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NURSING1600 PRACTICE TEST 2026 FULL
SOLUTION VIEW AHEAD
▶ A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension. Which is the priority nursing intervention? A) Place the client in Trendelenburg position to facilitate blood flow to the heart. B) Take the client's apical pulse for 1 full minute before drug administration. C) Instruct the client to drink 3 L of fluid daily when taking this medication. D) Educate the client to sit on the side of the bed for a few minutes before rising.. Answer: D Angiotensin-converting enzyme (ACE) inhibitors such as captopril can cause severe hypotension with initial use. The client should be instructed to rise slowly and sit on the side of the bed for a few minutes to prevent hypotension-induced falls. No indication is known for assessment of the apical pulse for 1 full minute before taking captopril. Placing the client in a Trendelenburg position is not indicated. In case of a precipitous drop in blood pressure, a modified Trendelenburg position may be used. Adequate fluid intake is necessary but is not the priority in this situation. ▶ A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect does the nurse monitor for in this client? A) New-onset confusion B) Repeated syncope C) Abdominal distention D) Spontaneous ecchymosis. Answer: D Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising, and liver dysfunction. The nurse should be alert for signs of bleeding, such as ecchymosis, bleeding gums, and tarry stools. Plavix does not cause syncope, confusion, or abdominal distention. ▶ A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response?
A) "I am preventing the spread of infection from you to me or any other client here." B) "The clothing protects me from accidentally absorbing these drugs." C) "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask." D) "These coverings protect you from getting an infection from me.". Answer: B Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, health care workers who prepare or give these drugs, especially nurses and pharmacists, are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect health. The Oncology Nursing Society and the Occupational Safety and Health Administration (OSHA) have specific guidelines for using caution and wearing protective clothing whenever preparing, giving, or disposing of chemotherapy drugs. ▶ The earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation would be: A) change in level of consciousness. B) unequal pupil size. C) loss of primitive reflexes. D) inability to focus visually.. Answer: A A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow Coma Scale (GCS), which assesses eye opening and verbal and motor response. The inability to focus may indicate a change, but it is not one of the earliest indicators or a component of the GCS. Primitive reflexes refers to those reflexes found in a normal infant that disappear with maturation. These reflexes may reappear with frontal lobe dysfunction and may be tested for with a suspected brain injury, so it would be the reappearance of primitive reflexes. A change in pupil size or unequal pupils may indicate a change, but they are not one of the earliest indicators or a component of the GCS. ▶ Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections?
Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessing, the nurse should document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed. ▶ Which nursing intervention best assists a bedridden client to keep skin intact? A) Use a lift sheet to move the client in bed. B) Turn the client every 2 to 4 hours. C) Use a foam mattress pad. D) Apply talcum powder to the perineal area.. Answer: A Friction forces are generated when the client is dragged or pulled across bed linen; this often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the skin clean and dry is an important intervention, but powders should not be used in the perineal area. To minimize vasoconstriction and possible pressure ulcer development from dependency, the client should be turned at a minimum of every 2 hours. A foam mattress will not significantly decrease pressure to an area. ▶ A client presents with an acute exacerbation of multiple sclerosis. Which prescribed medication does the nurse prepare to administer? A) Interferon beta-1b (Betaseron) B) Baclofen (Lioresal) C) Methylprednisolone (Medrol) D) Dantrolene sodium (Dantrium). Answer: C Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other medications are not appropriate. ▶ The nurse is assessing a client's understanding of his hypertension therapy. What client statement indicates a need for further teaching?
A) "When my blood pressure is normal, I will no longer need to take medication." B) "If my blood pressure stays under control, I will reduce my risk for a heart attack." C) "If I lose weight, I might be able to reduce my blood pressure medication." D) "When getting out of bed in the morning, I will sit for a few moments then stand.". Answer: A Compliance with antihypertensive therapy is difficult for two reasons. First, often clients have no distressing symptoms associated with hypertension and may not believe that they have a problem. Second, many clients believe that once blood pressure is brought back into the normal range, they are "cured" and no longer need to take medication. Losing weight might allow the client to reduce medications. Lowering blood pressure does lower risk for heart attack. Because blood pressure medications often lead to orthostatic hypotension, clients should be taught to change position slowly, sitting first before standing after lying flat. ▶ Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) A) Constricted pupils B) Flushed skin C) Tremors D) Nervousness E) Extreme thirst F) Profuse perspiration. Answer: C,D,F When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia. ▶ A client who has had a stroke with left-sided hemiparesis has been referred to a rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the nurse respond?
exudate is leaking. Dry gauze dressings should be changed when the outer layer becomes saturated. ▶ A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI? A) Hematuria B) Fever and chills C) Cloudy, dark urine D) Burning on urination. Answer: B Lower urinary tract infections are rarely associated with systemic symptoms of fever and chills. A client with a UTI who develops fever and chills should be assessed for the development of pyelonephritis. The other options can be seen with UTI. ▶ The nurse observes a small opening that is draining purulent material on the skin over the trochanter area of a bedridden client. Which is the nurse's next best action? A) Probe for a larger pocket of necrotic tissue. B) Apply alginate dressing daily. C) Apply a transparent film dressing. D) Measure the reddened area on the skin surface.. Answer: A This "hidden" wound may first be observed as a small opening in the skin through which purulent drainage exudes. Applying a transparent film dressing would not help this type of wound to heal. Measuring the reddened area would not assist in determining the actual size of the wound, because internal damage has occurred. Alginate dressings could not be applied if the area were not opened. ▶ When reviewing an older client's medical record, which findings lead the nurse to perform a nutrition assessment? (Select all that apply.) A) Widow/widower status B) Chronic constipation C) Cholecystectomy 4 years ago D) Random blood sugar level of 198 mg/dL
E) History of depression F) Inability to afford a new pair of glasses. Answer: A,B,E,F Many factors contribute to malnutrition in older clients. Depression and loneliness from the loss of a spouse; constipation; poor eyesight; chronic medical problems, including depression; and taking prescription and/or over-the-counter medications can contribute to malnutrition. Blood glucose levels and a previous cholecystectomy would not necessarily contribute. ▶ The nurse is caring for a female client who is 5 feet, 7 inches tall and weighs 115 pounds. The client asks the nurse if she needs to lose weight. Which response by the nurse is best? A) "No. In fact, your body mass index suggests that you are already underweight." B) "Yes. Your body mass index suggests you are slightly overweight." C) "Your weight is just fine. Don't worry about it." D) "Maybe. Let's look at your risks for cardiovascular disease.". Answer: A The client's body mass index (BMI) is 18.0, so she is already underweight. It is inaccurate to tell the client she is overweight, and it is unnecessary to consider her weight in light of any cardiovascular risk factors. The nurse should not reassure the client that her weight is just fine because she is underweight. ▶ A client who has type 2 diabetes is prescribed glipizide (Glucotrol). Which precautions does the nurse include in the teaching plan related to this medication? A) "Avoid taking nonsteroidal anti-inflammatory drugs." B) "Change positions slowly when you get up." C) "If you miss a dose of this drug, you can double the next dose." D) "Discontinue the medication if you develop an infection.". Answer: A Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.
▶ The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) A) Endocrine system B) Neurologic system C) Hepatic system D) Immune system E) Cardiovascular system F) Pulmonary system. Answer: B, E, F The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection. ▶ The nurse is discharging home a client at risk for venous thromboembolism (VTE) on low-molecular-weight heparin. What instruction does the nurse provide to this client? A) "You must have your aPTT checked every 2 weeks." B) "Notify your health care provider if your stools appear tarry." C) "An IV catheter will be placed to administer your heparin." D) "Massage the injection site after the heparin is injected.". Answer: B As with any anticoagulation, low-molecular-weight heparin incurs risk of bleeding. Clients should be taught to report to their health care provider the presence of tarry stools, bleeding gums, hematuria, ecchymosis, or petechiae. Low-molecular-weight heparin does not affect activated partial thromboplastin time (aPTT), as does intravenous heparin. This type of heparin is administered subcutaneously to deliver a slow sustained response. Massaging the site would hasten absorption and decrease effects. ▶ Which is the highest priority goal to set for a client with pneumonia? A) Maintenance of SaO2 of 95% B) Walking 20 feet three times daily
C) Absence of cyanosis D) Absence of confusion. Answer: A Maintenance of an SaO2 of at least 95% is a clear goal that indicates that the client has adequate oxygenation. Absence of cyanosis and the presence of confusion are assessment factors that contribute to evaluation of oxygen; however, they are not absolute measures. Likewise, walking three times a day does not directly address oxygenation. ▶ The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? A) "I sleep with four pillows at night." B) "I wake up coughing every night." C) "My shoes fit really tight lately." D) "I have trouble catching my breath.". Answer: C Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all could be results of left- sided heart failure. ▶ The nurse is caring for a client with Crohn's disease and colonic strictures. Which assessment finding requires the nurse to consult the health care provider immediately? A) Traces of blood in the stool B) Distended abdomen C) Temperature of 100.0° F (37.8° C) D) Crampy lower abdominal pain. Answer: B The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate that the client has developed an obstruction of the large bowel, and the client's provider should be notified right away. Low-grade fever, bloody diarrhea, and crampy abdominal pain are common symptoms of Crohn's disease. ▶ What is my favorite football team?
long as the patient understands and maintains the basic principles of infection control. ▶ A client is admitted with infection and a high fever. Which assessments by the nurse take priority? (Select all that apply.) A) Skin turgor B) Pulse quality C) Blood pressure D) Bowel sounds E) Respiratory effort F) Mental status. Answer: A, B, C, F Dehydration can accompany fever, especially if the client is sweating profusely. Blood pressure, pulse quality, and skin turgor are assessments of fluid status. Mental status changes can accompany fluid losses, especially in older clients. ▶ The health care provider has prescribed a client sodium warfarin (Coumadin) while he is still receiving intravenous heparin. Which is the nurse's best action? A) Turn off the heparin before administering the warfarin. B) Clarify the warfarin order with the nursing supervisor. C) Administer both heparin and warfarin as prescribed. D) Hold the warfarin dose until the heparin is discontinued.. Answer: C Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin. Once the warfarin is therapeutic, as evidenced by the international normalized ratio (INR), the client's heparin can be safely discontinued. Effects of heparin will be cleared from the client's bloodstream within a few hours. ▶ Individuals of low socioeconomic status are at an increased risk for infection because of which of the following? (Select all that apply.) A) High cost of medications B) Inadequate nutrition C) Easy access to health screenings D) Uninsured or underinsured status. Answer: A, B, D
Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. ▶ The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a: A) portal of entry. B) host. C) mode of transmission. D) reservoir.. Answer: A Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow. ▶ The nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious infection. Which action by the nurse is most important? A) Double check the "five rights." B) Assess the client for allergies. C) Teach the client about the drug. D) Check the IV for patency.. Answer: B All actions are appropriate and important before administering any medications. However, client safety is the priority. The nurse should first assess the client for medication allergies by asking the client or checking the chart (or both). Ensuring a patent IV and checking the five rights will not protect the client from an allergic reaction.
▶ A patient is being treated with an antibiotic. The nurse explains to the patient that this medication is required for the reduction of inflammation at the injury site because this medication: A) will decrease the pain at the site. B) helps to kill the infection causing the inflammation. C) will reduce the patients fever. D) inhibits cyclooxygenase.. Answer: B Antimicrobials treat the underlying cause of the infection which leads to inflammation. Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) help to treat pain. NSAIDs and other antipyretics are cyclooxygenase inhibitors. Antipyretics help to reduce fever. ▶ The nurse is caring for a client with ulcerative colitis and severe diarrhea. Which nursing assessment is the highest priority? A) Skin integrity B) Blood pressure C) Heart rate and rhythm D) Abdominal percussion. Answer: C Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Abdominal percussion is an important part of physical assessment but has lower priority for this client than heart rate and rhythm. ▶ The nurse assesses a client with pneumonia and notes decreased lung sounds on the left side and decreased lung expansion. What is the nurse's best action? A) Increase oxygen flow to 10 L/min. B) Perform an arterial blood gas analysis. C) Have the client cough and deep breathe. D) Check oxygen saturation and notify the health care provider.. Answer: D
Decreased lung sounds and decreased lung expansion could indicate the development of a complication such as empyema or pus in the pleural space. The nurse should check the client's oxygen saturation and notify the provider. Infection can also move into the bloodstream and result in sepsis, so quick treatment is needed. ▶ The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient: A) with a hemoglobin of 8.5 g/dL B) with a blood glucose of 350 mg/dL C) who has been on anticoagulants for 10 days D) with a heart rate of 100 beats/min and blood pressure of 100/60. Answer: A The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood. ▶ The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? A) "Increase your intake of foods high in potassium." B) "Avoid taking aspirin or aspirin-containing products." C) "Hold this medication if your pulse rate is below 80 beats/min." D) "Do not take this medication within 1 hour of taking an antacid.". Answer: D Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 is too high for this cutoff. ▶ The nurse is caring for a client with Crohn's disease who has developed a fistula. Which nursing intervention is the highest priority? A) Position the client to allow gravity drainage of the fistula. B) Check and record blood glucose levels every 6 hours. C) Encourage the client to consume a diet high in protein and calories.
▶ A client has recently been placed on prednisone (Deltasone). What is the highest priority instruction the nurse will provide? A) "Take the drug with food or milk." B) "Report any abdominal pain or dark-colored vomit." C) "Expect to experience weight gain." D) "Watch your diet while on this medication.". Answer: B All of these directions are appropriate to give the client; however, telling the client to report abdominal pain and dark-colored vomit is most important because these could signal gastric ulceration. ▶ An older adult client is admitted with an infection. On assessment, the nurse finds the client slightly confused. Vital signs are as follows: temperature 99.2° F (37.3° C), blood pressure 100/60 mm Hg, pulse 100, and respiratory rate 20. Which action by the nurse is most appropriate? A) Document the findings and continue to monitor. B) Assess the client's pain level and treat if needed. C) Perform a Mini-Mental Status Examination. D) Assess the client for other signs of infection.. Answer: D Because of an age-related decline in immune function, an older adult's normal temperature may be 1° to 2° lower than normal. A temperature of 99.2° F may be a fever in this population. Often a change in mental status is an early sign of illness for the older adult. The nurse should assess for other indications of infection. ▶ The nurse is caring for an older postoperative client. Which assessment finding causes the nurse to assess further for a wound infection? A) The client is now confused but was not confused previously. B) Moderate serosanguineous drainage is seen on the dressing. C) The white blood cell count is 8000/mm3. D) The white blood cell differential indicates a right shift.. Answer: A Older adult clients often do not demonstrate typical signs and symptoms of infection because of the diminished immune function seen with aging. Often, the first sign of infection is mental status changes. Any change in
mental status in the older postoperative client should lead the nurse to assess for a wound infection. ▶ The nurse is assessing a client's skin for local signs of infection. Which signs does the nurse assess for? (Select all that apply.) A) Redness B) Fever C) Increased erythrocyte sedimentation rate (ESR) D) Pain E) Swelling F) Warmth. Answer: A,D,E,F Localized signs of infection include redness, warmth, pain, swelling, heat, and pus. Fever and increased ESR are systemic signs of infection. ▶ Which client is at highest risk of compromised immunity? A) Client with extreme anxiety B) Client who is awaiting surgery C) Client who has just had surgery D) Client who just delivered a baby. Answer: C Intact skin is a defense to prevent infection; however, a client who has recently had surgery has a portal for organisms to enter the body and cause infection. ▶ A client is admitted with left lower lung pneumonia. Which assessment finding does the nurse correlate with this condition? A) Expiratory wheeze on the right side B) Crackles heard on expiration bilaterally C) Dullness to percussion on the lower left side D) Crepitus of the skin around the left lung. Answer: C The client with pneumonia may have dullness to percussion on the affected side. The other options are all inconsistent with pneumonia. ▶ The nurse auscultates the following lung sound in the client with pneumonia. What is the best intervention?
