NCLEX Review Exam Questions And Answers With Rationales /verified/latest/2024/2025, Exams of Nursing

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NCLEX Review Exam Questions And Answers With Rationales

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1. To determine the standards of care for the institution, the nurse should consult?
   1. Organizational Chart
   2. Personnel policies
   3. Policies and procedure manual
   4. Job descriptions Rationale: #3 Correct Answer: It defines standards of care for an institution #1 Shows which departments exist and their relationship with each other #2 Policies for personnel not standards of care #4 Doesn’t go into detail about standards of care
2. Which of the following goals is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit? 1. Reduction of anxiety 2. Referral to community resources 3. Identification of life style changes 4. Verbalization of energy-conservation techniques Rationale: #3 Correct Answer: On admission, the best starting point is to survey what is good and what needs to be changed. #1 No, we need some anxiety to change. #2 Not yet #3 For cardiac rehab-we want to exercise not conserve at this point. Conserving energy is for times of hypoxia or angina.

3. The nurse manager is having a problem on the unit with one staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best? 1. Call the staff nurse in and place on work improvement after a 3 day suspension 2. Have the other staff gather additional information on the delinquent staff member 3. Call the staff nurse in for an interview to investigate the problem and possible solutions 4. Assign her a mentor to call her at home and help her get to work on time Rationale: #3 Correct Answer: Give the nurse an opportunity to explain and then together work on a plan of resolution. #1 Jumping the gun, you need to investigate first. #2 Turning the rest of the staff against the one member is not helpful in creating a team environment and causes mistrust. #4 This is enabling, not helpful or necessary.
4. A client is having a tubal ligation in the outpatient surgical clinic. Postoperatively it is priority for the nurse to determine.
5. The client’s prior experiences with outpatient surgery.
6. The client’s medical plan and the extent of coverage for outpatient surgery.
7. The client’s plan for transportation and care at home.
8. The client’s plan to spend the night at the surgical center. Rationale: #3 Correct Answer: After outpatient surgery, the client should not be allowed to drive themselves home. An available driver and assistance at home is necessary to be determined prior to discharge. #1 The client’s prior experience would be a factor in the PRE-Operative phase, but not as important as Post Surgically. #2 The medical plan’s coverage would not be assessed by the nurse in the postoperative phase, but rather by the business office in the planning phase. #4 It would be atypical for the client to spend the night in a surgical clinic, as they are not generally open at night for overnight stays.

5. A child with newly diagnosed leukemia is receiving chemotherapy. Which would be included in his plan of care by the nurse? 1. Place him in a negative pressure isolation room 2. Administer prophylactic IV antibiotics 3. Avoid high protein food intake 4. Teach family and visitors handwashing techniques. Rationale: #4 Correct Answer: Any client on chemotherapy should have good infection control measures in place such as handwashing by all who they encounter. #1, and #2 This would be appropriate if the neutrophil count was low, however it is not necessary for all clients who are receiving chemotherapy #3 This client would likely need a high protein diet to meet the nutritional demands of the body during chemotherapy
6. Which nursing diagnosis has the highest priority for a client with insomnia?
   1. Ineffective breathing pattern.
   2. Disturbed sensory perception
   3. Ineffective coping
   4. Sleep deprivation Rationale: #1 Correct Answer: An airway issue causing sleep disturbance such as sleep apnea would take priority over other causes. #2 Disturbed sensory perception would be a less life threatening condition. #3 Ineffective coping would be less life threatening than an airway issue. #4 Sleep deprivation can be caused by many reasons but continues to be less threatening than an airway problem.
7. A client delivered a term male infant four hours ago. The infant was stillborn. Which room assignment would be most appropriate for this client? 1. Request a private room on the GYN floor 2. Assign to a private room on the postpartum unit 3. Discharge her home as soon as her condition is stable 4. Room her with another client with a pregnancy loss Rationale: #1 Correct Answer: This client needs a private room so she can feel free to grieve and other family members can stay with her for support. She should be transferred to a GYN unit so the sights and sounds of the maternity unit do not contribute to her pain.

#2 Difficult for mother with stillborn to be on postpartal unit with mothers and their babies. #3 She does not need to be rushed out of the hospital. She needs to have time with her stillborn and also still needs to assessed for postpartum complications. #4 This client and family needs privacy.

8. A RN on your unit has had an argument with the family of a client regarding the way in which the RN has changed the client’s dressing. The family is adamant that the dressing change was performed incorrectly. The RN insists that sterile technique was observed. As RN manager the best response is? 1. Meet with the family member and the RN to discuss the disagreement regarding the dressing change. 2. Talk to the family member and assure him that the nurse followed the hospital procedure 3. Discuss the dressing change procedure with the RN and compare to a current textbook 4. Change the RN’s assignment the next day to another client. Rationale: #1 Correct Answer: When conflict occurs, meet with both parties together to discuss the problem, is the BEST answer. Each part can hear what the other is saying and you are not caught in the middle. They will be able to come up with solutions together or you can mediate. #2 This is okay to do, but the family member will not believe you and try to convince you otherwise. #3 You may want to do this as well, but it will not address the conflict. #4 Avoidance may be the solution, but if a frank discussion does not occur first, then the family will think that the nurse really did do something wrong, and the nurse will feel like the manager is not supportive.
9. The women’s health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which group of clients should she assign to the medical surgical nurse? 1. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction 2. C-section planning discharge, post-partal infection, mastectomy 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma 4. 28 week gestation of bed rest, post-partal with HELLP syndrome, breast reconstruction Rationale: #1 Correct Answer: This group of clients is primarily med surgical #2 Needs too much specific teaching.

#3 Oh my who wants this team? Not the medical surgical nurse for sure-this is very specialized. #4 No, the monitoring is too specific for the med surg nurse.

10. A client with a history of peptic ulcer disease arrives to the emergency department complaining of weakness, and states that he vomited “a lot of dark coffee looking stomach contents”. The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?
    1. Initiate oxygen at 2 liters/nasal cannula.
    2. Start an IV of NS at 150 ml/hr.
    3. Insert NG tube to low suction
    4. Attach client to the ECG monitor Rationale: #1 Correct Answer: The client is showing signs of shock and needs all of the above interventions, however, go back to the ABC’s. Oxygen needs to be initiated first because of decreased blood volume. #2, 3, and 4 Not as important as oxygen (airway)
11. The nurse working the Emergency Department (ED) should see which client first?
    1. COPD client with a non-productive cough
    2. Diabetic client who has an infected sore on foot
    3. Client with adrenal insufficiency who feels weak
    4. Client with a fracture of the forearm in an air splint Rationale: #3 Correct Answer: Adrenal insufficiency + weakness think SHOCK #1 Well they sound terrible, but they always have a cough. #2 Not an emergency this minute #4 If the arm is splinted, then the client is stabilized.
12. The nurse should see the client with which problem first?
    1. Recurring crushing chest pain
    2. Needing an IV going to surgery in 5 minutes
    3. Needing PCA morphine for pain control post hysterectomy
    4. Waiting to get back to bed after sitting in a chair for 30 minutes. Rationale:

#1 Correct Answer: The client complaining of crushing chest pain is probably having an MI and should be seen first. This client takes priority over the other three clients. #2, 3, and 4 Not priority over oxygenation.

13. The nurse overhears two nursing students talking about a client in the cafeteria. The nurse should first :
    1. Report the incident to the nursing supervisor.
    2. Write up a variance report about the incidence.
    3. Instruct the students that this is a violation of HIPPA.
    4. Notify the students’ faculty regarding the violation. Rationale: #3 Correct Answer: The students should first be told of their violation of HIPPA and that they should stop immediately. Then the nurse should follow policy as to whether anyone else should be notified. #1 Yes per policy, but not first. #2 According to hospital policy #4 Yes, but not first
14. The newborn nursery is filled to capacity. Which newborn should the RN assess first?
    1. A one hour old sucking his fist.
    2. A two day old crying loudly.
    3. A three day old two hours after circumcision.
    4. A three hour old just waking up after a period of sleep. Rationale: #4 Correct Answer: The second period of reactivity, which occurs after the period of deep sleep approximately 3-5 hours after delivery is the most unstable for the newborn. This is when they are most likely to bring up and gag on mucus and may aspirate. #1 and #2 They are normal situations #3 The first hour after a circumcision is when the newborn is most likely to have excessive bleeding.

15. A pediatric nurse, caring for the following clients, tells the charge nurse she must leave due to a family emergency. Which client would the charge nurse reassign to a LPN?
    1. An eight year old in diabetic ketoacidosis.
    2. A six year old in sickle cell crisis.
    3. A two month old with dehydration.
    4. A five year old in skeletal traction. Rationale: #4 Correct Answer: The fracture would be most appropriate for a LPN and his/her scope of practice. This LPN would need minimal assistance from the RN. The children with DKA, sickle cell crisis, and dehydration all will need close observation and good assessment skills. Possibly all could have IVF needs and medications that would require skill from a RN. #1 DKA #2 sickle cell #3 Dehydration
16. What task by the RN should be performed first?
    1. Changing a burn dressing that is scheduled every four hours.
    2. Doing pinsite care on a client in skeletal traction ordered TID.
    3. Teaching a new diagnosed diabetic about diet and exercise.
    4. Assessing a newly admitted client. Rationale: #4 Correct Answer: The admit assessment should be done first. It is important to initiate the assessment and physical within one hour of being on a general acute unit. Completion of the assessment and establishing a plan of care should be completed by 8 hours of admission. #1 The other client needs are important, but seem to be scheduled and established in a routine. These routines can be continued once the new client’s assessment has been completed. #2 and #3 Not priority

17. A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?
    1. Ask the nursing assistant to complete emptying the catheter bag, and assess the new admission.
    2. Ask the nursing assistant to take VS on the new admit and begin the history until she can get there.
    3. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
    4. Ask the unit secretary to make the client and family comfortable until she can complete her present task. Rationale: #3 Correct Answer: The nursing assistant and unit secretary cannot do assessment of clients. The graduate nurse is only one who can assess. #1 and #2 They involve the nursing assistant in the assessment #4 The unit secretary cannot asses a client
18. Which task would be appropriate for the nurse to assign to an LPN?
    1. Changing a colostomy bag.
    2. Hanging a new bag of TPN.
    3. Drawing a peak antibiotic blood level from a central line.
    4. Administering IV pain medication to a two day post op client Rationale: #1 Correct Answer: The only procedure that is within the LPN’s practice range is changing the colostomy bag. #2, 3, and 4 Must be performed by an RN

19. Which client should be seen by the Emergency Department nurse first?
    1. A six year old with a femur fracture.
    2. A two year old with a fever of 102 degrees F.
    3. A three year old with wheezes in right lower lobe.
    4. A two year old whose gastrostomy tube came out. Rationale: #3 Correct Answer: The child having respiratory difficulty should be seen first. #1, 2, and 4 Are important, but are not interfering with an immediate vital function such as airway and breathing
20. Which control measure is priority for the nurse to implement in the care provided for a child admitted to the hospital with bacterial meningitis?
    1. Place child in a private room
    2. Gowns and masks must be worn by all personnel in the child’s room
    3. Visitors are restricted to parents only
    4. Hand washing is required by all personnel and visitors having contact with child. Rationale: #2 Correct Answer: The child with bacterial meningitis is contagious to others for at least 24 hours after the start of antibiotics. #1 Child is preferred in private room or Intensive Care Unit but may be in a semi-private room in the event of emergency with a child of like illness #3 It is best to limit visitors and stimulation to the child with meningitis, but not as important as wearing PPE for the workers and individuals entering the room. #4 Handwashing is always important with anyone, but this is actually a respiratory infection and requires airborne isolation.

21. Which would be appropriate to use in the client with shingles: (Select all that apply)
    1. Private room
    2. Negative-pressure airflow
    3. Respirator mask
    4. Gown
    5. Positive pressure room
    6. Gloves Rationale: #1, 2, and 3 Correct Answers: Are correct according to the current standards of Standard Precautions per CDC. #4 While it is not wrong to wear a gown, it is not currently listed on the standards for airborne transmission. #5 Negative pressure is required, positive is used only in protective environments. #6 Certain procedures will require gloves, but this is not part of the required PPE for Airborne precautions.
22. When preparing a client for surgery, the graduate nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure, but received his preoperative medication approximately 10 minutes prior. The appropriate action would be:
    1. Have the client sign the permit, as he verbalizes understanding.
    2. Witness the form after having the client to sign it.
    3. Have his wife sign the form as she witnessed him saying he wants the surgery. 4. Call the surgical area and explain the surgery will have to be cancelled. Rationale: #4 Correct Answer: The client must sign the operative permit or any other legal document prior to preoperative drugs being administered. #1 The client’s verbal understanding does not override that he has received medication that can alter thought process. #2 Witnessing would not make this document more legal #3 When a client is of sound mind, it would be inappropriate for the spouse to sign the form for surgery. It must be the client who signs it unless there is a legal power of attorney, durable power of attorney, or healthcare surrogate.

23. The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?
    1. “I had chickenpox when I was 8 years old.”
    2. “I had rheumatic fever when I was 10 years old”
    3. “I have a strong family history of gastric cancer.”
    4. “I have pain in my hip with any movement.” Rationale: #2 Correct Answer: After having rheumatic fever a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure. #1 Chicken pox would have no implications on this surgery. #3 Cancer history in the family would have no implication on this surgery #4 Pain in the hip is likely the reason for the surgery.
24. Which action by a graduate nurse would require the charge nurse to intervene?
    1. Walking in the hallway outside the operating room without a hair covering.
    2. Putting on a surgical mask, gown and cap before entering the operating room.
    3. Wearing a surgical mask into the holding area
    4. Wearing scrubs from home into the nursing station. Rationale: #1 Correct Answer: The area outside the OR is restricted to personnel with surgical attire and head coverings. #2 Putting on a surgical mask, gown and cap are all appropriate prior to entering the OR #3 Surgical mask may be worn in the holding area, but is not required. #4 Wearing scrubs into a nursing station is appropriate.

25. A client with sleep apnea has been ordered a CPAP machine. Which action could the RN delegate to a nursing assistant?
    1. Reminding the client to apply the CPAP at bedtime.
    2. Obtaining every three hour Oxygen saturation levels.
    3. Teaching the client how to turn on the CPAP machine.
    4. Assessing for fatigue or depression caused by poor sleep. Rationale: #1 Correct Answer: It is appropriate delegation for a nursing assistant to remind the client to do a previously taught intervention. #2 This is an assessment function and may be outside the nursing assistant’s scope of practice in some states. #3 Teaching is outside the nursing assistant’s scope of practice #4 Assessment is outside the nursing assistant’s scope of practice.
26. The graduate nurse is performing the admission assessment on a client who is having a breast augmentation. Which information would be most important for the nurse to report to the surgeon before surgery?
    1. The client is concerned about who will care for her two children while she recovers.
    2. The client has a history of postoperative dehiscence after a previous C-section.
    3. The client’s statement that her last menstrual period was 8 weeks prior.
    4. The client’s concerns over pain control postoperatively. Rationale: #3 Correct Answer: The client may be pregnant and a pregnancy test will need to be completed prior to anesthetic agents being administered. #1 Adequate caregivers can be discussed with the client without contacting the physician. #2 The incision dehiscence should not be an issue with breast augmentation but more likely due to a large abdomen after childbirth. #4 The client’s postoperative pain control will be discussed both prior to surgery and postsurgical. This is not a concern for the physician at this time either.

27. A 3 day post-operative client with a Left Knee Replacement is complaining of being chilled and nauseated. Her TPR is 100.4-94-28 and Blood Pressure is 146/90. What is the nurse’s best action?
    1. Call the surgeon immediately.
    2. Administer Extra Strength Tylenol per orders.
    3. Assess the surgical site.
    4. Offer extra blankets and increase fluids. Rationale: #1 Correct Answer: The client likely has an infection and the physician may want diagnostic tests performed. #2 While this may be appropriate, it may also delay treatment of the cause. #3 The physician may want the site assessed, but this also delays treatment. #4 Comfort measures are always appropriate, but this one is not the best action available.
28. A client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200cc/hr via pump. A priority action for the nurse would be:
    1. Obtaining Intake and Output.
    2. Frequent lung assessments.
    3. Vital signs every shift.
    4. Monitoring the IV site for infiltration. Rationale: #2 Correct Answer: The older adult is at risk for circulatory overload and should be closely monitored with rapid infusion rates #1 I and O are important, but less priority than lung assessment in the elderly client #3 Vital signs will probably be more frequent that every shift on the elderly client with dehydration. #4 The site should be monitored, but will not be priority over lung assessment in the elderly client.

29. The nurse is preparing to administer the 9am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?
    1. Notify maintenance to come and check the pump immediately.
    2. Continue with the administration of antibiotic and fill out an equipment maintenance request.
    3. Immediately discontinue use of this IVAC pump and obtain a replacement.
    4. Tag the equipment for maintenance. Rationale: #3 Correct Answer: Removing potentially hazardous equipment is priority. #1 Maintenance should be notified, but after equipment is removed from client care #2 Equipment identified as potentially hazardous should not be used. #4 This should occur after it has been removed from the client’s room.
30. While making rounds at 3am the nurse discovers a small fire in a client’s room. What should the nurse do first?
31. Remove the client from the room immediately.
32. Leave the client’s room to obtain a fire extinguisher.
33. Instruct nurse tech to pull the fire alarm.
34. Evacuate all clients from the unit. Rationale: #1 Correct Answer: Rescue/Remove the client first step in RACE #2 Never leave client in unsafe environment #3 and #4 Not first actions in RACE

31. Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?
32. Wearing clean gloves while performing a heel stick on an infant.
33. Wearing the same gloves for assessment of clients in the same room.
34. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client.
35. Donning a gown when responding to a request by the family to check the IV pump on a client with rotovirus. Rationale: #1 Correct Answer: When drawing blood a precaution is to wear gloves, so blood will not get on the nurse’s hands. Clean gloves are appropriate here. #2 Always change gloves between client’s in same room. #3 Sterile gloves are not necessary and cost more than clean gloves. #4 The gown would not be necessary unless handling the client/linens/bodily secretions. An IV pump could be checked without putting a gown on.
36. After a left heart catherterization (LHC) a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and cold extremity. What should the nurse’s next action be?
37. Administer an anticoagulant.
38. Warm the room and re-assess.
39. Increase IV fluids.
40. Notify the physician stat Rationale: #4 Correct Answer: This is an emergency and the doctor is the only one that can save this foot from ischemia-don’t delay. #1 Anticoagulants stabilize clots not lyse-thrombolytics lyse clots…too aggressive-just report and get some help coming. #2 These symptoms are too severe for warming the room. #3 Well in theory increasing blood volume increases blood flow-but this client hs an arterial obstruction.

33. The client is admitted with period of unobserved loss of consciousness and now has an EEG scheduled this am. The nurse should implement?
34. Keep NPO and hold medication.
35. Hold sedatives, but allow client to have breakfast and give other medicines.
36. Administer meds, but hold anticonvulsants.
37. Give additional fluids and some caffeine prior to the test. Rationale: #2 Correct Answer: Yes, prior to an EEG we want the client to eat so the blood sugar does not drop and they should take medications except sedatives prior to the EEG. #1 No-give them food and give them their meds except sedatives. #3 No-give all meds including anticovulsants unless specifically ordered #4 No need to give extra fluid, they will just have to stop and urinate, and caffeine will increase the electricity and interfere with the test so no caffeine.
38. The nurse is preparing for a dressing change on a full thickness burn to the flank area. The orders include irrigating the wound with each dressing change. To irrigate the wound the nurse will use?
39. Sterile saline.
40. Distilled water.
41. Betadine scrub.
42. Tap water. Rationale: #1 Correct Answer: Sterile Saline #2, 3, and 4 Must be sterile solution

35. The charge nurse is observing a student nurse caring for a 4 month old infant in isolation diagnosed with RSV. Which of the following would indicate to the charge nurse that the student nurse needs further instruction on isolation standards?
36. Donning sterile gloves each time she goes in the room.
37. Wearing a clean mask each time she goes in the room.
38. Labeling the door so staff will use Airborne Precautions.
39. Wearing a gown when she goes in the room to administer a medication. Rationale: #1 Correct Answer: It is not necessary to wear sterile gloves, when doing care. Clean gloves are acceptable and not expensive. #2 Wearing a mask is part of airborne precautions. Airborne precautions are used when the contagious particle is smaller than 5mm meaning they can be suspended in air for a period of time. #3 RSV is airborne, therefore documenting this on the door is acceptable. #4 Wearing a gown when administering meds is indicated. A 4 month old can sneeze or drain oral secretions when a nurse gets close enough to administer meds. The gown would protect the nurse’s clothing.
40. When observing a dressing change by a graduate nurse on a Stage III pressure ulcer to the greater trochanter by the staff nurse, a need for further teaching is indicated after the following observation by the nurse:
    1. The new graduate nurse irrigates the pressure ulcer with 50cc NS
    2. The new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide.
    3. The new graduate packs the wound with sterile kerlix soaked in NS
    4. The new graduate applies a Duoderm dressing over the wound after cleansing. Rationale: #2 Correct Answer: Pressure ulcers should not be cleaned with substances that are cytotoxic such as hydrogen peroxide or betadine. #1, 3, and 4 This action would be correct for a pressure ulcer.

37. The nurse is caring for a client while Fluoruracil (5FU®) is being infused. The client complains of burning at the IV site. What should the nurse do first?
    1. Aspirate IV site for blood return.
    2. Slow the infusion.
    3. Inspect the IV site.
    4. Stop the infusion. Rationale: #4 Correct Answer: Yes! Good stop the danger now and also add ice to the site. #1 No, it’s burning so irritating big sign of drug in tissues. #2 Slowly let the arm become necrotic? No-stop it! #3 Trust what the client is telling you and stop it now before too much damage is done.
38. Following a thyroidectomy a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?
    1. Stay with the client, remove the dressing, and elevate the head of bed.
    2. Call a code, open the trach set and position the client supine.
    3. Have the client say “EEE” to check for laryngeal integrity.
    4. Immediately go to the nurse’s station and call the physician. Rationale: #1 Correct Answer: Yes! Sounds like respiratory distress, Looks like respiratory distress, get that dressing off the neck and see if they can breathe any better. #2 Not yet! Do something first to see if it gets better. #3 Well just look and check and look and check-do something #4 Don’t’ leave the client

39. A laboring client dilated to 6 cms is receiving an epidural. Which is the priority nursing action?
    1. Continuous monitoring of maternal blood pressure.
    2. Frequent auscultation of the fetal heart rate.
    3. Administer an IV fluid bolus of at least 500 cc.
    4. Frequent monitoring of the maternal temperature. Rationale: #1 Correct Answer: Decreased blood pressure is dangerous to both the laboring mother and fetus because of the decrease in cardiac output and placental perfusion. The most common negative side effect of epidural anesthesia is a precipitous drop in blood pressure. #2 Incorrect because the fetal heart rate should be continuously monitored. #3 Incorrect because even though an IV fluid bolus may prevent hypotension, it should be administered before the epidural is placed. #4 Incorrect because the maternal temperature is not affected by epidural placement unless the entry site becomes infected, which is not likely to cause symptoms for several hours after placement.
40. In conducting a community health fair for a group of middle aged citizens, which statement should the nurse emphasize in reducing the risk of coronary heart disease?
    1. “Participate in at least 30 minutes of moderate physical activities 3 to 5 days per week.”
    2. “Engage in aerobic exercise class every day.”
    3. “Limit your alcohol intake to 10 drinks a day.”
    4. “The best way to lose weight is to eat a high-protein, high fat diet.” Rationale: #1 Correct Answer: Yes! Best way to keep fit, heart in shape and lower your BP and cholesterol. #2 Too specific for community class, and does not give minutes per day or times per week. #3 Is that a limit? Way over the limit. #4 Do you lose weight if you eat a high fat diet?

41. The nurse is caring for a client that is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery the mother asks to see the infant. What is the nurse’s best response/
    1. Bring the swaddled fetus to the mother.
    2. Explain that the cause of death must be determined before she can see the baby.
    3. Ask her if she is sure she wants to see the baby.
    4. Tell her it would be better to wait until she is in her room before she sees the baby. Rationale: #1 Correct Answer: Let the grieving mother see the infant to continue the grieving process. #2 We may never know #3 She is distraught and you should not make her doubt herself #4 Making it even more scary and emotional, putting off the mother’s request.
42. The nurse is caring for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). In planning the client’s care, the nurse should recognize that the child is likely to view this illness as?
    1. Punishment.
    2. Disturbance to body image.
    3. Rejection from parents.
    4. Change in routine with friends. Rationale: #1 Correct Answer: Yes the preschool child views illness as punishment. #2 Not yet that’s adolescent #3 and #4 Not a correct age response.

43. The nurse is caring for a client 28 weeks pregnant that complains of swollen hands and feet. Which symptom below would cause the greatest concern?
    1. Nasal congestion.
    2. Hiccoughs.
    3. Blood glucose of 150.
    4. Muscle spasms. Rationale: #4 Correct Answer: The muscle spasms-watch for seizure. #1 Not greatest concern with presenting S/S #2 Hiccoughs would be second best answer indicating nerve/muscle irritation #3 Not greatest concern with presenting S/S
44. When auscultating breath sounds, the nurse auscultates over the following locations:
    1. Trachea and lateral areas of thoracic cage
    2. Anterior and posterior aspects of all lung fields
    3. The mid section as well as the lateral section of the lungs
    4. The mid-clavicular to mid axillary lines comparing side to side Rationale: #2 Correct Answer: Yes, you must go side to side (lateralaspects) and also listen to the front and back (anterior and posterior) #1, 3, and 4 All areas not auscultated.

45. The client develops a tension pneumothorax. Assessment is expected to reveal?
    1. Sudden hypertension and bradycardia
    2. Productive cough with yellow mucus
    3. Tracheal deviation and dyspnea
    4. Sudden development of profuse hemoptysis and weakness Rationale: #3 Correct Answer: Yes! The trachea gets pushed to the other side from the tension, and they are very short of breath with high work of breathing. #1 Hypoxia is always tachycardia #2 Not pneumonia #4 Could be a ruptured vessel, bleb, but no signs of pushing across the mediastinum
46. A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first?
    1. Instruct the child to extend the affected knee
    2. Perform range of motion exercise on both knees
    3. Compare the appearance of the left knee to the right knee
    4. Have the child soak the affected knee in warm water Rationale: #3 Correct Answer: Comparing the appearance of the left knee to the right knee is the least invasive assessment and allows the nurse to assess if there is a change in the appearance of the affected knee to the unaffected knee. #1 Extending the affected knee may cause further damage. #2 Range of motion exercises may cause further damage to the affected knee. #4 Soaking the affected knee in warm water will not help the nurse assess whether or not an injury occurred.

47. What is the number one reason the person with alcohol addiction does not seek treatment?
    1. Co-dependency
    2. Denial
    3. Depression
    4. Stigma Rationale: #2 Correct Answer: They deny that they have a drinking problem and will argue with you if you suggest it. #1 Codependency makes alcohol abuse last longer, but not the reason they do not seek treatment. #3 No depression associated with substance abuse is usually reported in this population. #4 Yes, they are afraid of the stigma associated with addiction recovery, but not the reason they avoid.
48. Which of the following is at highest risk for suicide?
    1. 76 year old widow with chronic renal failure
    2. 19 year old with new SSRI therapy
    3. 28 year old post-partum crying weekly
    4. 50 year old client with obsessive-compulsive disorder (OCD) and depression Rationale: #1 Correct Answer: Yes-elderly with chronic disease especially men are very high risk #2 There is an increased incidence and risk in this population-but look for the highest risk. #3 Many post-partum clients cry weekly, this is not the red flag client #4 Another male, and chronic disease, but the widow wins out as the higher risk.

49. What must the nurse do while caring for a client with an eating disorder?
    1. Encourage client to cook for others
    2. Weigh the client daily and keep a journal
    3. Restrict access to mirrors
    4. Monitor food intake and behavior for one hour after meals Rationale: #4 Correct Answer: Yes! This is the primary problem and the most life threatening. #1 No-remember the focus is on control and attention to food-they need to eat #2 No-we don’t let them know their weight, if they gain one ounce, they will try anything to lose it! #3 They still have to brush their hair and put on make-up-it’s the eating we just focus on to keep them alive.
50. The emergency department charge nurse is reviewing the clients triaged in the last 30 minutes. The nurse is required to obtain a social service consult from?
    1. A 6 year old that drank some diluted bleach.
    2. A 10 year old that suffered burns in a house fire
    3. A 12 year old that fractured his arm in a fight at school
    4. A 12 month old without any oral intake for the last 12 hours Rationale: #1 Correct Answer: For children under 7 years, most states have laws that mandate certain situations/circumstances be reported to social services/child protection. Among these things are: ingestions of toxic substances, fractures, suspected neglect or abuse, burns. For children over 7 years, the health care provider uses their judgement as to whether the situation indicated neglect or abuse by the parents or caregivers. #2 The child in a burned house would be reported only if the story were inconsistent as to how the house caught on fire or if foul play was suspected by the family. #3 A child fighting at school is not good, but this doesn’t mean there is a family abuse/neglect at home. #4 A 12 month old that is sick may not take liquids, but the fact that the mother brought the child in means she is attentive and concerned. This would allow time to try and rehydrate the child to prevent dehydration.

51. The nurse is caring for a female that is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and says that she wants to have more children and is unsure if she should have the procedure. What should the nurse do?
    1. Allow the client to honestly discuss her fears and encourage her to talk more with her physician.
    2. Tell her the good things that she will be able to do without more children and encourage her to make a list of positive things.
    3. Explain to the client that her ovaries can be frozen for egg harvesting at a later time and she can find a surrogate.
    4. Advise the client to put off having the surgery until she is sure that she wants to undergo the procedure and notify the surgeon of the decision. Rationale: #1 Correct Answer: This is probably just anticipatory grieving and being scared-let the person talk and encourage them to talk again to the physician. They need reassurance that they are making the right decision. #2 This is not her fear and not helpful in this situation. #3 Not an appropriate answer and we don’t freeze ovaries #4 The cancer is already advanced stages, will the waiting help her survive?
52. The manic client has just interrupted group session with the counselor for the 4th^ time explaining that she already knows this information on “dealing with others when you are down” and constantly gets up and goes to the front. What should the nurse do at this time?
    1. Engage the client to walk with your to make another pot of coffee
    2. Ask the client to reflect on their behavior to determine if it is appropriate
    3. Ask the group to tell the client how they feel when she interrupts
    4. Instruct the client to perform jumping jacks and counting aloud to get rid of some energy. Rationale: #1 Correct Answer: Yes! Get them away and doing something purposeful #2 That is embarrassing and humiliating the client #3 Sometimes this will be helpful during times of therapy-but the client is manic at this time, will she even believe them? #4 No, this is getting her active, but can the group continue with this attention seeking jumping, counting person? No. Get her away from the activity.