Question 1

Scenario: A 4-year-old child presents with a fever of 39.4°C (103°F) and is shivering. The nurse is preparing to take a temperature. What is the most appropriate site for accurate temperature assessment?

Accepted Answer

Answer reason: It provides a rapid, minimally invasive estimate of core temperature via the tympanic membrane, which reflects blood flow from the hypothalamus. In a febrile, shivering preschool child, speed and cooperation matter; tympanic measurement is typically more feasible than oral while maintaining good accuracy. Axillary readings tend to underestimate core temperature, and oral can be unreliable in young children due to technique and recent intake. Rectal is accurate but more invasive and is generally avoided unless specifically indicated due to discomfort and safety concerns.
Category reason: This question tests selecting the best nursing assessment method/site to obtain an accurate vital sign in a pediatric patient, which is a system-specific clinical assessment decision.

Question 2

Scenario: A nurse is changing a dry sterile dressing on a surgical wound and notes moderate serosanguinous drainage. Q. What should the nurse do next?

Accepted Answer

Answer reason: Moderate serosanguinous drainage can be an expected finding in early postoperative wound healing, so the appropriate nursing action is to assess, protect the wound, and accurately record characteristics (amount, color, odor) while maintaining sterile technique. Culturing is generally reserved for signs of infection (e.g., purulent drainage, foul odor, increasing erythema, fever). Notifying the provider is indicated for abnormal or worsening findings (e.g., sudden large/bright-red drainage, dehiscence, systemic symptoms), not for expected moderate serosanguinous output. Leaving the wound open to air is not appropriate when a sterile dressing is ordered and drainage is present, as it increases contamination risk and can impair healing.
Category reason: This item tests a nurse’s appropriate next action and documentation when assessing postoperative wound drainage, emphasizing safe assessment and prevention of complications in patient care.

Question 3

Scenario: A male patient’s Foley catheter is removed after 3 days. Four hours later, he has not voided. Q. What is the best nursing action?

Accepted Answer

Answer reason: After Foley removal, failure to void within several hours raises concern for urinary retention, which should be assessed promptly. A bladder scan is a noninvasive way to determine bladder volume and differentiate retention from low urine production. This guides next steps (e.g., timed voiding measures vs. catheterization per protocol) and reduces unnecessary catheter reinsertion and CAUTI risk. Waiting longer or only encouraging fluids can delay recognition of retention and lead to bladder overdistention.
Category reason: This is a nursing decision about assessing for a potential post-catheter removal complication (urinary retention) and choosing the safest immediate assessment action, fitting System-Specific Assessments under Reduction of Risk Potential.

Question 4

At 20 weeks, the fundus is noted to be below the umbilicus. What should the nurse do first?

Accepted Answer

Answer reason: A full bladder can displace the uterus and make the fundal height measure lower than expected, creating a potentially false abnormal finding. The first nursing action is to correct common reversible factors and then repeat the measurement to validate accuracy before escalating care. If the fundal height remains low after recheck, it may indicate issues such as inaccurate dating, growth restriction, oligohydramnios, or fetal position and would warrant provider notification and further evaluation.
Category reason: This question tests a nursing assessment action and the appropriate first step to ensure an accurate obstetric measurement, which fits System-Specific Assessments under Reduction of Risk Potential.

Question 5

Scenario: A post-op patient is snoring loudly and breathing irregularly. Q. What is the nurse's first action?

Accepted Answer

Answer reason: Snoring with irregular respirations in the immediate post-op period commonly indicates partial upper-airway obstruction (e.g., tongue/soft tissue relaxation from residual anesthesia). The priority is ABCs: open the airway with positioning (head tilt–chin lift or jaw thrust as appropriate) and immediately assess airway patency, breathing effectiveness, and oxygenation. Suctioning is not first unless secretions are clearly obstructing, and calling anesthesia follows initial stabilization/assessment. Increasing IV fluids does not address the urgent airway/breathing problem.
Category reason: This item tests immediate nursing prioritization and assessment/intervention for airway compromise in a post-operative patient, which is a patient-care safety decision consistent with NCLEX Physiological Integrity focused on system-specific respiratory/airway assessment.

Question 6

The nurse is caring for a client after spinal surgery. What is the priority assessment?

Accepted Answer

Answer reason: B. Leg strength and sensation Post–spinal surgery, the most time-sensitive risk is neurologic compromise from edema, hematoma, or cord/nerve root injury. Frequent neuro checks of motor strength and sensation in the lower extremities allow early detection of deterioration that may require urgent intervention to prevent permanent deficits. Incision drainage and intake/output are important but are secondary to detecting acute neurologic changes. Respiratory rate is essential in general postoperative care, but in this specific surgery the targeted priority assessment is neurologic status below the level of surgery.
Category reason: This is a postoperative nursing judgment question focused on prioritizing assessments to detect complications, which fits NCLEX patient-care decision-making under system-specific assessments.

Question 7

Preterm Premature Rupture of Membranes (PPROM) A 32-week pregnant client presents with gush of clear fluid and no contractions. What is the priority nursing action?

Accepted Answer

Answer reason: A) Check fetal heart rate Rupture of membranes can lead to umbilical cord compression or prolapse, and fetal compromise may be the earliest life-threatening complication. Immediate assessment of fetal status is therefore the first priority before any other interventions. A digital vaginal exam should be avoided due to increased infection risk in PPROM. Oxytocin is not an initial step in a stable 32-week client without contractions, and discharge is unsafe without evaluation and monitoring.
Category reason: This question asks for the priority nursing action and immediate assessment in a pregnancy complication, which is a patient-care decision requiring nursing judgment.

Question 8

A client with diabetes reports blurred vision and frequent urination. The nurse should first.?

Accepted Answer

Answer reason: A. Check capillary blood glucose Blurred vision and frequent urination are classic manifestations of hyperglycemia due to osmotic diuresis and transient lens changes. The safest first nursing action is to obtain an objective bedside glucose value to confirm severity and guide the next interventions. Giving insulin without a current glucose risks inappropriate dosing and hypoglycemia, while calling the provider or encouraging fluids may be appropriate but should follow assessment data and any facility protocol for abnormal results.
Category reason: This item tests the nurse’s priority assessment action in response to symptoms suggesting an acute change in glycemic control, which aligns with system-specific assessment under Reduction of Risk Potential.

Question 9

A client with uncontrolled hypertension is now confused and has a severe headache. What is the priority action?

Accepted Answer

Answer reason: The sudden confusion and severe headache in a client with uncontrolled hypertension are red flags for hypertensive crisis and possible neurologic complication, so immediate assessment of current blood pressure is essential to determine severity and guide urgent interventions. This aligns with ABCs and assessment-first priorities: you must verify and quantify the problem before implementing or escalating treatment. After confirming a markedly elevated reading, rapid escalation of care (including notifying the provider/activating emergency response and preparing antihypertensive therapy) is indicated. Trendelenburg is inappropriate and can worsen intracranial pressure, and oxygen is not the first action unless hypoxia is present.
Category reason: This item tests the nurse’s priority assessment and immediate action in an acute change in condition (possible hypertensive emergency), which is a patient-care decision under system-specific assessment and risk reduction.

Question 10

Patient has intravenous fluids infusing in the right arm when taking a blood pressure on this patient, the nurse would?

Accepted Answer

Answer reason: Blood pressure should be measured on an extremity without infusing IV fluids to avoid occluding the line, altering flow rates, and increasing risk of infiltration or discomfort. Cuff inflation can transiently stop the infusion and may also yield an inaccurate reading due to local venous congestion and patient guarding. Measuring on the opposite arm is the safest and most reliable approach when available. Using a smaller cuff would worsen accuracy by falsely elevating readings, and it is not necessary to forgo measurement when an alternate limb is available.

Question 11

A mother brings her to the clinic, complaining that the child seems to be in pain. The nurse expects to find which of the following on the initial history and physical assessment?

Accepted Answer

Answer reason: B) Rash and redness Pain in a child is commonly associated with localized inflammation, where tissue injury triggers release of inflammatory mediators causing erythema, warmth, and tenderness. During an initial assessment, visible skin changes such as redness and rash can be immediate cues pointing toward an inflammatory or allergic process that may be painful. Fever and lethargy or increased sleeping/listlessness are more systemic and nonspecific findings that do not localize the source of pain as reliably on first exam. Diarrhea with poor skin turgor suggests dehydration from gastrointestinal illness and is less directly linked to a primary pain complaint unless abdominal findings are provided.

Question 12

A nurse is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen?

Accepted Answer

Answer reason: Deep breathing helps mobilize secretions from the lower airways and triggers an effective cough, which is necessary to produce true sputum rather than saliva. Taking several deep breaths increases lung expansion and loosens mucus so the specimen is more likely to be adequate in volume and quality. Limiting fluids can thicken secretions and make expectoration harder. Spitting into the container risks collecting saliva instead of sputum, and obtaining a specimen after eating increases contamination risk and can provoke nausea/vomiting.

Question 13

Which of the following signs and symptoms of increased ICP after head trauma would appear first?

Accepted Answer

Answer reason: Early increased intracranial pressure first affects cerebral function and perfusion, so subtle changes in level of consciousness are typically the earliest and most sensitive findings. Agitation, restlessness, and confusion reflect early cortical impairment and rising ICP before the body triggers later brainstem-mediated vital-sign changes. Bradycardia and widened pulse pressure are components of Cushing’s response, which usually occurs later with significant ICP elevation and impending herniation. Polyuria with very dilute urine suggests diabetes insipidus from hypothalamic/pituitary involvement, which is not usually the earliest presentation of increased ICP.

Question 14

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

Accepted Answer

Answer reason: Early stroke care prioritizes frequent neurologic assessment to detect deterioration and complications such as increasing intracranial pressure or hemorrhagic transformation. Pupillary size and reactivity are rapid, sensitive indicators of brainstem involvement and rising intracranial pressure and can signal the need for urgent escalation of care. In the first 24 hours, trending these findings helps identify worsening cerebral edema and guides timely interventions to protect airway, breathing, and cerebral perfusion. Tests like lipid panels or echocardiography help evaluate risk factors and etiology but do not provide immediate bedside detection of acute neurologic decline. Bowel sounds are not a priority compared with neurologic status in the acute phase of stroke.

Question 15

A nurse is assessing a toddler with a blood pressure of 84/52 mmHg and a pulse rate of 126 beats/min. Which of the following interventions is appropriate?

Accepted Answer

Answer reason: Pediatric vital signs must be interpreted against age-based norms before initiating emergency actions. For toddlers, a systolic blood pressure in the mid-80s and a resting heart rate in the 120s can be within expected ranges, especially with mild anxiety or activity, so this set does not by itself indicate shock. The safest appropriate nursing action is to record the assessment and continue routine monitoring/trending rather than escalate or start invasive therapy. Notifying the provider or giving an IV bolus is reserved for abnormal findings with clinical signs of poor perfusion (e.g., altered mental status, delayed cap refill, cool extremities) or a downward trend. Ordering labs such as BUN/electrolytes is not a first-line response to otherwise age-appropriate vital signs without additional concerning assessment data.

Question 16

The nurse cares for a young adult woman undergoing peritoneal dialysis. The nurse notes that the outflow is bloody. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Bloody peritoneal dialysis effluent can occur from benign contamination with menstrual blood due to proximity of the genital tract to the catheter exit site and drainage system. The nurse should first assess for this common, non-emergent cause because it can immediately clarify the finding and prevent unnecessary interruption of therapy or escalation. If bleeding is not explained by menses, then further assessment for complications (e.g., catheter trauma, intra-abdominal bleeding) and hemodynamic status becomes the priority. Calling the provider is appropriate after rapid nursing assessment, while simply continuing dialysis without clarifying the source risks missing a true complication.

Question 17

The clinic nurse evaluates a client diagnosed with type 1 diabetes. Which of the following observations indicates to the nurse that the client is not rotating insulin injection sites?

Accepted Answer

Answer reason: Failure to rotate injection sites causes repeated tissue trauma and local inflammatory changes that can lead to lipohypertrophy or scarring, making injections progressively more tender and sometimes altering absorption. A pattern of increasing local pain is a practical clinical cue that the same area is being used repeatedly. A wheal is more consistent with an immediate local reaction or intradermal placement rather than site overuse. Temporary glucose rises are nonspecific and can occur from many factors (diet, illness, missed dose) and do not directly indicate poor site rotation.

Question 18

The nurse gives a report to the next shift. During the report, a client’s ventilator alarm is activated. Which of the following actions should the nurse take FIRST?

Accepted Answer

Answer reason: Ventilator alarms can signal an immediately life-threatening ventilation/oxygenation problem, so the nurse must first assess the client rather than the equipment. Listening to breath sounds rapidly helps identify acute issues such as displacement/obstruction, bronchospasm, or absent/unilateral ventilation suggesting a possible pneumothorax or tube malposition. Equipment-focused steps (e.g., checking tubing for condensate) and calling the respiratory therapist are appropriate after a quick patient assessment confirms stability or identifies the likely cause. Silencing the alarm without assessing risks delaying recognition of respiratory compromise.

Question 19

A nurse is assessing a client's AV fistula before dialysis. Which finding is normal?

Accepted Answer

Answer reason: These findings reflect turbulent arterial-to-venous flow created by the surgical connection and are expected on routine assessment. In contrast, absence of a bruit suggests thrombosis or occlusion and requires urgent evaluation to prevent loss of access. Redness/swelling suggests infection or inflammation, and delayed capillary refill indicates impaired distal perfusion, neither of which is a normal pre-dialysis finding.

Question 20

A nurse is assessing a 1-year-old child with vomiting and diarrhea. Which finding indicates moderate dehydration?

Accepted Answer

Answer reason: In a child with vomiting and diarrhea, moisture of the mucous membranes is a sensitive bedside marker of fluid deficit and aligns with moderate dehydration. A bulging fontanel suggests increased intracranial pressure rather than dehydration (dehydration more often causes a sunken fontanel). Bradycardia is not typical of moderate dehydration and would be more concerning for severe decompensation, while normal skin turgor would argue against clinically significant dehydration.

Question 21

Which pulse site requires the location of Point of Maximal Impulse (PMI)?

Accepted Answer

Answer reason: Clinically, this is typically at the left 5th intercostal space at the midclavicular line in adults, so identifying the PMI guides accurate apical pulse assessment. Peripheral pulses like radial and femoral are palpated over superficial arteries and do not require chest landmarking. Carotid assessment is also a neck arterial palpation/auscultation and is unrelated to locating the PMI on the precordium.

Question 22

Position used for assessing jugular vein distention is?

Accepted Answer

Answer reason: This angle optimizes the balance between venous filling and gravitational collapse of the neck veins, making abnormal elevation easier to detect. A fully upright position may reduce venous distention and obscure the finding in some patients. Trendelenburg is not the standard assessment position for JVD and can artificially increase venous return, confounding interpretation.

Question 23

What is the primary purpose of a nasal cannula?

Accepted Answer

Answer reason: It provides controlled supplemental oxygen (commonly 1–6 L/min) to improve oxygenation and help correct mild hypoxemia. Suctioning secretions is performed with suction catheters, and monitoring oxygen levels is done with pulse oximetry/ABGs, not the cannula. Medication delivery to the lungs is typically accomplished via nebulizers or inhalers rather than a standard nasal cannula.

Question 24

A nurse is caring for a client 2 days post-op after abdominal surgery. The client reports nausea, abdominal distention, and has not passed gas. What is the priority action?

Accepted Answer

Answer reason: Auscultating bowel sounds provides immediate data about gastrointestinal function and helps determine whether oral intake is appropriate or should be withheld. Offering clear liquids could worsen nausea/vomiting and aspiration risk if ileus is present. Administering an antiemetic may relieve symptoms but does not address or clarify the underlying cause, and provider notification is best after obtaining focused assessment findings unless the patient shows signs of acute deterioration.

Question 25

The nurse is managing a client with postpartum hemorrhage who is becoming increasingly anxious. What should the nurse prioritize?

Accepted Answer

Answer reason: Postpartum hemorrhage is an actual/potential circulatory emergency where rapid blood loss can progress to hypovolemic shock. Increasing anxiety can be an early sign of hypoxia or worsening perfusion, so the priority is immediate assessment of hemodynamic stability with vital signs. Blood pressure trends and tachycardia guide urgency and escalation (e.g., activating hemorrhage protocol, fluids/blood products) more directly than comfort measures. Supportive interventions like calming techniques and environmental changes are appropriate but only after life-threatening deterioration is assessed and addressed.

Question 26

The LPN/LVN assesses a client diagnosed with Ménière’s disease. Which of the following client statements requires follow-up?

Accepted Answer

Answer reason: Ménière’s disease management includes reducing triggers that can worsen inner-ear fluid dynamics and symptoms. Nicotine can cause vasoconstriction and is a common aggravator of vertigo and tinnitus, so ongoing heavy smoking warrants follow-up teaching and risk-reduction counseling. The low-pitched roaring tinnitus is a classic expected symptom of the disorder. A focusing strategy during vertigo and some residual disequilibrium after an attack can occur and are generally less concerning than an ongoing modifiable trigger.

Question 27

A nurse is developing a care plan for a client with hypokalemia. Which intervention should the nurse prioritize?

Accepted Answer

Answer reason: Hypokalemia can precipitate dangerous cardiac dysrhythmias and conduction abnormalities, so rapid identification of electrical instability is the highest safety priority. Reviewing ECG findings helps detect changes such as ST depression, T-wave flattening, and prominent U waves that may signal imminent arrhythmia risk and guide urgency of potassium replacement and monitoring level. Magnesium assessment is important because hypomagnesemia can make hypokalemia refractory, but it is typically secondary to immediate cardiac risk screening. IV patency and BUN assessment support treatment planning, yet they do not address the most immediate life-threatening complication.

Question 28

The physician tells the nurse that a client has a rectocele. Which of the following should the nurse assess the client for?

Accepted Answer

Answer reason: Increased intra-abdominal pressure and repetitive straining can also contribute to development or worsening of hemorrhoids. Assessment should therefore include bowel habits, straining, and anorectal symptoms consistent with hemorrhoidal disease (pain, itching, bleeding). Diarrhea is not the typical associated bowel pattern, and vague “lesions” is nonspecific compared with the common, related anorectal complication. Backache can occur with some pelvic organ prolapse, but hemorrhoidal issues are more directly linked to the constipation/straining pattern commonly present with rectocele.

Question 29

The nurse is assessing a patient's abdomen. Which examination technique should the nurse use first ?

Accepted Answer

Answer reason: Visual inspection is noninvasive and should be performed before any technique that could stimulate peristalsis or cause guarding. Palpation and percussion can change bowel activity and increase discomfort, which can confound subsequent findings. Auscultation is done before percussion and palpation, but it is not the first overall step because inspection precedes it in the standard abdominal exam sequence.

Question 30

A nurse is preparing for a focused assessment of the chest and lungs of a client. Which position is best for the nurse to place this client?

Accepted Answer

Answer reason: Upright positioning improves diaphragmatic descent and lung expansion, making breath sounds clearer and reducing dependent atelectasis effects. It also allows the nurse to compare symmetric excursion and assess accessory muscle use and work of breathing more accurately. By contrast, dorsal recumbent, Sims’, and knee-chest positions are primarily used for abdominal, rectal, or pelvic procedures and limit posterior lung assessment and ventilation mechanics.

Question 31

CAPILLARY REFILL TIME IS?

Accepted Answer

Answer reason: In a healthy adult with warm extremities, normal refill is typically about 2 seconds (often cited as ≤2 seconds). A value longer than this raises concern for decreased peripheral perfusion from causes such as hypovolemia, shock, hypothermia, or peripheral vascular disease. Options like 3–4 seconds reflect delayed refill and are not considered normal.

Question 32

What actions should a nurse implement to correctly assess the progress of ascites and a dialysis?

Accepted Answer

Answer reason: Daily weights provide a sensitive, objective measure of overall fluid balance, and abdominal girth measurements specifically track intra-abdominal fluid accumulation. Together they show whether interventions (e.g., fluid removal via dialysis/ultrafiltration or other therapy) are reducing volume over time. Intake/output and electrolytes are important for monitoring dialysis effects but do not directly quantify ascitic volume, and vital signs/temperature/oxygenation are less specific for evaluating ascites progression unless complications develop.

Question 33

The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client’s peripheral response to pain?

Accepted Answer

Answer reason:  Motor response to pain should be assessed using a standardized noxious stimulus that can be applied distally to evaluate peripheral motor withdrawal/localization. Applying firm pressure to the nail bed provides a controlled, reproducible peripheral pain stimulus and allows observation of purposeful movement in the extremities. Central stimuli such as a sternal rub or pressure on the orbital rim primarily test central response and can increase risk of bruising or facial/ocular injury if done improperly. A peripheral stimulus is preferred when the goal is specifically to assess extremity motor function in an unconscious client.

Question 34

Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma?

Accepted Answer

Answer reason:  Early increased ICP most commonly first presents with subtle changes in level of consciousness due to reduced cerebral perfusion and impaired cortical function. New-onset agitation, restlessness, and confusion are sensitive early findings that often precede vital sign changes. Bradycardia and widened pulse pressure are later components of Cushing response, indicating more advanced brainstem compression. Large volumes of dilute urine suggests diabetes insipidus from hypothalamic/pituitary dysfunction, which is not the typical earliest sign of rising ICP after head trauma.

Question 35

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?

Accepted Answer

Answer reason: Applying pressure to the nail bed provides a controlled, reproducible stimulus to a peripheral site, allowing the nurse to observe extremity motor response without primarily stimulating central structures. Central stimuli such as a sternal rub, pressure on the orbital rim, or squeezing the sternocleidomastoid are less specific for peripheral motor assessment and can be unnecessarily aggressive or risk injury (especially near the eyes/face). A distal stimulus best isolates peripheral motor response in an unconscious client for neurologic assessment and trending.

Question 36

A client that has sustained a sports injury has just finished an arthroscopy on his left knee. The nurse caring for him should FIRST assess the client for which of the following factors?

Accepted Answer

Answer reason: Assessing distal circulation (pulses, capillary refill, color, temperature) and neurologic status (sensation, movement, pain/paresthesia) detects complications such as compromised perfusion from swelling, tight dressings, or compartment syndrome. These findings can progress rapidly and threaten limb viability, so they come before mobility or routine wound checks. Skin/wound integrity is important but typically not as urgent as ensuring adequate perfusion and nerve function immediately post-procedure.

Question 37

After the membrane rupture what is the priority assessment for the nurse-?

Accepted Answer

Answer reason: The fastest, most sensitive bedside indicator is the fetal heart rate pattern, which can reveal bradycardia or decelerations requiring emergent intervention. Maternal blood pressure is important but is not the first assessment tied to the most time-critical complication right after ROM. Vaginal/pelvic exams are not the priority action and can increase infection risk; presentation assessment may be done after confirming fetal well-being.

Question 38

A client undergoing chemotherapy develops white lesions on their tongue and inner cheeks. The LPN/LVN knows the condition is likely?

Accepted Answer

Answer reason: Oral Candida typically presents as white plaques/lesions on the tongue and buccal mucosa that may be removable and can be associated with burning or taste changes. Aphthous ulcers are usually painful shallow ulcers with an erythematous base rather than diffuse white plaques. Leukoplakia is a persistent, non-scrapable white patch usually linked to chronic irritation (e.g., tobacco) and is less directly tied to acute chemotherapy-related immunosuppression than thrush.

Question 39

The sequence in examining the quadrants of the abdomen is?

Accepted Answer

Answer reason: A common nursing convention is to start in the right upper quadrant at the ileocecal valve area for bowel sounds and proceed in an orderly clockwise direction. This improves reliability and reduces the chance of missing or mislabeling findings across quadrants. Options that jump between non-adjacent quadrants break the standardized sequence and increase documentation and reassessment errors.

Question 40

Your patient has just had carpal tunnel surgery to his left wrist. What should you check frequently following any surgery on a limb?

Accepted Answer

Answer reason: Monitoring skin color reflects adequacy of arterial flow and venous return, while checking sensation helps detect nerve compression or ischemia. Assessing movement evaluates motor function and can reveal evolving compartment syndrome or nerve injury. Options emphasizing cast characteristics are less applicable here because the priority is limb neurovascular status regardless of whether a cast is present. Including edema or grip strength can be helpful, but they are not as universally central as neurovascular checks.

Question 41

A 37-weeks-pregnant woman comes to the emergency department with a fractured ankle. Which assessment finding is most concerning and requires the nurse to follow up?

Accepted Answer

Answer reason: A sustained rate >160/min is concerning, and a value over 200/min is particularly abnormal and warrants immediate reassessment (maternal vitals, hydration, pain/anxiety control) and continuous fetal monitoring/OB notification. By contrast, 4 fetal movements in an hour can be reassuring depending on the counting method used. Mild irregular contractions at term and a hemoglobin of 11 g/dL can be expected in late pregnancy and are less urgent than a persistently extreme fetal heart rate.

Question 42

A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

Accepted Answer

Answer reason: In contrast, purulent drainage is thick/opaque and suggests bacterial infection. Red, hard skin can indicate worsening inflammation or cellulitis with induration rather than normal healing. Warmth with tenderness is more concerning when it is increasing, localized, and associated with other infection signs (progressive erythema, swelling, fever), so it is not the best “normal” finding here.

Question 43

A female client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess?

Accepted Answer

Answer reason: Respiratory excursion refers to the visible rise and fall and symmetry of the thorax during breathing, which is a core part of inspection of the respiratory system. Observing excursion helps the nurse judge whether chest expansion is equal bilaterally and whether accessory muscles or retractions suggest increased work of breathing. Lung vibrations (tactile fremitus) are assessed by palpation, not observation, and vocal sounds/breath sounds are assessed by auscultation. Therefore, observation of respiratory excursion most directly evaluates chest movement patterns.

Question 44

A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client’s chest wall, the nurse expects to elicit?

Accepted Answer

Answer reason: Normal lung tissue filled with air produces a resonant note on percussion over most of the chest. A history of asthma does not mean the client is currently in an acute exacerbation; in a stable preoperative assessment, expected percussion remains normal. Hyperresonance is more suggestive of significant air trapping (e.g., acute severe asthma attack or emphysema), which is not indicated here. Dullness or flatness would suggest increased tissue density such as consolidation, pleural effusion, or a solid organ and would be abnormal for typical lung fields.

Question 45

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the?

Accepted Answer

Answer reason: Cyanosis is best assessed in areas with minimal melanin because bluish discoloration is harder to detect in darker skin. The oral mucous membranes (e.g., inside the lips, buccal mucosa) provide a reliable site where hypoxemia-related color changes are more visible. In acute respiratory distress, this focused assessment helps the nurse rapidly identify inadequate oxygenation. Fingernail beds and earlobes can appear less obviously cyanotic in darkly pigmented skin and are therefore less dependable for early detection.

Question 46

For a male client with an endotracheal (ET) tube, which nursing action is most essential?

Accepted Answer

Answer reason:  Immediate assessment of airway and ventilation is the highest priority in an intubated client. Bilateral breath sounds help confirm effective ventilation and can quickly identify problems such as right mainstem intubation, tube displacement, or obstruction that can cause rapid hypoxemia. This bedside check is fast, repeatable, and directly tied to life-threatening complications of an ET tube. Turning, ABG trending, and oral care are important supportive measures, but they do not verify current tube function and ventilation as directly or as urgently.

Question 47

The nurse is assessing the vital signs of a 2 day old neonate. The appropriate method of measuring this patient’s temperature is?

Accepted Answer

Answer reason: Axillary temperature is recommended for routine assessment in neonates because it is noninvasive and avoids mucosal and tissue injury. Rectal temperatures can cause rectal perforation or vagal stimulation in newborns, and tympanic readings are less reliable due to small, curved ear canals and technique sensitivity. Oral temperatures are not appropriate in a 2-day-old because the infant cannot safely and consistently cooperate with oral placement.

Question 48

A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions are appropriate when caring for this access site?

Accepted Answer

Answer reason: Routine assessment each shift helps detect early thrombosis or stenosis so the provider can intervene before access loss occurs. Options about “tubing” apply to dialysis circuits or grafts with external components, not a surgically created internal fistula. Circulation checks should focus distal to the fistula (hand/fingers) for steal syndrome rather than proximal circulation.

Question 49

A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every two hours. Which of the following outcome criteria would the nurse use?

Accepted Answer

Answer reason:  Peripheral circulation is evaluated by perfusion markers that reflect arterial blood flow to distal tissues. Capillary refill time under 3 seconds is a standard, objective indicator of adequate peripheral perfusion in the extremities, which is directly relevant in sickle cell disease where vaso-occlusion can impair blood flow. In contrast, ability to move toes and intact sensation primarily assess neuromuscular function and can remain normal despite reduced perfusion early on. Temperature is nonspecific and does not specifically measure lower-extremity perfusion status.

Question 50

A mother brings her child to the clinic, complaining that the child seems to be “constantly thirsty.” The nurse expects to find which of the following on the initial history and physical assessment?

Accepted Answer

Answer reason: Moist mucous membranes are consistent with adequate hydration despite the reported thirst and may be seen early before objective dehydration is evident. By contrast, diarrhea with poor skin turgor and dry mucosa would indicate dehydration and would more strongly suggest fluid loss as the driver rather than isolated excessive thirst. Fever/lethargy or excessive sleeping/listlessness are nonspecific and do not directly correlate with the expected physical finding related to hydration in a focused initial assessment.

Train with a large NCLEX question bank and jump into a full exam-style simulator

System-Specific Assessments NCLEX Practice Test

Continue Learning