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UWorld NCLEX-RN Practice Questions and Answers
Here’s how we can proceed with your NCLEX-RN preparation:
1. Study Strategies:
- Understand the NCLEX-RN Format: The exam is adaptive, meaning questions become more difficult or easier based on your previous answers. It’s important to familiarize yourself with the types of questions and the time constraints.
- Focus on Key Topics: The NCLEX-RN covers a wide range of nursing topics. Key areas to focus on include:
- Safe and Effective Care Environment (management of care, safety, infection control)
- Health Promotion and Maintenance (developmental stages, prevention of illness)
- Psychosocial Integrity (mental health, coping mechanisms)
- Physiological Integrity (basic care and comfort, pharmacological therapies)
- Use NCLEX-RN Question Banks: UWorld is a great tool for practice questions. Consider using other resources such as Kaplan, Hurst Review, or NCLEX-RN prep books.
2. Concepts to Focus On:
- Pharmacology: Know common drugs, dosages, and side effects.
- Cardiovascular: Understand ECG interpretation, heart failure, hypertension management.
- Respiratory: Learn about oxygen therapy, COPD, and acute respiratory distress syndrome (ARDS).
- Infection Control: Standard precautions, isolation procedures, and common infectious diseases.
- Endocrine: Diabetes management, thyroid disorders, and insulin types.
- Musculoskeletal: Fractures, joint replacements, and pain management.
3. Practice Questions:
- Regular practice of NCLEX-style questions is crucial to becoming comfortable with the exam format.
- If you want, I can walk you through answering a sample question to give you insight into how to approach them effectively.
Sample NCLEX-RN Questions
1. A nurse is caring for a client who is receiving IV potassium. The nurse notices that the client’s ECG shows peaked T-waves. Which action should the nurse take?
A) Increase the infusion rate of the potassium.
B) Administer a calcium gluconate IV.
C) Increase the rate of normal saline infusion.
D) Stop the potassium infusion immediately.
Answer: D) Stop the potassium infusion immediately.
Explanation: Peaked T-waves are a sign of hyperkalemia, which can cause serious cardiac arrhythmias. The first priority is to stop the potassium infusion and notify the healthcare provider.
2. A nurse is teaching a client with asthma how to use a metered-dose inhaler (MDI). Which instruction should the nurse include?
A) Inhale slowly and deeply while pressing the inhaler.
B) Exhale through the mouth after inhaling the medication.
C) Shake the inhaler before use.
D) Wait 1 minute before administering a second puff.
Answer: C) Shake the inhaler before use.
Explanation: The inhaler should be shaken to mix the medication properly before use. The patient should inhale slowly and deeply, and wait 1 minute before taking another puff if prescribed.
3. A nurse is caring for a client who is receiving chemotherapy and is experiencing nausea. The nurse should administer which of the following medications?
A) Omeprazole
B) Ondansetron
C) Diphenhydramine
D) Famotidine
Answer: B) Ondansetron
Explanation: Ondansetron is an antiemetic commonly used to prevent nausea and vomiting associated with chemotherapy.
4. The nurse is caring for a client who has just undergone a total hip replacement. Which position is appropriate for the client in the immediate postoperative period?
A) Prone with the legs extended.
B) Side-lying on the unaffected side.
C) Supine with a pillow between the legs.
D) Sitting with the legs dangling over the side of the bed.
Answer: C) Supine with a pillow between the legs.
Explanation: After a hip replacement, the client should be positioned supine with a pillow between the legs to maintain proper alignment and prevent dislocation.
5. A nurse is reviewing the laboratory results of a client with liver cirrhosis. The nurse would expect the following result to be elevated:
A) Hemoglobin
B) Bilirubin
C) Serum albumin
D) Platelet count
Answer: B) Bilirubin
Explanation: In liver cirrhosis, the liver’s ability to conjugate and excrete bilirubin is impaired, leading to elevated levels in the blood.
6. A nurse is caring for a client with a history of heart failure. Which of the following findings indicates worsening heart failure?
A) Increased urine output
B) Decreased heart rate
C) Bilateral crackles in the lungs
D) Improved oxygen saturation
Answer: C) Bilateral crackles in the lungs.
Explanation: Bilateral crackles are indicative of pulmonary congestion, which is a sign of worsening heart failure.
7. A nurse is caring for a client with severe burns. Which lab result should the nurse monitor closely?
A) Serum sodium
B) Serum potassium
C) Hemoglobin
D) Serum albumin
Answer: B) Serum potassium.
Explanation: After burns, potassium can shift from the intracellular to the extracellular space, which can lead to hyperkalemia.
8. The nurse is caring for a client with acute pancreatitis. Which action should the nurse take first?
A) Administer pain medication.
B) Insert an NG tube.
C) Encourage oral fluid intake.
D) Provide a high-protein, high-calorie diet.
Answer: B) Insert an NG tube.
Explanation: An NG tube is often inserted in acute pancreatitis to reduce nausea, vomiting, and abdominal distention, and to rest the pancreas.
9. A nurse is teaching a client with diabetes mellitus about foot care. Which statement by the client indicates the need for further teaching?
A) “I will wash my feet daily and dry them thoroughly.”
B) “I will apply lotion between my toes to prevent dryness.”
C) “I will wear properly fitted shoes to avoid blisters.”
D) “I will inspect my feet every day for cuts or blisters.”
Answer: B) “I will apply lotion between my toes to prevent dryness.”
Explanation: Moisture between the toes can lead to fungal infections. It is important to keep the spaces between the toes dry.
10. A nurse is assessing a client with pneumonia. Which of the following findings is most consistent with this diagnosis?
A) Fine crackles at the bases of the lungs
B) A dry, non-productive cough
C) Wheezing on inspiration and expiration
D) Decreased tactile fremitus
Answer: A) Fine crackles at the bases of the lungs.
Explanation: Fine crackles are commonly heard in pneumonia due to fluid in the alveoli.
11. The nurse is caring for a client who is receiving warfarin. The nurse notices that the client’s INR is 5.0. What is the nurse’s priority action?
A) Administer vitamin K.
B) Monitor the client’s vital signs.
C) Increase the warfarin dosage.
D) Contact the healthcare provider.
Answer: A) Administer vitamin K.
Explanation: An INR of 5.0 is above the therapeutic range for most patients on warfarin, indicating the risk of bleeding. Vitamin K should be administered to reverse the anticoagulant effects.
12. A nurse is caring for a client who has just undergone a colonoscopy. Which of the following should the nurse expect to find during the immediate postoperative period?
A) Abdominal pain and cramping
B) Decreased appetite
C) Bloody stool
D) Low-grade fever
Answer: A) Abdominal pain and cramping.
Explanation: Abdominal cramping is a common and expected side effect after a colonoscopy due to the air introduced into the colon during the procedure.
13. A nurse is caring for a client with acute kidney injury. Which of the following laboratory values is most indicative of the condition?
A) Elevated BUN and creatinine
B) Decreased hematocrit
C) Elevated white blood cell count
D) Low serum sodium
Answer: A) Elevated BUN and creatinine.
Explanation: Elevated BUN and creatinine levels are classic signs of kidney injury or impaired kidney function.
14. A nurse is educating a client with hypertension on lifestyle modifications. Which of the following statements by the client indicates understanding of the teaching?
A) “I will increase my sodium intake to help lower my blood pressure.”
B) “I will try to walk for 30 minutes a day most days of the week.”
C) “I will avoid eating fruits and vegetables because they contain too much potassium.”
D) “I will stop drinking alcohol entirely.”
Answer: B) “I will try to walk for 30 minutes a day most days of the week.”
Explanation: Regular physical activity like walking can help lower blood pressure. Sodium intake should be reduced, not increased, and potassium-rich foods should be encouraged.
15. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following should the nurse encourage the client to do?
A) Increase fluid intake.
B) Avoid high-protein foods.
C) Use oxygen therapy only during sleep.
D) Increase physical activity to build endurance.
Answer: A) Increase fluid intake.
Explanation: Increased fluid intake helps to thin secretions, making it easier to expectorate and manage respiratory symptoms in COPD.
16. A nurse is caring for a client who is post-operative following a total knee replacement. Which of the following interventions is most appropriate for the nurse to include in the client’s care plan?
A) Encourage early ambulation to prevent venous thromboembolism.
B) Restrict fluid intake to minimize swelling.
C) Apply a cold compress to the surgical site for 24 hours.
D) Elevate the affected leg above heart level continuously.
Answer: A) Encourage early ambulation to prevent venous thromboembolism.
Explanation: Early ambulation is key to reducing the risk of venous thromboembolism (VTE) after surgery. The other options are not standard post-operative care.
17. A nurse is caring for a client receiving lithium for bipolar disorder. Which of the following lab results would be most concerning?
A) Sodium level of 136 mEq/L
B) Serum lithium level of 1.2 mEq/L
C) Serum lithium level of 2.0 mEq/L
D) Potassium level of 4.1 mEq/L
Answer: C) Serum lithium level of 2.0 mEq/L.
Explanation: A serum lithium level of 2.0 mEq/L is toxic and requires immediate intervention. The therapeutic range for lithium is typically 0.6–1.2 mEq/L.
18. A nurse is caring for a client with diabetes insipidus. Which of the following findings would the nurse expect?
A) Decreased urine output
B) Increased urine specific gravity
C) Increased thirst
D) Increased blood pressure
Answer: C) Increased thirst.
Explanation: Diabetes insipidus leads to excessive urine output and increased thirst due to an inability to concentrate urine.
19. A nurse is assessing a client with a new diagnosis of gout. Which of the following foods should the nurse recommend the client avoid?
A) Whole grain bread
B) Fresh fruit
C) Red meat
D) Low-fat yogurt
Answer: C) Red meat.
Explanation: Red meat is high in purines, which can increase uric acid levels and exacerbate gout.
20. A nurse is teaching a client about the side effects of a new prescription for prednisone. Which statement by the client indicates a need for further teaching?
A) “I should take the medication with food.”
B) “I may notice an increase in my appetite.”
C) “I need to take the medication on an empty stomach.”
D) “I may experience mood swings.”
Answer: C) “I need to take the medication on an empty stomach.”
Explanation: Prednisone should be taken with food to reduce gastrointestinal irritation.
21. A nurse is caring for a client with hypothyroidism. Which of the following symptoms would the nurse expect to observe?
A) Weight loss
B) Tachycardia
C) Cold intolerance
D) Diarrhea
Answer: C) Cold intolerance.
Explanation: Hypothyroidism can cause cold intolerance, weight gain, and constipation due to slowed metabolic processes.
22. A nurse is caring for a child who is diagnosed with acute rheumatic fever. Which of the following is the priority intervention?
A) Administer antibiotics.
B) Monitor for signs of heart failure.
C) Educate the family about long-term care.
D) Provide comfort measures for joint pain.
Answer: B) Monitor for signs of heart failure.
Explanation: Acute rheumatic fever can lead to damage of the heart valves, so monitoring for signs of heart failure is a priority.
23. A nurse is caring for a client with a history of chronic alcohol use. Which vitamin deficiency should the nurse be concerned about?
A) Vitamin A
B) Vitamin D
C) Vitamin B1 (thiamine)
D) Vitamin K
Answer: C) Vitamin B1 (thiamine).
Explanation: Chronic alcohol use can lead to a deficiency in thiamine, which can result in Wernicke-Korsakoff syndrome.
24. A nurse is caring for a client who is 24 hours post-partum and experiencing excessive bleeding. Which action should the nurse take first?
A) Increase the IV fluids.
B) Massage the fundus.
C) Administer oxytocin.
D) Insert a Foley catheter.
Answer: B) Massage the fundus.
Explanation: Uterine atony is a common cause of postpartum hemorrhage, and massaging the fundus helps stimulate uterine contraction to control bleeding.
25. A nurse is caring for a client with a history of seizure disorders. The nurse should immediately administer which of the following medications if a seizure occurs?
A) Lorazepam
B) Phenytoin
C) Carbamazepine
D) Valproic acid
Answer: A) Lorazepam.
Explanation: Lorazepam (a benzodiazepine) is used for emergency seizure management because of its fast onset of action.
26. A nurse is caring for a client who is post-operative following a cholecystectomy. Which of the following should the nurse encourage the client to do?
A) Avoid deep breathing exercises.
B) Ambulate in the hall every hour.
C) Begin a low-fat diet immediately.
D) Maintain the head of the bed flat.
Answer: B) Ambulate in the hall every hour.
Explanation: Early ambulation helps prevent complications such as deep vein thrombosis and promotes circulation.
27. A nurse is caring for a client with a chest tube. The nurse notes that the water seal chamber is bubbling continuously. Which action should the nurse take?
A) Check for an air leak.
B) Increase the suction pressure.
C) Tape the tube to prevent air from entering.
D) Disconnect the chest tube from the drainage system.
Answer: A) Check for an air leak.
Explanation: Continuous bubbling in the water seal chamber indicates an air leak, which should be investigated.
28. A nurse is caring for a client who has just been diagnosed with tuberculosis (TB). Which of the following precautions should the nurse implement?
A) Droplet precautions
B) Airborne precautions
C) Contact precautions
D) Standard precautions
Answer: B) Airborne precautions.
Explanation: Tuberculosis is transmitted through airborne droplets, so airborne precautions are necessary.
29. A nurse is caring for a client with acute glomerulonephritis. Which of the following is a common finding in this condition?
A) Polyuria
B) Hypotension
C) Proteinuria
D) Hyperkalemia
Answer: C) Proteinuria.
Explanation: Proteinuria is common in glomerulonephritis due to damage to the glomerular membrane.
30. A nurse is caring for a client who is receiving chemotherapy. The nurse should immediately report which of the following findings?
A) Decreased appetite
B) Vomiting after chemotherapy
C) Fever and sore throat
D) Alopecia
Answer: C) Fever and sore throat.
Explanation: Fever and sore throat can indicate neutropenia (low white blood cell count) and place the client at risk for infection.
31. A nurse is assessing a client who has been on a prolonged course of antibiotics. Which of the following findings should the nurse assess for?
A) Hypotension
B) C. difficile infection
C) Hyperglycemia
D) Bradycardia
Answer: B) C. difficile infection.
Explanation: Prolonged antibiotic use can disrupt normal gut flora and increase the risk of Clostridium difficile infection.
32. A nurse is caring for a client who is 2 days post-operative following a hip replacement. The client is complaining of pain and is prescribed oxycodone. The nurse should monitor for which of the following potential adverse effects?
A) Bradycardia
B) Diarrhea
C) Respiratory depression
D) Hypertension
Answer: C) Respiratory depression.
Explanation: Oxycodone, an opioid, can cause respiratory depression, which is a serious side effect that requires monitoring.
33. A nurse is caring for a client who has been diagnosed with acute pancreatitis. Which of the following interventions is most appropriate in the acute phase?
A) Administer pancreatic enzymes.
B) Encourage a high-fat diet.
C) Provide IV fluids and electrolytes.
D) Increase protein intake.
Answer: C) Provide IV fluids and electrolytes.
Explanation: Acute pancreatitis often leads to dehydration and electrolyte imbalances, so IV fluids and electrolytes are crucial.
34. A nurse is assessing a client with a history of chronic obstructive pulmonary disease (COPD). Which finding should the nurse expect to observe?
A) Bradypnea
B) Productive cough
C) Hyperactive reflexes
D) Increased heart rate
Answer: B) Productive cough.
Explanation: COPD often causes chronic cough with sputum production due to airway inflammation and mucus buildup.
35. A nurse is caring for a client with osteoarthritis. Which of the following is a priority intervention?
A) Encourage weight-bearing exercises.
B) Monitor for signs of infection.
C) Administer prescribed pain medication.
D) Teach the client how to use assistive devices.
Answer: C) Administer prescribed pain medication.
Explanation: Managing pain is a priority for clients with osteoarthritis to improve comfort and mobility.
36. A nurse is caring for a client with deep vein thrombosis (DVT). Which of the following actions should the nurse take?
A) Encourage the client to massage the affected leg.
B) Apply a warm compress to the leg.
C) Elevate the affected leg above the heart.
D) Perform active range-of-motion exercises on the affected leg.
Answer: C) Elevate the affected leg above the heart.
Explanation: Elevating the affected leg helps reduce swelling and promote venous return.
37. A nurse is caring for a client who has been prescribed a loop diuretic. Which of the following electrolyte imbalances should the nurse monitor for?
A) Hypokalemia
B) Hypercalcemia
C) Hypernatremia
D) Hypomagnesemia
Answer: A) Hypokalemia.
Explanation: Loop diuretics can cause the body to excrete potassium, leading to hypokalemia.
38. A nurse is teaching a client about the use of a metered-dose inhaler (MDI) for asthma. Which of the following statements indicates the client needs further teaching?
A) “I should shake the inhaler before using it.”
B) “I should exhale before inhaling the medication.”
C) “I should hold my breath for 10 seconds after inhaling.”
D) “I should inhale deeply and rapidly while using the inhaler.”
Answer: D) “I should inhale deeply and rapidly while using the inhaler.”
Explanation: Inhalation should be slow and deep, not rapid, to allow the medication to reach the lungs.
39. A nurse is caring for a client with a history of peptic ulcer disease. The nurse should teach the client to avoid which of the following?
A) Low-fat dairy products
B) Foods high in vitamin C
C) Spicy foods
D) Small, frequent meals
Answer: C) Spicy foods.
Explanation: Spicy foods can irritate the stomach lining and exacerbate ulcer symptoms.
40. A nurse is assessing a client’s ECG and notices that the QRS complex is wide and bizarre. Which of the following should the nurse do first?
A) Administer oxygen.
B) Call the healthcare provider.
C) Check the client’s pulse.
D) Prepare to administer a calcium channel blocker.
Answer: C) Check the client’s pulse.
Explanation: A wide and bizarre QRS complex could indicate a life-threatening arrhythmia. The first step is to assess the client’s pulse to determine if the rhythm is perfusing.
41. A nurse is caring for a client with a history of myocardial infarction (MI). The nurse should monitor the client for which of the following complications?
A) Pulmonary embolism
B) Heart failure
C) Hypoglycemia
D) Cerebral vascular accident (CVA)
Answer: B) Heart failure.
Explanation: Heart failure is a common complication following a myocardial infarction due to damage to the heart muscle, reducing its pumping ability.
42. A nurse is caring for a client who is 12 hours post-surgery for a total hip replacement. Which of the following actions should the nurse take to prevent complications?
A) Apply a compression stocking to both legs.
B) Encourage the client to avoid bending at the waist.
C) Restrict fluid intake to prevent edema.
D) Place the client in a knee-chest position.
Answer: B) Encourage the client to avoid bending at the waist.
Explanation: After a hip replacement, the client should avoid hip flexion (e.g., bending at the waist) to prevent hip dislocation.
43. A nurse is providing dietary teaching to a client with celiac disease. Which food is appropriate for the client to eat?
A) Wheat bread
B) Oatmeal
C) Cornflakes
D) Rye crackers
Answer: C) Cornflakes.
Explanation: Celiac disease requires the elimination of gluten-containing foods. Cornflakes do not contain gluten and are safe for the client to eat.
44. A nurse is assessing a client for signs of dehydration. Which of the following findings should the nurse expect?
A) Moist mucous membranes
B) Decreased skin turgor
C) Clear, yellow urine
D) Weight gain
Answer: B) Decreased skin turgor.
Explanation: Dehydration causes a loss of skin elasticity, resulting in decreased skin turgor.
45. A nurse is assessing a client with acute renal failure. Which of the following laboratory results would the nurse expect to find?
A) Decreased BUN and creatinine
B) Elevated BUN and creatinine
C) Decreased potassium
D) Elevated albumin
Answer: B) Elevated BUN and creatinine.
Explanation: In acute renal failure, the kidneys’ ability to filter waste is impaired, leading to elevated BUN and creatinine levels.
46. A nurse is caring for a client who is on the third day of hospitalization after a stroke. The client is unable to swallow pills. Which of the following interventions should the nurse prioritize?
A) Crush the client’s medication and mix it with applesauce.
B) Call the healthcare provider to switch medications to a liquid form.
C) Administer the medication through a nasogastric tube.
D) Withhold all oral medications until the client can swallow safely.
Answer: B) Call the healthcare provider to switch medications to a liquid form.
Explanation: If a client cannot swallow pills, medications should be provided in a liquid form when possible. Crushing pills may not be safe for all medications.
47. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following is an appropriate nursing intervention?
A) Encourage slow, shallow breathing.
B) Administer oxygen therapy at high flow rates.
C) Encourage deep breathing and coughing exercises.
D) Place the client in a supine position.
Answer: C) Encourage deep breathing and coughing exercises.
Explanation: Deep breathing and coughing exercises help clear the lungs of secretions, which is important for clients with COPD.
48. A nurse is assessing a client with iron-deficiency anemia. Which of the following findings is most likely?
A) Pale skin
B) Jaundiced skin
C) Increased energy levels
D) Red, beefy tongue
Answer: A) Pale skin.
Explanation: Iron-deficiency anemia leads to decreased hemoglobin levels, resulting in pallor or pale skin.
49. A nurse is caring for a client who is receiving warfarin. The nurse notes that the client’s INR is 3.5. What action should the nurse take?
A) Administer vitamin K.
B) Decrease the dosage of warfarin.
C) Continue to monitor the INR without any intervention.
D) Hold the next dose of warfarin and notify the healthcare provider.
Answer: D) Hold the next dose of warfarin and notify the healthcare provider.
Explanation: An INR of 3.5 is elevated, which increases the risk for bleeding. The next dose of warfarin should be held, and the healthcare provider should be notified.
50. A nurse is teaching a client with hypertension about dietary changes. Which statement by the client indicates the need for further teaching?
A) “I will eat more fruits and vegetables.”
B) “I will decrease my intake of sodium.”
C) “I will eat more lean meats like chicken and fish.”
D) “I will reduce my alcohol intake.”
Answer: C) “I will eat more lean meats like chicken and fish.”
Explanation: While lean meats are a good choice, the client should also avoid excessive animal fats and focus on a diet high in fruits, vegetables, and whole grains.
51. A nurse is caring for a client who has received a new prescription for lisinopril. The nurse should monitor for which of the following adverse effects?
A) Hyperkalemia
B) Hypoglycemia
C) Hypokalemia
D) Weight gain
Answer: A) Hyperkalemia.
Explanation: Lisinopril, an ACE inhibitor, can cause potassium retention, leading to hyperkalemia.
52. A nurse is caring for a client with schizophrenia. Which of the following actions is the priority in establishing a therapeutic relationship?
A) Engaging the client in long conversations.
B) Giving the client detailed information about medications.
C) Establishing trust through consistency and structure.
D) Avoiding eye contact with the client.
Answer: C) Establishing trust through consistency and structure.
Explanation: Consistency and structure are key to building trust with clients who have schizophrenia and may have difficulty trusting others.
53. A nurse is caring for a client with a fractured femur. Which of the following actions should the nurse take first?
A) Elevate the affected leg.
B) Apply ice to the affected leg.
C) Administer prescribed pain medication.
D) Perform a neurovascular assessment.
Answer: D) Perform a neurovascular assessment.
Explanation: A neurovascular assessment is the priority to assess for signs of compartment syndrome or impaired circulation.
54. A nurse is caring for a client with a history of seizures. The nurse should educate the client about which of the following triggers for a seizure?
A) Consistent sleep schedule
B) Excessive fluid intake
C) Use of alcohol
D) Increased physical activity
Answer: C) Use of alcohol.
Explanation: Alcohol can lower the seizure threshold and increase the risk of seizures.
55. A nurse is caring for a client with a diagnosis of hyperthyroidism. Which of the following findings would the nurse expect to observe?
A) Weight gain
B) Cold intolerance
C) Bradycardia
D) Heat intolerance
Answer: D) Heat intolerance.
Explanation: Hyperthyroidism speeds up metabolism, leading to heat intolerance, weight loss, and tachycardia.
56. A nurse is caring for a client with end-stage renal disease. Which of the following should the nurse include in the care plan?
A) Limit protein intake.
B) Restrict fluid intake to 200 mL per day.
C) Encourage the use of salt substitutes.
D) Increase potassium intake.
Answer: A) Limit protein intake.
Explanation: Clients with end-stage renal disease should limit protein intake to reduce the kidneys’ workload and prevent further kidney damage.
57. A nurse is caring for a client with a history of peptic ulcer disease. Which of the following medications should the nurse anticipate the healthcare provider prescribing?
A) Antacids
B) NSAIDs
C) Corticosteroids
D) Diuretics
Answer: A) Antacids.
Explanation: Antacids can help neutralize stomach acid and provide relief from the symptoms of peptic ulcer disease.
58. A nurse is providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD). Which statement by the client indicates an understanding of the teaching?
A) “I will avoid all physical activity to prevent shortness of breath.”
B) “I should stop smoking to prevent further damage to my lungs.”
C) “I will increase my fluid intake to 500 mL per day.”
D) “I should wear a mask when going outside in cold weather.”
Answer: B) “I should stop smoking to prevent further damage to my lungs.”
Explanation: Smoking cessation is crucial in managing COPD and preventing further damage to the lungs.
59. A nurse is caring for a client with a diagnosis of diverticulitis. Which of the following interventions should the nurse include in the client’s care plan?
A) Encourage a high-fiber diet.
B) Encourage the client to avoid spicy foods.
C) Maintain NPO status during acute episodes.
D) Provide stool softeners for regular bowel movements.
Answer: C) Maintain NPO status during acute episodes.
Explanation: During acute diverticulitis, the client should be NPO to allow the bowel to rest and heal.
60. A nurse is caring for a client with a history of seizures. Which of the following interventions is most appropriate for preventing injury during a seizure?
A) Hold the client down to prevent movement.
B) Place a tongue depressor in the client’s mouth.
C) Remove sharp objects from the environment.
D) Restrain the client to prevent harm.
Answer: C) Remove sharp objects from the environment.
Explanation: Safety is a priority during a seizure, so removing potential hazards is important to prevent injury.
61. A nurse is caring for a client who is post-operative following a coronary artery bypass graft (CABG). Which of the following actions should the nurse take to reduce the risk of deep vein thrombosis (DVT)?
A) Encourage the client to rest in bed.
B) Provide elastic stockings or pneumatic compression devices.
C) Elevate the affected leg above the heart.
D) Administer aspirin for pain relief.
Answer: B) Provide elastic stockings or pneumatic compression devices.
Explanation: Elastic stockings or pneumatic compression devices help improve circulation and reduce the risk of DVT.
62. A nurse is teaching a client with diabetes mellitus about foot care. Which statement by the client indicates an understanding of the teaching?
A) “I should soak my feet daily in warm water.”
B) “I should apply lotion between my toes.”
C) “I should wear shoes that fit properly and have soft soles.”
D) “I should clip my toenails in a curved shape.”
Answer: C) “I should wear shoes that fit properly and have soft soles.”
Explanation: Proper-fitting shoes with soft soles prevent injury to the feet and help reduce the risk of complications in clients with diabetes.
63. A nurse is caring for a client receiving hemodialysis. Which of the following findings should the nurse report to the healthcare provider?
A) Blood pressure of 130/80 mmHg
B) Weight gain of 1.5 kg (3.3 lb) since last session
C) Complaints of slight dizziness
D) Serum potassium level of 3.8 mEq/L
Answer: B) Weight gain of 1.5 kg (3.3 lb) since last session.
Explanation: A weight gain of more than 1 kg (2.2 lbs) between dialysis sessions could indicate fluid retention, which needs to be managed promptly.
64. A nurse is caring for a client with a new diagnosis of Parkinson’s disease. Which of the following interventions should the nurse include in the care plan?
A) Encourage the client to eat a low-protein diet.
B) Teach the client to avoid physical therapy.
C) Provide a thickened liquid diet.
D) Encourage the client to engage in regular exercise.
Answer: D) Encourage the client to engage in regular exercise.
Explanation: Regular exercise helps maintain mobility and function in clients with Parkinson’s disease.
65. A nurse is caring for a client who is 2 days post-operative following a laparoscopic cholecystectomy. Which of the following instructions should the nurse include in the client’s discharge teaching?
A) “You should avoid fatty foods for several weeks.”
B) “You can resume heavy lifting within one week.”
C) “You should drink alcohol in moderation to aid digestion.”
D) “You should take a warm bath to relieve discomfort.”
Answer: A) “You should avoid fatty foods for several weeks.”
Explanation: After a cholecystectomy, the client should avoid fatty foods to reduce the workload on the digestive system.
66. A nurse is caring for a client with hypertension who is prescribed enalapril. Which of the following findings should the nurse monitor for as a potential adverse effect of this medication?
A) Hyperkalemia
B) Hypoglycemia
C) Decreased respiratory rate
D) Decreased urine output
Answer: A) Hyperkalemia.
Explanation: Enalapril, an ACE inhibitor, can cause potassium retention, leading to hyperkalemia.
67. A nurse is caring for a client receiving IV fluids of normal saline. The nurse notes that the client’s IV site is red, swollen, and warm to the touch. Which action should the nurse take first?
A) Change the IV site to the opposite arm.
B) Apply a warm compress to the site.
C) Stop the infusion and remove the IV catheter.
D) Document the findings and continue the infusion.
Answer: C) Stop the infusion and remove the IV catheter.
Explanation: The red, swollen, and warm IV site indicates potential phlebitis or infiltration. The nurse should stop the infusion and remove the catheter.
68. A nurse is caring for a client with chronic kidney disease (CKD). The nurse should monitor the client for which of the following complications?
A) Hypernatremia
B) Hyperkalemia
C) Hypocalcemia
D) Hyperglycemia
Answer: B) Hyperkalemia.
Explanation: Chronic kidney disease can impair potassium excretion, leading to hyperkalemia.
69. A nurse is assessing a client who has undergone a total hip replacement. Which of the following interventions is most important to prevent hip dislocation?
A) Maintain abduction of the affected hip.
B) Limit fluid intake to prevent urinary retention.
C) Encourage the client to bend at the waist to reach for objects.
D) Keep the affected leg in a flexed position.
Answer: A) Maintain abduction of the affected hip.
Explanation: Maintaining abduction of the affected hip helps prevent dislocation after a hip replacement.
70. A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is prescribed albuterol. The nurse should monitor for which of the following adverse effects?
A) Tachycardia
B) Hyperkalemia
C) Hypotension
D) Respiratory depression
Answer: A) Tachycardia.
Explanation: Albuterol is a bronchodilator that can cause tachycardia as a side effect.
71. A nurse is teaching a client about the use of nitroglycerin for angina. Which statement by the client indicates understanding of the teaching?
A) “I will take one tablet every hour until the pain is gone.”
B) “I will take the medication with food to prevent nausea.”
C) “I will place the tablet under my tongue and let it dissolve.”
D) “I will take the medication on an empty stomach for better absorption.”
Answer: C) “I will place the tablet under my tongue and let it dissolve.”
Explanation: Nitroglycerin tablets should be placed under the tongue to dissolve and provide rapid relief of angina.
72. A nurse is caring for a client with asthma. Which of the following findings should the nurse expect to observe during an asthma exacerbation?
A) Hyperresonance on percussion
B) Bradycardia
C) Clear, thin sputum
D) Increased oxygen saturation
Answer: A) Hyperresonance on percussion.
Explanation: Hyperresonance is heard on percussion due to air trapping in the lungs during an asthma attack.
73. A nurse is caring for a client with a history of ulcerative colitis. The nurse should monitor for which of the following complications?
A) Hypokalemia
B) Hemorrhoids
C) Gastroesophageal reflux disease (GERD)
D) Deep vein thrombosis (DVT)
Answer: A) Hypokalemia.
Explanation: Ulcerative colitis can cause diarrhea, which leads to potassium loss and hypokalemia.
74. A nurse is assessing a client with a history of alcohol use disorder. Which vitamin deficiency should the nurse suspect?
A) Vitamin A
B) Vitamin C
C) Vitamin B1 (thiamine)
D) Vitamin K
Answer: C) Vitamin B1 (thiamine).
Explanation: Chronic alcohol use can lead to thiamine deficiency, resulting in Wernicke-Korsakoff syndrome.
75. A nurse is caring for a client with an infection who is prescribed ceftriaxone. Which of the following should the nurse monitor for as a potential adverse effect of this medication?
A) Ototoxicity
B) Hypertension
C) Hepatotoxicity
D) Hematuria
Answer: C) Hepatotoxicity.
Explanation: Ceftriaxone can cause liver dysfunction and hepatotoxicity, especially in high doses.
76. A nurse is providing teaching to a client with glaucoma who is prescribed pilocarpine eye drops. Which statement by the client indicates an understanding of the teaching?
A) “I should instill the drops once every 12 hours.”
B) “I should wait at least 10 minutes before applying other eye medications.”
C) “I should wear sunglasses while taking this medication.”
D) “I should rub my eyes after instilling the drops to improve absorption.”
Answer: B) “I should wait at least 10 minutes before applying other eye medications.”
Explanation: The nurse should advise clients to wait at least 10 minutes between different eye medications to ensure proper absorption.
77. A nurse is caring for a client who is receiving a blood transfusion and begins to experience chills and back pain. What is the nurse’s priority action?
A) Stop the transfusion and notify the healthcare provider.
B) Administer acetaminophen for pain relief.
C) Monitor vital signs every 15 minutes.
D) Give the client an antihistamine for the reaction.
Answer: A) Stop the transfusion and notify the healthcare provider.
Explanation: Chills and back pain are signs of a transfusion reaction. The transfusion should be stopped immediately, and the healthcare provider should be notified.
78. A nurse is caring for a client who is experiencing a seizure. Which action should the nurse take first?
A) Call for help.
B) Insert a padded tongue depressor in the client’s mouth.
C) Position the client on their side to prevent aspiration.
D) Document the duration and characteristics of the seizure.
Answer: C) Position the client on their side to prevent aspiration.
Explanation: The priority during a seizure is to ensure the client’s safety, including preventing aspiration by positioning the client on their side.
79. A nurse is caring for a client with a history of asthma who is prescribed a corticosteroid inhaler. The nurse should instruct the client to do which of the following?
A) Take the medication only during an asthma attack.
B) Rinse the mouth after using the inhaler.
C) Hold the breath for 5 seconds after inhaling the medication.
D) Use the inhaler once a day.
Answer: B) Rinse the mouth after using the inhaler.
Explanation: Rinsing the mouth after using a corticosteroid inhaler helps prevent oral fungal infections, such as thrush.
80. A nurse is providing teaching to a client who is prescribed levothyroxine for hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching?
A) “I should take this medication in the evening before bed.”
B) “I should take this medication with food to prevent nausea.”
C) “I should take this medication on an empty stomach, 30 minutes before breakfast.”
D) “I should stop taking the medication when I feel better.”
Answer: C) “I should take this medication on an empty stomach, 30 minutes before breakfast.”
Explanation: Levothyroxine should be taken on an empty stomach to maximize absorption.
81. A nurse is caring for a client with a history of myocardial infarction (MI). Which of the following is the priority intervention during the acute phase of MI?
A) Administer oxygen to maintain oxygen saturation levels above 95%.
B) Assist the client in performing deep breathing exercises.
C) Provide a high-fat, high-calorie diet to promote healing.
D) Encourage the client to ambulate to reduce the risk of deep vein thrombosis.
Answer: A) Administer oxygen to maintain oxygen saturation levels above 95%.
Explanation: Oxygen therapy is critical to ensure adequate oxygenation to the heart and other vital organs during the acute phase of MI.
82. A nurse is teaching a client about the use of albuterol inhaler for asthma. Which of the following statements indicates the need for further teaching?
A) “I will use the inhaler before exercising to prevent an asthma attack.”
B) “I should shake the inhaler before using it.”
C) “I can use the inhaler every 4 hours if needed.”
D) “I will use the inhaler only when I have trouble breathing.”
Answer: D) “I will use the inhaler only when I have trouble breathing.”
Explanation: Albuterol is a short-acting bronchodilator used for immediate relief, but it should also be used prophylactically before exercise or when asthma symptoms worsen.
83. A nurse is caring for a client with a history of chronic alcoholism. The client is experiencing confusion and unsteady gait. The nurse suspects which condition?
A) Vitamin B12 deficiency
B) Wernicke-Korsakoff syndrome
C) Hypoglycemia
D) Hepatic encephalopathy
Answer: B) Wernicke-Korsakoff syndrome.
Explanation: Wernicke-Korsakoff syndrome is a neurological disorder caused by thiamine (vitamin B1) deficiency, often seen in clients with chronic alcoholism.
84. A nurse is teaching a client with heart failure about sodium restriction. Which food choice by the client indicates understanding?
A) Hot dog
B) Fresh fruit
C) Canned soup
D) Processed cheese
Answer: B) Fresh fruit.
Explanation: Fresh fruit is naturally low in sodium and is an appropriate choice for clients with heart failure who need to limit sodium intake.
85. A nurse is caring for a client who is 24 hours post-op following a total knee replacement. The nurse observes swelling and redness at the surgical site. Which of the following is the priority action?
A) Apply a warm compress to the knee.
B) Assess the client’s vital signs.
C) Administer prescribed pain medication.
D) Document the findings and notify the healthcare provider.
Answer: B) Assess the client’s vital signs.
Explanation: The priority action is to assess vital signs, as these symptoms may indicate infection or complications requiring immediate intervention.
86. A nurse is caring for a client who is receiving chemotherapy. Which of the following statements indicates the need for further teaching about infection control?
A) “I will wash my hands before eating and after using the bathroom.”
B) “I should avoid large crowds and sick people.”
C) “I can continue to clean the litter box, but I will wear gloves.”
D) “I will take a daily shower to prevent infections.”
Answer: C) “I can continue to clean the litter box, but I will wear gloves.”
Explanation: Clients receiving chemotherapy are at risk for infections due to immunosuppression. They should avoid handling cat litter due to the risk of toxoplasmosis.
87. A nurse is caring for a client who has a new prescription for digoxin. The nurse should monitor the client for which of the following potential adverse effects?
A) Hypertension
B) Hyperkalemia
C) Visual disturbances
D) Hypoglycemia
Answer: C) Visual disturbances.
Explanation: Digoxin toxicity can cause visual disturbances, including seeing yellow or green halos around objects.
88. A nurse is providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD). Which statement by the client indicates an understanding of the teaching?
A) “I will limit my activity to avoid getting short of breath.”
B) “I should get a flu vaccine every year.”
C) “I can stop smoking after I feel better.”
D) “I will take my medications only when I feel short of breath.”
Answer: B) “I should get a flu vaccine every year.”
Explanation: Annual flu vaccination is important for clients with COPD to prevent respiratory infections, which can exacerbate their condition.
89. A nurse is caring for a client who has a new diagnosis of type 1 diabetes. The nurse teaches the client to recognize signs of hypoglycemia. Which of the following is a common symptom?
A) Increased thirst
B) Increased appetite
C) Shaking and sweating
D) Frequent urination
Answer: C) Shaking and sweating.
Explanation: Hypoglycemia commonly presents with symptoms such as shaking, sweating, irritability, and confusion.
90. A nurse is caring for a client with acute pancreatitis. The nurse should monitor for which of the following complications?
A) Hypercalcemia
B) Hypoglycemia
C) Acute renal failure
D) Hepatitis
Answer: C) Acute renal failure.
Explanation: Acute pancreatitis can lead to complications such as acute renal failure due to fluid shifts, hypovolemia, and sepsis.
91. A nurse is teaching a client with hypertension about lifestyle changes. Which of the following statements by the client indicates understanding of the teaching?
A) “I will increase my intake of foods high in sodium.”
B) “I will start an exercise program to walk 30 minutes a day.”
C) “I should avoid taking my antihypertensive medication.”
D) “I can continue drinking alcohol in moderation.”
Answer: B) “I will start an exercise program to walk 30 minutes a day.”
Explanation: Regular physical activity is an effective intervention for lowering blood pressure and managing hypertension.
92. A nurse is caring for a client with rheumatoid arthritis. The nurse should encourage the client to:
A) Rest the affected joints during flare-ups.
B) Apply heat to reduce inflammation.
C) Engage in high-impact exercises to increase joint flexibility.
D) Avoid all physical activity to prevent further joint damage.
Answer: A) Rest the affected joints during flare-ups.
Explanation: Rest during flare-ups is important to reduce joint inflammation and prevent further damage in rheumatoid arthritis.
93. A nurse is caring for a client with a history of peptic ulcer disease. The nurse should teach the client to avoid which of the following foods?
A) Milk
B) Bananas
C) Spicy foods
D) Oatmeal
Answer: C) Spicy foods.
Explanation: Spicy foods can irritate the stomach lining and exacerbate the symptoms of peptic ulcer disease.
94. A nurse is caring for a client who is experiencing a panic attack. Which intervention is the nurse’s priority?
A) Administer an anti-anxiety medication.
B) Help the client focus on slow, deep breathing.
C) Encourage the client to talk about their feelings.
D) Offer reassurance that the attack will pass soon.
Answer: B) Help the client focus on slow, deep breathing.
Explanation: Helping the client focus on slow, deep breathing is the priority intervention during a panic attack to help reduce anxiety and restore normal breathing.
95. A nurse is assessing a client with a history of chronic kidney disease. The nurse should monitor for which of the following signs of fluid overload?
A) Weight loss
B) Shortness of breath
C) Decreased heart rate
D) Hypotension
Answer: B) Shortness of breath.
Explanation: Fluid overload in chronic kidney disease can lead to pulmonary edema, causing shortness of breath and difficulty breathing.
96. A nurse is teaching a client with diabetes mellitus about foot care. Which of the following instructions should the nurse include?
A) “Check your feet daily for cuts, blisters, or redness.”
B) “Soak your feet in warm water for 20 minutes daily.”
C) “Apply lotion between your toes to keep them moisturized.”
D) “Trim your toenails into a curved shape to prevent ingrown nails.”
Answer: A) “Check your feet daily for cuts, blisters, or redness.”
Explanation: Clients with diabetes should check their feet daily for signs of injury or infection, as they are at higher risk for foot problems.
97. A nurse is caring for a client who is receiving intravenous fluids. The nurse notes that the client’s IV site is swollen and has a cool temperature. What action should the nurse take?
A) Remove the IV catheter and apply a warm compress.
B) Continue the infusion and monitor the site.
C) Flush the IV line with normal saline.
D) Increase the IV flow rate to reduce swelling.
Answer: A) Remove the IV catheter and apply a warm compress.
Explanation: The cool, swollen IV site indicates infiltration. The IV catheter should be removed, and a warm compress can be applied to reduce swelling.
98. A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse implement?
A) Encourage the client to perform deep breathing exercises.
B) Administer high-flow oxygen to improve oxygen saturation.
C) Restrict fluid intake to prevent fluid retention.
D) Instruct the client to breathe rapidly during periods of dyspnea.
Answer: A) Encourage the client to perform deep breathing exercises.
Explanation: Deep breathing exercises help promote lung expansion and improve oxygenation in clients with COPD.
99. A nurse is assessing a client who is taking an opioid analgesic. Which of the following is the priority assessment?
A) Respiratory rate
B) Blood pressure
C) Pain level
D) Heart rate
Answer: A) Respiratory rate.
Explanation: Opioids can cause respiratory depression, making the respiratory rate the priority assessment when monitoring clients on these medications.
100. A nurse is caring for a client who has been prescribed atorvastatin. Which of the following findings should the nurse report to the healthcare provider?
A) Mild muscle pain
B) Headache
C) Yellowing of the skin
D) Insomnia
Answer: C) Yellowing of the skin.
Explanation: Yellowing of the skin (jaundice) can indicate liver dysfunction, which is a potential side effect of atorvastatin.
101. A nurse is caring for a client who is receiving morphine for pain management. Which of the following is a priority assessment?
A) Heart rate
B) Respiratory rate
C) Blood pressure
D) Temperature
Answer: B) Respiratory rate.
Explanation: Morphine can cause respiratory depression, so monitoring the respiratory rate is the priority assessment.
102. A nurse is caring for a client with acute renal failure. Which of the following laboratory values should the nurse monitor most closely?
A) Sodium
B) Potassium
C) Calcium
D) Hemoglobin
Answer: B) Potassium.
Explanation: Acute renal failure can lead to hyperkalemia, which is life-threatening and requires close monitoring.
103. A nurse is teaching a client about the use of a metered-dose inhaler (MDI) for asthma. Which of the following actions should the nurse include?
A) Hold the breath for at least 10 seconds after inhaling.
B) Shake the inhaler before each use.
C) Use the inhaler every 2 hours during the day.
D) Inhale through the nose while using the inhaler.
Answer: B) Shake the inhaler before each use.
Explanation: Shaking the inhaler ensures the proper distribution of the medication in the aerosol form before inhalation.
104. A nurse is providing discharge teaching to a client with newly diagnosed hypertension. Which of the following statements indicates understanding of the teaching?
A) “I will take my blood pressure medications only when my blood pressure is elevated.”
B) “I should avoid eating foods that are high in sodium.”
C) “I will limit my physical activity to reduce stress on my heart.”
D) “I should monitor my blood pressure once a month.”
Answer: B) “I should avoid eating foods that are high in sodium.”
Explanation: Reducing sodium intake is important for managing hypertension.
105. A nurse is caring for a client who has a blood pressure of 150/90 mm Hg. Which of the following is the most appropriate action for the nurse to take?
A) Administer the prescribed antihypertensive medication.
B) Monitor the blood pressure again in 1 hour.
C) Notify the healthcare provider immediately.
D) Assess the client for signs of orthostatic hypotension.
Answer: A) Administer the prescribed antihypertensive medication.
Explanation: The blood pressure is elevated, and administering the prescribed antihypertensive medication is appropriate to help reduce the risk of complications.
106. A nurse is teaching a client about using a nicotine patch to help stop smoking. Which of the following statements by the client indicates an understanding of the teaching?
A) “I will place the patch on the same site every day.”
B) “I should remove the patch before showering or exercising.”
C) “I can use the patch for up to 6 months.”
D) “I should apply the patch to a hairless area of skin.”
Answer: D) “I should apply the patch to a hairless area of skin.”
Explanation: The patch should be applied to a clean, hairless area of skin to promote proper absorption.
107. A nurse is caring for a client who is receiving a blood transfusion. The nurse should stop the transfusion immediately and take which of the following actions if the client exhibits signs of an allergic reaction?
A) Increase the rate of the transfusion.
B) Obtain a blood sample for crossmatching.
C) Administer diphenhydramine (Benadryl) as prescribed.
D) Notify the healthcare provider and continue the transfusion.
Answer: C) Administer diphenhydramine (Benadryl) as prescribed.
Explanation: Allergic reactions to blood transfusions are typically managed with antihistamines like diphenhydramine.
108. A nurse is providing education to a client with osteoarthritis. Which of the following interventions should the nurse recommend to manage the condition?
A) Engage in high-impact exercises to strengthen the joints.
B) Use cold therapy to reduce swelling during flare-ups.
C) Perform weight-bearing exercises to increase bone density.
D) Apply heat to the joints to reduce pain and stiffness.
Answer: D) Apply heat to the joints to reduce pain and stiffness.
Explanation: Heat therapy can help to relieve pain and stiffness associated with osteoarthritis.
109. A nurse is caring for a client with hyperthyroidism. The nurse should monitor the client for which of the following symptoms?
A) Weight gain and cold intolerance
B) Bradycardia and fatigue
C) Increased appetite and heat intolerance
D) Decreased energy and constipation
Answer: C) Increased appetite and heat intolerance.
Explanation: Hyperthyroidism increases metabolism, which often causes symptoms such as weight loss, increased appetite, and heat intolerance.
110. A nurse is caring for a client who is 2 days post-op following abdominal surgery. The nurse observes that the client’s surgical wound is red, swollen, and warm. Which of the following is the most appropriate intervention?
A) Apply a cool compress to the wound area.
B) Administer prescribed antibiotics as ordered.
C) Notify the healthcare provider and continue to monitor.
D) Document the findings and reassure the client.
Answer: C) Notify the healthcare provider and continue to monitor.
Explanation: Redness, swelling, and warmth around a surgical wound could indicate an infection, which requires prompt attention from the healthcare provider.
111. A nurse is caring for a client with a new diagnosis of type 2 diabetes mellitus. The nurse should teach the client to do which of the following?
A) Test blood glucose levels before meals and at bedtime.
B) Take insulin injections after each meal.
C) Follow a high-protein, low-carbohydrate diet.
D) Take oral hypoglycemic agents only when blood glucose is elevated.
Answer: A) Test blood glucose levels before meals and at bedtime.
Explanation: Regular monitoring of blood glucose levels is essential for managing type 2 diabetes and preventing complications.
112. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse should instruct the client to perform which of the following actions to help manage the disease?
A) Perform pursed-lip breathing to slow exhalation.
B) Breathe rapidly to improve oxygen intake.
C) Limit fluid intake to prevent respiratory distress.
D) Take deep breaths when short of breath.
Answer: A) Perform pursed-lip breathing to slow exhalation.
Explanation: Pursed-lip breathing helps to slow the exhalation and prevent airway collapse, improving air exchange in COPD.
113. A nurse is caring for a client with a history of stroke. The nurse should assess the client for which of the following complications?
A) Hypertension
B) Seizures
C) Hemorrhage
D) Deep vein thrombosis
Answer: D) Deep vein thrombosis.
Explanation: Clients who have had a stroke are at increased risk for deep vein thrombosis due to immobility and decreased circulation.
114. A nurse is caring for a client who is receiving chemotherapy and is at risk for infection. Which of the following actions should the nurse take to prevent infection?
A) Limit visitors and avoid large crowds.
B) Encourage the client to eat raw vegetables for additional nutrients.
C) Encourage the client to engage in strenuous exercise to improve circulation.
D) Place the client in a room with no special precautions.
Answer: A) Limit visitors and avoid large crowds.
Explanation: Clients receiving chemotherapy are immunocompromised and should avoid exposure to infections by limiting visitors and large crowds.
115. A nurse is providing dietary teaching to a client with hypertension. Which of the following foods should the nurse recommend to the client?
A) Canned soup
B) Fresh vegetables
C) Processed meats
D) Whole milk
Answer: B) Fresh vegetables.
Explanation: Fresh vegetables are low in sodium and high in essential nutrients, making them an appropriate choice for clients with hypertension.
116. A nurse is providing teaching to a client with cirrhosis. The nurse should include which of the following dietary recommendations?
A) Consume a high-protein diet.
B) Limit sodium intake.
C) Increase fluid intake.
D) Avoid foods that are high in fiber.
Answer: B) Limit sodium intake.
Explanation: Clients with cirrhosis are at risk for fluid retention and should limit sodium intake to prevent complications like ascites.
117. A nurse is caring for a client with a history of seizures. The nurse should educate the client about which of the following triggers?
A) Smoking
B) Stress and lack of sleep
C) Low blood pressure
D) High-protein diet
Answer: B) Stress and lack of sleep.
Explanation: Stress and lack of sleep are common triggers for seizures and should be managed to prevent episodes.
118. A nurse is providing education to a client who has been prescribed warfarin. Which of the following statements by the client indicates an understanding of the teaching?
A) “I can eat foods that are high in vitamin K, such as spinach.”
B) “I will need to have regular blood tests to monitor my INR.”
C) “I will take the medication on an empty stomach every morning.”
D) “I should stop taking warfarin if I feel tired or dizzy.”
Answer: B) “I will need to have regular blood tests to monitor my INR.”
Explanation: Clients taking warfarin need regular monitoring of their international normalized ratio (INR) to ensure the medication is within the therapeutic range.
119. A nurse is caring for a client with a history of anxiety. The nurse should encourage which of the following interventions to help manage anxiety?
A) Limiting social interaction to avoid stress.
B) Practicing deep breathing and relaxation techniques.
C) Avoiding all physical activity to reduce stress.
D) Focusing on stressful situations to increase coping abilities.
Answer: B) Practicing deep breathing and relaxation techniques.
Explanation: Deep breathing and relaxation techniques can help reduce anxiety by promoting relaxation and decreasing the physiological effects of stress.
120. A nurse is caring for a client who is scheduled for a colonoscopy. Which of the following instructions should the nurse include in the pre-procedure teaching?
A) “You will be awake during the procedure but sedated.”
B) “You should avoid drinking any fluids for 24 hours before the procedure.”
C) “You will need to take a laxative the evening before the procedure.”
D) “You should take your regular medications the morning of the procedure.”
Answer: C) “You will need to take a laxative the evening before the procedure.”
Explanation: A bowel cleanse, typically with a laxative, is necessary before a colonoscopy to ensure the colon is clear for visualization.
121. A nurse is caring for a client with a history of diabetes mellitus. The client is experiencing nausea, vomiting, and abdominal pain. The nurse suspects diabetic ketoacidosis (DKA). Which of the following should the nurse monitor first?
A) Serum glucose levels
B) Respiratory rate
C) Electrolyte levels
D) Urine output
Answer: B) Respiratory rate.
Explanation: DKA can cause rapid, deep breathing (Kussmaul respirations), which requires immediate assessment of the respiratory status.
122. A nurse is caring for a client who has been prescribed digoxin for heart failure. Which of the following symptoms indicates a potential side effect of the medication?
A) Increased appetite
B) Muscle weakness
C) Increased thirst
D) Increased heart rate
Answer: B) Muscle weakness.
Explanation: Muscle weakness is a sign of digoxin toxicity, which may occur due to high levels of the medication.
123. A nurse is caring for a client with a history of heart failure. Which of the following laboratory values should the nurse monitor closely?
A) Potassium
B) Calcium
C) Sodium
D) Creatinine
Answer: A) Potassium.
Explanation: Clients with heart failure who are taking diuretics are at risk for electrolyte imbalances, particularly hypokalemia.
124. A nurse is caring for a client who is taking an oral contraceptive. The nurse should educate the client about which of the following potential side effects?
A) Increased appetite and weight gain
B) Decreased risk of breast cancer
C) Increased risk of blood clots
D) Reduced risk of ovarian cysts
Answer: C) Increased risk of blood clots.
Explanation: Oral contraceptives increase the risk of venous thromboembolism, including deep vein thrombosis and pulmonary embolism.
125. A nurse is teaching a client with a new diagnosis of asthma about the use of a peak flow meter. Which statement by the client indicates understanding?
A) “I will use the peak flow meter after I take my medication.”
B) “I will use the peak flow meter before I take my medication.”
C) “I will use the peak flow meter every 4 hours.”
D) “I will use the peak flow meter when I feel short of breath.”
Answer: B) “I will use the peak flow meter before I take my medication.”
Explanation: The peak flow meter should be used before medication to assess the baseline lung function and determine the need for a bronchodilator.
126. A nurse is providing discharge teaching to a client with a colostomy. Which of the following statements by the client indicates the need for further teaching?
A) “I will empty the colostomy bag when it is one-third full.”
B) “I will avoid eating foods that cause gas, such as beans.”
C) “I should wear the colostomy bag at all times.”
D) “I can remove the colostomy bag at night to sleep.”
Answer: D) “I can remove the colostomy bag at night to sleep.”
Explanation: The colostomy bag should be worn at all times to prevent leakage and maintain hygiene. It should not be removed during sleep unless specifically directed by the healthcare provider.
127. A nurse is caring for a client who has been prescribed warfarin. Which of the following foods should the nurse recommend the client limit in their diet?
A) Carrots
B) Spinach
C) Apples
D) Bananas
Answer: B) Spinach.
Explanation: Spinach and other foods high in vitamin K can interfere with the effectiveness of warfarin, so clients should limit their intake of these foods.
128. A nurse is assessing a client who is at 38 weeks gestation. The nurse should expect which of the following signs of labor?
A) Increased fetal movement
B) Lower abdominal cramping
C) Bloody show
D) Decreased Braxton Hicks contractions
Answer: C) Bloody show.
Explanation: A bloody show, which consists of a small amount of blood or mucus discharge, is a common sign that labor is imminent.
129. A nurse is caring for a client who has a prescription for enoxaparin (Lovenox). Which of the following actions should the nurse take?
A) Monitor the client’s hemoglobin levels.
B) Administer the medication via the oral route.
C) Monitor the client for signs of bleeding.
D) Assess the client’s blood pressure frequently.
Answer: C) Monitor the client for signs of bleeding.
Explanation: Enoxaparin is an anticoagulant, and the nurse should monitor the client for signs of bleeding, such as petechiae or bruising.
130. A nurse is providing teaching to a client with hypertension about lifestyle modifications. Which of the following statements by the client indicates understanding?
A) “I will start exercising for at least 30 minutes most days of the week.”
B) “I should decrease my intake of fruits and vegetables.”
C) “I will avoid weight loss programs because they are not effective.”
D) “I can continue to drink alcohol in moderation, but I will limit it to weekends.”
Answer: A) “I will start exercising for at least 30 minutes most days of the week.”
Explanation: Regular physical activity helps reduce blood pressure and is an important lifestyle modification for managing hypertension.
131. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following should the nurse monitor closely?
A) Urine output
B) Hemoglobin and hematocrit
C) Blood glucose levels
D) Oxygen saturation
Answer: C) Blood glucose levels.
Explanation: TPN contains glucose, which can raise blood glucose levels, so frequent monitoring is necessary to prevent hyperglycemia.
132. A nurse is caring for a client who is post-op following an appendectomy. The nurse notes that the client’s abdomen is firm and distended. Which of the following actions should the nurse take?
A) Encourage the client to drink fluids.
B) Administer a laxative as ordered.
C) Assess the client for signs of peritonitis.
D) Palpate the abdomen again in 2 hours.
Answer: C) Assess the client for signs of peritonitis.
Explanation: Firm, distended abdomen post-op may indicate peritonitis, a serious complication requiring immediate assessment and intervention.
133. A nurse is caring for a client with a history of alcohol use disorder. Which of the following findings should the nurse report immediately?
A) Blood pressure of 140/90 mm Hg
B) Complaints of nausea and vomiting
C) Tremors and diaphoresis
D) Decreased level of consciousness and confusion
Answer: D) Decreased level of consciousness and confusion.
Explanation: Decreased LOC and confusion may indicate alcohol withdrawal delirium, a life-threatening condition requiring immediate attention.
134. A nurse is caring for a client with a diagnosis of Parkinson’s disease. Which of the following interventions should the nurse prioritize?
A) Assist with ambulation to prevent falls.
B) Provide a high-fiber diet to prevent constipation.
C) Encourage the client to participate in speech therapy.
D) Administer prescribed levodopa at regular intervals.
Answer: A) Assist with ambulation to prevent falls.
Explanation: Clients with Parkinson’s disease are at increased risk for falls due to tremors, rigidity, and postural instability.
135. A nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about smoking cessation. Which of the following statements indicates the need for further teaching?
A) “I should use nicotine patches to help quit smoking.”
B) “I can try to reduce my cigarette use gradually.”
C) “Smoking cessation will help improve my lung function.”
D) “I can continue smoking as long as I reduce the number of cigarettes.”
Answer: D) “I can continue smoking as long as I reduce the number of cigarettes.”
Explanation: Quitting smoking entirely is the most effective intervention for managing COPD and improving lung function.
136. A nurse is caring for a client who has a prescription for furosemide (Lasix). Which of the following laboratory values should the nurse monitor closely?
A) Potassium
B) Sodium
C) Calcium
D) Magnesium
Answer: A) Potassium.
Explanation: Furosemide is a diuretic that can cause potassium loss, leading to hypokalemia, which can be life-threatening.
137. A nurse is caring for a client with a history of asthma. The client is using a peak flow meter. Which of the following readings indicates that the client’s asthma is poorly controlled?
A) 80% of personal best
B) 90% of personal best
C) 60% of personal best
D) 100% of personal best
Answer: C) 60% of personal best.
Explanation: A peak flow reading of less than 80% of the personal best indicates poorly controlled asthma and may require additional intervention.
138. A nurse is assessing a client with a history of stroke. Which of the following signs should the nurse recognize as indicative of a stroke?
A) Sudden onset of severe headache
B) Sudden loss of balance and difficulty walking
C) Gradual onset of dizziness and confusion
D) Difficulty swallowing after a meal
Answer: B) Sudden loss of balance and difficulty walking.
Explanation: A sudden loss of balance and difficulty walking are signs of a stroke and should be reported immediately.
139. A nurse is teaching a client with diabetes mellitus about blood glucose monitoring. Which of the following statements indicates that the client understands how to perform the test correctly?
A) “I will clean the testing site with alcohol and wait for it to dry.”
B) “I will prick the side of my fingertip for the blood sample.”
C) “I will test my blood glucose before meals and 1 hour after meals.”
D) “I will wash my hands with hot water before testing.”
Answer: B) “I will prick the side of my fingertip for the blood sample.”
Explanation: Pricking the side of the fingertip causes less discomfort and is a recommended site for blood glucose testing.
140. A nurse is caring for a client who is taking oral contraceptives. The nurse should educate the client about which of the following potential risks?
A) Decreased risk of breast cancer
B) Increased risk of blood clots
C) Decreased risk of ovarian cysts
D) Increased risk of heart disease
Answer: B) Increased risk of blood clots.
Explanation: Oral contraceptives increase the risk of blood clots, which can lead to deep vein thrombosis or pulmonary embolism.
141. A nurse is caring for a client receiving intravenous (IV) morphine for post-operative pain. Which of the following findings should the nurse address immediately?
A) Respiratory rate of 10 breaths per minute
B) Pain intensity rating of 4 out of 10
C) Blood pressure of 130/80 mm Hg
D) Heart rate of 90 beats per minute
Answer: A) Respiratory rate of 10 breaths per minute.
Explanation: A respiratory rate of 10 breaths per minute is a sign of respiratory depression, which can be a life-threatening side effect of morphine.
142. A nurse is caring for a client who has received a blood transfusion. The nurse observes that the client is experiencing chills, fever, and tachycardia. Which of the following actions should the nurse take first?
A) Increase the rate of the blood transfusion.
B) Notify the healthcare provider.
C) Administer acetaminophen for fever.
D) Stop the blood transfusion immediately.
Answer: D) Stop the blood transfusion immediately.
Explanation: Chills, fever, and tachycardia are signs of a transfusion reaction. The first priority is to stop the transfusion to prevent further complications.
143. A nurse is providing discharge teaching for a client with a new diagnosis of hypertension. Which of the following statements by the client indicates the need for further teaching?
A) “I will take my blood pressure at home to monitor it regularly.”
B) “I should follow a low-sodium diet to help manage my blood pressure.”
C) “I will reduce my alcohol intake to one drink per day.”
D) “I will continue to eat processed foods to save time.”
Answer: D) “I will continue to eat processed foods to save time.”
Explanation: Processed foods often contain high amounts of sodium, which can worsen hypertension. Clients should be educated to limit processed food consumption.
144. A nurse is caring for a client who is 24 hours post-operative following a hip replacement surgery. Which of the following interventions should the nurse implement to prevent deep vein thrombosis (DVT)?
A) Apply compression stockings to the legs.
B) Elevate the affected leg above the heart.
C) Encourage the client to cross their legs when sitting.
D) Instruct the client to keep the affected leg immobilized.
Answer: A) Apply compression stockings to the legs.
Explanation: Compression stockings help promote venous return and reduce the risk of DVT in post-operative patients.
145. A nurse is preparing to administer insulin to a client with diabetes mellitus. Which of the following actions is the most important for the nurse to take?
A) Check the client’s blood glucose level.
B) Instruct the client to eat breakfast before receiving the insulin.
C) Assess the client’s blood pressure.
D) Provide the client with a snack after the injection.
Answer: A) Check the client’s blood glucose level.
Explanation: Checking the blood glucose level is essential before administering insulin to ensure the correct dose and prevent hypoglycemia.
146. A nurse is teaching a client with chronic kidney disease (CKD) about dietary modifications. Which of the following foods should the nurse advise the client to limit?
A) Apples
B) Spinach
C) Chicken
D) Rice
Answer: B) Spinach.
Explanation: Spinach is high in potassium, which clients with CKD should limit to avoid hyperkalemia.
147. A nurse is assessing a client who has just received a prescription for a benzodiazepine for anxiety. Which of the following findings is the priority for the nurse to assess?
A) Respiratory rate
B) Blood pressure
C) Heart rate
D) Level of consciousness
Answer: A) Respiratory rate.
Explanation: Benzodiazepines can cause respiratory depression, so it is a priority to assess the client’s respiratory rate to ensure safety.
148. A nurse is caring for a client who is receiving chemotherapy and has developed neutropenia. Which of the following actions should the nurse take to reduce the risk of infection?
A) Place the client in a private room.
B) Encourage the client to participate in group activities.
C) Limit visitors to those who are healthy.
D) Provide the client with a high-calorie diet.
Answer: A) Place the client in a private room.
Explanation: Neutropenic precautions include placing the client in a private room to minimize exposure to infectious agents.
149. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client is experiencing dyspnea and chest pain. Which of the following actions should the nurse take first?
A) Stop the blood transfusion immediately.
B) Administer oxygen via nasal cannula.
C) Notify the healthcare provider.
D) Take the client’s vital signs.
Answer: A) Stop the blood transfusion immediately.
Explanation: Dyspnea and chest pain are signs of a possible transfusion reaction, and the blood transfusion should be stopped immediately to prevent further complications.
150. A nurse is caring for a client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor. Which of the following adverse effects should the nurse educate the client to report?
A) Dry cough
B) Weight gain
C) Increased appetite
D) Swelling of the face
Answer: A) Dry cough.
Explanation: A persistent dry cough is a common side effect of ACE inhibitors and should be reported to the healthcare provider.
151. A nurse is caring for a client who is 6 hours post-operative following a total knee replacement. The client is experiencing pain, but the pain management plan is not providing adequate relief. Which of the following actions should the nurse take?
A) Administer the prescribed pain medication and assess its effectiveness in 30 minutes.
B) Ask the client to perform relaxation techniques to reduce pain.
C) Instruct the client to request pain medication every 4 hours.
D) Increase the dose of the pain medication without contacting the healthcare provider.
Answer: A) Administer the prescribed pain medication and assess its effectiveness in 30 minutes.
Explanation: Adequate pain control is essential post-operatively, and the nurse should administer prescribed pain medication and reassess after the appropriate time.
152. A nurse is caring for a client with a history of seizures. The client is prescribed phenytoin (Dilantin). Which of the following instructions should the nurse provide?
A) “You can skip a dose if you are feeling better.”
B) “You will need to have your blood levels monitored regularly.”
C) “This medication will cure your seizure disorder.”
D) “You should avoid taking any other medications while on phenytoin.”
Answer: B) “You will need to have your blood levels monitored regularly.”
Explanation: Phenytoin has a narrow therapeutic range, and blood levels should be monitored regularly to prevent toxicity.
153. A nurse is providing discharge teaching to a client who is prescribed a bronchodilator inhaler. Which of the following statements by the client indicates understanding?
A) “I will use the inhaler before my other medications.”
B) “I will use the inhaler after my other medications.”
C) “I will only use the inhaler when I feel short of breath.”
D) “I will rinse my mouth after using the inhaler.”
Answer: D) “I will rinse my mouth after using the inhaler.”
Explanation: Rinsing the mouth after using a bronchodilator inhaler helps prevent oral thrush, a common side effect of inhaled corticosteroids.
154. A nurse is assessing a client with a suspected diagnosis of pneumonia. Which of the following findings is most indicative of pneumonia?
A) Productive cough with green sputum
B) Unexplained weight loss
C) Hyperactive bowel sounds
D) Lethargy and confusion
Answer: A) Productive cough with green sputum.
Explanation: A productive cough with green sputum is characteristic of a bacterial infection, such as pneumonia.
155. A nurse is providing teaching to a client who is newly diagnosed with hypertension. Which of the following statements by the client indicates the need for further teaching?
A) “I will try to decrease my salt intake.”
B) “I should take my blood pressure medication at the same time every day.”
C) “I can stop taking my medication if I feel better.”
D) “I will follow a heart-healthy diet.”
Answer: C) “I can stop taking my medication if I feel better.”
Explanation: Hypertension is a chronic condition that requires continuous management, even if symptoms improve. The client should not stop taking medication without consulting a healthcare provider.
156. A nurse is caring for a client who has been prescribed alendronate (Fosamax) for osteoporosis. Which of the following actions should the nurse instruct the client to take?
A) Take the medication with food.
B) Take the medication just before bedtime.
C) Take the medication with a full glass of water.
D) Lie down immediately after taking the medication.
Answer: C) Take the medication with a full glass of water.
Explanation: Alendronate should be taken with a full glass of water, and the client should remain upright for at least 30 minutes to prevent esophageal irritation.
157. A nurse is assessing a client who is 4 days post-operative following abdominal surgery. The nurse notes that the client’s abdomen is soft and distended, and there is no bowel movement. Which of the following actions should the nurse take?
A) Encourage the client to increase fluid intake.
B) Administer a laxative as prescribed.
C) Notify the healthcare provider of the findings.
D) Continue to monitor for bowel sounds.
Answer: C) Notify the healthcare provider of the findings.
Explanation: Abdominal distension and the absence of bowel movements may indicate a post-operative ileus or bowel obstruction, requiring prompt medical evaluation.
158. A nurse is caring for a client with a chest tube. Which of the following findings should the nurse immediately report to the healthcare provider?
A) Continuous bubbling in the water-seal chamber
B) Intermittent bubbling in the suction chamber
C) Drainage from the chest tube that is pink and watery
D) Drainage from the chest tube that is 50 mL in the last hour
Answer: A) Continuous bubbling in the water-seal chamber.
Explanation: Continuous bubbling in the water-seal chamber may indicate an air leak, which requires immediate investigation to ensure the chest tube is functioning properly.
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