NCLEX-RN Practice Test 1
1. A patient nearing the end of life expresses relief at having made decisions regarding their care and designated decision-makers for when they can no longer do so. During a discussion with their spouse, the patient states, “Since we’re married, my spouse can automatically make all healthcare decisions for me without a formal durable power of attorney.” The spouse responds, “That’s not entirely accurate. I can only make decisions not outlined in your advance directive.”
As the nurse, how should you address this situation?
A. Clarify that only decisions about treatments not documented in the advance directive can be made by the designated durable power of attorney.
B. Plan an educational session for the spouse regarding advance directives and healthcare powers of attorney.
C. Plan an educational session for the patient regarding advance directives and healthcare powers of attorney.
D. Confirm that legally married spouses automatically act as a durable power of attorney and that no additional documentation is needed.
Correct Answer: A.
Clarify that decisions not included in the advance directive are made by the appointed durable power of attorney. Highlight that legally married spouses are not automatically designated as healthcare decision-makers unless explicitly documented.
2. The PSDA protects individuals’ rights regarding their healthcare decisions. Which rights are included under this Act? Select all that apply:
A. The right to medical information confidentiality unless explicitly authorized by the patient.
B. The right to make healthcare decisions, which are communicated and respected if the individual becomes incapacitated.
C. The right to be fully informed about treatment options, including risks, benefits, and alternatives.
D. The right to select healthcare providers without undue influence or coercion.
Correct Answers: B, D.
The PSDA ensures individuals have the right to make their own healthcare decisions and have them respected, including refusal of treatments, as documented in advance directives. It also protects patients from coercion in choosing their providers. Confidentiality is upheld by HIPAA, and informed consent is a separate legal and ethical standard.
3. A 45-year-old patient with severe burns and trauma has an advance directive requesting all life-saving measures, including CPR and mechanical ventilation. During your shift, the patient experiences cardiac arrest, and their survival prognosis is extremely poor. As the nurse, your first action should be:
A. Inform the physician about the patient’s cardiac arrest.
B. Begin CPR and other life-saving interventions as per the advance directive.
C. Notify the family and ask for their guidance.
D. Focus on ensuring the patient is comfortable and free from distress.
Correct Answer: B.
Nurses are ethically and legally obligated to honor the advance directive and initiate life-saving measures. Informing the physician or family can follow after initiating CPR.
4. You are caring for a pregnant patient whose life-threatening condition poses risks to both her and the fetus. Some treatments favor the mother’s survival while jeopardizing the fetus, and others do the opposite. What is your primary nursing role in this scenario?
A. Case Manager
B. Collaborator
C. Care Coordinator
D. Advocate
Correct Answer: D.
The nurse’s priority is to advocate for both the patient and the fetus. This includes seeking guidance from ethics committees or other resources to address the ethical conflict.
5. A nurse establishes a political action committee (PAC) to address healthcare accessibility and affordability in the local community. What role is the nurse primarily fulfilling?
A. Client Advocate
B. Collaborator
C. Politician
D. Entrepreneur
Correct Answer: A.
By advocating for the community’s needs, the nurse is acting as a client advocate. While collaboration and political action may be involved, advocacy is the central focus.
6. Which of the following reflects the Five Rights of Delegation?
A. Right task, circumstances, person, competency, and supervision/feedback.
B. Right task, circumstances, person, direction/communication, and supervision/feedback.
C. Right competency, education/training, scope of practice, environment, and client condition.
D. Right competency, person, scope of practice, environment, and client condition.
Correct Answer: B.
The Five Rights of Delegation include task, circumstances, person, direction/communication, and supervision/feedback. Competency and scope of practice are assessed within these rights.
7. Before delegating tasks, a nurse evaluates the staff’s qualifications based on:
A. ANA’s Scope of Practice
B. ANA’s Standards of Care
C. State laws
D. Federal laws
Correct Answer: C.
Delegation must comply with state statutes, which define roles and responsibilities for various levels of nursing staff and unlicensed personnel.
8. What is the best method to evaluate a staff member’s time management over time?
A. Observe the staff member’s prioritization during one shift.
B. Observe the staff member’s completion of priority tasks during one shift.
C. Ask the staff member for feedback on their time management.
D. Collect and analyze data over time regarding task completion within scheduled shifts.
Correct Answer: D.
Objective evaluation of time management involves analyzing patterns over time, including task completion within scheduled shifts and reliance on overtime.
9. Which task is appropriately assigned to the indicated team member?
A. Certified unlicensed staff: Monitoring telemetry
B. Certified unlicensed staff: Inserting urinary catheters
C. LPN: Serving as a circulating nurse in surgery
D. LPN: Acting as first assistant in surgery
Correct Answer: A.
Certified unlicensed staff can monitor telemetry but cannot interpret results or act on findings. Inserting catheters and perioperative roles requires licensed professionals.
10. A 28-year-old veteran, permanently disabled and receiving VA disability benefits, is eligible for:
A. Only VA healthcare services due to age.
B. Medicare after two years of disability.
C. Medicaid due to disability and inability to work.
D. Both B and C.
Correct Answer: B.
The veteran qualifies for Medicare after being permanently disabled for two years, regardless of age. Medicaid eligibility depends on financial need, which is not demonstrated here.
11. You are a registered nurse serving as a case manager in your hospital. You are asked to present to newly hired nurses about your responsibilities and ways they can work with you. Which of the following is a primary responsibility of case management in terms of reimbursement that you should include?
A. The case manager’s involvement in organization-wide performance improvement activities
B. The case manager’s role in ensuring complete, timely, and accurate documentation
C. The case manager’s role is to verify that clients are at the appropriate level of care
D. The case manager’s role in disputing denied reimbursements
Correct Response: C
A primary responsibility of case managers in reimbursement is ensuring that clients receive care at the appropriate level based on their medical needs and the continuum of care. Failure to align care with medical necessity jeopardizes reimbursement. For instance, reimbursement for acute care is unlikely if the client’s condition only necessitates subacute or long-term care.
While case managers contribute to performance improvement, accurate documentation, and addressing denied reimbursements, these tasks are typically managed by quality assurance teams, supervisors, or billing professionals.
12. Identify the case management model paired correctly with a descriptor:
A. ProACT Model: Nurses serve as primary caregivers and handle coding and billing
B. Collaborative Practice Model: Nurses act as primary caregivers and manage administrative duties
C. Case Manager Model: Coordination of care for groups of clients sharing a medical diagnosis
D. Triad Model: Collaboration among social workers, case managers, and utilization review teams
Correct Response: D
The Triad Model focuses on collaboration among social workers, nurse case managers, and utilization review teams.
The ProACT Model involves nurses as primary caregivers and case managers but excludes billing duties, which are handled by specialized personnel. The Case Manager Model generally applies to managing care for clients within the same medical diagnosis or group. The Collaborative Practice Model involves broader roles for nurses, encompassing care coordination across diagnoses and client groups.
13. Which case management approach uses care plans that outline interventions and outcomes within set timelines?
A. Case Manager Model
B. ProACT Model
C. Collaborative Practice Model
D. Triad Model
Correct Response: A
The Case Manager Model and the Collaborative Practice Model often require the use of structured, multidisciplinary care plans known as critical pathways. These pathways guide care based on the client’s condition, expected interventions, and desired outcomes.
In contrast, the ProACT and Triad Models may employ various documentation methods, but they do not inherently rely on critical pathways.
14. What type of consent is implied when a client voluntarily admits themselves to a hospital?
A. Opt-out consent
B. Implicit consent
C. Explicit consent
D. No consent
Correct Response: B
Implicit consent is given indirectly by clients when they voluntarily enter a hospital for care. This contrasts with explicit consent, which requires a formal agreement, and opt-out consent, where lack of objection implies agreement.
15. Your supervisor asks you to photograph residents and family members during a holiday event at your long-term care facility. What should you do?
A. Take the photographs because it is a tradition at the facility
B. Take the photographs since the residents are in a dignified condition
C. Refuse unless all individuals consent to the photos
D. Refuse because taking photos is not part of a nurse’s role
Correct Response: C
Photographing individuals without their consent violates their right to privacy and confidentiality, as protected by regulations like HIPAA. Even if the event is a tradition or residents appear presentable, consent is required.
16. Which law is correctly matched with its purpose?
A. Patient Self-Determination Act: Client’s right to choose the level of care
B. Patient Self-Determination Act: Insurance coverage for mental health disorders
C. Mental Health Parity Act: Privacy of psychiatric records
D. HIPAA: Privacy and security of medical information
Correct Response: D
HIPAA ensures the confidentiality and security of all medical information, including electronic records. The Patient Self-Determination Act allows clients to accept or refuse care but does not guarantee a choice of care level or insurance for mental health services. The Mental Health Parity Act ensures mental health coverage equality but does not address record privacy.
17. Who would you most likely collaborate with for a client at risk of falling due to gait issues?
A. Physical therapist
B. Occupational therapist
C. Podiatrist
D. Nurse practitioner
Correct Response: A
Physical therapists specialize in assessing and improving mobility, balance, and gait, often recommending assistive devices like walkers or canes. Occupational therapists focus on daily living activities, podiatrists address foot health, and nurse practitioners may collaborate but are not primary specialists in gait management.
18. According to Lewin, which of the following represents the types of conflict? (Select all that apply)
A. Conceptualization conflicts
B. Avoidance-Avoidance conflicts
C. Approach-Approach conflicts
D. Resolvable conflicts
E. Unresolvable conflicts
F. Double Approach-Avoidance conflicts
G. Approach-Avoidance conflicts
Correct Answers: B, C, F, G
Lewin identified the following types of conflict: Avoidance-Avoidance conflicts, Approach-Approach conflicts, Double Approach-Avoidance conflicts, and Approach-Avoidance conflicts.
19. Which federal regulation primarily enforces the principle of “need to know” in healthcare?
A. Patient Self-Determination Act
B. Mental Health Parity Act
C. Health Insurance Portability and Accountability Act (HIPAA)
D. Americans with Disabilities Act
Correct Answer: C
HIPAA restricts access to medical information, ensuring it is shared only with individuals directly involved in patient care.
20. Which of the following individuals does not have a legitimate need to access patient information?
A. Performance Improvement Director with no direct patient interaction
B. Nursing student under supervised care of a client
C. Safety Officer analyzing patient safety data
D. Department supervisor with no direct or indirect care duties
Correct Answer: D
A department supervisor without care-related responsibilities does not need access to medical information. The others require information for direct or indirect patient care.
21. As a Nurse Manager, which staff comment suggests the need for further training on confidentiality?
A. “A computer with patient information was left unattended in the hallway.”
B. “A nursing student was reviewing records of a patient not assigned to them.”
C. “A dietitian was reading progress notes from the lab and other dietitians.”
D. “I declined to share my electronic password with another nurse.”
Correct Answer: C
Dietitians typically need access only to relevant patient data. Reviewing unrelated notes indicates a potential breach of confidentiality. The other scenarios demonstrate adherence to privacy protocols.
22. Which of the following are correct sterile asepsis practices? Select all that apply:
A. Only sterile items are placed on a sterile field.
B. The sterile field is kept below waist level.
C. Sneezing or coughing contaminates the sterile field.
D. A 1/2-inch border around the sterile field is considered non-sterile.
E. Moisture compromises the sterility of the field.
F. Masks are used during sterile field setup or maintenance.
Correct Answers: A, C, E
Key principles include placing only sterile items on the sterile field, avoiding sneezing or coughing to prevent contamination, and recognizing that moisture compromises sterility. Additional practices include maintaining the field above waist level and observing a one-inch non-sterile border around the sterile field.
23. When caring for elderly clients with multiple chronic and acute conditions requiring new medications, it is essential to recognize that older adults are more susceptible to side effects, adverse reactions, and toxicity due to physiological changes. This increased risk is primarily attributed to:
A. Increased creatinine clearance
B. Impaired immune function
C. Reduced liver metabolism (Correct Answer)
D. Increased body fat
Correct Answer: C. Reduced liver metabolism
Older adults experience a decline in liver function, including decreased hepatic blood flow and metabolic efficiency, which affects how medications are processed. While creatinine clearance also decreases with age, it primarily affects renal drug excretion rather than hepatic metabolism. Immune function declines with age, impacting infection resistance rather than drug toxicity. Lastly, an increase in body fat alters drug distribution but does not directly cause toxicity.
24. To calculate the expected delivery date (EDD) based on the first day of the last menstrual period (LMP), apply Naegele’s Rule:
1. Subtract three months from the LMP.
2. Add seven days to the result.
3. Adjust the year if necessary.
For an LMP of October 20, 2016:
Subtract three months: July 20, 2016.
Add seven days: July 27, 2016.
Add one year: July 27, 2017.
Correct Answer: A. July 27, 2017
25. During labor, the nurse assesses fetal lie, presentation, attitude, station, and position. When the client inquires about these terms, an appropriate response includes:
A. Fetal lie refers to the presenting part within the birth canal.
B. Fetal presentation is the relationship of the fetus’s spine to the mother’s spine.
C. Fetal attitude relates to the fetus’s presenting part within the pelvis.
D. Fetal station measures the fetus’s position relative to the maternal ischial spines. (Correct Answer)
Fetal station: Indicates the position of the fetal presenting part in relation to the ischial spines, measured in centimeters.
Fetal lie: Describes the alignment of the fetus’s spine with the mother’s spine (longitudinal, transverse, or oblique).
Fetal presentation: Identifies which part of the fetus (e.g., head, buttocks, shoulder) enters the birth canal first.
Fetal attitude: Refers to the position of the fetus’s body parts relative to one another, with normal being general flexion.
26. In a pediatric health clinic, applying age-appropriate developmental tasks enhances care. For preschool children:
A. Initiative is the key developmental principle. (Correct Answer)
B. Sensorimotor thought applies.
C. Intimacy is relevant for adolescents.
D. Concrete operations are appropriate for older children.
According to Erik Erikson’s developmental stages:
Preschool: Initiative vs. Guilt.
Infancy: Trust vs. Mistrust.
Toddlerhood: Autonomy vs. Shame and Doubt.
School Age: Industry vs. Inferiority.
Adolescence: Identity vs. Role Confusion.
27. When working with pediatric clients across various age groups, it is crucial to recognize significant life transitions, such as:
A. Pregnancy
B. Puberty (Correct Answer)
C. Childhood immunizations
D. Separation anxiety
Puberty is a natural developmental transition requiring adaptation and support. While immunizations and separation anxiety are relevant, they are not considered developmental transitions.
28. Using the Dimensions Model of Health to assess and improve community health involves multiple factors. Which is NOT included in this model?
A. Biophysical Dimension
B. Psychological and Emotional Dimension
C. Spiritual Dimension (Correct Answer)
D. Health Systems Dimension
The six dimensions of this model are:
1. Biophysical
2. Psychological and Emotional
3. Health Systems
4. Behavioral
5. Socio-Cultural
6. Physical Environment
The spiritual dimension, while significant in holistic health models, is not part of this framework.
29. When screening clients for genetic risks, identifying ethnicity-specific predispositions helps target assessments. For example:
A. Mediterranean ethnicity for cystic fibrosis.
B. African American ethnicity for Tay-Sachs disease.
C. British Isles ethnicity for mental health disorders.
D. Saudi Arabian ethnicity for sickle cell anemia. (Correct Answer)
Ethnic groups and their associated risks include:
Sickle Cell Anemia: African, Latin American, Saudi Arabian, and Mediterranean populations.
Thalassemia: Mediterranean ethnicity.
Tay-Sachs Disease: Ashkenazi Jewish descent.
Cystic Fibrosis: European ancestry.
30. The need for a targeted assessment arises when clinical knowledge and presenting symptoms suggest specific areas of concern.
A. Targeted assessments rely on understanding pathophysiology and symptoms. (Correct Answer)
B. They are based on developmental delays.
C. Targeted assessments occur annually for existing clients.
D. These assessments are limited to a brief medical history.
For example, a targeted assessment may involve:
Evaluating weight gain in infants showing developmental delays.
Screening visual acuity in adolescents with reported difficulties.
31. Among various risk factors, lifestyle choices are the most modifiable.
A. Genetic predisposition
B. Lifestyle choices (Correct Answer)
C. High-risk behaviors
D. External locus of control
Examples of modifiable risks include:
Smoking cessation.
Adopting a balanced diet and regular exercise.
Reducing alcohol consumption.
32. For clients with a history of deep vein thrombosis, smoking, and poor adherence to medical regimens, the following contraceptives are NOT recommended:
A. Transdermal patch
B. Diaphragm
C. Vaginal ring
D. None of the above (Correct Answer)
Hormonal options, such as patches and rings, increase clotting risks, while diaphragms require consistent use, unsuitable for non-adherent individuals.
33. Your 87-year-old client has a history of heart disease, fibromyalgia, and diabetes, and also has an internal pacemaker. During your annual visit, the client expresses interest in exploring alternative and homeopathic healthcare practices. What should be included in your teaching plan?
A. Provide information on the lack of scientific evidence supporting the effectiveness of all herbs.
B. Present research suggesting that magnets might help alleviate fibromyalgia pain, which could be beneficial for this client.
C. Share evidence indicating that prayer can be effective in reducing stress and pain, which may benefit this client.
D. Advise against biofeedback, as it may interfere with the functioning of the client’s pacemaker.
Correct Answer: C
Research shows that prayer can be a helpful method for managing stress, anxiety, and pain, making it a potentially valuable option for this client.
It is important to educate clients about alternative therapies. For example, while some herbs may be safe and effective, others can pose risks. Magnets are not recommended for clients with pacemakers or insulin pumps, as they can disrupt these devices. Additionally, biofeedback does not interfere with pacemaker function and can be considered safe.
34. You determine that a family is struggling with instrumental activities of daily living (IADLs). To which healthcare professional should you refer them?
A. Social worker
B. Physical therapist
C. Occupational therapist
D. Speech therapist
Correct Answer: A
A social worker is the most appropriate referral for addressing deficits in instrumental activities of daily living (IADLs), such as grocery shopping, meal preparation, and transportation.
Basic activities of daily living (ADLs) involve tasks like bathing, grooming, and eating and are typically managed by physical or occupational therapists. In contrast, IADLs require more advanced skills and may benefit from the support of a social worker to help the family access necessary resources or develop practical solutions.
35. Match the cranial nerves with their primary functions. Select all that apply:
A. Olfactory: Sensory nerve for the sense of smell.
B. Optic: Sensory nerve transmitting vision from the retina to the brain.
C. Oculomotor: Motor and sensory nerve controlling eye movements and visual clarity.
D. Trochlear: Motor nerve controlling eye movements via the superior oblique muscle.
E. Abducens: Motor nerve involved in eye abduction using the lateral rectus muscle.
F. Facial: Motor nerve for facial movements and anterior tongue taste perception.
G. Glossopharyngeal: Sensory nerve providing taste perception from the posterior tongue and salivary gland innervation.
Correct Answer: A, B, D, E
Olfactory (A): Sensory nerve responsible for transmitting the sense of smell.
Optic (B): Sensory nerve relaying visual signals from the retina to the brain.
Trochlear (D): Motor nerve enabling eye movement via the superior oblique muscle.
Abducens (E): Motor nerve controlling lateral movement of the eye via the lateral rectus muscle.
The oculomotor nerve is primarily motor and regulates eye movement, pupil constriction, and focusing, but it does not contribute to visual clarity. The facial and glossopharyngeal nerves are both mixed nerves, with motor and sensory roles.
36. A comprehensive health assessment includes:
A. Complete medical history, general survey, and complete physical assessment.
B. Complete medical history, general survey, and focused physical assessment.
C. Client and significant other interviews, general survey, and complete physical assessment.
D. Client and significant other interviews, general survey, and focused physical assessment.
Correct Answer: A
A comprehensive health assessment includes a full medical history, general survey, and a complete physical exam.
While client and significant other interviews contribute to the medical history, they are not standalone components of the assessment. Focused assessments are condition-specific and not part of a comprehensive evaluation.
37. Match the percussion sound with its description:
A. Tympany: Hollow sound
B. Dullness: Thud-like sound
C. Dullness: Hollow sound
D. Resonance: Booming sound
Correct Answer: B
Tympany: Drum-like sound over air-filled areas.
Dullness: Thud-like sound over solid organs.
Resonance: Hollow sound over normal lung tissue.
38. Which couple is at the highest risk for domestic violence?
A. A couple with both partners diagnosed with Alzheimer’s disease.
B. A low-income couple without access to healthcare resources.
C. A pregnant woman with a husband who was abused as a child.
D. A wealthy couple with a strong sense of entitlement.
Correct Answer: C
Pregnancy and a history of childhood abuse are significant risk factors for domestic violence.
Other vulnerable populations include children, elderly individuals, and people with physical or cognitive disabilities. Perpetrators may have poor coping skills, low self-esteem, substance abuse, or mental health disorders.
39. You are caring for a client with a history of violent behavior. What is your first step to ensure safety for others?
A. Apply restraints.
B. Place the client in seclusion.
C. Administer sedating medication.
D. Build trust with the client.
Correct Answer: D
Establishing trust is the foundation of a therapeutic relationship and helps de-escalate potential violence.
Restraining or isolating the client should only be considered when immediate danger exists. Sedative medications may be used but are not the initial step.
40. A client using illicit amphetamines explains they continue using to avoid the distress of stopping. What is the most appropriate nursing diagnosis?
A. Psychological dependence related to amphetamine use
B. Substance misuse related to amphetamine use
C. Addiction related to amphetamine use
D. Physical dependence related to amphetamine use
Correct Answer: A
Psychological dependence occurs when an individual continues substance use to avoid the distressing experiences of withdrawal. Amphetamines and similar substances often result in psychological dependence.
Substance misuse refers to the excessive use of drugs or alcohol, including legal and illegal substances.
Addiction involves persistent, compulsive use despite adverse consequences and can occur with or without physical dependence.
Physical dependence is associated with withdrawal symptoms when stopping the substance, often linked to alcohol, opioids, and benzodiazepines.
41. A rehabilitation center uses a philosophy stating disabilities arise from a mismatch between a person’s abilities and environmental limitations. What model underpins this approach?
A. Orem’s Self-Care Model
B. Nagi’s Model
C. Cognitive Model of Disability
D. Biomedical Model of Disability
Correct Answer: B
Nagi’s model explains disability as resulting from the interaction between individual capabilities and environmental or social barriers.
Orem’s Self-Care Model focuses on self-care needs but is not a disability framework.
Cognitive models emphasize independence and empowerment.
Biomedical models concentrate on pathology and impairments without addressing environmental factors.
42. Place the following crisis phases in order:
1. Signs of General Adaptation Syndrome (GAS)
2. Detachment and disorientation
3. Trying alternative coping strategies
4. Use of psychological defense mechanisms
Options:
A. 3, 2, 1, 4
B. 1, 2, 3, 4
C. 4, 3, 2, 1
D. 4, 3, 1, 2
Correct Answer: D
Crisis progression typically follows these phases:
1. Initial defense mechanisms (e.g., denial, repression).
2. Trying new coping strategies when usual methods fail.
3. Physical responses like fight-or-flight, reflecting GAS.
4. Severe distress with detachment or disorientation.
43. A client detaching from their surroundings is likely using which defense mechanism?
A. Displacement
B. Sublimation
C. Dissociation
D. Reaction Formation
Correct Answer: C
Dissociation involves detaching from reality to temporarily manage stress.
Displacement redirects emotions to safer targets.
Sublimation channels unacceptable impulses into constructive activities.
Reaction formation leads to acting in ways opposite to true feelings.
44. What theoretical framework supports nursing care in a culturally diverse setting?
A. Jean Watson’s theory
B. Martha Rogers’ theory
C. Nagi’s theory
D. Madeleine Leininger’s theory
Correct Answer: D
Leininger’s Transcultural Nursing theory emphasizes holistic care considering cultural differences.
Watson’s theory focuses on the essence of caring.
Rogers’ theory addresses human energy fields.
Nagi’s model is centered on disability but not cultural diversity.
45. What is the most common goal for clients receiving hospice care?
A. Acceptance of impending death
B. Resolving guilt
C. Addressing spiritual distress
D. Managing pain
Correct Answer: A
Promoting acceptance of death is central to hospice care. While addressing pain, guilt, and spiritual distress are important, they are not universal goals.
46. A hospice client nearing death is comatose, dehydrated, and free of pain. What is the most appropriate intervention?
A. Relieving constipation
B. Maintaining freedom from pain and distress
C. Preventing dehydration with antiemetics
D. Administering an enema
Correct Answer: B
In imminent death, ensuring comfort and alleviating pain are priorities. Other interventions, like enemas, are unnecessary unless they address immediate discomfort.
47. Grandparents refuse family therapy, citing that only their grandson’s addiction is the issue. How should you respond?
A. “Try attending a few sessions; they may be helpful.”
B. “This isn’t your problem.”
C. “Crises impact the whole family, including you.”
D. “The doctor has ordered this therapy for everyone.”
Correct Answer: C
Families in crisis benefit from therapy because stress affects all members, even if only one has the primary issue.
48. Which theory would guide grief counseling for bereaved family members?
A. Engel’s theory
B. Kubler-Ross’s theory
C. Lewin’s theory
D. Worden’s theory
Correct Answer: D
Worden’s Four Tasks of Mourning provide a structured approach to coping with loss, including acceptance and moving forward while maintaining a connection with the deceased.
49. What cultural issue is most relevant during psychological evaluations?
A. Stigma around reporting mental health symptoms
B. Lack of resources for treatment
C. Noncompliance due to poor support systems
D. Cultural apathy toward nursing care
Correct Answer: A
In some cultures, mental health stigma inhibits open discussion of symptoms, creating barriers to accurate assessments.
50. For hospital admissions staff, which religion’s practices are most relevant when assigning patient rooms?
A. Hinduism
B. Buddhism
C. Islam
D. Mormonism
Correct Answer: C
In Islam, followers pray facing Mecca, making it important to assign rooms that align with this direction when possible.
Other religious practices influencing care include:
Christianity: Rituals like baptisms and the Sacrament of the Sick.
Judaism: Kosher diets, circumcision, and specific mourning practices.
Hinduism: Emphasis on vegetarianism, hygiene, and certain death rituals.
Mormonism: Restrictions on substances like alcohol and caffeine, with an emphasis on baptism and last rites.
Jehovah’s Witnesses: Prohibition of blood transfusions, certain dietary restrictions, and abstinence from tobacco and alcohol.
51. A new client enters your care area using a cane that appears too short. What is your best course of action?
A. Provide the client with a wheelchair to ensure their safety.
B. Take the cane from the client to avoid potential risks.
C. Educate the client on proper cane height and adjustment.
D. Advise the client to use a wheelchair instead of a cane.
Correct Answer: C
The best action is to teach the client about the correct height for a cane. A properly fitted cane allows the elbow to flex slightly. Non-adjustable wooden canes may need replacement, while adjustable canes can be customized to suit the client’s height.
Placing the client in a wheelchair or removing their cane is unnecessary and may undermine their independence. Instead, use the opportunity to provide guidance on safe and effective cane use.
52. Which hazard of immobility is correctly matched with a prevention strategy?
A. Bone demineralization: Turn and reposition every two hours
B. Urinary stasis: Consume 1,000 mL of fluids daily
C. Muscle atrophy: Perform range-of-motion exercises three times a day
D. Hypercalcemia: Maintain fluid intake of 1,000 mL per day
Correct Answer: C
Range-of-motion exercises help prevent muscle atrophy in immobile clients.
For urinary stasis and hypercalcemia, fluid intake should generally exceed 1,000 mL daily—closer to 2,000 mL. Bone demineralization is addressed through weight-bearing activities, not simply repositioning.
53. During a musculoskeletal exam, a client demonstrates muscle strength against gravity but not against resistance. How is this documented?
A. 1 on a 1-3 scale
B. 2 on a 0-5 scale
C. 3 on a 0-5 scale
D. 4 on a 0-5 scale
Correct Answer: C
This client’s muscular strength is rated as 3/5, which reflects movement against gravity but not resistance.
0: No contraction
1: Muscle quiver only
2: Movement only with gravity eliminated
3: Movement against gravity
4: Movement against resistance
5: Full strength and movement
54. A wound measures 3 cm deep, 2 cm long, and 4 cm wide. What is the documented size?
A. 6 cm
B. 12 cm
C. 20 cm
D. 24 cm
Correct Answer: D
Wound size is calculated by multiplying depth, length, and width. In this case:
\( 3 \, \text{cm} \times 2 \, \text{cm} \times 4 \, \text{cm} = 24 \, \text{cm}^3 \).
55. A client with a ruptured appendix and peritonitis is likely to experience what type of wound healing?
A. Secondary intention
B. Tertiary intention
C. Primary prevention
D. Secondary prevention
Correct Answer: A
Secondary intention healing is used for wounds with contamination or infection, allowing the wound to heal from the bottom up to avoid trapping bacteria. This method typically involves cleaning and packing the wound.
The primary intention involves clean, closed wounds with minimal risk of infection. Tertiary intention combines aspects of secondary and primary healing, with delayed closure to reduce infection risk. Primary and secondary prevention are not healing methods but refer to health intervention strategies.
56. You acknowledge that low endorphin levels or anxiety can increase pain, while reduced anxiety can lessen it. This aligns with which pain theory?
A. Moritz Schiff’s Pain Theory
B. The Intensive Theory of Pain
C. Gate Control Theory
D. Specificity Theory of Pain
Correct Answer: C
The Gate Control Theory of Pain by Melzack and Wall describes how psychological and physiological factors can either amplify or diminish pain. The “gate,” located in the spinal cord’s substantia gelatinosa, controls the transmission of pain signals to the brain. Anxiety and low endorphin levels may “open” the gate, while reduced anxiety can “close” it, decreasing pain perception.
Other theories include:
Specificity Theory: Suggests pain travels specific pathways to the brain.
Intensive Theory: Views pain as an emotional experience triggered by intense stimuli.
Neuromatrix Theory: Highlights pain as a complex, multidimensional experience influenced by physical, psychological, and social factors.
57. The PQRST method for assessing pain includes which components?
A. Pain severity, quality, location, intensity, and triggers
B. Precipitating factors, quality, relief methods, severity, and triggers
C. Pain level, numerical score, location, severity, and triggers
D. Precipitating factors, quality, location, severity, and triggers
Correct Answer: D
The PQRST framework helps assess pain systematically:
P: Precipitating factors (what causes or worsens the pain)
Q: Quality (how the pain feels, e.g., sharp, dull)
R: Region (location of the pain)
S: Severity (pain scale from 0 to 10)
T: Triggers (what alleviates or worsens it)
58. What do the A, B, C, and D of a comprehensive nutritional assessment represent?
A. Assessment data, biochemical data, clinical data, and dietary data
B. Anthropometric data, biological data, chemical data, and dietary data
C. Ancestral cultural data, biochemical data, clinical data, and dietary data
D. Anthropometric data, biochemical data, clinical data, and dietary data
Correct Answer: D
A complete nutritional assessment includes:
A: Anthropometric data (e.g., height, weight, BMI, mid-arm circumference).
B: Biochemical data (lab values like hemoglobin, serum albumin).
C: Clinical data (e.g., skin condition, energy level, mucous membranes).
D: Dietary data (details of food and fluid intake over 24 hours).
59. A client receiving tube feeding is at risk of complications. Which preventive measure is correctly paired with its complication?
A. Constipation: Provide a high-fiber diet
B. Urinary pH changes: Encourage fluid intake
C. Aspiration: Maintain the head of the bed at 30 degrees
D. Aspiration: Maintain the head of the bed at 90 degrees
Correct Answer: C
Maintaining the client’s head at a minimum of 30 degrees helps prevent aspiration during tube feeding. Elevating the head higher than necessary (e.g., to 90 degrees) can increase the risk of pressure ulcers.
Other complications and their prevention include:
Diarrhea: Adjusting feeding rate or formula
Dehydration: Monitoring intake/output and addressing abnormalities
Tube dislodgment: Securing and regularly inspecting the tube
60. What is a key factor influencing an individual’s hygiene preferences and routines?
A. Culture
B. Locus of control
C. Body surface area
D. Diaphoresis
Correct Answer: A
Cultural beliefs and practices significantly shape personal hygiene habits. Factors like religion, economic conditions, cognitive status, and energy levels can also impact hygiene practices, but culture is the primary influence on preferences and routines.
61. Which age group is paired correctly with their recommended hours of sleep?
A. Neonates: 10 to 15 hours/day
B. Toddlers: 11 to 14 hours/day
C. Preschoolers: 12 to 15 hours/day
D. School-aged children: Less than 8 hours/day
Correct Answer: B
Toddlers typically need 11 to 14 hours of sleep daily.
Neonates: 14 to 17 hours/day
Preschoolers: 10 to 13 hours/day
School-aged children: 9 to 11 hours/day
62. A client receiving IV antibiotics shows signs of anaphylaxis. What is your first priority?
A. Stop the IV infusion
B. Slow the IV rate
C. Notify the physician
D. Begin CPR
Correct Answer: A
The immediate priority is to stop the antibiotic infusion, as it is likely the cause of the anaphylactic reaction. After stopping the infusion, assess the client’s condition and administer emergency interventions, such as CPR, if needed. Notifying the physician comes after the client is stabilized.
63. How can a nurse determine IV fluid and medication compatibility?
A. Mix small amounts and observe for changes
B. Consult a compatibility chart
C. Contact the prescribing physician
D. Mix small amounts and check for precipitates
Correct Answer: B
The safest and most reliable method is consulting a compatibility chart. Visual changes (e.g., cloudiness, precipitates) might not always occur, so direct reference to a chart is essential to avoid errors.
64. What is the primary goal of medication reconciliation?
A. Prevent polypharmacy
B. Save costs
C. Avoid drug interactions
D. Identify medication allergies
Correct Answer: C
Medication reconciliation ensures the nurse has an accurate, complete list of the client’s medications to identify and prevent potential drug interactions. While it can also address polypharmacy and reduce costs, these are secondary benefits. Identifying allergies is a fundamental step before prescribing or administering any medication.
65. Your pregnant patient has a new prescription for medication. What principle should guide your decision?
A. Medications categorized as C, D, and X pose risks to pregnant women and should generally be avoided.
B. Medications categorized as A, B, and C are unsafe for pregnant women.
C. Medications categorized as C, D, and E are contraindicated during pregnancy.
D. Medications categorized as C, D, and Z are not recommended for pregnant women.
Correct Answer: A
Drugs classified as C, D, and X have varying levels of potential risk to the fetus, particularly when they cross the placental barrier. These should be avoided unless the benefit outweighs the risk.
66. What key consideration should you remember when administering blood to a patient with B-negative blood type?
A. The patient’s blood contains A and B antibodies and lacks the Rh factor.
B. The patient’s blood contains B and O antibodies and lacks the Rh factor.
C. The patient’s blood contains B antibodies and lacks the Rh factor.
D. The patient’s blood contains A antibodies and lacks the Rh factor.
Correct Answer: D
Individuals with B-negative blood have A antibodies and are Rh-negative. Blood type compatibility is crucial to prevent transfusion reactions.
67. Match the complication of a blood transfusion with its preventive measure:
A. Hemolysis: Ensuring blood type and cross-matching before administration.
B. Hemolysis: Confirming no prior history of hemolysis.
C. Febrile reactions: Confirming no prior history of hemolysis.
D. Febrile reactions: Ensuring blood type and cross-matching before administration.
Correct Answer: A
Hemolysis is typically prevented by thorough blood typing, cross-matching, and confirming ABO compatibility. Febrile reactions, while common, are not linked to hemolysis but often occur due to the recipient’s immune response to donor white blood cells.
68. Which guideline should you follow when administering packed red blood cells?
A. Ensure the patient has a patent intravenous catheter, at least 20 gauge.
B. Verify blood compatibility and patient identity with another nurse before administration.
C. Begin transfusion no later than one hour after picking up the blood.
D. Stay with the patient for at least 30 minutes after starting the transfusion.
Correct Answer: B
Two nurses must confirm the blood type, patient identity, and the provider’s order before starting the transfusion. Other principles include using at least an 18-gauge catheter, initiating transfusion within 30 minutes of receiving the blood, and closely monitoring the patient for 15 minutes after starting.
69. For a critically injured trauma patient requiring long-term intravenous therapy, what venous access device is most appropriate?
A. Percutaneous, non-tunneled subclavian catheter
B. 20-gauge peripheral IV catheter
C. Multi-lumen tunneled central venous catheter with a cuff
D. Peripherally inserted central catheter (PICC line)
Correct Answer: C
A multi-lumen tunneled central catheter is ideal for long-term therapies, including blood products, medications, and parenteral nutrition. PICC lines and non-tunneled catheters are more suitable for short-term use.
70. How many tablets are required daily with this prescription?
Order: 200 mg of medication daily
Medication label: 150 mg per tablet
A. 1.5 tablets
B. 1.25 tablets
C. 1.33 tablets
D. 1 tablet
Correct Answer: C
To calculate:
\[
\text{Number of tablets} = \frac{\text{Desired Dose (mg)}}{\text{Dose Per Tablet (mg)}} = \frac{200}{150} = 1.33 \text{ tablets}
\]
71. How much liquid medication would you administer intramuscularly?
Order: 10 mg twice daily
Label: 1 mL = 12 mg
A. 0.8 mL
B. 0.9 mL
C. 0.75 mL
D. 0.125 mL
Correct Answer: A
To calculate:
\[
\text{Volume (mL)} = \frac{\text{Desired Dose (mg)}}{\text{Concentration (mg/mL)}} = \frac{10}{12} = 0.833 \text{ mL, rounded to } 0.8 \text{ mL}.
\]
72. How many units of heparin would you administer subcutaneously?
Order: 6,500 units
Label: 4,500 units per mL
A. 1.4 mL
B. 1.5 mL
C. 1.475 mL
D. 1.425 mL
E. 1.375 mL
Correct Answer: A
To calculate:
\[
\text{Volume (mL)} = \frac{\text{Desired Dose (units)}}{\text{Concentration (units/mL)}} = \frac{6,500}{4,500} = 1.44 \text{ mL, rounded to } 1.4 \text{ mL}.
\]
73. How many mg should you administer per dose to a pediatric patient?
Order: 5 mg/kg/day in two divided doses
Weight: 48 lbs
A. 45 mg
B. 60 mg
C. 52 mg
D. 55 mg
Correct Answer: D
Steps:
1. Convert weight: \(48 \, \text{lbs} \div 2.2 = 21.81 \, \text{kg}\).
2. Calculate total dose: \(21.81 \, \text{kg} \times 5 \, \text{mg/kg} = 109.05 \, \text{mg/day}\).
3. Divide into two doses: \(109.05 \div 2 = 54.53 \, \text{mg}\), rounded to 55 mg per dose.
74. Calculate the infusion rate for 1 liter of fluid over 8 hours using a set with 20 drops/mL:
A. 31 drops/min
B. 42 drops/min
C. 48 drops/min
D. 51 drops/min
Correct Answer: B
Steps:
1. Determine hourly rate: \(1,000 \, \text{mL} \div 8 \, \text{hours} = 125 \, \text{mL/hour}\).
2. Convert to drops/min: \((125 \div 60) \times 20 = 41.67 \, \text{gtts/min}\), rounded to 42 gtts/min.
75. A patient requires 1200 mL of IV fluid over 8 hours. At the start of your shift (8:00 AM), 600 mL remains in the IV bag. How much fluid will remain at 12:00 PM?
Options:
A. 0 mL
B. 5 mL
C. 10 mL
D. 7.5 mL
Correct Answer: A
To calculate:
1. Determine the hourly infusion rate:
\( 1200 \div 8 = 150 \, \text{mL/hour} \).
2. Calculate fluid infused over 4 hours (8:00 AM to 12:00 PM):
\( 150 \times 4 = 600 \, \text{mL} \).
Since 600 mL was left at 8:00 AM, it will all be infused by 12:00 PM, leaving 0 mL.
76. Which method should be used to administer intramuscular ferrous sulfate?
Options:
A. Subcutaneous injection
B. PQRST technique
C. Z-track technique
D. Sublingual administration
Correct Answer: C
The Z-track technique is used for intramuscular administration of ferrous sulfate to prevent leakage and staining of the skin at the injection site.
77. A new nurse identifies the gluteus maximus for an intramuscular injection. What action should you take?
Options:
A. Allow the nurse to proceed.
B. Suggest the vastus lateralis as an alternative.
C. Recheck the doctor’s order.
D. Stop the nurse from administering the injection.
Correct Answer: D
Intramuscular injection sites are determined using bony landmarks, not by palpating muscles. You must stop the nurse to ensure the correct technique is followed.
78. You discard 0.2 mL from a 1 mL vial and then prepare 0.8 mL for a patient, who subsequently refuses the medication. What error did you make?
Options:
A. Failing to have another nurse witness the 0.2 mL and 0.8 mL waste.
B. Failing to have another nurse witness the 0.8 mL waste.
C. Failing to have another nurse witness the 0.2 mL waste.
D. Failing to verify the dose calculation with another nurse.
Correct Answer: A
Any waste of controlled substances, whether partial or full, must be witnessed and documented by another nurse.
79. Which client has the highest risk for extravasation?
A. Client with heart failure receiving Ringer’s lactate
B. Client with cancer receiving bendamustine
C. Client receiving intravenous potassium supplementation
D. Client on total parenteral nutrition (TPN)
Correct Answer: B
Clients receiving vesicant drugs like bendamustine are at the highest risk for extravasation. Extravasation occurs when a vesicant medication leaks into surrounding tissues, potentially causing severe damage, including tissue necrosis or limb loss.
Ringer’s lactate and potassium supplementation are not vesicants and are more associated with infiltration, not extravasation. While TPN has other risks, such as infection, it does not pose a significant extravasation risk.
80. Match the IV therapy complication with its appropriate intervention.
A. Infection: Lower the limb to improve circulation
B. Infiltration: Apply cold compresses to the site
C. Extravasation: Aspirate fluid and blood from the IV cannula
D. Hematoma: Administer dexrazoxane
Correct Answer: C
In cases of extravasation, aspirating as much fluid and blood as possible from the IV cannula is one intervention. Additional steps include stopping the infusion, elevating the limb, using warm compresses initially to disperse the drug, and applying cool compresses to minimize swelling. A specific medication like dexrazoxane may also be ordered.
For infection, the affected limb is elevated rather than lowered. Infiltration is treated with warm compresses, not cold. Hematoma management typically involves applying pressure and warmth, not dexrazoxane.
81. What is the purpose of the CRIES scale?
A. Assess motor functioning
B. Assess sensory functioning
C. Evaluate tactile response
D. Assess pain response to analgesics
Correct Answer: D
The CRIES scale is used to evaluate pain and the effectiveness of analgesics in neonates. This observational pain assessment is applied to infants and includes factors such as crying, oxygen requirement, vital signs, and sleeplessness.
Other pediatric pain scales include FLACC, NIPS, CHEOPS, and the FACES Pain Scale, which cater to specific age groups and conditions.
82. Select the opioid type that is correctly paired with an example and one of its effects.
A. Opioid Agonist: Dilaudid — Constipation
B. Opioid Agonist: Naloxone — Constipation
C. Opioid Antagonist: Dilaudid — Anaphylaxis
D. Opioid Antagonist: OxyContin — Anaphylaxis
Correct Answer: A
Dilaudid (hydromorphone) is an opioid agonist commonly associated with side effects like constipation, sedation, and respiratory depression. Other opioid agonists include OxyContin and codeine.
Opioid antagonists like naloxone and naltrexone are used to counteract opioid effects and may cause side effects such as nausea, anxiety, and insomnia.
83. Which statement about TPN is accurate?
A. TPN clients are at high infection risk due to immunosuppression.
B. Diabetic clients on TPN have a high hyperglycemia risk.
C. The Valsalva maneuver prevents embolism during tubing changes.
D. A mask is used for TPN dressing changes due to embolism risk.
Correct Answer: C
The Valsalva maneuver helps prevent air embolism during TPN tubing changes.
Infection risk in TPN is due to high dextrose content and the invasive nature of the procedure, not necessarily due to immunosuppression. Similarly, hyperglycemia is a risk because of the high glucose in TPN solutions, not just because a client may have diabetes. A mask is used for infection control during dressing changes, not for embolism prevention.
84. A 2-year-old has the following vitals:
Respiratory rate: 32 breaths/min
Pulse: 110 bpm
Blood pressure: 55/82
What is the appropriate response to the parent’s query about normalcy?
A. “The respiratory rate is slightly high, but the others are normal.”
B. “The pulse is slightly high, but the others are normal.”
C. “The blood pressure is low, but the others are normal.”
D. “All vitals are normal for a 2-year-old.”
Correct Answer: D
These vitals fall within normal ranges for a 2-year-old:
Respiratory rate: 20–40 breaths/min
Pulse: 90–140 bpm
Blood pressure: 80/50 to 112/80 mmHg
85. A 5-year-old has the following vitals:
Respiratory rate: 32 breaths/min
Pulse: 100 bpm
Blood pressure: 85/55
How should you respond to the parent’s concerns?
A. “The respiratory rate is slightly high, but the others are normal.”
B. “The pulse is slightly high, but the others are normal.”
C. “The blood pressure is low, but the others are normal.”
D. “All vitals are normal for a 5-year-old.”
Correct Answer: A
A normal respiratory rate for a 5-year-old is 22–30 breaths/min, so 32 is slightly elevated. Pulse (80–110 bpm) and blood pressure (82–110 systolic, 50–78 diastolic) are normal.
86. Which hemodynamic reading is abnormal and requires reporting?
A. Pulmonary artery systolic pressure: 22 mmHg
B. Pulmonary artery wedge pressure: 22 mmHg
C. Pulmonary artery diastolic pressure: 10 mmHg
D. Central venous pressure: 5 mmHg
Correct Answer: B
A normal pulmonary artery wedge pressure is 4–12 mmHg, so 22 mmHg is elevated and should be reported. Other hemodynamic values provided are within normal limits:
Pulmonary artery systolic pressure: 15–26 mmHg
Pulmonary artery diastolic pressure: 5–15 mmHg
Central venous pressure: 1–8 mmHg
87. How should an ambulatory female client collect a midstream urine sample?
A. Cleanse the perineal area with circular wipes.
B. Cleanse from “dirtiest” to “cleanest.”
C. Use a new wipe for each stroke, cleaning inner to outer labia.
D. Use a new wipe for each stroke, cleaning outer to inner labia.
Correct Answer: C
Clients should clean the perineal area with a new antiseptic wipe for each stroke, moving from the inner labia (cleanest) to the outer labia (dirtiest). This technique aligns with aseptic principles.
88. Which step in blood glucose monitoring is incorrect?
A. Hold the finger downward to let gravity assist blood flow.
B. Use sterile gauze to remove the first drop of blood.
C. Use the lancet to prick the side of the finger.
D. Use the lancet to prick the fingertip pad.
Correct Answer: D
Using the lancet to prick the fingertip pad is not recommended for blood glucose testing. The correct technique is to prick the side of the finger to reduce discomfort and ensure accuracy.
89. Which arterial blood gas value would you report as abnormal?
A. PaO₂: 65 mmHg
B. PaCO₂: 40 mmHg
C. Blood pH: 7.39
D. SaO₂: 96%
Correct Answer: A
A PaO₂ level of 65 mmHg is below the normal range of 75–100 mmHg and indicates hypoxemia, which warrants physician notification.
Normal ranges:
PaCO₂: 38–42 mmHg
Blood pH: 7.38–7.42
SaO₂: 94–100%
90. Which client has the highest risk of poor vascular circulation?
A. A 76-year-old woman with a history of alcohol use.
B. A 76-year-old woman exposed to radon gas.
C. A 64-year-old man with a history of smoking.
D. A 64-year-old man with low blood pressure.
Correct Answer: D
Hypotension increases the risk of poor vascular perfusion, leading to potential complications such as tissue hypoxia.
Other risk factors for impaired circulation include:
Fluid volume imbalances (hypervolemia/hypovolemia)
Anemia
Immobility
Cardiac dysfunction
91. Which client has the highest risk of developing cancer?
A. A 76-year-old woman with a history of alcohol use.
B. A 76-year-old woman with diabetes.
C. A 64-year-old man with oxygen transport issues.
D. A 64-year-old man with low blood pressure.
Correct Answer: A
Chronic alcohol use increases the risk of certain cancers, including liver and gastrointestinal cancers.
92. How should you explain patient movement under general anesthesia?
A. “The patient is experiencing anesthesia awareness.”
B. “This is common during stage 2 of general anesthesia.”
C. “The patient needs a higher dose of anesthesia.”
D. “The patient is having a seizure.”
Correct Answer: B
Movement during stage 2 of general anesthesia (the excitement phase) is typical and includes irregular breathing, muscle activity, and possibly vomiting. This stage does not require an increase in anesthetic dosage and is not indicative of anesthesia awareness or seizures.
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