Question 1

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Accepted Answer

Answer reason: a. Completes a comprehensive database The first phase of the nursing process is assessment, which focuses on collecting subjective and objective data to establish a baseline. Building a comprehensive database is the core assessment activity that supports accurate problem identification and planning. Nursing diagnoses occur in the diagnosis phase, interventions belong to implementation, and judging whether outcomes were achieved is evaluation.
Category reason: This question tests nursing process judgment about what actions belong to assessment versus diagnosis, implementation, and evaluation, which aligns with nursing assessment and risk reduction through appropriate system-specific assessment.

Question 2

A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?

Accepted Answer

Answer reason: Assessment begins with a general survey to rapidly establish the patient’s overall status and identify any immediate threats requiring urgent intervention. In a problem-oriented approach, the nurse still starts by observing appearance, behavior, breathing effort, and other global cues before narrowing the assessment to the chief complaint. Interpretation comes after data are gathered, and following chronological questions is not the priority when focused assessment is needed. Starting with observation improves safety and guides what targeted questions and exams should follow.
Category reason: This item tests the nursing assessment sequence and clinical judgment about what to do first during data collection, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 3

When analyzing patient cues, what should the nurse prioritize?

Accepted Answer

Answer reason: B. Trends and patterns Patient cue analysis focuses on recognizing changes over time and relationships among findings to identify deterioration, complications, or response to therapy. Single isolated data points (including an initial symptom) can be misleading without context, whereas patterns support accurate clinical judgment and prioritization. Abnormal findings are important, but trends help determine significance, urgency, and likely etiology across body systems. Weight is only one datum and is prioritized mainly when it contributes to a broader pattern (e.g., fluid balance).
Category reason: This item tests nursing assessment and clinical judgment in synthesizing patient cues to guide safe care decisions, which aligns with System-Specific Assessments under Reduction of Risk Potential rather than foundational biomedical science.

Question 4

A patient with diabetes mellitus reports nausea and sweating. What is the priority nursing action?

Accepted Answer

Answer reason: Nausea and sweating in a patient with diabetes are potential signs of hypoglycemia, which can rapidly progress to neuroglycopenia and altered mental status. The safest priority is to assess capillary blood glucose immediately to confirm the problem and guide treatment (carbohydrate vs. insulin adjustment). Giving insulin could worsen unrecognized hypoglycemia, while offering a snack without checking may delay recognition of severe dysglycemia or other acute issues. Assessment first enables timely, appropriate intervention and reduces risk of complications.
Category reason: This question tests the nurse’s priority assessment action in response to possible acute glycemic instability, which is an immediate patient-care judgment and fits NCLEX System-Specific Assessments under Reduction of Risk Potential.

Question 5

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 baseline assessment is a core nursing responsibility to identify instability (e.g., fever, hypotension, tachycardia) that may require notifying the provider or delaying surgery. Obtaining informed consent/permit and explaining the procedure are primarily the provider’s duties; the nurse’s role is to verify the consent is present and the client understands, and to advocate if questions remain. Reviewing lab results can be part of pre-op checks, but the most primary, direct nursing assessment task listed is establishing and documenting current vital signs for comparison and safety monitoring.
Category reason: This is a perioperative patient-care decision focused on nursing assessment responsibilities to reduce surgical risk, which fits NCLEX Reduction of Risk Potential (system-specific assessment).

Question 6

As a nurse, you are treating a patient who had asthma attack, how would you assess If the medication is effective?

Accepted Answer

Answer reason: Peak expiratory flow is an objective, system-specific respiratory assessment that reflects airway caliber and response to bronchodilators during/after an asthma exacerbation. Improvement in peak flow indicates decreased bronchospasm and better airflow, making it a direct measure of medication effectiveness. Heart rate and blood pressure are nonspecific and may change due to anxiety, hypoxia, or medication side effects rather than improved ventilation. Ability to walk can improve later but is less sensitive and can be limited by fatigue or other factors.
Category reason: This question focuses on selecting the best objective nursing assessment to evaluate response to asthma medication, which is a respiratory system-specific assessment used to detect improvement and reduce risk of complications.

Question 7

An elder male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom but that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?

Accepted Answer

Answer reason: The symptoms (hesitancy, weak start, nocturia, and a sensation of incomplete emptying) suggest urinary retention, commonly from benign prostatic hyperplasia. Palpating/percussing the suprapubic area helps assess for bladder distention and guides immediate next nursing actions (e.g., further assessment with bladder scan and notifying the provider). Urine culture is more appropriate when infection signs are present (dysuria, fever, foul/cloudy urine). Fingerstick glucose and fluid intake review do not directly assess for retention and are lower priority than evaluating bladder distention.
Category reason: This is primarily a nursing assessment decision in response to urinary symptoms, focusing on identifying a potential complication (urinary retention) through a targeted genitourinary assessment.

Question 8

A nurse is preparing to administer a medication via a nasogastric tube. What is the first step?

Accepted Answer

Answer reason: Verifying correct nasogastric tube placement is the priority safety step before giving any medication because malposition can lead to aspiration and serious pulmonary complications. Placement is typically confirmed by checking external tube markings and aspirating gastric contents and assessing pH per facility policy; some situations require radiographic confirmation. Flushing, diluting, or preparing the medication comes after placement is confirmed to ensure safe administration and tube patency.
Category reason: This item tests a nursing safety action and assessment required prior to administering medications through an NG tube, which is a patient-care judgment consistent with System-Specific Assessments under Reduction of Risk Potential.

Question 9

A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect?

Accepted Answer

Answer reason: Stupor is a depressed level of consciousness in which the patient requires vigorous, repeated stimulation to elicit a brief, limited response and then quickly lapses back into unresponsiveness. A painful stimulus such as a sternal rub may produce transient arousal, minimal verbalization, or purposeful withdrawal. A GCS

Question 10

A nurse is caring for a client with chest pain. Which action should the nurse take first?

Accepted Answer

Answer reason: Initial assessment comes first to rapidly determine hemodynamic stability and identify immediate life threats such as hypotension, hypoxia, or dysrhythmia. Vital signs also guide the safety of subsequent interventions (e.g., nitrates can worsen hypotension) and establish baseline data for ongoing monitoring. After stabilization and rapid assessment, obtaining a 12-lead ECG and initiating oxygen only if hypoxemic are prioritized, along with other chest pain protocols.
Category reason: This item tests nursing prioritization of immediate assessment and monitoring in a symptomatic client, aligning with system-specific assessment and prevention of complications rather than foundational science knowledge.

Question 11

The primary element required to match individual patient needs with appropriate services is proper?

Accepted Answer

Answer reason: Matching services to a patient’s needs requires first collecting comprehensive subjective and objective data to identify problems, strengths, risks, and preferences. Without accurate data, subsequent steps may target the wrong priorities or miss key safety issues. Planning and implementation depend on the identified needs, and evaluation occurs after interventions to determine effectiveness.
Category reason: This question tests the nursing process step used to identify patient needs and guide appropriate care services, which aligns with nursing assessment and risk reduction through system-specific assessments.

Question 12

A 5-year-old child with type 1 diabetes mellitus has had repeated hospitalizations for episodes of hyperglycemia. The parents tell the nurse that they can’t keep track of everything they need to do to be done to care for their child. The nurse reviews medications, diet, and symptom management with the parents and draws up a daily checklist for the family to use. These activities are completed in which step of the nursing process?

Accepted Answer

Answer reason: c. Implementation These actions describe carrying out nursing interventions: teaching the parents about medication, diet, and symptom monitoring and providing a practical tool (a checklist) to support adherence at home. Assessment would be gathering and validating data about the family’s needs and barriers; planning would be setting goals and selecting interventions. Evaluation would occur later by determining whether the checklist and education reduced hyperglycemia episodes and improved self-management.
Category reason: This question tests identification of the nursing process step for patient/family teaching and executing a care plan, which is a nursing judgment/intervention task consistent with NCLEX-style patient care content.

Question 13

What is the first step in the nursing process?

Accepted Answer

Answer reason: The nursing process begins by collecting subjective and objective data to establish a baseline, identify actual/potential problems, and determine client needs. Accurate data gathering supports appropriate nursing diagnoses and ensures subsequent planning is individualized and safe. Starting with later steps (planning/implementation/evaluation) without initial data risks inappropriate interventions and missed complications.
Category reason: This item tests nursing judgment about the sequence of the nursing process, with emphasis on performing an initial client assessment before other care decisions, fitting NCLEX assessment-focused content.

Question 14

A client with type 2 diabetes mellitus reports a blood glucose level of 300 mg/dL. What is the nurse’s first action?

Accepted Answer

Answer reason: Assessment is the priority before implementing interventions unless there is an immediate life-threatening emergency. A glucose of 300 mg/dL warrants evaluation for severity and complications (e.g., dehydration, polyuria/polydipsia, altered mental status, abdominal pain, tachypnea) that could suggest impending DKA/HHS. The findings guide urgency, need for ketone testing, and whether sliding-scale insulin is appropriate or if higher-level intervention is needed. Calling the provider or giving insulin may be necessary, but should follow rapid focused assessment and verification per facility protocol.
Category reason: This question tests the nurse’s priority first action using the nursing process, emphasizing focused assessment to reduce risk from a potentially worsening physiologic condition, which fits System-Specific Assessments.

Question 15

What activity should the nurse use in the evaluation phase of the nursing process?

Accepted Answer

Answer reason: Evaluation focuses on judging whether expected outcomes/goals were achieved by comparing current client data with the planned outcomes. This requires assessing the client’s response to interventions and determining if the plan of care was effective. If outcomes are not met, the nurse revises the nursing diagnoses, goals, or interventions and continues the cycle of the nursing process. Asking the client’s opinion can contribute data, but the core evaluation task is measuring outcome attainment and intervention effectiveness.
Category reason: This item tests a nurse’s use of the nursing process (evaluation) to assess whether interventions achieved client outcomes, which is a patient-care judgment and assessment activity aligned with NCLEX clinical practice.

Question 16

A patient with a new colostomy reports foul-smelling drainage. What should the nurse do first?

Accepted Answer

Answer reason: Foul-smelling ostomy drainage can indicate infection or other complications, so the priority is to assess for abnormal findings (e.g., erythema, warmth, swelling, purulent drainage, fever) before implementing interventions. Assessment first supports safe, appropriate decision-making and helps determine whether provider notification and treatment are needed. Changing the pouch may temporarily reduce odor but could delay recognition of a potentially serious problem. Encouraging oral intake or giving analgesics does not address the immediate safety concern without first evaluating the ostomy and surrounding tissue.
Category reason: This item asks what the nurse should do first in response to a possible complication of a new colostomy, emphasizing nursing assessment to identify risk/complications before intervening.

Question 17

A patient post-appendectomy has abdominal pain. What should the nurse do first?

Accepted Answer

Answer reason: Abdominal pain after appendectomy can indicate expected postoperative discomfort but may also signal complications such as wound infection, hematoma, or dehiscence. The priority is to assess for cues that change the plan of care (appearance of the incision, drainage, swelling, temperature, and increasing tenderness) before intervening. Pain medication may be appropriate, but giving it first can mask worsening symptoms and delay recognition of a complication. Ambulation and fluids are supportive measures but are not the immediate priority when new or increased pain is reported.
Category reason: This is a postoperative nursing judgment question focused on the first priority nursing action and assessment to detect complications, aligning with System-Specific Assessments under Reduction of Risk Potential.

Question 18

What is the first step in the nursing process?

Accepted Answer

Answer reason: The nursing process begins by collecting and verifying subjective and objective data to establish a baseline and identify actual or potential problems. Without accurate data gathering, subsequent steps (diagnoses, planning interventions, and implementation) may be unsafe or ineffective. Assessment is also ongoing, as new findings require reassessment and adjustment of the care plan.
Category reason: This question tests the sequence of nursing actions in the nursing process, emphasizing the nurse’s initial patient-care judgment to gather data, which aligns with System-Specific Assessments.

Question 19

A client is receiving oxygen at 2 L/min via nasal cannula. Which assessment finding indicates the oxygen therapy is effective?

Accepted Answer

Answer reason: This reflects adequate arterial oxygenation and indicates the supplemental oxygen is improving gas exchange. The other findings (tachypnea, cyanosis, and accessory muscle use) are signs of ongoing respiratory distress and possible hypoxemia or increased work of breathing, suggesting therapy is not sufficient or the condition is worsening. Pulse oximetry is a primary bedside measure to evaluate response to oxygen therapy in a stable perfusion state.
Category reason: This is a patient-care assessment question asking which clinical finding demonstrates effective oxygen therapy, which aligns with nursing evaluation of respiratory status.

Question 20

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

Accepted Answer

Answer reason: Preoperative nursing care includes collecting baseline assessment data to detect instability and inform perioperative safety planning. Vital signs are a core nursing assessment that must be performed and interpreted by the nurse, with abnormal findings communicated promptly to the provider/anesthesia team. Obtaining the surgical permit and explaining the procedure for informed consent are provider responsibilities (the nurse may witness the signature and reinforce teaching). Reviewing labs is important, but the primary nursing responsibility among these choices is direct patient assessment.
Category reason: This item asks about the nurse’s role in preoperative patient care, focusing on assessment responsibilities and perioperative safety, which aligns with System-Specific Assessments under Reduction of Risk Potential.

Question 21

What is the nurse’s priority when a 6-month-old infant refuses to feed and has sunken fontanelles?

Accepted Answer

Answer reason: Sunken fontanelles in an infant are a classic assessment finding suggesting dehydration, and refusal to feed increases risk of worsening fluid deficit. The first priority is to assess severity (e.g., mucous membranes, tears, capillary refill, urine output, level of alertness) to determine urgency and the appropriate route of rehydration. Interventions like oral rehydration or IV fluids depend on whether dehydration is mild/moderate versus severe or if the infant cannot tolerate oral intake. Encouraging breastfeeding can help with hydration but should follow assessment and clinical determination of acuity.
Category reason: This is a nursing priority/assessment decision in a pediatric patient to identify risk of a complication (dehydration) before choosing the correct intervention, which aligns with system-specific assessment under Reduction of Risk Potential.

Question 22

A client at 40 weeks gestation reports ruptured membranes with no contractions. What is the nurse's initial action?

Accepted Answer

Answer reason: With rupture of membranes at term and no contractions, the priority initial nursing action is to assess fetal status to identify distress early. Fetal heart rate monitoring helps detect hypoxia and complications that may follow membrane rupture (e.g., cord compression or prolapse), guiding urgent escalation if abnormalities are found. Initiating oxytocin or preparing for cesarean are provider-directed interventions that should follow assessment and clinical indication. Encouraging oral intake does not address the immediate maternal-fetal safety priority.
Category reason: This is a patient-care priority question focused on the nurse’s first assessment/intervention in an obstetric situation, which aligns with NCLEX-style clinical judgment under system-specific assessment to reduce risk.

Question 23

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take?

Accepted Answer

Answer reason: The rhythm description fits normal sinus rhythm: regular P waves preceding each QRS, normal PR interval (0.12–0.20 s), narrow QRS (

Question 24

What should the nurse do first when a postpartum woman develops a temperature of 38.3°C on day 2 after a vaginal delivery?

Accepted Answer

Answer reason: A postpartum temperature on day 2 can indicate developing infection (e.g., endometritis or a perineal wound infection), and the priority is to assess for the source before treating symptoms. Inspecting lochia (amount, color, odor) and the perineum for redness, swelling, tenderness, or discharge helps identify infection early and guides timely provider notification and culture/antibiotic decisions. Giving antipyretics or fluids may lower fever transiently but can delay recognition of the underlying cause if assessment is not done first. Checking blood glucose is not the most immediate or likely first step for postpartum fever without other supporting cues.
Category reason: This is a nursing judgment question focused on the first action in response to a postpartum change in condition, emphasizing targeted assessment to detect complications, which fits NCLEX Reduction of Risk Potential—System-Specific Assessments.

Question 25

A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect?

Accepted Answer

Answer reason: Stupor indicates markedly decreased responsiveness, where the patient can be aroused only with vigorous or repeated stimulation and quickly returns to an unresponsive state when stimulation stops. A painful stimulus such as a sternal rub may produce brief arousal, minimal verbalization, or purposeful movement. A GCS

Question 26

In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading?

Accepted Answer

Answer reason: Deflation should be slow enough to avoid underestimating systolic pressure and overestimating diastolic pressure while allowing clear identification of Korotkoff sounds. Standard technique is to deflate at about 2–3 mmHg per second; with a typical adult inflation level (about 30 mmHg above expected systolic), this corresponds to roughly 30–45 seconds of deflation time. Deflating faster can miss the true systolic point, and deflating too slowly can cause venous congestion and discomfort that may distort the reading. A prior measurement 4 hours earlier helps estimate the expected systolic level but does not change the required controlled deflation rate.
Category reason: This question tests correct nursing technique for measuring blood pressure (a focused cardiovascular assessment skill), which is best classified under System-Specific Assessments within Reduction of Risk Potential.

Question 27

Which artery is best for assessing true pulse contour?

Accepted Answer

Answer reason: The carotid artery is a central pulse point that most closely reflects true arterial pulse contour because it is proximal to the aorta and less affected by peripheral vasoconstriction. It remains more reliable during low cardiac output states (e.g., shock) when distal pulses such as radial or popliteal may be weak or absent. Assessing a central pulse provides a better representation of overall hemodynamic status than peripheral sites.
Category reason: This question tests selection of the most appropriate pulse site during patient assessment, which is a system-specific nursing assessment skill rather than foundational biomedical science.

Question 28

Scenario: A diabetic patient becomes pale, diaphoretic, and confused. What is the nurse's immediate action?

Accepted Answer

Answer reason: The presentation (pallor, diaphoresis, confusion) is highly suspicious for acute hypoglycemia, a rapidly reversible and life-threatening complication in a diabetic patient. Immediate bedside capillary glucose confirms the problem and directs urgent treatment (e.g., oral glucose if safe to swallow or IV dextrose/glucagon if altered). Administering insulin could worsen hypoglycemia, and calling the physician delays essential assessment and intervention. IV fluids may be needed in other metabolic derangements but are not the first step when hypoglycemia is likely.
Category reason: This question tests the nurse’s immediate assessment action in response to acute symptoms in a diabetic patient, focusing on recognizing risk and performing a system-specific bedside assessment before further interventions.

Question 29

Which pulse site is best to assess circulation in the lower limb?

Accepted Answer

Answer reason: It directly reflects arterial perfusion to the lower extremity because it is the major proximal artery supplying the leg. Proximal pulses are assessed when evaluating lower-limb circulation, especially when distal pulses may be weak or absent. Radial and carotid assess upper extremity/central circulation, and apical is a cardiac auscultation site rather than a peripheral pulse for limb perfusion.
Category reason: This question tests selection of an appropriate pulse point as part of a focused physical assessment to evaluate perfusion, which aligns with System-Specific Assessments.

Question 30

A client who is suspected of having pheochromocytoma, complains of sweating, palpitation and headache. Which assessment is essential to make first?

Accepted Answer

Answer reason: Pheochromocytoma causes episodic surges of catecholamines, which can precipitate severe hypertension and hypertensive crisis presenting with headache, palpitations, and diaphoresis. Immediate assessment of blood pressure identifies life-threatening instability and guides urgent interventions to prevent stroke, myocardial ischemia, or arrhythmias. Other assessments (neuro checks, glucose, strength) may be relevant but do not address the most imminent risk first.
Category reason: This question asks the nurse to choose the most essential first assessment to detect urgent physiologic instability in a client with suspected catecholamine-secreting tumor, which aligns with system-specific assessment and complication risk monitoring.

Question 31

The nurse is taking vital signs on her patient with a diagnosis of ALL. His temperature is 38.7°C. What is the nurse's priority?

Accepted Answer

Answer reason: A fever in a patient with acute lymphoblastic leukemia can indicate infection and possible neutropenia, so the nurse should promptly gather focused data to determine stability and the need for urgent escalation. Completing an assessment (including symptoms, hemodynamics, and potential infection sources) guides immediate actions such as notifying the provider, obtaining cultures per protocol, and initiating timely therapy. The other options are either symptomatic comfort measures without addressing risk, or interventions that are premature without confirming overall status and orders.
Category reason: This is a nursing priority question about responding to an abnormal vital sign in an immunocompromised patient, emphasizing ongoing assessment to detect complications and guide timely interventions.

Question 32

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take?

Accepted Answer

Answer reason: Severe pain after a large-volume IV infiltration raises concern for impaired distal perfusion and possible evolving compartment syndrome, which is a limb-threatening complication. The nurse’s priority is neurovascular assessment (pulse quality, capillary refill, color/temperature, sensation, and movement) to identify compromised circulation early and escalate care promptly. Assessing ecchymosis or edema can be done after confirming that distal circulation is intact, and focusing on substance-use history does not address the immediate safety risk.
Category reason: This question tests priority nursing assessment and risk reduction after an IV infiltration, focusing on detecting complications through a system-specific (neurovascular) assessment.

Question 33

Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently assess a child with laryngotracheobronchitis for?

Accepted Answer

Answer reason: Early hypoxia in children commonly presents as agitation, anxiety, and restlessness before more obvious signs like cyanosis develop. Laryngotracheobronchitis can cause upper airway obstruction and increased work of breathing, so subtle neurobehavioral changes may be an early indicator of deteriorating oxygenation. Drooling and muffled voice are more suggestive of epiglottitis or other supraglottic pathology rather than typical croup. Leg pain is not a relevant sign of hypoxia in this context.
Category reason: This item tests nursing monitoring for early signs of respiratory compromise in a pediatric airway condition, emphasizing assessment to prevent complications rather than underlying pathophysiology details.

Question 34

Scenario: A nurse prepares for a fingerstick glucose test. The patient's hand is cold. What should the nurse do next?

Accepted Answer

Answer reason: Cold hands indicate peripheral vasoconstriction and reduced capillary perfusion, which can make it difficult to obtain an adequate drop of blood and may increase the need for repeat punctures. Warming or gently rubbing increases local blood flow and improves sample yield while reducing patient discomfort and tissue trauma. Proceeding without warming risks insufficient specimen volume, and the thumb is typically avoided due to increased sensitivity and callus risk. Cold water would worsen vasoconstriction and further impair capillary blood flow.
Category reason: This item tests a nursing action to optimize a bedside diagnostic assessment (capillary glucose) and prevent complications like inadequate sample or repeat punctures, fitting System-Specific Assessments under Reduction of Risk Potential.

Question 35

The community health nurses' primary concern in the immediate control of hemorrhage among patients with dengue is?

Accepted Answer

Answer reason: In dengue hemorrhagic states, the most immediate life-threatening risk is hypovolemic shock from plasma leakage and bleeding, so rapid detection of deterioration is the priority. Close monitoring of vital signs and perfusion indicators (tachycardia, narrowing pulse pressure, hypotension, cool clammy skin, altered mental status, decreased urine output) enables timely escalation and fluid resuscitation. The other options are supportive but do not address early recognition of shock, which is critical to prevent death.
Category reason: This item tests nursing prioritization of assessment to detect impending shock during hemorrhage, which is a patient-care safety focus rather than foundational biomedical theory, fitting System-Specific Assessments under Reduction of Risk Potential.

Question 36

In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy, the first thing that a nurse should do is to?

Accepted Answer

Answer reason: D. check for the general danger signs IMCI begins with rapidly identifying general danger signs to determine whether the child needs urgent referral or immediate treatment. These signs (e.g., inability to drink/breastfeed, vomiting everything, convulsions, lethargy/unconsciousness) signal potentially life-threatening illness and must be ruled out before proceeding to symptom-specific assessment. Only after excluding danger signs does the nurse move to assessing the four main symptoms and other focused history/assessment.
Category reason: This question tests the sequence of a structured nursing assessment approach (IMCI) to identify urgent risk and guide immediate clinical action, which aligns with System-Specific Assessments under Reduction of Risk Potential.

Question 37

A child with diarrhea is observed for the following EXCEPT?

Accepted Answer

Answer reason: Diarrhea assessment focuses on duration, stool characteristics (including blood), and hydration status because these guide severity, likely cause, and urgency of treatment. Dehydration is a primary complication in children and requires close monitoring of clinical signs. Petechiae suggest bleeding/platelet or vascular pathology and are not a routine observation specific to uncomplicated diarrhea, so it is the exception.
Category reason: This item asks what a nurse should observe/assess in a child with diarrhea, emphasizing clinical monitoring to detect complications, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 38

When assessing for postural hypotension, how long should the patient stand before measuring BP?

Accepted Answer

Answer reason: Orthostatic (postural) vital signs are assessed after changing position to allow hemodynamic stabilization and reveal abnormal autonomic compensation. Standard bedside practice measures BP and pulse after the client has been standing for about 1 minute (and often again at 3 minutes) compared with supine/sitting readings. Measuring immediately or at 10 seconds may miss the typical sustained drop used to define orthostatic hypotension. Waiting 5 minutes is not the usual initial assessment interval and can delay recognition and increase fall risk.
Category reason: This question tests correct technique/timing for obtaining orthostatic blood pressure as part of a nursing assessment to identify risk for complications (e.g., dizziness, syncope), which fits System-Specific Assessments.

Question 39

Scenario: A female patient has an indwelling Foley catheter and reports lower abdominal pain. What should the nurse assess first?

Accepted Answer

Answer reason: Lower abdominal pain in a patient with a Foley catheter can indicate bladder distention from impaired drainage. The fastest, most safety-focused first assessment is to check for a mechanical cause such as a kinked tube, dependent loop, occlusion, or a full drainage bag, because correcting it can rapidly relieve retention and prevent backflow and infection. Urine color, output trends, and labs are important but are secondary after confirming patency and positioning of the catheter system. If obstruction is not found, then assess output, urine characteristics, and notify the provider for further evaluation.
Category reason: This question tests immediate nursing assessment and troubleshooting of an indwelling urinary catheter in response to a symptom, which is a patient-care judgment task under system-specific assessment for preventing complications.

Question 40

Scenario: A patient with a head injury becomes drowsy and confused. What is the priority nursing assessment?

Accepted Answer

Answer reason: A head-injured patient who becomes drowsy and confused may be developing increased intracranial pressure or acute neurologic deterioration. Immediate focused neurologic assessment helps detect early signs of brain herniation risk, including pupillary size, equality, and reactivity. This assessment is rapidly actionable and directly reflects cranial nerve/brainstem function compared with less specific measures. Vital signs are also important, but they may change later than key neurologic findings in early deterioration.
Category reason: This question tests a nurse’s priority assessment in a deteriorating head-injury scenario, emphasizing early detection of complications through focused neurologic assessment, which aligns with System-Specific Assessments under Reduction of Risk Potential.

Question 41

A client with chronic hypertension develops blurred vision, headache, and confusion. What is the nurse’s priority?

Accepted Answer

Answer reason: C. Check blood pressure immediately These symptoms suggest possible hypertensive emergency with acute target-organ involvement (e.g., encephalopathy), requiring rapid assessment to determine severity and guide urgent treatment. Immediate blood pressure measurement is the most time-critical step before giving interventions that could worsen perfusion or delay definitive care. Analgesics and reassurance do not address the life-threatening cause, and IV fluids may be inappropriate if blood pressure is severely elevated or if there is risk of fluid overload.
Category reason: This question focuses on the nurse’s immediate priority assessment in a potentially unstable patient, which is a patient-care judgment and risk reduction task rather than foundational science knowledge.

Question 42

A pregnant woman reports pica (eating clay). What should the nurse assess next?

Accepted Answer

Answer reason: Pica in pregnancy is strongly associated with iron deficiency anemia, and clay ingestion can worsen iron absorption and contribute to complications. Assessing hemoglobin helps identify anemia requiring supplementation and further evaluation, which directly impacts maternal oxygen-carrying capacity and fetal oxygenation. Weight gain and appetite pattern are less specific to the key safety concern, and fetal heart rate assessment does not address the likely underlying maternal deficiency driving the symptom.
Category reason: This question asks for the next nursing assessment in a pregnancy-related symptom to reduce risk of complications, fitting System-Specific Assessments under Reduction of Risk Potential.

Question 43

Which newborn reflex is abnormal and requires further assessment?

Accepted Answer

Answer reason: The rooting reflex is a key feeding-related primitive reflex in newborns and should be present; absence can indicate neurologic dysfunction, prematurity, sedation/exposure to maternal medications, or illness that interferes with feeding readiness. In contrast, Moro, Babinski, and the asymmetric tonic neck reflex are expected primitive reflexes in neonates within normal developmental timeframes. An absent rooting reflex raises immediate concern for ineffective feeding and warrants prompt neurologic and overall clinical evaluation.
Category reason: This question tests recognition of normal vs abnormal newborn primitive reflex findings and when to escalate assessment, which is part of nursing system-specific assessment to reduce risk and detect complications early.

Question 44

A nurse auscultates a murmur over the precordium. What is the next appropriate action?

Accepted Answer

Answer reason: A. Palpate for thrills A murmur is an auscultatory finding that should be followed by a focused cardiovascular assessment to better characterize its significance. Palpating the precordium for a thrill helps determine murmur intensity (a palpable thrill generally corresponds to a louder murmur) and adds objective data to report. Immediate provider notification is typically reserved for new/unstable findings with symptoms or hemodynamic compromise; otherwise the nurse should first complete the assessment before escalating. Repositioning can help clarify certain murmurs, but it is not the most direct next step after identifying a murmur.
Category reason: This item tests the nurse’s immediate bedside assessment action after detecting an abnormal heart sound, which is a patient-care judgment under system-focused assessment rather than foundational anatomy/physiology knowledge.

Question 45

Scenario: During a wound dressing change, the nurse notes yellow tissue in the wound bed. What should the nurse document?

Accepted Answer

Answer reason: Yellow tissue in a wound bed typically represents devitalized, moist fibrinous material and is documented as slough. Healthy granulation is usually beefy red and bleeds easily, while epithelialization appears as thin pink tissue migrating from wound edges. Eschar is devitalized tissue that is generally black or brown and leathery, not yellow. Accurate identification supports appropriate wound care planning and monitoring of healing progress.
Category reason: This item tests nursing assessment and documentation of wound-bed tissue characteristics, which is a system-specific assessment to identify healing status and potential complications.

Question 46

Scenario: An elderly patient becomes dizzy when standing from a seated position. What is the nurse's best action?

Accepted Answer

Answer reason: This presentation is consistent with orthostatic hypotension, which is common in older adults and increases fall risk during position changes. Having the patient rise gradually supports venous return and reduces sudden cerebral hypoperfusion. Measuring blood pressure and pulse in supine, sitting, and standing positions helps confirm the diagnosis and guides further evaluation of contributing factors such as dehydration or medications. The other options either increase fall risk, use inappropriate restrictive measures, or do not address the underlying hemodynamic issue.
Category reason: This is a patient-care safety and assessment question focused on nursing actions to prevent falls and evaluate orthostatic changes, aligning with System-Specific Assessments under Reduction of Risk Potential.

Question 47

A patient post-CABG complains of numbness and tingling in the right foot. What is the nurse’s first action?

Accepted Answer

Answer reason: B. Assess pedal pulse and temperature New numbness/tingling in an extremity after CABG can indicate impaired peripheral perfusion (e.g., arterial occlusion/embolus or compromised circulation related to graft harvest). The priority is an immediate neurovascular assessment to determine adequacy of blood flow by checking distal pulses, skin temperature, and other perfusion indicators before implementing interventions. Elevation could worsen arterial insufficiency, reassurance delays evaluation, and documentation comes after assessment and any urgent notification/intervention.
Category reason: This item tests the nurse’s immediate assessment and recognition of a potential postoperative complication affecting limb perfusion, which aligns with system-specific assessment under Reduction of Risk Potential.

Question 48

Which is the most appropriate action for a nurse seeing early decelerations on the fetal heart monitor?

Accepted Answer

Answer reason: Early decelerations are typically caused by fetal head compression during contractions and are generally a benign, expected finding during labor. They are usually gradual, mirror the contraction pattern, and are not associated with fetal hypoxemia or acidemia when variability is otherwise reassuring. Therefore, no immediate corrective intervention is needed beyond ongoing assessment and documentation of fetal status and labor progress. Escalating measures like oxygen, repositioning, or emergent cesarean are more appropriate for nonreassuring patterns such as late decelerations, variable decelerations with concerning features, or persistent bradycardia.
Category reason: This question tests interpretation of fetal heart rate tracings and the appropriate nursing response during labor, which is a patient-care monitoring/assessment decision rather than foundational physiology alone.

Question 49

A nurse is caring for a client with cardiomyopathy. Which activity is contraindicated during the assessment?

Accepted Answer

Answer reason: Isometric exercise acutely increases systemic vascular resistance and blood pressure, raising afterload and myocardial oxygen demand. In cardiomyopathy, this can worsen cardiac workload, precipitate symptoms (e.g., dyspnea, chest discomfort), and increase risk of decompensation or arrhythmias. The other options are standard, low-risk assessment actions that help evaluate volume status and cardiopulmonary function.
Category reason: This is a nursing clinical judgment question about which assessment-related activity is unsafe/contraindicated for a client with a cardiac disorder, fitting system-specific assessment and risk reduction.

Question 50

Which assessment best reflects fluid status in a client with heart failure?

Accepted Answer

Answer reason: C. Daily weight Rapid changes in body weight are the most sensitive and objective bedside indicator of fluid gain or loss, especially in heart failure where edema and congestion can fluctuate day to day. Monitoring weight at the same time each day with the same scale captures small but clinically meaningful volume changes before overt symptoms worsen. Skin turgor and mucous membranes are less reliable in many adults (e.g., aging, mouth breathing), and urine color is affected by factors like concentration, medications, and intake and does not directly reflect overall fluid volume status.
Category reason: This item tests the nurse’s selection of the most accurate assessment method to monitor fluid volume changes in a heart-failure client, which fits System-Specific Assessments under Reduction of Risk Potential.

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The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?

When analyzing patient cues, what should the nurse prioritize?

A patient with diabetes mellitus reports nausea and sweating. What is the priority nursing action?

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

As a nurse, you are treating a patient who had asthma attack, how would you assess If the medication is effective?

An elder male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom but that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?

A nurse is preparing to administer a medication via a nasogastric tube. What is the first step?

A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect?

A nurse is caring for a client with chest pain. Which action should the nurse take first?

The primary element required to match individual patient needs with appropriate services is proper?

What is the first step in the nursing process?

A client with type 2 diabetes mellitus reports a blood glucose level of 300 mg/dL. What is the nurse’s first action?

What activity should the nurse use in the evaluation phase of the nursing process?

A patient with a new colostomy reports foul-smelling drainage. What should the nurse do first?

A patient post-appendectomy has abdominal pain. What should the nurse do first?

What is the first step in the nursing process?

A client is receiving oxygen at 2 L/min via nasal cannula. Which assessment finding indicates the oxygen therapy is effective?

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

What is the nurse’s priority when a 6-month-old infant refuses to feed and has sunken fontanelles?

A client at 40 weeks gestation reports ruptured membranes with no contractions. What is the nurse's initial action?

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take?

What should the nurse do first when a postpartum woman develops a temperature of 38.3°C on day 2 after a vaginal delivery?

A nurse is told during change of shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect?

In a client with a previous blood pressure of 130/80 4 hours ago, how long will it take to release the blood pressure cuff to obtain an accurate reading?

Which artery is best for assessing true pulse contour?

Scenario: A diabetic patient becomes pale, diaphoretic, and confused. What is the nurse's immediate action?

Which pulse site is best to assess circulation in the lower limb?

A client who is suspected of having pheochromocytoma, complains of sweating, palpitation and headache. Which assessment is essential to make first?

The nurse is taking vital signs on her patient with a diagnosis of ALL. His temperature is 38.7°C. What is the nurse's priority?

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take?

Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently assess a child with laryngotracheobronchitis for?

Scenario: A nurse prepares for a fingerstick glucose test. The patient's hand is cold. What should the nurse do next?

The community health nurses' primary concern in the immediate control of hemorrhage among patients with dengue is?

In assessing the patient’s condition using the Integrated Management of Childhood Illness approach strategy, the first thing that a nurse should do is to?

A child with diarrhea is observed for the following EXCEPT?

When assessing for postural hypotension, how long should the patient stand before measuring BP?

Scenario: A female patient has an indwelling Foley catheter and reports lower abdominal pain. What should the nurse assess first?

Scenario: A patient with a head injury becomes drowsy and confused. What is the priority nursing assessment?

A client with chronic hypertension develops blurred vision, headache, and confusion. What is the nurse’s priority?

A pregnant woman reports pica (eating clay). What should the nurse assess next?

Which newborn reflex is abnormal and requires further assessment?

A nurse auscultates a murmur over the precordium. What is the next appropriate action?

Scenario: During a wound dressing change, the nurse notes yellow tissue in the wound bed. What should the nurse document?

Scenario: An elderly patient becomes dizzy when standing from a seated position. What is the nurse's best action?

A patient post-CABG complains of numbness and tingling in the right foot. What is the nurse’s first action?

Which is the most appropriate action for a nurse seeing early decelerations on the fetal heart monitor?

A nurse is caring for a client with cardiomyopathy. Which activity is contraindicated during the assessment?

Which assessment best reflects fluid status in a client with heart failure?

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