NCLEX PRACTICE TESTS

A client comes to the local clinic complaining that sometimes his heart pounds and he has trouble sleeping. The physical exam is normal. The nurse learns that the client has recently started a new job with expanded responsibilities and is worried about succeeding. Which of the following responses by the nurse is BEST? 1. "You appear to have concerns about your ability to do your job." 2. "You could benefit from counseling." 3. "It's normal to feel anxious when starting a new job." 4. "Have you talked to your family about your concerns?"

1) "You appear to have concerns about your ability to do your job." Use reflection to repeat the patient's words back at them.

The nurse is caring for a patient with Meniere's disease. The nurse knows that the most important consideration in regard for patient safety is to: 1. Ask the nursing assistant to walk with the patient when she needs to use the bathroom. 2. Remind the patient to wash her hands frequently, especially after voiding or before meal times. 3. Raise the side rails on the patient's bed. 4. Offer the patient alternative meal choices from the cafeteria.

1) Ask the nursing assistant to walk with the patient when she needs to use the bathroom. Patients with Meniere's disease can get attacks of vertigo very suddenly, so a nursing assistant can provide stability. Raising the side rails counts as a restraint.

The lab results are now available for a nurse caring for a patient with Addison's disease. Which of the following results are UNEXPECTED in this patient? 1. Hypokalemia. 2. Hyperkalemia. 3. Hyponatremia. 4. Hypocalcemia.

1) Hypokalemia. A patient with Addison's may have hypocalcemia due to poor diet and lack of appetite. They are expected to have hyponatremia and hyperkalemia as part of their labs. Hypokalemia, however, is related to Cushing's, not Addison's.

The nurse is caring for a client after an ECT treatment. The nurse is MOST concerned if which of the following is observed? 1. The client complains of backache. 2. The client is unable to remember what she ate for breakfast. 3. The client is unable to recall her name. 4. The client complains of headache.

1) The client complains of backache. Temporary short term and long term memory loss is common after ECT, as well as a headache. Backaches are not expected and therefore needs to be further investigated.

A patient begins hyperventilating due to a panic attack. The registered nurse knows that the correct intervention is to: 1. Put the patient on 2L of oxygen. 2. Call the physician. 3. Have the patient breathe into a paper bag. 4. Have the patient bear down.

3) Have the patient breathe into a paper bag. Paper bag is the best method because it allows the patient to breathe back in their own CO2 with less oxygen and correct the balance.

Which of the following materials would the graduate nurse require to test the function of a patient's glossopharyngeal nerve? 1. A stethoscope. 2. A handheld mirror. 3. Tongue depressor. 4. Soft cotton swab and a toothpick.

3) Tongue depressor. The glossopharyngeal nerve can be tested for function by assessing gag reflex. The tongue depressor checks gag reflex.

A patient comes to the ER complaining of joint pain that began in his great toe. Which of the following risk factors, if seen in the patient's history, does the nurse suspect triggered the patient's condition? 1. Smoking. 2. Vegetarian diet. 3. Lactovegetarian diet. 4. One glass of wine weekly with dinner.

4) One glass of wine weekly with dinner. Pain that begins in the great toe is caused by gout, a condition triggered by meats, dense proteins, and alcohol.

After a cardiac catheterization, the nurse instructs the patient to lie in which position?

A) The patient needs to be on bedrest, on their back, to avoid moving their leg and possibly restarting bleeding in the femoral artery.

The nurse gives discharge teaching to a patient going home on Doxycycline. Which of the following patient statements, if made by the patient to the nurse, requires further teaching? Select all that apply: 1. "I should take this medication after I eat a meal." 2. "I will use sunscreen when I plan on spending time outdoors." 3. "I am glad that, unlike most antibiotics, I won't have to use a backup method of birth control." 4. "If I get a white coating on my tongue, I will immediately stop the medication." 5. "I will follow up with my doctor visits and get my labs checked every month."

1) "I should take this medication after I eat a meal." 3) "I am glad that, unlike most antibiotics, I won't have to use a backup method of birth control." 4) "If I get a white coating on my tongue, I will immediately stop the medication." It is always appropriate to wear sunscreen when going outside. This patient will have to use a backup method of birth control and take the medication on an empty stomach. The white coating is glossitis, a normal side effect, but the patient should not stop the medication. This patient needs to follow up and have their renal function checked.

A nurse assesses the health of a 78 year-old male patient at his annual wellness check-up. Which of the following statements, if spoken by the patient, would be considered normal and EXPECTED? Select all that apply:: 1. "I'm really enjoying spending time with my grandchildren." 2. "Ever since my husband died, I don't want to go out of the house anymore." 3. "Although I feel more tired during the day, I can only seem to sleep for about six hours every night." 4. "I seem to have less of an appetite lately." 5. "I am worried that I will be unable to afford my new blood pressure medication."

1) "I'm really enjoying spending time with my grandchildren." 3) "Although I feel more tired during the day, I can only seem to sleep for about six hours every night." 4) "I seem to have less of an appetite lately." It is normal for the elderly to have a decreased appetite and less sleep. It is also normal for them to enjoy their next phase of life as "grandparent" instead of "parent."

A six-year-old boy with a casted left leg rings his call bell. Which of the following statements, if made by the nurse, requires an immediate intervention? 1. "My leg feels funny." 2. "The edge of the cast is hurting my skin." 3. "Can you give me a ruler so I can scratch my leg inside my cast?" 4. "My leg itches."

1) "My leg feels funny." This option is a sign of impaired sensation (paresthesias). The cast is too tight!

A patient with tuberculosis asks why he must take two drugs for his one disease. The nurse explains that: 1. "The combination of two drugs against tuberculosis will help eliminate resistance from forming against the medications." 2. "We use two medications against tuberculosis to reduce the amount of time it takes to make your condition non-transmissible." 3. "The drug companies want more money." 4. "It works better with two medications. No one knows why."

1) "The combination of two drugs against tuberculosis will help eliminate resistance from forming against the medications." It is better to completely eliminate tuberculosis in the first attempt than only take one med and leave 5% of the organism alive... creating a resistant strain.

The nurse on a locked psychiatric unit is administering morning medications to a patient with schizophrenia. The patient refuses and says, "I'm not going to take that!" What is the nurse's BEST response? 1. "You have the right to refuse this medication, but the doctor may get a second opinion and have it ordered as an intramuscular injection." 2. "The doctor has ordered it for you so you have to take it." 3. "You do not have the right to refuse this medication because you are on a locked unit." 4. "Why not? This medication will make you feel a lot better."

1) "You have the right to refuse this medication, but the doctor may get a second opinion and have it ordered as an intramuscular injection." A 'locked unit' does not mean that patients are forced to take the medications. If they refuse enough, however, their prescribing doctor can get a second opinion from another doctor and the medication is made mandatory if refused by mouth.

A patient at the outpatient clinic describes leg pain that occurs while walking and is relieved with rest. The patient asks why this happens to him. The nurse knows that the pain is related to: 1. Arterial insufficiency. 2. Venous insufficiency. 3. Angina. 4. Heart failure.

1) Arterial insufficiency. This pain only occurs in arterial insufficiency and is known as intermittent claudication.

A 22-year-old patient and her husband come to the ER after a fall down the stairs. The patient has a black eye, avoids looking at the nurse, and gives yes/no answers to the nurse's assessment questions. Which of the following actions should the nurse take NEXT? 1. Ask the patient to produce a urine sample in the presence of the nurse. 2. Ask the patient how she fell down the stairs. 3. Report the patient's husband for abuse to the nurse's immediate supervisor. 4. Ask the patient if she hit her head when she fell.

1) Ask the patient to produce a urine sample in the presence of the nurse. The goal is to get the patient away from her potential abuser and ask her, face to face, "Are you being abused?" If so, you can offer help. You may NEVER report a capable adult unless they ask for it.

A patient on the psychiatric unit has been taking Haldol for three days as ordered by the physician. During the nurse's shift, she enters the patient's room to find the patient in a prolonged muscle spasm, with his eyes looking upward, and a fever of 103.5 degrees. Which of the following actions, if performed by the nurse, would be considered CORRECT? Select all that apply: 1. Call the physician. 2. Withhold the next dose of Haldol. 3. Prepare the patient to move to ICU (intensive care unit). 4. Withhold all medications. 5. Retrieve a cooling blanket for the patient.

1) Call the physician. 2) Withhold the next dose of Haldol. 3) Prepare the patient to move to ICU (intensive care unit). 5) Retrieve a cooling blanket for the patient. These are all the correct actions in responding to the signs/symptoms of neuroleptic malignant syndrome. Withholding all medications would not be appropriate.

A patient takes Nardil for depression and is confused by the dietary restrictions and allowances that are required with the medication. Which food on the list below is NOT permitted when taking Nardil? Select all that apply: 1. Cheddar cheese and crackers. 2. An apple and a cup of tea. 3. Miso soup. 4. Smoked salmon and cream cheese on a bagel. 5. A four (4) ounce glass of wine. 6. Sandwich with fresh lunchmeat.

1) Cheddar cheese and crackers. 3) Miso soup. 4) Smoked salmon and cream cheese on a bagel. 5) A four (4) ounce glass of wine. 6) Sandwich with fresh lunchmeat. The patient may not eat foods containing preservatives or foods/wine that have been aged.

The nurse notes that a physician new to the hospital's computer system has input three out of four orders INCORRECTLY for a patient. Which of the following medications is CORRECT for a patient with the following criteria: Diabetes Insipidus, Dehydration, Hypertension. 1. DDAVP. 2. Furosemide. 3. Insulin. 4. Hypertonic saline.

1) DDAVP. Lasix is a diuretic, which is not good for a dehydrated patient. Insulin is for diabetes mellitus, not diabetes insipidus. Hypertonic saline is for SIADH, not diabetes insipidus. DDAVP will help the patient hold onto more water.

The charge nurse implements a change in the nursing assistant's job description. The change increases the nursing assistant's responsibilities. A nurse with 20 years of service on the unit verbally agrees to the change, but her behaviors indicate otherwise. Which of the following actions by the charge nurse is MOST appropriate? 1. Enable an open discussion during a prescheduled meeting. 2. Inform the charge nurse that you have observed her verbal agreement differs from her behavior. 3. Schedule an appointment to speak with the nurse in private. 4. Ask the nursing assistants to accommodate the nurse.

1) Enable an open discussion during a prescheduled meeting. Do not directly confront the nurse or ask anyone to accommodate her. Instead, use a meeting to bring up the issue and allow her peers to speak positively about the change. Peer pressure can be an effective tool.

On a psychiatric unit, the preferred milieu environment is BEST described as: 1. Fostering a therapeutic social, cultural, and physical environment. 2. Providing an environment that will support the patient in his or her therapeutic needs. 3. Fostering a sense of well-being and independence in the patient. 4. Providing an environment that is safe for the patient to express feelings.

1) Fostering a therapeutic social, cultural, and physical environment. The milieu environment includes the whole spectrum of environments a patient interacts with. This answer has the most correct range.

The nurse enters a patient's room and observes via the monitor that their vital signs are as follows: blood pressure 80/42, heart rate 118, respirations 32. The nurse will place the patient in which of the following positions? 1. Head slightly elevated and midline, knees straight, all four extremities elevated on pillows. 2. Reverse trendelenburg position. 3. HOB elevated 30 degrees, head midline, pillow under the patient's knees. 4. Trendelenburg position.

1) Head slightly elevated and midline, knees straight, all four extremities elevated on pillows. This patient's vital signs indicate s/he is going into shock. The correct shock position on NCLEX is all extremities elevated on pillows.

The incoming nurse received the day's endorsement for her assigned clients. One particular client needs to be monitored for signs of thyroid storm. Which of the following are considered signs of thyroid storm? Select all that apply: 1. Hyperkinesis. 2. Enlarged thyroid gland. 3. Increased urine output. 4. Hypertension. 5. Fever. 6. Vomiting.

1) Hyperkinesis. 4) Hypertension. 5) Fever. 6) Vomiting. Thyrotoxic crisis (also called thyroid storm) is a severe hyperthyroid state that can occur in hyperthyroid individuals who are untreated or who are experiencing another illness or stressor. It may also occur following thyroid surgery. Symptoms include hyperkinesis, tachycardia, high fever, hypertension (with eventual heart failure and hypotension), vomiting, dehydration, restlessness, and delirium or coma.

A patient with Cushing's disease asks the nurse to help him choose a meal for dinner later. Which of the following meals is the best option? 1. Roasted chicken with corn and green beans. 2. Mexican-style beef with guacamole and beans on the side. 3. Pork chops in cream sauce with mashed potatoes and carrots. 4. Hamburger with french fries and apple slices.

1) Roasted chicken with corn and green beans. A patient with Cushing's disease needs to eat a low sodium, high protein, low fat diet. Hamburger and french fries is high fat, pork chops in cream sauce is high fat, guacamole is high fat. Roasted chicken is high protein with low fat.

A nurse is caring for a patient with 2nd degree burns all over her body. The nurse knows that which of the following measures is appropriate when the patient is prescribed application of silver sulfadiazine cream? Select all that apply: 1. The nurse checks the patient's chart for allergies to sulfa medications. 2. The nurse tells the patient, "I'm going to apply the cream the doctor ordered. It won't hurt a bit." 3. The nurse uses sterile technique to care for the patient. 4. The nurse gives the patient pain medication after the cream has been applied. 5. The patient signs a consent form to be able to apply the cream. 6. The lab technician draws blood specimens the day after the cream has been applied.

1) The nurse checks the patient's chart for allergies to sulfa medications. 3) The nurse uses sterile technique to care for the patient. 6) The lab technician draws blood specimens the day after the cream has been applied. Any patient allergic to sulfa will be allergic to the cream, which is treatment for burns. As it is applied, it causes a burning sensation as a normal side effect. A consent form is unnecessary. Sterile technique for burns is recommended. Labs need to be drawn to check for neutropenia as a complication of the medication. Patients should be pre-medicated before having treatment for burns.

The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? Select all that apply: 1. The nursing assistant checks the residual and records it before returning it to the patient. 2. The nursing assistant elevates the head of the bed approximately 15 degrees during the tube feeding. 3. The nursing assistant elevates the head of the bed to semi-Fowler's position during the tube feeding and for thirty minutes after the tube feeding. 4. The nursing assistant uses a stethoscope to listen for bowel sounds. 5. The nursing assistant listens for a "puff" of air in the patient's stomach to check tube placement.

1) The nursing assistant checks the residual and records it before returning it to the patient. 3) The nursing assistant elevates the head of the bed to semi-Fowler's position during the tube feeding and for thirty minutes after the tube feeding. The head of the bed must be elevated sufficiently to decrease the risk of aspiration- 15 degrees is not enough. Listening for a "puff" of air is not as accurate as an x-ray or pH assessment. Residuals should be returned to patients via tubes, always. The nursing assistant cannot perform assessments and therefore isn't qualified to listen to bowel sounds.

A patient is scheduled for a cardiac catheterization this afternoon. Which of the following, if noted in the patient's chart by the nurse, is a contraindication to the test? 1. The patient is allergic to clams. 2. The patient is allergic to eggs. 3. The patient has a history of asthma. 4. The patient is unable to lie on her right side for more than 15 minutes.

1) The patient is allergic to clams. Cardiac catheterizations require dye, which is made of iodine. Iodine's cross-allergy is shellfish!

The nurse changes a dressing on a client with an abdominal wound with a Penrose drain in place. What priority information should the nurse chart about this procedure? 1. The time the dressing was changed, a general description of the wound, and the amount of drainage overall. 2. The color and the amount of drainage from the wound and the time the dressing was changed. 3. A picture of the wound and a description of its healing process. 4. The amount of pain the client experienced during the dressing change and a general description of the wound.

1) The time the dressing was changed, a general description of the wound, and the amount of drainage overall. This includes the best overall picture of drainage and how the wound appears. Time is a factor that allows the next nurse to assess correctly.

A patient with glaucoma asks the nurse what he can do to improve his vision. The nurse knows that: 1. Vision loss from glaucoma is irreparable once present. 2. Vision loss from glaucoma will heal itself over time. 3. Vision loss from glaucoma can be helped with daily medication. 4. Vision loss from glaucoma can be corrected with glasses.

1) Vision loss from glaucoma is irreparable once present. Vision from glaucoma cannot be fixed, only stabilized.

A patient is admitted to the cardiac intensive care unit following diagnosis of a myocardial infarction. Please order the following actions from first to last. a. Provide the patient with water. b. Administer oxygen at 2L. c. Initiate thrombolytic therapy. d. Initiate an intravenous catheter. e. Connect the patient to continuous cardiac monitoring equipment.

1) b. Administer oxygen at 2L. 2) e. Connect the patient to continuous cardiac monitoring equipment. 3) d. Initiate an intravenous catheter. 4) c. Initiate thrombolytic therapy. 5) a. Provide the patient with water. Standard nursing interventions call for oxygen and cardiac monitoring first. Then begin using an IV to give medication. Last, give water if allowed but be careful of fluid overload.

The charge nurse in the emergency department receives a call that four patients will be arriving immediately with various injuries. Based on the following reports, order the patients from first to last to be seen: a. A child with a break through the skin and obvious deformity of the right leg who is pale and complains he feels dizzy. b. A child who cries loudly with a cut on her forehead and a heart rate of 105. c. An adult with no obvious injuries, a heart rate of 135, and confusion. d. An adult with an obvious deformity of the left forearm, a strong radial pulse, and complaints of extreme pain.

1) c. An adult with no obvious injuries, a heart rate of 135, and confusion. 2) a. A child with a break through the skin and obvious deformity of the right leg who is pale and complains he feels dizzy. 3) d. An adult with an obvious deformity of the left forearm, a strong radial pulse, and complaints of extreme pain. 4) b. A child who cries loudly with a cut on her forehead and a heart rate of 105. Change of level of consciousness is the first sign of shock or head injury. No obvious injuries mean that they could be internal, leading the nurse to suspect internal hemorrhage. The child who is pale may be about to go into shock and should be seen next. See the adult in pain next, then the child upset about the cut.

A primipara is in the transition phase of labor on the maternity unit. On the fetal heart monitor, the nurse observes a contraction begin. Shortly after a delay, the fetal heart rate dips. It only recovers after the contraction has already been ended for a period of 30 seconds. Please place the following actions in order from first to last. a. Turn the mother on her left side. b. Call the physician. c. Administer oxygen by facial mask. d. Reassure the mother. e. Stop the Pitocin drip.

1) e. Stop the Pitocin drip. 2) a. Turn the mother on her left side. 3) c. Administer oxygen by facial mask. 4) b. Call the physician. 5) d. Reassure the mother. Stop the Pitocin drip first. Pitocin can cause the late decelerations that are described above. Reposition and give oxygen to the mom, then call the physician, and reassure the mother (psychosocial item is last).

A patient comes into the ER with the complaint of inability to void. The nurse performs a bladder scan and receives a result of 2,000 mL. The nurse prepares to catheterize the patient and knows that the most important part of the procedure relies on: 1. Clamping the tubing after every 500mL is drained and waiting five minutes. 2. Educating the patient about possible causes of inability to void. 3. Teaching the patient how to self-catheterize themselves at home. 4. Allowing the patient to attempt to void after 500mL has been drained.

1). Clamping the tubing after every 500mL is drained and waiting five minutes. Clamping the tubing after each 500mL prevents bladder spasms, which are painful and not good for the bladder.

The nurse receives a call from a patient with type one diabetes. The patient asks for exercise guidelines in regard to eating and insulin administration. Which of the following instructions are MOST appropriate for the nurse to give to the patient? Select all that apply: 1. "It is best to eat a more complex carbohydrate before you exercise so that you don't bottom out." 2. "Be sure to eat a simple carbohydrate snack before you exercise." 3. "It is smart to alert your gym that you have type one diabetes." 4. "Do not administer insulin immediately before and after exercise." 5. "You may want to leave an energy drink with electrolytes in your gym locker in case you need it."

2) "Be sure to eat a simple carbohydrate snack before you exercise." 3) "It is smart to alert your gym that you have type one diabetes." 4) "Do not administer insulin immediately before and after exercise." It is best to eat a simple carbohydrate to boost the blood sugar slightly before exercise. Giving insulin soon before or after exercise can cause a patient to bottom out. Alerting the patient's gym to their medication condition is recommended.

The nurse cares for a ninety-two year-old patient whose wife recently passed away. Which of the following statements, if made by the patient to the nurse, requires further investigation? 1. "Since her death, I just haven't felt like eating much." 2. "I gave away my favorite watch to my nephew the other day. I wanted him to have it, in case I'm not around for much longer." 3. "Sometimes I think I feel my wife's presence in the house. It makes me feel better to think she's still looking after me." 4. "Without my wife, life is so tasteless. I keep asking God why this happened to me."

2) "I gave away my favorite watch to my nephew the other day. I wanted him to have it, in case I'm not around for much longer." Giving away valuable possessions and making vague statements like "I may not be around" are signs of suicidal ideations. This comment needs to be further addressed.

The nurse observes that a preschooler who was admitted to the unit three days ago has enuresis. His mother is very upset and says, "But he hasn't done that in years!" Which of the following responses, if made by the nurse to the mother, is MOST appropriate? 1. "Sometimes that happens. It's okay, I'll clean him up." 2. "It is very common for children who have been admitted to the hospital to experience regression, where they fall back on old childhood habits. It is usually very temporary." 3. "This behavior is unusual for a child for this age. I'll call the doctor." 4. "I remember when my child used to do that. We had her in pull-ups forever!"

2) "It is very common for children who have been admitted to the hospital to experience regression, where they fall back on old childhood habits. It is usually very temporary." Children who have been admitted to the hospital may deal with this stress by regressing, or falling back on former behaviors. This is normal and temporary.

The nurse teaches a 20-year-old female how to perform SBE (self breast exams). Which of the following instructions, if given by the nurse, is INCORRECT? 1. "Remember that breast tissue may feel tender at times, and this is normal." 2. "The best time to perform your SBE is at the end of the month." 3. "The first position you will use to inspect your breasts is to stand with your arms at your sides." 4."Use your index, pointer, and ring fingers to firmly palpate the breast in a circular motion."

2) "The best time to perform your SBE is at the end of the month." The best time to perform SBE is one week after the onset of the woman's menstrual period, when hormones are at the lowest. It is normal for hormonal changes during the month to make breast tissue tender or enlarged. The other options are correct as well.

The nurse in an emergency room receives a call from an ambulance alerting that a bomb has gone off in a nearby shopping center and a minimum of forty victims will be arriving shortly for medical care. What action should the nurse take NEXT? 1. Prepare enough stretchers to accommodate overflow. 2. Alert the nursing supervisor. 3. Tell the ambulance crew to take half the victims to the next-nearest hospital. 4. Alert the rest of the ER nurses that they will be working mandatory double shifts.

2) Alert the nursing supervisor. There is most likely a disaster plan in place, which must be implemented by the nursing supervisor. The ER nurse must go up the chain of command to resolve this issue.

A 67-year-old client is seen in the outpatient clinic for complaints of perineal irritation due to frequent incontinence. Which of the following measures, if suggested to the client by the nurse, is BEST? Select all that apply: 1. Apply Bacitracin cream to the perineum. 2. Gently cleanse the perineum 2 to 3 times per day with warm water and pat dry. 3. Apply a generous amount of barrier cream. 4. Use extra large incontinence briefs to provide for air movement. 5. Ambulate the patient to the bathroom every two hours. 6. Expose the perineum to air for thirty minutes of each day.

2) Gently cleanse the perineum 2 to 3 times per day with warm water and pat dry. 3) Apply a generous amount of barrier cream. Keeping the skin clean and protected is most important. Ambulating the patient to the bathroom every two hours assumes this is a particular type of incontinence. There is no infection that warrants Bacitracin cream. Extra large briefs may not fit and will cause further irritation/rubbing.

The nurse cares for a client who suffered a severe eye injury related to an acid splash. The nurse administers proparacaine hydrochloride (Ophthaine) before each eye examination. It is MOST important for the nurse to take which of the following actions? 1. Measure the client's intraocular pressure. 2. Instruct the client not to rub the eye. 3. Instruct the client about the action of the drug. 4. Inform the client that effects of the medication last about 30 minutes.

2) Instruct the client not to rub the eye. Rubbing the eye could cause further injury because the medication numbs the eye- the patient would not know he is causing himself injury.

Which of the following skin manifestations in an infant MOST concerns the nurse? 1. A three inch by four inch bluish-purple, bruised-looking area on the buttocks. 2. Large, flat, irregularly shaped macular patch on the left side of the face. 3. Irregularly shaped light pink patches on the back of the neck. 4. Red, raised, clearly delineated nodules with a rough surface. Incorrect

2) Large, flat, irregularly shaped macular patch on the left side of the face. This is neveus flammeus, commonly known as a birth mark, and will not fade. The pink patches are stork bites and will fade, as will the nodules. The bluish-purple bruised-looking area is the normal occurrence of a mongolian spot.

A client with baseline decreased mental status is ordered to receive a tube feeding. The nurse knows the best position for the patient once the feeding has finished is: 1. Left side with head of the bed elevated. 2. Right side with head of the bed elevated. 3. Semi-Fowler's. 4. High-Fowler's.

2) Right side with head of the bed elevated. Placing the patient on the right side is ideal for digestion and having the head of the bed elevated will prevent aspiration.

The nurse notices a significant increase in the number of patients admitted to the medical/surgical unit who do not have ID bracelets on their wrists. Instead, the ID bracelets are taped to the chart and are often lost in the process. Which of the following actions, if taken by the nurse, is BEST to resolve this issue? 1. Call down to the ER and demand to speak with the charge nurse about this problem. 2. Schedule a meeting with the charge nurse of the ER to discuss a solution that will benefit everyone. 3. Encourage the nurses to place the ID band on the patient as soon as they arrive on the unit. 4. Address the issue during a prescheduled meeting and ask why the nurses in the ER have not been doing their job correctly.

2) Schedule a meeting with the charge nurse of the ER to discuss a solution that will benefit everyone. This issue can be resolved with minimal fuss in a brainstorming session to discuss solutions. This option avoids blame (unlike 1 and 4) and does not put all the responsibility on the unit nurses.

A five-month-old boy is brought to the clinic by his parents for a routine visit. Which of the following observations would require an intervention by the nurse? 1. The child cannot walk. 2. The child abducts his extremities and fans his fingers when he hears a loud noise. 3. The child cries when he sees the nurse. 4. The infant has gained 7 pounds since birth.

2) The child abducts his extremities and fans his fingers when he hears a loud noise. It is normal for the child to have gained 7 lbs since birth (doubling weight, which is normal). A 5-month-old cannot walk. The Moro (startle) reflex, however, should have disappeared by 4 months of age.

Which of the following situations is an example of negligence? 1. The nurse observes a UAP enter the room of a patient on contact precautions wearing gloves and a gown. 2. The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization. 3. A nurse transcribes a new medication order: Questran powder 2 oz bid with wet food or one full glass of water. 4. The UAP fills a water basin with warm water while the patient with depression combs her hair.

2) The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization. The nurse should have checked the patient's distal pulse immediately after the cardiac catheterization.

A graduate nurse prepares a patient to undergo a liver biopsy. The graduate nurse administers what pre-op medication? 1. Coumadin. 2. Vitamin K. 3. Vitamin B-12. 4. Vitamin A.

2) Vitamin K. Vitamin K is administered before a liver biopsy to reduce the risk of bleeding.

The nurse in the outpatient clinic reviews the history of a client recently diagnosed with essential hypertension. The nurse is MOST concerned if the client states which of the following? 1. "I eat one orange and one banana every day." 2. "I take vitamin B and C and mineral supplements daily." 3. "I consume three cocktails every night." 4. "I jog two miles three times per week."

3) "I consume three cocktails every night." Alcohol is a huge risk factor for essential hypertension.

The nurse on the medical/surgical unit cares for an elderly client two days after hip replacement surgery. The nurse asks the client if she is in pain. The client responds, "I am just fine." Which of the following responses by the nurse is MOST appropriate? 1. "I want to give you some pain medication anyway, just in case." 2. "Well, be sure to let me know when you start to hurt." 3. "Look at this faces pain scale. Please show me which you are closest to right now." 4. "Are you sure you're not in pain? I see you haven't touched your PCA pump."

3) "Look at this faces pain scale. Please show me which you are closest to right now." Elderly clients may express pain differently. Pain to them is not considered the same as "discomfort."

A nurse's aide comes to the nurse and expresses concerns about a patient's T-tube. The aide says, "I'm kind of worried because it's drained 700mL over the course of our shift. That's a lot!" Which of the following responses does the nurse give to the aide? 1. "That is a small amount of drainage for a T-tube. Once I had a patient who drained 2,000mL in one shift!" 2. "That is an excessive amount of drainage for a T-tube. I will further assess the patient." 3. "That is a normal amount of drainage for a T-tube because this is his first day after surgery." 4. "That is a normal amount of drainage for a T-tube because this is his fifth day after surgery."

3) "That is a normal amount of drainage for a T-tube because this is his first day after surgery." First day post-op, a T-tube can drain anywhere between 500mL to 1000mL. After the first day, it decreases and eventually tapers off.

A patient with rheumatoid arthritis complains to the nurse that exercise is very painful for her. What does the nurse recommend to the patient? 1. "Use ice packs on the joints that hurt after you exercise." 2. "Do not exercise if your joints hurt. Instead, try again the next day." 3. "Try taking a warm bath in the morning before you begin your exercise." 4. "I'm sure it doesn't hurt that much to exercise, right?"

3) "Try taking a warm bath in the morning before you begin your exercise." Exercise will always be painful for a patient with rheumatoid arthritis, but if they skip exercise, they can develop contractures. Warm baths and heating pads can help to loosen and relax joints for better function with less pain in exercise.

The nurse performs discharge teaching for a client with a left leg cast who will be using crutches to ambulate. Which of the following statements, if made by the patient to the nurse, would require further teaching? 1. "When going down stairs, I will follow my bad leg with my good leg." 2. "I will remember not to scratch inside the cast." 3. "When going up stairs, I will first lift my bad leg and then my good one." 4. "I will put all of my body weight on the handholds and keep it off my armpits."

3) "When going up stairs, I will first lift my bad leg and then my good one." When dealing with crutches and stairs, remember: up with the good, down with the bad.

The nurse at the daycare center observes children playing on the playground. The nurse is MOST concerned if which of the following is observed? 1. Two children are fighting over a ball. 2. One child tries to pull another off the swing. 3. A 3-year-old is leaning forward with mouth open, tongue protruding, and drooling. 4. A 2-year-old is crying, tugging at his ear, and hugging a stuffed animal.

3) A 3-year-old is leaning forward with mouth open, tongue protruding, and drooling. Children fighting over balls or pulling others off of swings are normal safety issues of child development and play. The child crying while tugging at his ear depicts classic signs of an earache or ear infection. The child leaning forward with mouth open, tongue protruding, and drooling is the most immediate threat to safety because it describes signs of epiglottitis where the child is in danger of losing his or her airway.

The nurse cares for four clients in labor on the maternity unit. Which of the following patients should the nurse see FIRST? 1. A multigravida at thirty-five weeks gestation whose fetal heartbeat is 160 with variation of plus or minus five beats. 2. A multigravida at forty-one weeks gestation whose fetal heartbeat is 132 and dips with each contraction before returning to baseline at its conclusion. 3. A primigravida at thirty-nine weeks gestation whose fetal heartbeat is 147 with minimal variation and dips twenty beats at a time, independent of contractions. 4. A primigravida, two weeks preterm, who is entering the transitional phase of labor and requests to use the bathroom.

3) A primigravida at thirty-nine weeks gestation whose fetal heartbeat is 147 with minimal variation and dips twenty beats at a time, independent of contractions. It is normal to feel increased pressure with the transition phase of labor. A fetal heartbeat of 160 plus or minus five beats describes good variation. A fetal heartbeat that dips during a contraction before returning to baseline "at its conclusion" perfectly describes early decelerations. The correct answer, however, describes variable decelerations (unrelated to contractions) which are due to cord compression.

A patient with diverticulitis asks the nurse what meal choice in the cafeteria is best for him to eat today. The nurse helps him select which choice of the following: 1. Broiled chicken and corn on the cob. 2. A peanut butter sandwich with a snack of sunflower seeds for later. 3. Grilled chicken and pasta with red sauce. 4. A freshly made salad with almonds, steak, and potatoes.

3) Grilled chicken and pasta with red sauce. Patients with diverticulitis should avoid foods with seeds, nuts, or corn.

Two days after a coronary artery bypass graft (CABG), a patient is sitting up in a chair by the side of the bed. The nurse walks in and discovers the patient is cold, pale, and responds only to tactile stimulation. Which of the following actions does the nurse take NEXT? 1. Take the client's vital signs. 2. Administer oxygen 2L by nasal cannula. 3. Help the client back to bed. 4. Review charts to see if anything like this has ever happened before.

3) Help the client back to bed. Safety first before the patient falls! Then oxygen.

The nurse on the surgical unit receives a call from the operating room to administer a preoperative medication to a client scheduled for surgery. After giving the ordered medication, the nurse discovers the consent form for the surgery has not been signed. Which of the following actions should the nurse take NEXT? 1. Call the physician. 2. Call the operating room and inform them that the surgery must be canceled. 3. Inform the nursing supervisor. 4. Transfer the client to the operating room.

3) Inform the nursing supervisor. Always go up the chain of command to your superior- nursing supervisor.

A patient has the following medication orders: pantaprozole 40mg PO qAM, metoprolol 50mg PO bid, lorazepam 0.5mg PO now, albuterol 1 puff PRN. The patient's medical history includes high cholesterol and asthma. Which of the orders should the nurse question? 1. Lorazepam. 2. Albuterol. 3. Metoprolol. 4. Pantaprozole.

3) Metoprolol. A patient with a history of breathing issues like asthma cannot take a beta blocker like metoprolol because it affects beta-1 and beta-2 receptors and can result in brochospasm.

The home health nurse visits the home of a client diagnosed with moderate-stage Alzheimer's disease. The patient is pleasantly confused and lives with his son-in-law and daughter. Which of the following observations, if made by the nurse, is MOST concerning? 1. The rugs are secured safely to the floor. 2. The stovetops do not turn on without activation of a hidden switch in the nearby drawer. 3. The door has a lock with a bolt. 4. There are extension cords on the floors behind furniture.

3) The door has a lock with a bolt. Doors need to have locks in atypical locations (eg, tops of doors) to prevent the patient from nighttime confused wandering.

Which of the following situations on a psychiatric unit are an example of a trusting patient-nurse relationship? 1. The nurse enforces rules strictly on the unit. 2. The nurse offers to contact the doctor if the patient has a headache. 3. The patient tells the nurse that he feels suicidal. 4. The nurse gives the patient his daily medications right on schedule.

3) The patient tells the nurse that he feels suicidal. The trusting relationship between the patient and nurse means that the patient feels he can express his feelings in a safe environment.

A nurse is teaching a patient with type one diabetes about measures to prevent long-term complications of the disease. The nurse should include which of the following instructions? 1. Wear shoes made of artificial fibers. 2. Wear knee-high nylons instead of pantyhose. 3. Wear slippers when hanging out around the house. 4. Avoid wearing insulated boots in cold weather.

3) Wear slippers when hanging out around the house. Slippers will protect the feet, which might get cut/bruised/banged and the patient wouldn't know due to diabetic neuropathy. Shoes should be made of natural fibers and knee-high nylons should never be worn.

An older client is admitted to the cardiac floor for new-onset atrial fibrillation. As the nurse is gathering admission history on the client, the client states, "Did you know that they can keep people alive even after they're brain dead? I never want to end up on those breathing machines." Which of the following questions should the nurse ask NEXT? 1. "Have you talked with your family about this?" 2. "Your lawyer can help you draft up papers to deal with this situation." 3. "I will make a note in your chart just in case." 4. "Do you have an advance directive?"

4) "Do you have an advance directive?" An advance directive is a legal document that will ensure the patient's wishes are carried out, independent of what his family would like to do.

A patient is diagnosed with a DVT. Which of the following, if stated by a UAP, requires intervention by the nurse? 1. "The patient and I were talking, and we both play softball!" 2. "The patient states that her leg is warm, swollen, and painful." 3. "Sometimes I wish the patient would talk a little less. It's hard to get out of the room." 4. "I am going to ambulate the patient to the bathroom and assist her with using the toilet."

4) "I am going to ambulate the patient to the bathroom and assist her with using the toilet." This patient is on strict bedrest to prevent the clot in her leg from moving.

The nurse cares for children at a daycare. On a hot summer day, four children return from recess with various complaints. Which of the following children should the nurse see FIRST? 1. A child with asthma is complaining of dizziness and a sore throat. 2. A child diagnosed with type one diabetes is sweaty, pale, and complains of shakiness. 3. A child diagnosed with hemophilia says she has a headache and has slurred speech. 4. A child diagnosed with leukemia was stung by a bee and is complaining of feeling hot and itchy all over.

4) A child diagnosed with leukemia was stung by a bee and is complaining of feeling hot and itchy all over. This patient is beginning to experience anaphylactic shock and needs emergency treatment. The others also need treatment, but are more potential problems than immediate ones.

The nursing team consists of one RN, two LPNs, and one nursing assistant. The nurse determines that assignments are appropriate if the nursing assistant is assigned to which of the following patients? 1. A client with a colostomy requesting assistance with an irrigation. 2. A patient with sepsis who needs an IV push medication. 3. A patient diagnosed with cerebral palsy requiring medication. 4. A patient diagnosed with CVA three days ago who needs assistance ambulating to the bathroom.

4) A patient diagnosed with CVA three days ago who needs assistance ambulating to the bathroom. The nursing assistant can walk patients to the bathroom. The patient with cerebral palsy and the client with the colostomy can each see an LPN. The patient with sepsis needs an RN.

A patient with a crush injury to her right arm calls the nurse and requests pain medicine, which the nurse administers as ordered. An hour later, the patient is still complaining of intense pain. Which of the following actions does the nurse take next? 1. Tell the patient that she can have more medication in three hours. 2. Tell the patient that this is to be expected with a crush injury. 3. Offer the patient a distraction, such as television or a magazine. 4. Ask the patient to describe the pain in quality and intensity.

4) Ask the patient to describe the pain in quality and intensity. Unrelieved pain is a sign of a complication. Crush injuries are prone to compartment syndrome, so this pain must be further assessed with a description.

On a psychiatric unit, the preferred milieu environment is BEST described as: 1. Providing an environment that will support the patient in his or her therapeutic needs. 2. Fostering a sense of well-being and independence in the patient. 3. Providing an environment that is safe for the patient to express feelings. 4. Fostering a therapeutic social, cultural, and physical environment.

4) Fostering a therapeutic social, cultural, and physical environment. The milieu environment includes the whole spectrum of environments a patient interacts with. This answer has the most correct range.

The nurse cares for a client diagnosed with conversion reaction. The nurse identifies the client is utilizing which of the following defense mechanisms? 1. Identification. 2. Introjection. 3. Displacement. 4. Repression.

4) Repression. The patient is repressing their stressful thoughts and converting them into a physical symptom (conversion reaction).

The nurse cares for a patient with myasthenia gravis. Which of the following is a symptom that is NOT typically part of the disease? 1. Ptosis. 2. Diplopia. 3. Muscle weakness. 4. Shuffling gait.

4) Shuffling gait. Shuffling gait is always typical of Parkinson's, not myasthenia gravis.

A nursing assistant on the nurse's unit was injured 4 months ago in a fire. Her right leg was badly burned. She has just been cleared for work by a rehabilitation facility, but she walks with a prominent limp and an extremely unsteady gait. The nursing assistant wants to return to work on her unit, which has a critical care level of acuity. To assist the nursing assistant, the nurse should take which of the following actions? 1. Recommend the assistant take a leave of absence without pay until her rehab is more complete. 2. Transfer the nursing assistant to a surgical unit. 3. Offer the nursing assistant a secretarial position on the nursing unit. 4. Survey other units for positions more suitable for the nursing assistant's abilities.

4) Survey other units for positions more suitable for the nursing assistant's abilities. The ADA requires reasonable accommodations, but the nursing assistant should also be able to perform the job. The surgical unit will also be demanding. The nurse is unable to offer the secretarial position, as this is a different job type. The nursing assistant needs a position more appropriate, so other units should be investigated.

The nurse supervises a UAP (unlicensed assistive personnel) assist a legally blind patient with their meal at dinner time. What action, if performed by the UAP, is correct? 1. The UAP tells the patient which quadrant the food is in on the plate. 2. The UAP feeds the patient and tells them "Open." when it is time for the next bite. 3. The UAP cuts up the food for the patient and hands them the knife and fork. 4. The UAP tells the patient where each food item is located on the plate by referring to the image of a clock face.

4) The UAP tells the patient where each food item is located on the plate by referring to the image of a clock face. Use a clock-face image for legally blind patients to tell them where things are on a plate or in the room.

After a female patient has completed six months of multidisciplinary treatment for anorexia nervosa, the nurse evaluates whether the patient has met the goal of balanced nutrition sufficient to meet metabolic demands. Which of the following is the BEST indicator that the goal has been met? 1. The patient eats well-balanced meals without former obsessive behaviors. 2. The patient no longer sees herself as fat or overweight. 3. The patient's ideal body weight has been attained. 4. The patient's menstrual period has returned and is regular.

4) The patient's menstrual period has returned and is regular. If a patient is meeting metabolic demands, her body will have enough calories/electrolytes to produce a period. If her body does not have the resources to spare, her period will not return.

A patient with a suspected broken femur begins to experience tachycardia, shortness of breath, and chest pain. Which of the following actions should the nurse take NEXT? 1. Turn the patient on his right side in trendelenburg, administer oxygen 10L by facial mask, and call the physician. 2. Take vital signs and call the physician. 3. Place the patient in trendelenburg and call the physician. 4. Turn the patient on his left side in trendelenburg, administer oxygen 10L by facial mask, and call the physician.

4) Turn the patient on his left side in trendelenburg, administer oxygen 10L by facial mask, and call the physician. This patient is experiencing a fat embolism. Turning the patient on the left side in trendelenburg decreases the risk that the fat globule will travel and block further.

A primigravida at term is admitted to the birthing room in active labor. Later, when the client is 8 cm dilated, she tells the nurse that she has the urge to push. The nurse instructs her to pant-blow at this time because pushing could: 1. rupture the uterus. 2. lead to a precipitous birth. 3. prolapse the cord. 4. cause cervical edema.

4) cause cervical edema. Pushing when the cervix is not fully dilated and the head cannot emerge can cause cervical edema, predisposing the client to lacerations.

The nurse is discharging a patient who had recurrent kidney stones. Which of the following statements, if made by the patient to the nurse, would be considered correct? Select all that apply: 1."I will eat a low-calcium diet because kidney stones are made of calcium." 2."I am glad to know that eliminating alcohol from my diet will prevent kidney stones." 3."I will eat a high sodium diet." 4."I will make it my goal to drink two to three liters of water per day." 5."If I'm told my kidney stone is smaller than 5mm, it will probably pass on its own." 6."I will restrict my water intake to 1500mL per day."

4)"I will make it my goal to drink two to three liters of water per day." 5) "If I'm told my kidney stone is smaller than 5mm, it will probably pass on its own." Patients with a history of kidney stones should eat a low-sodium diet and increase their water. Eliminating alcohol does nothing to prevent kidney stones.

The nurse is caring for a patient with pneumonia using ________ precautions.

A) droplet Pneumonia requires droplet precautions.

A patient with Addison's disease knows to eat foods that are high in sodium but are low in _____.

A) potassium Patients with Addison's disease require a high protein, high carbohydrate, high sodium, low potassium diet.