What is the nurse's next action?

Accepted Answer

Answer reason: C) Assess for warmth and redness in the leg These findings are classic for suspected deep vein thrombosis in a postpartum client, especially after a cesarean birth. The priority is prompt assessment for additional DVT indicators to guide urgent escalation and prevent pulmonary embolism. Massaging the leg or encouraging ambulation can dislodge a clot and worsen outcomes. Ice packs do not address the underlying thrombotic risk and may delay needed evaluation and provider notification.
Category reason: This is a postpartum patient-care scenario requiring nursing judgment to assess for potential complications (suspected DVT) and choose the safest next action, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 20

A client with type 1 diabetes becomes drowsy and confused. What is the nurse’s priority action?

Accepted Answer

Answer reason: A. Check the client’s blood glucose level Drowsiness and confusion in a client with type 1 diabetes can indicate hypoglycemia or hyperglycemia, and immediate assessment is needed to guide safe treatment. A rapid point-of-care glucose check is the fastest way to determine whether to administer carbohydrates or insulin and prevents worsening neurologic compromise. Giving long-acting insulin without knowing the glucose could precipitate or worsen severe hypoglycemia. Calling the provider and encouraging water may be appropriate later, but they do not address the immediate need to identify and treat a potentially life-threatening glucose abnormality.
Category reason: This is a priority nursing assessment in an acute change in condition (possible hypo/hyperglycemia), which fits NCLEX-focused system-specific assessment to reduce risk of complications.

Question 21

The nurse is preparing to do a focused assessment of the abdomen on an assigned client. Which of the following is most important for the nurse to do to the examination?

Accepted Answer

Answer reason: A full bladder can cause suprapubic discomfort and abdominal distention, which may interfere with palpation and percussion findings and reduce the client’s tolerance for the exam. Emptying the bladder improves comfort and helps prevent misinterpretation of lower abdominal fullness as a pathologic mass. While positioning and equipment are important, ensuring physiologic readiness and minimizing confounders is the priority for an accurate abdominal assessment.
Category reason: This question tests nursing actions to prepare for and perform an abdominal physical assessment, which fits system-specific assessment within Reduction of Risk Potential.

Question 22

When counting the apical pulse during the physical assessment, it is the most accepted practice for the nurse to count the apical pulse in which of the following ways?

Accepted Answer

Answer reason: Counting an apical pulse for a full 60 seconds is the standard because it improves accuracy and helps detect irregular rhythms that can be missed with shorter counts. This is especially important when the rate is slow/fast, irregular, or when evaluating the effects of cardioactive medications. Shorter intervals multiplied to estimate the rate increase measurement error and may under- or overestimate true heart rate. Therefore the best accepted practice is to count for a full minute.
Category reason: This question tests correct nursing technique for obtaining an apical pulse during a physical assessment, which is a system-specific assessment skill used to reduce risk by ensuring accurate vital sign measurement.

Question 23

You highly suspect that your assigned client has abdominal distention. You must need to do and chart which of the following things? to do an ___?

Accepted Answer

Answer reason: B) Measure the abdominal girth at the umbilicus. Serial abdominal girth measurements must be performed using a consistent landmark to ensure accurate trending over time. The umbilicus is the standard reference point used in many nursing protocols because it is easy to identify and reproducible between assessments and between clinicians. Having another nurse “verify” or asking the client does not produce objective, measurable data for documentation. Measuring at the “most distended level” is less reliable because that level can shift as distention changes, reducing comparability between measurements.
Category reason: This question focuses on how to perform and document a nursing assessment (objective measurement of abdominal distention), which fits System-Specific Assessments under Reduction of Risk Potential.

Question 24

A diabetic client is sweating, confused, and pale. What is the nurse's first action?

Accepted Answer

Answer reason: The client is showing classic signs of hypoglycemia: sweating, confusion, and pallor. In any suspected hypoglycemic episode, the nurse’s immediate priority is to assess by checking the blood glucose level. This confirms the problem and guides appropriate treatment. Giving insulin would be unsafe, and notifying the physician or calling rapid response are not first actions before assessment.
Category reason: The question focuses on immediate nursing assessment of a client with possible metabolic imbalance, which falls under focused clinical assessment of body systems.

Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first?
A. "Do you have any chronic illness?"
B. "Do you have any allergies?"
C. "What is your expected due date?"
D. "Who will be with you during labor?"

Question 25

Client with a crush injury to the left lower leg! What is the priority to monitor?

Accepted Answer

Answer reason: A crush injury to an extremity places the client at high risk for acute compartment syndrome and compromised distal perfusion. The earliest limb-threatening changes are neurovascular, so frequent assessment of distal circulation is critical; a weakening/absent pulse suggests arterial compression requiring urgent intervention. Pain is important but can be subjective and may be masked by analgesics, while temperature is not a key early indicator. Urinary output can reflect rhabdomyolysis-related kidney injury, but loss of perfusion to the limb is the most immediate priority to detect.
Category reason: This item asks for the nurse’s priority monitoring focus after an acute extremity injury, requiring clinical judgment about complications and targeted assessment rather than recalling isolated biomedical facts, fitting NCLEX System-Specific Assessments.

Question 26

A child diagnosed with pertussis (whooping cough) is admitted to the pediatric unit. Which action should the nurse perform first as soon as the child arrives on the unit?

Accepted Answer

Answer reason: Pertussis can cause paroxysmal coughing with apnea or hypoxia, so immediate assessment of oxygenation is the priority on arrival. Continuous pulse oximetry provides rapid, ongoing data to detect desaturation and guide timely interventions (e.g., oxygen, suctioning, escalation of care). Weight and temperature are important baseline data but do not address the most immediate threat to airway/breathing. Antibiotics help reduce transmission and may shorten illness if given early, but initiating treatment should follow stabilization and assessment of respiratory status.
Category reason: This question tests the nurse’s first action on admission using immediate physiologic priority assessment (airway/breathing/oxygenation) rather than recall of disease facts, which fits NCLEX nursing judgment under system-specific assessment.

Question 27

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider?

Accepted Answer

Answer reason: A baseline fetal heart rate above 160 beats/min indicates fetal tachycardia, which can signal fetal distress, maternal fever/infection (e.g., chorioamnionitis), dehydration, medication effects, or hypoxia. This abnormal fetal assessment finding warrants prompt provider notification before proceeding with surgery to evaluate and stabilize maternal-fetal status. The other findings listed are generally expected/within acceptable ranges in pregnancy (mild physiologic leukocytosis and a normal maternal pulse), and hemoglobin of 11 g/dL is at the lower limit of normal for pregnancy.
Category reason: This is a nursing assessment and decision about when to notify the provider based on maternal-fetal clinical findings prior to a cesarean delivery, which fits NCLEX-focused system-specific assessment and risk reduction.

Question 28

A client, who is gravida 5, para 4, delivers an 11-pound, 4-ounce neonate at 38 weeks' gestation. The client has been noncompliant with her insulin administration for gestational diabetes and her blood sugar has been poorly controlled throughout this pregnancy. Which nursing intervention is the most important for the neonate?

Accepted Answer

Answer reason: Infants of mothers with poorly controlled diabetes are at high risk for neonatal hypoglycemia due to fetal hyperinsulinemia after the placental glucose supply stops at delivery. The priority nursing action is to assess the newborn’s glucose promptly to identify an immediate, potentially life-threatening complication and guide timely treatment. Giving IV dextrose without confirming hypoglycemia is not first-line and could cause rebound issues, and routine insulin is contraindicated in a neonate. Feeding may be indicated if glucose is low, but assessment is the first critical step to determine the need and urgency of intervention.
Category reason: This question tests the nurse’s priority assessment and immediate post-birth monitoring for a high-risk newborn (infant of a diabetic mother), which fits System-Specific Assessments under Reduction of Risk Potential.

Question 29

How would the nurse check for clonus in a patient with preeclampsia?

Accepted Answer

Answer reason: Clonus is a sign of neuromuscular irritability and hyperreflexia seen in worsening preeclampsia and risk for seizures (eclampsia). To assess it, the nurse rapidly dorsiflexes the ankle and observes for rhythmic, involuntary oscillations (“beating”) of the foot. Deep tendon reflex grading alone does not specifically test clonus, and the other maneuvers do not reproduce the characteristic ankle oscillations.
Category reason: This item tests a bedside nursing assessment technique used to detect neurologic hyperexcitability and impending complications in preeclampsia, fitting System-Specific Assessments under Reduction of Risk Potential.

Question 30

A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is located midline at the level of the umbilicus. Based on this finding, what is the most appropriate nursing action?

Accepted Answer

Answer reason: A firm, midline fundus at the level of the umbilicus in the immediate postpartum period indicates normal uterine tone and involution, suggesting low risk for uterine atony and postpartum hemorrhage. No corrective intervention (e.g., fundal massage) is indicated when the uterus is already firm. Assisting to void is prioritized when the fundus is boggy or deviated from midline (often due to a distended bladder). There is no abnormal assessment finding requiring escalation to the health care provider.
Category reason: This item tests postpartum nursing assessment interpretation and the appropriate action based on a normal fundal tone/location finding, aligning with System-Specific Assessments under Reduction of Risk Potential.

Question 31

The nurse palpates the dorsalis pedis artery to assess circulation to which body part?

Accepted Answer

Answer reason: The dorsalis pedis pulse is palpated on the dorsum of the foot and reflects arterial perfusion distal to the anterior tibial artery. It is a key peripheral pulse used to evaluate circulation to the foot, especially in peripheral arterial disease, diabetes, or after lower-extremity procedures. Diminished or absent pulsation can indicate reduced blood flow and prompts further neurovascular assessment (color, temperature, capillary refill, sensation).
Category reason: This item tests a nursing physical assessment skill—identifying which body region is evaluated by palpating a specific peripheral pulse—so it fits System-Specific Assessments within Reduction of Risk Potential.

Question 32

A 54-year-old postoperative patient (abdominal surgery 12 hours ago) is resting in bed. The UAP reports the following vital signs: • Temp: 100.8°F (38.2°C) • HR: 96 bpm • RR: 22 breaths/min • BP: 118/74 mm Hg • SpO₂: 94% on room air Which action should the nurse take first?

Accepted Answer

Answer reason: The priority is to validate and further assess a potentially early respiratory compromise in the immediate postoperative period, where atelectasis is common and can present with mild hypoxemia, tachypnea, and low-grade fever. UAP-reported vitals require RN confirmation before initiating interventions or escalating to the provider. A SpO₂ of 94% on room air with RR 22 may be clinically relevant, and pulse oximetry can be artifact-prone (poor perfusion, motion, probe placement), so confirming accuracy is the safest first step to guide next actions.
Category reason: This item tests nursing prioritization and immediate postoperative assessment to identify potential complications (e.g., respiratory compromise/atelectasis), which fits System-Specific Assessments under Reduction of Risk Potential.

Question 33

Q.1519: What does AVPU stand for?

Accepted Answer

Answer reason: AVPU is a rapid neurologic assessment of a patient’s level of consciousness used in emergency and routine observations. It categorizes responsiveness from fully conscious to no response: alert, responds to verbal stimuli, responds only to painful stimuli, or unresponsive. This standardized sequence helps nurses quickly detect deterioration and communicate findings consistently during handoff and escalation of care.
Category reason: This question tests a bedside clinical assessment tool for level of consciousness, which is part of nursing-focused system-specific assessment and monitoring for risk detection.

Question 34

A nurse is assessing a full-term newborn arm admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Accepted Answer

Answer reason: This finding can be associated with chromosomal abnormalities (e.g., trisomy 21) and warrants further evaluation and provider notification. In contrast, circumoral cyanosis can be transient in a newborn with otherwise normal oxygenation, subconjunctival hemorrhage commonly results from birth pressure and resolves spontaneously, and urate crystals (“brick dust”/rust-stained urine) can be normal with early newborn dehydration. Reporting the abnormal dysmorphic sign supports early identification of potential genetic conditions and appropriate diagnostic follow-up.
Category reason: This item tests nursing assessment and when to report an abnormal newborn finding to the provider, which aligns with System-Specific Assessments under Reduction of Risk Potential.

Question 35

A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Accepted Answer

Answer reason: t." Intussusception is assessed by focusing on acute GI symptoms such as intermittent severe abdominal pain (often with drawing up of legs), vomiting that may become bilious, and abdominal distention; these data directly support or refute bowel obstruction. Asking about changes in abdominal size helps identify distention, and characterizing pain helps identify the classic episodic pattern. Vomit appearance is relevant because progression to bilious emesis suggests obstruction. A “usual diet” history is less specific and contributes little to confirming this urgent diagnosis compared with symptom-focused questions.
Category reason: This item tests nursing assessment/history taking to evaluate a suspected acute GI complication (bowel obstruction), which is a system-specific assessment under Reduction of Risk Potential.

Question 36

The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature?

Accepted Answer

Answer reason: B. Axillary An oral temperature may be inaccurate or contraindicated when a client has ongoing vomiting and recent oral fluid intake, and it may be unsafe if nausea leads to emesis during measurement. The axillary route is noninvasive, safer in this situation, and avoids oral mucosal irritation and contamination. Radial is a pulse site rather than a temperature method, and heat-sensitive tape is less accurate for core temperature assessment.
Category reason: This question tests choosing the safest and most appropriate temperature measurement method based on the client’s condition, which is a nursing assessment decision.

Question 37

The nurse is performing behaviors and actions that assist clients and significant others in meeting their needs and the identified outcomes of the plan of care. What is the correct term for these nursing behaviors?

Accepted Answer

Answer reason: These are the concrete nursing actions and behaviors carried out to help the client achieve the goals and expected outcomes established in the plan of care. Assessment is data collection, planning is selecting outcomes and strategies, and evaluation is judging the client’s response and whether outcomes were met. The description specifically focuses on implementing actions to assist the client and family, which corresponds to the implementation/intervention phase of the nursing process.
Category reason: This item tests nursing process terminology—identifying the phase where the nurse carries out actions in the plan of care—so it fits NCLEX-style nursing judgment rather than foundational biomedical science.

Question 38

A patient on a beta-blocker reports dizziness. What is the nurse’s first action?

Accepted Answer

Answer reason: Beta-blockers can cause bradycardia and hypotension, both common causes of dizziness. The nurse’s first action is to assess vital signs to identify an immediate hemodynamic problem and guide next steps. If hypotension/bradycardia is present, holding the medication and escalating care can be done based on objective data. Oxygen, IV fluids, or provider notification may be appropriate later but should follow initial assessment unless the patient shows signs of acute instability.
Category reason: This item tests the nurse’s initial assessment and safety-focused response to a potential cardiovascular medication effect (dizziness), which aligns with system-specific nursing assessments under Reduction of Risk Potential.

Question 39

A client recovering from a stroke is having a residual dysphagia. The nurse should ask the client to perform which action to assist in checking the client’s swallowing ability?

Accepted Answer

Answer reason: An effective, audible cough suggests the client can protect the airway by clearing secretions and helps screen for impaired laryngeal function after stroke. Offering thin liquids (water) is higher aspiration risk in dysphagia, and starting with food or candy can also increase choking/aspiration risk if the swallow is unsafe. The cough check is a safer, rapid bedside component of swallowing assessment before progressing to oral intake trials.
Category reason: This item tests a nursing assessment action to reduce aspiration risk by evaluating airway protection in a post-stroke client, which aligns with system-specific assessment within Reduction of Risk Potential.

Question 40

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?

Accepted Answer

Answer reason: Using the adult Rule of Nines, each entire lower extremity (anterior 9% + posterior 9%) equals 18% total body surface area. Because both lower extremities are involved on all surfaces, the burn area is 18% × 2. This yields 36% total body surface area to document, which also guides initial fluid resuscitation and burn severity classification.
Category reason: This item tests nursing assessment and documentation of burn size (TBSA) using a standardized clinical tool (Rule of Nines), which is part of system-specific assessment for risk reduction in acute care.

Question 41

A mother brings her to the clinic, complaining that the child seems to be on the inattentive and physical assessment?

Accepted Answer

Answer reason: Excessive sleepiness and decreased responsiveness are concerning for worsening illness and reduced perfusion/oxygenation or neurologic depression, and they can be subtle early signs in children. Compared with more localized findings (rash, diarrhea), this represents a more global change in mental status that warrants prompt focused assessment and possible escalation of care. A caregiver report of decreased interaction and listlessness should cue the nurse to assess vital signs, hydration status, and neurologic status for potential deterioration.
Category reason: This question asks the nurse to recognize the most concerning assessment finding in a child based on caregiver report, emphasizing clinical assessment and risk detection rather than underlying basic science.

Question 42

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

Accepted Answer

Answer reason: Mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from brain tissue into the intravascular space, thereby lowering intracranial pressure. The most direct indicator of effectiveness is a decreased ICP into the normal range (about 5–15 mm Hg). Increased urine output is an expected pharmacologic effect but does not by itself confirm improved intracranial dynamics. Fixed, dilated pupils suggest worsening neurologic status/herniation, and a stable elevated systolic BP does not specifically indicate improved ICP.
Category reason: This item tests monitoring and interpretation of a neurologic parameter (ICP) to evaluate response to therapy in a patient at risk for intracranial complications, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 43

A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse?

Accepted Answer

Answer reason: Preoperative nursing care prioritizes obtaining current baseline assessment data to identify instability and prevent perioperative complications. Vital signs help detect fever, hypotension/hypertension, tachycardia, or respiratory compromise that may require notifying the provider and potentially delaying surgery. Obtaining informed consent and explaining the procedure are the provider’s responsibilities, while the nurse verifies paperwork and supports understanding. Checking lab work is important, but immediate patient assessment is the nurse’s primary responsibility before transfer to surgery.
Category reason: This item tests the nurse’s preoperative assessment role and identification of physiologic risk through baseline data collection, which aligns with System-Specific Assessments under Reduction of Risk Potential.

Question 44

Suitable site to check pulse in newborn

Accepted Answer

Answer reason: In newborns and infants, peripheral pulses can be difficult to palpate reliably due to small vessel size, subcutaneous fat, and movement, so heart rate is best assessed by auscultation. The apical pulse provides the most accurate and consistent measurement of cardiac rate and rhythm in this age group. Carotid assessment is not preferred in infants because it can be hard to locate and may stimulate a vagal response. Femoral and pedal pulses are more useful for perfusion assessment (e.g., coarctation screening) rather than routine pulse rate counting.
Category reason: This item tests a nursing assessment decision about the safest and most accurate site to measure a newborn’s pulse, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 45

A nurse is caring for a client who is in the third trimester of pregnancy and reports headaches, visual disturbances, and swelling of the hands and face. Which action should the nurse take first?

Accepted Answer

Answer reason: B. Check the client's blood pressure. Headache, visual changes, and edema in the third trimester are concerning for preeclampsia, which can rapidly progress to severe hypertension, seizure, stroke, placental abruption, and fetal compromise. The priority initial nursing action is to obtain an objective, high-yield assessment that confirms severity and guides urgency of escalation. While reflexes and urine output are relevant for worsening disease, they are secondary to immediately determining whether severe-range hypertension is present. Positioning on the left side can be supportive but should not delay critical assessment and timely provider notification.
Category reason: This is a nursing priority question requiring immediate assessment and risk recognition for a potentially life-threatening obstetric complication, fitting NCLEX patient-care decision-making under system-specific assessment.

Question 46

A neonate with a history of BPD is being weaned from oxygen. Which of the following assessments is MOST important before discontinuing oxygen therapy?

Accepted Answer

Answer reason: These are the highest-risk periods for intermittent hypoxemia in infants with bronchopulmonary dysplasia because oxygen demand increases and ventilation may be less stable. Demonstrating adequate saturations during feeding and sleep helps confirm the infant can maintain oxygenation without supplemental oxygen in real-world conditions. Anthropometric measures and crying pattern do not directly assess oxygenation adequacy and would not predict desaturation after discontinuation.
Category reason: This item tests a nursing assessment decision to reduce risk when discontinuing oxygen therapy in a high-risk neonate, which aligns with system-specific respiratory monitoring under Reduction of Risk Potential.

Question 47

A nurse is caring for a patient admitted with pneumonia. Which of the following actions reflects the assessment phase of the nursing process?

Accepted Answer

Answer reason: A. Auscultating lung sounds and measuring oxygen saturation Assessment is the data-gathering phase of the nursing process and includes collecting objective findings such as breath sounds and pulse oximetry to determine respiratory status. These findings help identify problems like impaired gas exchange and guide subsequent nursing diagnoses and planning. Administering antibiotics is an intervention (implementation), evaluating response is evaluation, and developing a care plan is planning.
Category reason: This question tests identifying a nursing assessment action (collecting respiratory data) for a patient with pneumonia, which aligns with system-specific nursing assessment within Reduction of Risk Potential.

Question 48

A patient with a history of heart failure reports increased shortness of breath and swelling in the legs. Which action should the nurse take first?

Accepted Answer

Answer reason: This presentation suggests possible acute fluid overload with pulmonary congestion, so assessing airway and breathing is the immediate priority. Pulse oximetry rapidly identifies hypoxemia and helps determine urgency for supplemental oxygen, positioning, and escalation of care. Administering a diuretic may be appropriate but should follow a focused assessment and evaluation of respiratory status and overall stability. Weighing and leg elevation are supportive measures but do not address a potentially compromised oxygenation problem first.
Category reason: This item tests a nurse’s first action and prioritization using ABCs in a symptomatic heart failure patient, which is a patient-care judgment within system-focused assessment.

Question 49

A nurse is assessing a 2-day-old newborn who appears jaundiced. Which of the following findings would indicate pathologic jaundice rather than physiologic jaundice?

Accepted Answer

Answer reason: Jaundice that develops in the first 24 hours is a red flag for hemolysis or other disease processes and is therefore considered pathologic until proven otherwise. Physiologic jaundice typically begins after 24 hours of age and peaks later as hepatic conjugation matures. A bilirubin of 12 mg/dL at 48 hours can be within expected ranges depending on gestational age and risk factors. Poor breastfeeding intake more commonly contributes to breastfeeding-associated jaundice but does not by itself define pathologic timing criteria.
Category reason: This item tests nursing assessment and recognition of abnormal newborn findings that increase risk for complications, fitting system-specific assessment under Reduction of Risk Potential.

Question 50

A mother reported that her son is throwing up each time she feeds him. What would be the best assessment question the nurse would ask?

Accepted Answer

Answer reason: Projectile or recurrent vomiting in an infant requires assessment for urgent gastrointestinal pathology and associated red-flag symptoms. A "jelly-like" stool (classically currant jelly) suggests intestinal bleeding/mucus that can occur with intussusception, a time-sensitive condition that can quickly progress to bowel ischemia. Identifying this finding helps the nurse recognize potential complications and the need for immediate medical evaluation rather than focusing on routine feeding technique issues. This assessment targets a high-risk symptom tied to the vomiting presentation.
Category reason: This item tests nursing assessment for a potentially serious complication (GI obstruction/bleeding) in a symptomatic child, which aligns with system-specific assessment to reduce risk potential.

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