NCLEX Practice Test 1

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Question 1 of 85

1. Question

A client is admitted to the hospital after experiencing a myocardial infarction. The nurse performing the initial assessment inquires about any advance directives, which the client does not have. The client asks, “What is an advance directive?”

>Which is the most appropriate response by the nurse?

1. “An advance directive is a document that only states whether or not you want CPR to be performed should your heart stop.”
Correct Incorrect Correct answer

2. “An advance directive details which health interventions you do and do not want in certain situations in case you cannot make those decisions yourself, such as if you are on a ventilator.”
Correct Incorrect Correct answer

3. “An advance directive is a form that needs to be filled out by an attorney to be legally binding.”
Correct Incorrect Correct answer

4. “An advance directive lets you pick someone to make all of your future healthcare decisions, including treatment during your current admission.”
Correct Incorrect Correct answer

Correct

Incorrect
Question 2 of 85

2. Question

The nursing instructor is lecturing on ethical principles in nursing, including definitions and examples of such. She asks the students the following question:

>Which of the following scenarios best exemplifies the ethical principle of justice?

1. The nurse gives the same care to all clients, whether insured or uninsured.
Correct Incorrect Correct answer

2. After a surgeon orders penicillin for a client, the operative nurse alerts the surgeon to the client’s allergy to penicillin.
Correct Incorrect Correct answer

3. The nurse discusses with a client her right to refuse treatment after a client declines a new medication.
Correct Incorrect Correct answer

4. The nurse holds the hand of a dying man who has no family.
Correct Incorrect Correct answer

Correct

Incorrect
Question 3 of 85

3. Question

The nursing student is currently studying for a maternal-child examination and is reviewing maternal changes in pregnancy.

>Which of the following is not considered a probable sign of pregnancy?

1. A positive human chorionic gonadotropin or HCG test
Correct Incorrect Correct answer

2. Chadwick’s sign
Correct Incorrect Correct answer

3. Amenorrhea
Correct Incorrect Correct answer

4. Braxton Hicks contractions
Correct Incorrect Correct answer

Correct

Incorrect
Question 4 of 85

4. Question

A nurse is assessing a client who was admitted to the medical-surgical floor from the local nursing home. She performs a skin assessment, noting a Stage III pressure ulcer on the client’s right heel. She notifies the physician and wound care team.

>The nurse anticipates which of the following types of wound healing for this client?

1. Primary intention healing
Correct Incorrect Correct answer

2. Secondary intention healing
Correct Incorrect Correct answer

3. Secondary preventive healing
Correct Incorrect Correct answer

4. Tertiary intention healing
Correct Incorrect Correct answer

Correct

Incorrect
Question 5 of 85

5. Question

A client at 28 weeks gestation is to receive a Rhogam injection as she is blood type A-negative. The client asks the nurse “What is the purpose of this medication?”

>How should the nurse respond?

1. “Rhogam helps your immune system from reacting to your baby’s blood and producing antibodies at the time of delivery.”
Correct Incorrect Correct answer

2. “Rhogam helps mature your baby’s lungs.”
Correct Incorrect Correct answer

3. “Rhogam helps protect your baby against pertussis.”
Correct Incorrect Correct answer

4. “Rhogam changes your blood type from negative to positive.”
Correct Incorrect Correct answer

Correct

Incorrect
Question 6 of 85

6. Question

A nurse is monitoring a patient during a procedure using conscious sedation.

>Which of the following actions by the nurse is concerning?

1. The nurse maintains IV access throughout the procedure.
Correct Incorrect Correct answer

2. The nurse administers the sedation just prior to the physician entering the room so the procedure can begin immediately.
Correct Incorrect Correct answer

3. The nurse monitors the client’s respiratory status frequently, including oxygen saturation, breath sounds, and respiratory rate and depth.
Correct Incorrect Correct answer

4. The nurse has prepared appropriate medication antagonists to use if needed.
Correct Incorrect Correct answer

Correct

Incorrect

Question 7 of 85

7. Question

Case Study Question 1 of 6

The emergency room nurse is admitting a 55-year-old male who presents with dyspnea, chest pain, and a cough.

Nurse Notes:

Notes	Time 1000. Client reports symptoms started almost a week ago, and he was diagnosed with an upper respiratory infection by his primary care physician. Reports worsening dyspnea since yesterday. Has a productive cough sometimes tinged with blood. Complains of chills. Has intermittent chest pain when he breathes deeply. Pain 0/10 at present. Appears restless but can speak in full sentences. No known drug allergies.
Vital Signs	Blood pressure = 100/65 RR = 28 Pulse = 110bpm Temp= 100.8 degrees Fahrenheit
Neurologic	Awake alert and oriented x 3.
Cardio-respiratory	HR regular rhythm, rales and rhonchi heard on auscultation, productive cough. Oxygen saturation 90% on room air.
Gastrointestinal	Abdomen soft, nontender. Denies nausea, vomiting, diarrhea, constipation
Extremities	Warm to touch, no edema
Social Assessment	Smokes 1 pack a week. Denies alcohol use. Lives independently at home.

>Select the answer below that correctly highlights all the findings that require immediate follow-up.

Correct Incorrect Correct answer

Correct

Incorrect

Question 8 of 85

8. Question

Case Study Question 2 of 6

The emergency room nurse is admitting a 55-year-old male who presents with dyspnea, chest pain, and a cough.

Nurse Notes:

Notes	Time 1000. Client reports symptoms started almost a week ago, and he was diagnosed with an upper respiratory infection by his primary care physician. Reports worsening dyspnea since yesterday. Has a productive cough sometimes tinged with blood. Complains of chills. Has intermittent chest pain when he breathes deeply. Pain 0/10 at present. Appears restless but can speak in full sentences. No known drug allergies.
Vital Signs	Blood pressure = 100/65 RR = 28 Pulse = 110bpm Temp= 100.8 degrees Fahrenheit
Neurologic	Awake alert and oriented x 3.
Cardio-respiratory	HR regular rhythm, rales and rhonchi heard on auscultation, productive cough. Oxygen saturation 90% on room air.
Gastrointestinal	Abdomen soft, nontender. Denies nausea, vomiting, diarrhea, constipation
Extremities	Warm to touch, no edema
Social Assessment	Smokes 1 pack a week. Denies alcohol use. Lives independently at home.

>For each client finding, click to indicate if the finding is consistent with asthma, pneumonia, or pulmonary embolism. Each finding may support more than one type of respiratory condition. Select the answer below.

Correct Incorrect Correct answer

Correct

Incorrect

Question 9 of 85

9. Question

Case Study Question 3 of 6

The emergency room nurse is admitting a 55-year-old male who presents with dyspnea, chest pain, and a cough.

Nurse Notes:

Notes	Time 1000. Client reports symptoms started almost a week ago, and he was diagnosed with an upper respiratory infection by his primary care physician. Reports worsening dyspnea since yesterday. Has a productive cough sometimes tinged with blood. Complains of chills. Has intermittent chest pain when he breathes deeply. Pain 0/10 at present. Appears restless but can speak in full sentences. No known drug allergies.
Vital Signs	Blood pressure = 100/65 RR = 28 Pulse = 110bpm Temp= 100.8 degrees Fahrenheit
Neurologic	Awake alert and oriented x 3.
Cardio-respiratory	HR regular rhythm, rales and rhonchi heard on auscultation, productive cough. Oxygen saturation 90% on room air.
Gastrointestinal	Abdomen soft, nontender. Denies nausea, vomiting, diarrhea, constipation
Extremities	Warm to touch, no edema
Social Assessment	Smokes 1 pack a week. Denies alcohol use. Lives independently at home.

Chest X-Ray:

Notes

Reveals pulmonary infiltrates bilaterally. Consolidation left lower lobe. No hilar lymphadenopathy.

Laboratory Report:

Lab	Results	Reference range
Hematocrit	45%	Males: 42-52% Females: 35-47%
Hemoglobin	14 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	13,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Potassium(serum)	4.5 mEq/L	3.5 to 5 mEq/L
Sodium (serum)	137 mEq/L	135 to 145 mEq/L

The chest x-ray report has been sent from radiology and labs are ready.

>Complete the sentence from the list of options below.

The nurse should recognize that the client is most likely experiencing (choose a, b, or c). As evidence by (choose d, e, f, or g) and (choose d, e, f, or g).

a. Pneumonia

Correct Incorrect Correct answer

b. Chronic obstructive pulmonary

Correct Incorrect Correct answer

c. Acute asthma

Correct Incorrect Correct answer

d. Fever and chills

Correct Incorrect Correct answer

e. Hemoglobin of 14g/dL

Correct Incorrect Correct answer

f. Infiltrates on chest x-ray

Correct Incorrect Correct answer

g. Oxygen saturation 90%

Correct Incorrect Correct answer

Correct

Incorrect

Question 10 of 85

10. Question

Case Study Question 4 of 6

The emergency room nurse is admitting a 55-year-old male who presents with dyspnea, chest pain, and a cough.

Nurse Notes:

Notes	Time 1000. Client reports symptoms started almost a week ago, and he was diagnosed with an upper respiratory infection by his primary care physician. Reports worsening dyspnea since yesterday. Has a productive cough sometimes tinged with blood. Complains of chills. Has intermittent chest pain when he breathes deeply. Pain 0/10 at present. Appears restless but can speak in full sentences. No known drug allergies.
Vital Signs	Blood pressure = 100/65 RR = 28 Pulse = 110bpm Temp= 100.8 degrees Fahrenheit
Neurologic	Awake alert and oriented x 3.
Cardio-respiratory	HR regular rhythm, rales and rhonchi heard on auscultation, productive cough. Oxygen saturation 90% on room air.
Gastrointestinal	Abdomen soft, nontender. Denies nausea, vomiting, diarrhea, constipation
Extremities	Warm to touch, no edema
Social Assessment	Smokes 1 pack a week. Denies alcohol use. Lives independently at home.

Chest X-Ray:

Notes

Reveals pulmonary infiltrates bilaterally. Consolidation left lower lobe. No hilar lymphadenopathy.

Laboratory Report:

Lab	Results	Reference range
Hematocrit	45%	Males: 42-52% Females: 35-47%
Hemoglobin	14 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	13,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Potassium(serum)	4.5 mEq/L	3.5 to 5 mEq/L
Sodium (serum)	137 mEq/L	135 to 145 mEq/L

The chest x-ray report has been sent from radiology and labs are ready.

>Select the orders from each of the categories the nurse should include in the plan of care at this time. Each category may have more than one order.

Categories	Orders
Nursing	a. Prepare to place client on airborne precautions
	b. Place client in a semi-fowlers position
	c. Encourage use of incentive spirometer
	d. Encourage PO fluids every 1-2 hours
Medications	e. Ceftriaxone 1gram IV q 24 hours and Azithromycin 500mg IV q 24 hours
	f. Tylenol 650mg PO q 4 hours PRN temperature greater than 101
	g. Dextromethorphan 20mg ever 4 hours

a. Prepare to place client on airborne precautions

Correct Incorrect Correct answer

b. Place client in a semi-fowlers position

Correct Incorrect Correct answer

c. Encourage use of incentive spirometer

Correct Incorrect Correct answer

d. Encourage PO fluids every 1-2 hours

Correct Incorrect Correct answer

e. Ceftriaxone 1gram IV q 24 hours and Azithromycin 500mg IV q 24 hours

Correct Incorrect Correct answer

f. Tylenol 650mg PO q 4 hours PRN temperature greater than 101

Correct Incorrect Correct answer

g. Dextromethorphan 20mg ever 4 hours

Correct Incorrect Correct answer

Correct

Incorrect

Question 11 of 85

11. Question

Case Study Question 5 of 6

The emergency room nurse is admitting a 55-year-old male who presents with dyspnea, chest pain, and a cough.

Nurse Notes:

Notes	Time 1000. Client reports symptoms started almost a week ago, and he was diagnosed with an upper respiratory infection by his primary care physician. Reports worsening dyspnea since yesterday. Has a productive cough sometimes tinged with blood. Complains of chills. Has intermittent chest pain when he breathes deeply. Pain 0/10 at present. Appears restless but can speak in full sentences. No known drug allergies.
Vital Signs	Blood pressure = 100/65 RR = 28 Pulse = 110bpm Temp= 100.8 degrees Fahrenheit
Neurologic	Awake alert and oriented x 3.
Cardio-respiratory	HR regular rhythm, rales and rhonchi heard on auscultation, productive cough. Oxygen saturation 90% on room air.
Gastrointestinal	Abdomen soft, nontender. Denies nausea, vomiting, diarrhea, constipation
Extremities	Warm to touch, no edema
Social Assessment	Smokes 1 pack a week. Denies alcohol use. Lives independently at home.

Chest X-Ray:

Notes

Reveals pulmonary infiltrates bilaterally. Consolidation left lower lobe. No hilar lymphadenopathy.

Most Recent Laboratory Report:

Lab	Results	Reference range
Hematocrit	42%	Males: 42-52% Females: 35-47%
Hemoglobin	13 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	9,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Potassium(serum)	4.5 mEq/L	3.5 to 5 mEq/L
Sodium (serum)	139 mEq/L	135 to 145 mEq/L

>Five days later, the nurse is assessing the client and reviewing labs. Select the word choices that complete the sentence (order does not matter).

a. Performs ADLs without dyspnea

Correct Incorrect Correct answer

b. Expectorates moderate amount of thick yellow-green sputum

Correct Incorrect Correct answer

c. Oxygen saturation 96% on room air

Correct Incorrect Correct answer

d. Afebrile for past 48 hours

Correct Incorrect Correct answer

e. WBC count is 9,000 cells/mm3

Correct Incorrect Correct answer

f. Repeat chest x-ray shows consolidation in left lower lobe

Correct Incorrect Correct answer

Correct

Incorrect

Question 12 of 85

12. Question

Case Study Question 6 of 6

The emergency room nurse is admitting a 55-year-old male who presents with dyspnea, chest pain, and a cough.

Nurse Notes:

Notes	Time 1000. Client reports symptoms started almost a week ago, and he was diagnosed with an upper respiratory infection by his primary care physician. Reports worsening dyspnea since yesterday. Has a productive cough sometimes tinged with blood. Complains of chills. Has intermittent chest pain when he breathes deeply. Pain 0/10 at present. Appears restless but can speak in full sentences. No known drug allergies.
Vital Signs	Blood pressure = 100/65 RR = 28 Pulse = 110bpm Temp= 100.8 degrees Fahrenheit
Neurologic	Awake alert and oriented x 3.
Cardio-respiratory	HR regular rhythm, rales and rhonchi heard on auscultation, productive cough. Oxygen saturation 90% on room air.
Gastrointestinal	Abdomen soft, nontender. Denies nausea, vomiting, diarrhea, constipation
Extremities	Warm to touch, no edema
Social Assessment	Smokes 1 pack a week. Denies alcohol use. Lives independently at home.

Chest X-Ray:

Notes

Reveals pulmonary infiltrates bilaterally. Consolidation left lower lobe. No hilar lymphadenopathy.

Most Recent Laboratory Report:

Lab	Results	Reference range
Hematocrit	42%	Males: 42-52% Females: 35-47%
Hemoglobin	13 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	9,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Potassium(serum)	4.5 mEq/L	3.5 to 5 mEq/L
Sodium (serum)	139 mEq/L	135 to 145 mEq/L

>The nurse is performing discharge teaching. Which of the following statements indicates that teaching has been successful? Select all that apply.

a. “I will continue my turn, cough, deep breathe exercises at home.”

Correct Incorrect Correct answer

b. “I will continue my antibiotics until my cough is gone.”

Correct Incorrect Correct answer

c. “I will continue to drink lots of fluids.”

Correct Incorrect Correct answer

d. “I can take Robitussin for my cough if needed.”

Correct Incorrect Correct answer

e. “If I can’t breathe well, have chest pain or fever, or I keep bringing up yellow, green, or bloody sputum, I will notify my doctor.”

Correct Incorrect Correct answer

f. “I will get a pneumonia vaccine after I am healed.”

Correct Incorrect Correct answer

Correct

Incorrect

Question 13 of 85

13. Question

It is a very busy day on the medical-surgical unit. The nurse has a new admission and has to hang blood on another client. She needs help with her other clients.

>Which of the following is an example of inappropriate delegation by the registered nurse?

1. Instructing unlicensed assistive personnel to take vital signs on a client that is 2 days post-op cholecystectomy.
Correct Incorrect Correct answer

2. Asking a registered nurse to give intravenous hydralazine to a client with an exacerbation of hypertension.
Correct Incorrect Correct answer

3. Asking unlicensed assistive personnel to speak to the client’s doctor and document orders in the chart.
Correct Incorrect Correct answer

4. Asking the licensed practical nurse to insert a catheter in a client who is scheduled for surgery in 2 hours.
Correct Incorrect Correct answer

Correct

Incorrect
Question 14 of 85

14. Question

A couple is taking their newborn baby home. The nurse wheels mother and baby outside and watches as the baby is buckled into the rear-facing car seat.

>Which of the following is a concern for an incorrect fit?

1. The shoulder straps sit above the baby’s shoulders.
Correct Incorrect Correct answer

2. The chest clip is at the level of the baby’s armpits.
Correct Incorrect Correct answer

3. The father is unable to pinch the straps by the baby’s shoulders.
Correct Incorrect Correct answer

4. The child’s head is flat against the seat and positioned in the middle of the head area.
Correct Incorrect Correct answer

Correct

Incorrect
Question 15 of 85

15. Question

The nurse is reviewing charts on several GYN clients, concentrating on cervical cancer surveillance.

>Which of the following is an example of inappropriate cervical cancer screening, according to current recommendations by the United States Preventive Services Task Force (USPSTF)?

1. A 17-year-old female receives her first cervical cancer screening after she becomes sexually active.
Correct Incorrect Correct answer

2. A 25-year-old female recently had a Pap smear performed and is scheduled to return for her next screening in 3 years.
Correct Incorrect Correct answer

3. A 37-year-old multiparous woman returns to the clinic for co-testing (Pap and high-risk HPV testing together) every 5 years.
Correct Incorrect Correct answer

4. A 69-year-old woman with history of high-grade precancerous lesion 15 years ago is regularly screened for cervical cancer.
Correct Incorrect Correct answer

Correct

Incorrect
Question 16 of 85

16. Question

A nurse has a physician’s order to perform an ear irrigation secondary to cerumen impaction in a 60-year-old male. The nurse gathers her supplies and warms the irrigating solution.

>Which of the following is an incorrect step in the process of irrigating the ear?

1. Place the client on his side with the affected ear up.
Correct Incorrect Correct answer

2. Pull the pinna of the ear down and back to straighten the auditory canal.
Correct Incorrect Correct answer

3. Irrigate towards the top of the auditory canal with gentle pressure.
Correct Incorrect Correct answer

4. Have the client rest with the affected ear down to allow the solution to leak out of ear after the irrigation is finished.
Correct Incorrect Correct answer

Correct

Incorrect
Question 17 of 85

17. Question

A graduate nurse has a client that requires insulin at breakfast. He receives both NPH and regular insulin. The order reads “Give 10 units of NPH insulin and 6 units of Regular insulin.” The graduate nurse has a second nurse present with her while she is drawing up the insulin.

>Which is the correct order of steps for this procedure?

A. Inject 10 units of air into the vial of NPH.
B. Draw up 6 units of Regular insulin into the syringe.
C. Draw up 10 units of NPH insulin into the syringe.
D. Inject 6 units of air into the vial of Regular insulin.

1. A,C,D,B
Correct Incorrect Correct answer

2. D,A,C,B
Correct Incorrect Correct answer

3. D,A,B,C
Correct Incorrect Correct answer

4. A,D,B,C
Correct Incorrect Correct answer

Correct

Incorrect
Question 18 of 85

18. Question

A client has been intubated after presenting with respiratory distress. The oncoming nurse for the night shift hears the high-pressure alarm go off on the ventilator and enters the room to investigate.

>Which of the following requires immediate action by the nurse?

1. Deviation of the trachea to the right side
Correct Incorrect Correct answer

2. Client being unable to talk or swallow.
Correct Incorrect Correct answer

3. Carbon dioxide is detected via the end-tidal CO2 monitor.
Correct Incorrect Correct answer

4. Oxygen saturation is 95%
Correct Incorrect Correct answer

Correct

Incorrect
Question 19 of 85

19. Question

A 32-year-old female presents to the labor unit complaining of contractions every 5 minutes apart.

Nurse Notes:

Time 1000.
Client is having regular contractions every 5 minutes, rating pain 3/10 on pain scale. Fetal heart rate 130s baseline with moderate variability and accelerations.

1045.
Client requesting epidural as pain has increased to 6/10 on pain scale. IV fluid bolus started, and anesthesia notified.

1105.
Epidural placed by anesthesia. Fetal heart rate 130s baseline with moderate variability and accelerations.

1115.
Client calls out, complaining of dizziness, nausea, and cold sweats. Pain level 0/10. Fetal heart rate 105bpm with moderate variability, late decelerations noted.

1118.
Ephedrine IV given and IV bolus started.

1125.
Client is still nauseated and vomits a small amount of bile. The dizziness is worsening. Pain 0/10. Fetal heart rate 110bpm with moderate variability with late decelerations.

Vital Signs:

1100 1105 1115 1125

Blood pressure 115/78 112/80 90/55 82/48

Pulse 90 94 105 110

Respirations 18 18 20 20

Temperature 97.9 degrees F 98 degrees F 98 degrees F 98.1 degrees F

>Complete the sentence from the list below.

The nurse should recognize that the client is most likely experiencing (choose a, b, or c). With the priority intervention being (choose d, e, f, or g).

a. vena cava syndrome
Correct Incorrect Correct answer

b. epidural-induced hypotension
Correct Incorrect Correct answer

c. dehydration
Correct Incorrect Correct answer

d. To position client on left side
Correct Incorrect Correct answer

e. To continue IV bolus of fluid
Correct Incorrect Correct answer

f. To give another dose of ephedrine
Correct Incorrect Correct answer

g. To continue to monitor client closely
Correct Incorrect Correct answer

Correct

Incorrect
Question 20 of 85

20. Question

A client is admitted with an exacerbation of congestive heart failure. The nurse walks into the room to give the client Lasix per physician orders, but the client refuses. He states “I don’t want it. It makes me pee too much.”

>Which of the following actions is appropriate in this situation?

1. Discard the medication but document that it was given so the nurse doesn’t get in trouble with the physician.
Correct Incorrect Correct answer

2. Give it anyway as it is important to treat the client’s disease process.
Correct Incorrect Correct answer

3. Advise the client that he has the right to refuse treatment and then notify the physician to get further orders.
Correct Incorrect Correct answer

4. Give half of the ordered dose to lower the risk of urinary frequency.
Correct Incorrect Correct answer

Correct

Incorrect
Question 21 of 85

21. Question

A healthcare facility is undergoing a bioterrorism drill, and a client is admitted with the following symptoms: high fever, red spots and sores on tongue and mouth, and body aches.

>Which bioterrorism agent is most likely?

1. Cutaneous anthrax
Correct Incorrect Correct answer

2. Smallpox
Correct Incorrect Correct answer

3. Bubonic plague
Correct Incorrect Correct answer

4. Botulism
Correct Incorrect Correct answer

Correct

Incorrect
Question 22 of 85

22. Question

The nurse is reviewing the health history of a woman who wants to use a combined hormonal contraceptive for birth control.

>Which of the following would be considered a contraindication to this form of birth control?

1. The client is currently on macrodantin for a UTI.
Correct Incorrect Correct answer

2. The client has a history of menstrual-related migraines.
Correct Incorrect Correct answer

3. The client had a deep vein thrombosis during pregnancy, and is not currently on anticoagulants..
Correct Incorrect Correct answer

4. The client is 32 years old and is a smoker.
Correct Incorrect Correct answer

Correct

Incorrect
Question 23 of 85

23. Question

The nurse is educating a newly diagnosed type 2 diabetic about foot care.

>Which of the following statements indicates the need for further teaching?

1. “I will avoid removing calluses myself. I will go to a foot doctor instead.”
Correct Incorrect Correct answer

2. “I will file any sharp edges with a nail file.”
Correct Incorrect Correct answer

3. “I will use a mirror to check the bottom of my feet for any cuts or sores.”
Correct Incorrect Correct answer

4. “I will soak my feet for 20 minutes each day in warm water and dry them carefully after.”
Correct Incorrect Correct answer

Correct

Incorrect
Question 24 of 85

24. Question

A nurse volunteers to help with an immunization clinic at the local hospital.

>Which of the following is considered inappropriate injection technique?

1. A 6-month-old receives the DTap vaccine in the right anterolateral thigh.
Correct Incorrect Correct answer

2. A 6-year-old receives a vaccine in the deltoid muscle.
Correct Incorrect Correct answer

3. A 5-year-old receives an MMR vaccine using the Z-track method.
Correct Incorrect Correct answer

4. A 13-year-old receives the meningitis vaccine in the vastus lateralis muscle per his request.
Correct Incorrect Correct answer

Correct

Incorrect
Question 25 of 85

25. Question

A client presents to the emergency room, complaining of significant abdominal pain and heavy vaginal bleeding. She reports she received a positive urine pregnancy test a few weeks ago. Upon further assessment, the client is diagnosed with an ectopic pregnancy.

>Which of the following are priority nursing interventions as the patient is prepped for emergent surgery?

1. Insert Foley catheter, shave pubic area, administer oxygen.
Correct Incorrect Correct answer

2. Fluid bolus, type and cross match, IV pain medication.
Correct Incorrect Correct answer

3. IV fluid bolus, incentive spirometry, methotrexate administration
Correct Incorrect Correct answer

4. Blood cultures, antibiotics, oxygen
Correct Incorrect Correct answer

Correct

Incorrect
Question 26 of 85

26. Question

A client is admitted with a small bowel obstruction secondary to metastatic cancer. The physician orders total parenteral nutrition (TPN) given through a single lumen central venous catheter.

Nurse Notes:

Time 1330.
Client received to room 205 with TPN infusing. Reviewed the label on the infusion, noting it contains lipids, vitamins, minerals, carbohydrates in the form of dextrose, and proteins. Central venous catheter site without redness or tenderness.

Day 2 at 0800.
TPN infusing at ordered rate. Catheter site within normal limits.

Blood glucose checked (glucose = 185) and standing order insulin given.

Day 2 at 1100.
Rounded on client who states “I’m going to the bathroom a lot.” Physician notified and urinalysis ordered.

Day 2 at 1400.
Client calls out complaining of headache and feeling very thirsty.

Urinalysis results are back.

Urinalysis:

Lab Results

Color Dark Yellow

Ketones 1+

Glucose 3+

Bilirubin Negative

Blood Negative

Bacteria None

Specific gravity 1.020

>The nurse concludes that the client is likely experiencing (choose a, b, c, or d). The best action for the nurse to take is (choose e, f, g, h, i) and (choose e, f, g, h, i).

a. Fluid volume deficit
Correct Incorrect Correct answer

b. Fluid overload
Correct Incorrect Correct answer

c. Hyperglycemia
Correct Incorrect Correct answer

d. Hypoglycemia
Correct Incorrect Correct answer

e. Immediately give D50 via IV push
Correct Incorrect Correct answer

f. Check a blood glucose
Correct Incorrect Correct answer

g. Give fluid bolus through the central line
Correct Incorrect Correct answer

h. Give standing order insulin.
Correct Incorrect Correct answer

i. Stop the TPN immediately
Correct Incorrect Correct answer

Correct

Incorrect
Question 27 of 85

27. Question

A Hispanic man is admitted to the hospital and will be undergoing a reconstruction of the anterior cruciate ligament. He needs to sign a consent form prior to the procedure.

>Which of the following is a nurse’s responsibility regarding informed consent?

1. A nurse has to argue with the client until he or she consents to the treatment or procedure.
Correct Incorrect Correct answer

2. A nurse has to be a witness to the signing of the consent form.
Correct Incorrect Correct answer

3. A nurse has to provide a verbal explanation of the consent form in a client’s native language.
Correct Incorrect Correct answer

4. A nurse has to discuss all risks, benefits, and alternatives to the procedure or treatment.
Correct Incorrect Correct answer

Correct

Incorrect
Question 28 of 85

28. Question

A nurse is assisting an elderly man to learn to ambulate with a walker after an orthopedic surgery.

>Which of the following actions by the client requires additional teaching?

1. The client lifts and moves the walker forward; when he places it down, all four tips are solidly on the floor.
Correct Incorrect Correct answer

2. The client steps forward with the strong leg first, then brings the weaker leg forward.
Correct Incorrect Correct answer

3. The client stares ahead while walking instead of looking at his feet.
Correct Incorrect Correct answer

4. The client supports his weight with his hands on the hand grips.
Correct Incorrect Correct answer

Correct

Incorrect
Question 29 of 85

29. Question

The nurse is observing a student test the twelve cranial nerves. The student asks the client to smile, puff out their cheeks, raise eyebrows, and show their teeth.

>Which cranial nerve is the student assessing?

1. Cranial nerve I (1)
Correct Incorrect Correct answer

2. Cranial nerve VII (7)
Correct Incorrect Correct answer

3. Cranial nerve VIII (8)
Correct Incorrect Correct answer

4. Cranial nerve XII (12)
Correct Incorrect Correct answer

Correct

Incorrect
Question 30 of 85

30. Question

The nurse is creating a care plan for an adult female who is having difficulty sleeping. The woman reports insomnia several days a week.

>Which of the following would be inappropriate to include in the plan of care?

1. Avoid large amounts of fluid before bed.
Correct Incorrect Correct answer

2. Drink a glass of warm milk before bed.
Correct Incorrect Correct answer

3. Perform physical activity before bed to expend energy.
Correct Incorrect Correct answer

4. Avoid alcohol and caffeine before bed.
Correct Incorrect Correct answer

Correct

Incorrect
Question 31 of 85

31. Question

A nurse is gathering her supplies to administer medication to a client with a PEG tube. The client has a hydralazine tablet and a metformin extended-release tablet ordered.

>Which of the following actions is appropriate when administering the above medications?

1. Crush both medications and administer together.
Correct Incorrect Correct answer

2. Break the metformin in half, dilute it in water, and administer it separately from the hydralazine.
Correct Incorrect Correct answer

3. Stop the tube feeding, administer the medications, and restart the feeding.
Correct Incorrect Correct answer

4. Notify the physician that metformin extended release is ordered and request to change to a different formulation, such as liquid medicine.
Correct Incorrect Correct answer

Correct

Incorrect
Question 32 of 85

32. Question

A nurse is caring for a client who has been diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH).

>Which lab result would the nurse expect to find in this client?

1. Potassium level of 4.7 mEq/L
Correct Incorrect Correct answer

2. Calcium level of 6.5mg/dL
Correct Incorrect Correct answer

3. Sodium level of 128 mEq/L
Correct Incorrect Correct answer

4. Chloride level of 112 mEq/L
Correct Incorrect Correct answer

Correct

Incorrect

Question 33 of 85

33. Question

Case Study Question 1 of 6

A 24-year-old G2P1 at 32 1/7 weeks gestation presents to the triage area of labor and delivery, complaining of abdominal and back pain.

Nurses Notes:

1200.
Client brought to triage and placed on fetal monitor/tocodynamometer. Fetal heart rate 145 baseline with moderate variability, 15×15 accelerations, no decelerations. Client complains of abdominal tightening every 5 minutes for the past 2 hours. Fetal fibronectin collected. ROMPlus collected to check for ruptured membranes. Cervical exam reveals cervical dilation of 1cm.

Client reports history of cesarean section 5 years ago at 35 weeks gestation secondary to labor and breech presentation.

1230.
Client continuing to have contractions, complaining of increasing pain. Toco shows contractions every 3-5 minutes. Fetal heart rate 155 baseline with moderate variability, 15×15 accelerations, no decelerations. Abdomen palpated during and after contractions, with uterus relaxing fully after contraction. Moderate amount of bloody mucus-like discharge noted upon exam. Cervical dilation 2.5cm.

L&D Flowsheet:

Time	1200	1230
Blood pressure	120/70	125/72
Heart rate	72	74
Respirations	18	18
Pulse oximetry	99% on RA	99% on RA
Pain	5/10	7/10
Cervical dilation	1cm	2.5cm

Labs:

Lab	Results	Reference range
Hematocrit	32%	Males: 42-52% Females: 35-47%
Hemoglobin	10 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	9,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Fetal fibronectin	Positive	Negative
ROMPlus	Negative	Negative

>Which 4 findings are most significant?

a. Increasing abdominal pain

Correct Incorrect Correct answer

b. ROMPlus negative

Correct Incorrect Correct answer

c. Fetal fibronectin positive

Correct Incorrect Correct answer

d. Bloody discharge

Correct Incorrect Correct answer

e. Fetal baseline 155bpm

Correct Incorrect Correct answer

f. Cervical dilation of 2.5cm

Correct Incorrect Correct answer

g. Hemoglobin level

Correct Incorrect Correct answer

Correct

Incorrect

Question 34 of 85

34. Question

Case Study Question 2 of 6

A 24-year-old G2P1 at 32 1/7 weeks gestation presents to the triage area of labor and delivery, complaining of abdominal and back pain.

Nurses Notes:

Client reports history of cesarean section 5 years ago at 35 weeks gestation secondary to labor and breech presentation.

L&D Flowsheet:

Time	1200	1230
Blood pressure	120/70	125/72
Heart rate	72	74
Respirations	18	18
Pulse oximetry	99% on RA	99% on RA
Pain	5/10	7/10
Cervical dilation	1cm	2.5cm

Labs:

Lab	Results	Reference range
Hematocrit	32%	Males: 42-52% Females: 35-47%
Hemoglobin	10 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	9,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Fetal fibronectin	Positive	Negative
ROMPlus	Negative	Negative

>For each client finding, click to indicate if the finding is consistent with placental abruption, preterm labor, uterine rupture, or placenta previa. Each finding may support more than one type of condition.

Correct Incorrect Correct answer

Correct

Incorrect

Question 35 of 85

35. Question

Case Study Question 3 of 6

A 24-year-old G2P1 at 32 1/7 weeks gestation presents to the triage area of labor and delivery, complaining of abdominal and back pain.

Nurses Notes:

Client reports history of cesarean section 5 years ago at 35 weeks gestation secondary to labor and breech presentation.

L&D Flowsheet:

Time	1200	1230
Blood pressure	120/70	125/72
Heart rate	72	74
Respirations	18	18
Pulse oximetry	99% on RA	99% on RA
Pain	5/10	7/10
Cervical dilation	1cm	2.5cm

Labs:

Lab	Results	Reference range
Hematocrit	32%	Males: 42-52% Females: 35-47%
Hemoglobin	10 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	9,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Fetal fibronectin	Positive	Negative
ROMPlus	Negative	Negative

Select the option that completes the following sentence.

>The nurse should recognize that the client is most likely experiencing (choose a, b, c, or d).

a. Placental abruption

Correct Incorrect Correct answer

b. Preterm Labor

Correct Incorrect Correct answer

c. Uterine Rupture

Correct Incorrect Correct answer

d. Placenta previa

Correct Incorrect Correct answer

Correct

Incorrect

Question 36 of 85

36. Question

Case Study Question 4 of 6

A 24-year-old G2P1 at 32 1/7 weeks gestation presents to the triage area of labor and delivery, complaining of abdominal and back pain.

Nurses Notes:

Client reports history of cesarean section 5 years ago at 35 weeks gestation secondary to labor and breech presentation.

L&D Flowsheet:

Time	1200	1230
Blood pressure	120/70	125/72
Heart rate	72	74
Respirations	18	18
Pulse oximetry	99% on RA	99% on RA
Pain	5/10	7/10
Cervical dilation	1cm	2.5cm

Labs:

Lab	Results	Reference range
Hematocrit	32%	Males: 42-52% Females: 35-47%
Hemoglobin	10 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	9,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Fetal fibronectin	Positive	Negative
ROMPlus	Negative	Negative

>The client has been diagnosed with preterm labor. For each nursing intervention, click to specify whether the intervention is indicated or not indicated.

Correct Incorrect Correct answer

Correct

Incorrect

Question 37 of 85

37. Question

Case Study Question 5 of 6

A 24-year-old G2P1 at 32 1/7 weeks gestation presents to the triage area of labor and delivery, complaining of abdominal and back pain.

Nurses Notes:

Client reports history of cesarean section 5 years ago at 35 weeks gestation secondary to labor and breech presentation.

1245.
Terbutaline 0.25mg subcutaneous administered.

1255.
Betamethasone 12mg intramuscular to left ventrogluteal administered. Magnesium sulfate 6gram bolus started. Patient education on medications and side effects provided.

L&D Flowsheet:

Time	1200	1230	1255
Blood pressure	120/70	125/72	122/75
Heart rate	72	74	96
Respirations	18	18	20
Pulse oximetry	99% on RA	99% on RA	99% on RA
Pain	5/10	7/10	5/10
Cervical dilation	1cm	2.5cm	——-

Labs:

Lab	Results	Reference range
Hematocrit	32%	Males: 42-52% Females: 35-47%
Hemoglobin	10 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	9,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Fetal fibronectin	Positive	Negative
ROMPlus	Negative	Negative

>For each medication, select the appropriate option for Role in Preterm Labor and Common Side Effects

Sort elements

Magnesium sulfate
Terbutaline
Betamethasone

Main Role in Preterm Labor: Protects against fetal neurologic morbidities such as cerebral palsy

Common Side Effects: Flushing, diaphoresis, nausea

Correct Incorrect Correct answer

Main Role in Preterm Labor: Beta adrenergic receptor agonist; helps suppress uterine contractility

Common Side Effects: Tachycardia, palpitations, tremor

Correct Incorrect Correct answer

Main Role in Preterm Labor: Promotes fetal lung maturity

Common Side Effects: Trouble sleeping, increased blood glucose

Correct Incorrect Correct answer

Correct

Incorrect

Question 38 of 85

38. Question

Case Study Question 6 of 6

A 24-year-old G2P1 at 32 1/7 weeks gestation presents to the triage area of labor and delivery, complaining of abdominal and back pain.

Nurses Notes:

Client reports history of cesarean section 5 years ago at 35 weeks gestation secondary to labor and breech presentation.

1245.
Terbutaline 0.25mg subcutaneous administered.

1255.
Betamethasone 12mg intramuscular to left ventrogluteal administered. Magnesium sulfate 6gram bolus started. Patient education on medications and side effects provided.

1330.
Magnesium sulfate bolus complete, now infusing at 2grams/hour. Patient reports contraction frequency has slowed, and pain has decreased. Contractions noted every 15 minutes per toco. Fetal heart rate 160 baseline with moderate variability, accelerations, no decelerations. Vaginal exam repeated and cervix unchanged.

L&D Flowsheet:

Time	1200	1230	1255	1330
Blood pressure	120/70	125/72	122/75	115/70
Heart rate	72	74	96	86
Respirations	18	18	20	18
Pulse oximetry	99% on RA	99% on RA	99% on RA	99% on RA
Pain	5/10	7/10	5/10	2/10
Cervical dilation	1cm	2.5cm	——-	2.5cm

Labs:

Lab	Results	Reference range
Hematocrit	32%	Males: 42-52% Females: 35-47%
Hemoglobin	10 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	9,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Fetal fibronectin	Positive	Negative
ROMPlus	Negative	Negative

>Complete the following sentence by choosing from the list of options.

The nurse determines the client’s status is (choose a, b, or c). The nurse should now (choose d, e, or f).

a. improving

Correct Incorrect Correct answer

b. deteriorating

Correct Incorrect Correct answer

c. unchanged

Correct Incorrect Correct answer

d. stop the magnesium sulfate infusion

Correct Incorrect Correct answer

e. administer a second dose of terbutaline

Correct Incorrect Correct answer

f. continue monitoring fetus and contraction pattern

Correct Incorrect Correct answer

Correct

Incorrect

Question 39 of 85

39. Question

A nurse on the postpartum floor receives report from the night shift nurse.

>Which of the following clients should she assess first?

1. The 22-year-old who is postop day 2 s/p cesarean section and is having incisional pain 5 out of 10.
Correct Incorrect Correct answer

2. The 30-year-old who had gestational diabetes during pregnancy, is postop day 1 s/p cesarean section, and complains of dizziness when attempting to ambulate for the first time.
Correct Incorrect Correct answer

3. The 35-year-old smoker who complains of leg pain, mild chest pain, and shortness of breath after returning from seeing her baby in the neonatal ICU.
Correct Incorrect Correct answer

4. The 16-year-old who had a postpartum hemorrhage after delivery and is now 3 days post-delivery with moderate amount of dark red vaginal discharge with occasional small clots.
Correct Incorrect Correct answer

Correct

Incorrect
Question 40 of 85

40. Question

A 70-year-old woman is preparing to go home after spending five days in the hospital with pneumonia. She is being sent home on oxygen therapy and the nurse has just completed discharge teaching.

>Which of the following statements by the client is a concern?

1. “I will keep the oxygen at least 6 feet away from sources of heat or flames.”
Correct Incorrect Correct answer

2. “I will make sure that my son does not smoke around me while I am using the oxygen.”
Correct Incorrect Correct answer

3. “I will use hand-sanitizer to clean my hands before using my oxygen.”
Correct Incorrect Correct answer

4. “I will use a water-based lubricant around my nose and lips.”
Correct Incorrect Correct answer

Correct

Incorrect
Question 41 of 85

41. Question

The nurse is reviewing history on a client who regularly visits the rural clinic. There is documentation in the record that indicates history of possible physical abuse, though the client has previously denied it. The nurse begins the screening process for domestic violence and the client responds, “Can you help me get out of this situation?”

>Which stage of the Stages of Change Model is the client exhibiting?

1. Precontemplation
Correct Incorrect Correct answer

2. Contemplation
Correct Incorrect Correct answer

3. Action
Correct Incorrect Correct answer

4. Preparation
Correct Incorrect Correct answer

Correct

Incorrect
Question 42 of 85

42. Question

A client with long-standing type 2 diabetes must undergo a CT scan with contrast. The nurse reviews the client’s medication list.

>The nurse understands which of the following client medications requires special attention in the client undergoing a CT scan with contrast?

1. Lisinopril 10mg daily.
Correct Incorrect Correct answer

2. Metformin 500mg bid.
Correct Incorrect Correct answer

3. Atorvastatin 20mg daily.
Correct Incorrect Correct answer

4. Vitamin C 500mg daily.
Correct Incorrect Correct answer

Correct

Incorrect
Question 43 of 85

43. Question

A client is admitted with advanced liver disease. The nurse is reviewing his labs and notes an ammonia level of 225 micrograms/milliliter.

>Which complication of liver disease does the nurse anticipate with this level of ammonia?

1. Ascites
Correct Incorrect Correct answer

2. Hepatic encephalopathy
Correct Incorrect Correct answer

3. Hepatorenal syndrome
Correct Incorrect Correct answer

4. Coagulopathy
Correct Incorrect Correct answer

Correct

Incorrect
Question 44 of 85

44. Question

A client presents to the ER complaining of palpitations, dyspnea, and dizziness. An electrocardiogram is ordered. The EKG shows a ventricular rate of 130bpm with irregular narrow QRS complexes and absent p waves.

>The nurse reviews the EKG and identifies the rhythm as:

1. Supraventricular tachycardia
Correct Incorrect Correct answer

2. Sinus tachycardia
Correct Incorrect Correct answer

3. First degree atrioventricular block
Correct Incorrect Correct answer

4. Atrial fibrillation
Correct Incorrect Correct answer

Correct

Incorrect

Question 45 of 85

45. Question

A 45-year-old Caucasian female is admitted through the emergency room with complaints of abdominal pain with nausea and vomiting.

Nurse Notes:

Time 1400.
Client arrives to triage and is assessed. She reports increasing bouts of right-sided abdominal pain with nausea and vomiting, currently 7/10 on pain scale. Client is diaphoretic. There is tenderness upon palpation of right upper quadrant. The client has a positive Murphy’s sign. She also reports right shoulder pain 7/10.

CBC, liver function tests, amylase and lipase are drawn. Abdominal ultrasound ordered.

1445.
Labs and US results are back.

1455.
Physician reviews labs and ultrasound, and client is diagnosed with acute cholecystitis.

1700.
Client to OR for laparoscopic cholecystectomy.

1930.
Client received to post-surgical floor post cholecystectomy. Incisions within normal limits. IV infusing per order.

Day 2 post-op at 0900

Client reports feeling well, except for continued right shoulder pain, rating 6/10 on pain scale. She reports some mild incisional pain 3/10. Denies nausea/vomiting. She is tolerating diet well.

Postop labs repeated.

Vital Signs Initial:

Time	1400
Temp	100.7 F
P	106
RR	20
B/P	130/86
Pain	7/10

Vital Signs Post-Op Day 2:

Time	0900
Temp	98.7 F
P	84
RR	18
B/P	125/70
Pain	6/10

Lab Report Initial:

Lab	Results	Reference Range
White Blood Cells (WBC)	15 x 10³cells/mm³	4.5 – 10.5 x 10³cells/mm³
Hemoglobin	11.5 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
Hematocrit	33%	Males: 42-52% Females: 35-47%
AST	30	8-48 U/L
ALT	35	7-55 U/L
Amylase	60	23-85 U/L
Lipase	42	7-59 U/L

Lab Report Day 2 Postop:

Lab	Results	Reference Range
White Blood Cells (WBC)	11 x 10³cells/mm³	4.5 – 10.5 x 10³cells/mm³
Hemoglobin	10.5 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
Hematocrit	30%	Males: 42-52% Females: 35-47%

Diagnostic Reports:

Abdominal ultrasound shows enlarged gallbladder with thickened wall of 5mm. Positive Murphy’s sign elicited with ultrasound probe.

>For each finding, click to specify if the finding indicates that the client’s status has improved or is unchanged since the onset of symptoms.

Correct Incorrect Correct answer

Correct

Incorrect

Question 46 of 85

46. Question

A nurse is admitting a Muslim client and when asked about any cultural or religious concerns, he advises the nurse of the great importance of prayer time at certain times each day. A few days later, the same nurse is caring for the client and realizes that he has a procedure scheduled the next day at the same time as prayer time.

>Which is the most appropriate response of the nurse in this situation?

1. Apologize to the client and advise him that the procedure cannot be rescheduled.
Correct Incorrect Correct answer

2. Discuss with the healthcare team how important prayer time is to the client and ask what can be done to reschedule the procedure.
Correct Incorrect Correct answer

3. Go on lunch break when the procedure is scheduled and have the charge nurse deal with the situation.
Correct Incorrect Correct answer

4. Ask the client to skip his prayer time, advising him that the procedure is more important.
Correct Incorrect Correct answer

Correct

Incorrect
Question 47 of 85

47. Question

A home health nurse is performing a home safety check for a 75-year-old male.

>Which of the following statements by the client is most concerning?

1. “I change my smoke detector batteries once a year.”
Correct Incorrect Correct answer

2. “I make sure any extension cords are secured behind furniture.”
Correct Incorrect Correct answer

3. “There are grab rails in my shower.”
Correct Incorrect Correct answer

4. “I keep my refrigerator temperature at 37 degrees.”
Correct Incorrect Correct answer

Correct

Incorrect
Question 48 of 85

48. Question

A client with history of heavy alcohol abuse is admitted to the hospital. The physician orders several days of thiamine supplementation.

>The nurse understands thiamine supplementation is needed to lower the risk of which of the following?

1. Wernicke-Korsakoff syndrome
Correct Incorrect Correct answer

2. Delirium tremens
Correct Incorrect Correct answer

3. Seizures
Correct Incorrect Correct answer

4. Gastric ulcers
Correct Incorrect Correct answer

Correct

Incorrect

Question 49 of 85

49. Question

The nurse is admitting at 4-year-old Asian-American boy to the emergency room, who presents with fever x 5 days.

Nurse Notes:

1200.
The child is brought in by his parents, with reports of high fever for the past 3 days, and two days of moderate grade fever before that. Tylenol and Motrin have been alternated per pediatrician recommendation with minimal effectiveness. The child is assessed and noted to have reddened eyes without drainage, strawberry tongue with red oral mucosa, and redness/swelling of the hands and feet. Cervical lymphadenopathy is present upon palpation. A macular rash is present on the trunk and extremities, which appeared today per the mother’s report. Grade III cardiac murmur noted on auscultation.

Pediatric cardiologist consulted.

1215.
CBC with differential, electrolytes, blood cultures, rapid strep test, Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) are drawn. Tylenol administered.

1230.
Pediatric cardiologist performs bedside echocardiogram.

1300.
Lab results return.

Vital Signs:

Time	1200	1300
Temp	103 degrees F	102.8 degrees F
HR	140	142
RR	32	30
B/P	100/72	102/70
Pulse oximeter	96% on RA	96% on RA

Diagnostic Reports:

Echocardiogram: No congenital heart defect. Pericardial effusion noted. Mild dilation of left main coronary artery noted.

>Using the diagram below, select 2 actions to take, 1 potential condition, and 2 parameters to monitor.

Actions to Take	Potential Conditions	Parameters to Monitor
a. Administer IV immunoglobulin	f. Streptococcal A infection	j. Temperature
b. Give oxygen	g. Scarlet Fever	k. Blood cultures
c. Give corticosteroids	h. Kawasaki Disease	l. Blood pressure
d. Administer aspirin	i. Drug-eruption/drug reaction	m. Oxygenation saturation
e. Give antibiotics		n. Murmur

a. Administer IV immunoglobulin

Correct Incorrect Correct answer

b. Give oxygen

Correct Incorrect Correct answer

c. Give corticosteroids

Correct Incorrect Correct answer

d. Administer aspirin

Correct Incorrect Correct answer

e. Give antibiotics

Correct Incorrect Correct answer

f. Streptococcal A infection

Correct Incorrect Correct answer

g. Scarlet Fever

Correct Incorrect Correct answer

h. Kawasaki Disease

Correct Incorrect Correct answer

i. Drug-eruption/drug reaction

Correct Incorrect Correct answer

j. Temperature

Correct Incorrect Correct answer

k. Blood cultures

Correct Incorrect Correct answer

l. Blood pressure

Correct Incorrect Correct answer

m. Oxygenation saturation

Correct Incorrect Correct answer

n. Murmur

Correct Incorrect Correct answer

Correct

Incorrect

Question 50 of 85

50. Question

A 2-year-old male is brought to the emergency room after accidentally ingesting antifreeze.

>Which of the following is an antidote to ethylene glycol poisoning?

1. Calcium gluconate
Correct Incorrect Correct answer

2. Protamine sulfate
Correct Incorrect Correct answer

3. Fomepizole
Correct Incorrect Correct answer

4. N-acetylcysteine
Correct Incorrect Correct answer

Correct

Incorrect
Question 51 of 85

51. Question

A client is admitted with complaints of sudden onset of significant epigastric pain, nausea and vomiting, and fever. He is diagnosed with acute pancreatitis.

>The nurse anticipates which of the following labs will be elevated with acute pancreatitis? Select all that apply.

1. Amylase
Correct Incorrect Correct answer

2. Calcium
Correct Incorrect Correct answer

3. Potassium
Correct Incorrect Correct answer

4. White blood cell count
Correct Incorrect Correct answer

5. Lipase
Correct Incorrect Correct answer

Correct

Incorrect
Question 52 of 85

52. Question

A client was recently diagnosed with a spinal cord injury at the level of T3 after a motor vehicle accident. The nurse is educating the patient on his condition, potential complications, and preventive actions.

>Which of the following are signs and symptoms of autonomic dysreflexia that the nurse should educate the patient about? Select all that apply.

1. Pounding headache
Correct Incorrect Correct answer

2. Fast heart rate
Correct Incorrect Correct answer

3. High blood pressure
Correct Incorrect Correct answer

4. Sweating below the level of spinal cord injury
Correct Incorrect Correct answer

5. Flushing of skin above the level of injury
Correct Incorrect Correct answer

6. Cool, pale skin below the level of spinal cord injury
Correct Incorrect Correct answer

Correct

Incorrect

Question 53 of 85

53. Question

A 55-year-old female with a history of hypothyroidism is brought to the emergency room by her son.

Nurse Notes:

0900.
Client appears confused, stating “Where am I?” Has dry skin that is cold to the touch. Her son reports that the client has been using multiple blankets at home as she has been feeling chilled. Periorbital edema noted. Hypoactive bowel sounds. Client breathing is shallow with decreased breath sounds on auscultation. Per report, client has steadily been gaining weight.

0905.
Oxygen applied via nonrebreather with improvement in oxygen saturation to 95%

0910.
Arterial blood gases, chest x-ray, blood cultures, and electrocardiogram ordered by provider.

0920.
Client’s son reports his mother ran out of her thyroid medication several weeks ago and he is unsure if she ever restarted it. Client increasingly confused and is trying to leave the room.

Vital Signs:

Time	0900
Temp	94.5 F
P	48
RR	12
B/P	90/60
Pulse oximeter	88% on RA
Pain	0

Lab Report:

Lab	Results	Reference Range
White Blood Cells (WBC)	10 x 10³cells/mm³	4.5 – 10.5 x 10³cells/mm³
Potassium (serum)	4.0 mEq/L	3.5 to 5 mEq/L
Sodium (serum)	130 mEq/L	135 to 145 mEq/L
Thyroid stimulating hormone (TSH)	55mU/L	0.45 to 4.5 mU/L
Serum triiodothyronine (T₃)	55 ng/dL	80 to 200 ng/dL
Serum free thyroxine (FT₄)	0.5 ng/dL	0.8-1.7 ng/dL
Serum glucose	48mg/dL	70-100 mg/dL

Diagnostic Reports:

Electrocardiogram shows sinus bradycardia.
Chest X-ray unremarkable.
ABG shows respiratory acidosis.

>Using the diagram below, select 2 actions to take, 1 potential condition, and 2 parameters to monitor.

Actions to Take	Potential Conditions	Parameters to Monitor
a. Provide warming blanket	f. Adrenal insufficiency	j. Cortisol levels
b. Administer methimazole IV	g. Sepsis	k. Body temperature
c. Administer fludrocortisone	h. Thyroid storm	l. Daily weights
d. Collect lactate level	i. Myxedema Crisis	m. Thyroid levels
e. Administer levothyroxine IV		n. Fluid status

a. Provide warming blanket

Correct Incorrect Correct answer

b. Administer methimazole IV

Correct Incorrect Correct answer

c. Administer fludrocortisone

Correct Incorrect Correct answer

d. Collect lactate level

Correct Incorrect Correct answer

e. Administer levothyroxine IV

Correct Incorrect Correct answer

f. Adrenal insufficiency

Correct Incorrect Correct answer

g. Sepsis

Correct Incorrect Correct answer

h. Thyroid storm

Correct Incorrect Correct answer

i. Myxedema Crisis

Correct Incorrect Correct answer

j. Cortisol levels

Correct Incorrect Correct answer

k. Body temperature

Correct Incorrect Correct answer

l. Daily weights

Correct Incorrect Correct answer

m. Thyroid levels

Correct Incorrect Correct answer

n. Fluid status

Correct Incorrect Correct answer

Correct

Incorrect

Question 54 of 85

54. Question

A 62-year-old woman, who was independent prior to surgery, is recovering from a total knee replacement. While the nurse is performing discharge teaching, the client reports that her husband has Parkinson’s and may have trouble helping her at home, including changing her dressings. The closest family member lives 60 minutes away.

>Which of the following actions by the nurse is most appropriate?

1. Discuss with the client placement in a long-term care facility for her and her husband.
Correct Incorrect Correct answer

2. Assure the client that she can do the dressing changes herself.
Correct Incorrect Correct answer

3. Offer to teach a family member how to change the dressing.
Correct Incorrect Correct answer

4. Discuss other care options with client, including home health services.
Correct Incorrect Correct answer

Correct

Incorrect
Question 55 of 85

55. Question

A nurse is filling out an incident report after a client experienced a fall while in the bathroom. The client states that he became very dizzy and felt as though he would faint.

>Which of the following would be inappropriate to include in the incident report?

1. Using objective language to describe the incident.
Correct Incorrect Correct answer

2. Placing a note that the nursing assistant was at fault for not watching the client closely.
Correct Incorrect Correct answer

3. Name of the physician and nursing manager who was notified after the fall occurred.
Correct Incorrect Correct answer

4. Injuries that occurred secondary to the fall.
Correct Incorrect Correct answer

Correct

Incorrect
Question 56 of 85

56. Question

An 18-year-old female has recently been admitted for management of an eating disorder. She reports binging episodes followed by intense guilt and purging. She is diagnosed with bulimia.

>Which of the following would the nurse expect to find with this client?

1. Muscle wasting
Correct Incorrect Correct answer

2. Amenorrhea
Correct Incorrect Correct answer

3. Russell’s sign
Correct Incorrect Correct answer

4. Lanugo
Correct Incorrect Correct answer

Correct

Incorrect
Question 57 of 85

57. Question

A physician adds spironolactone to a client’s medication regimen. The client is also taking lisinopril to treat hypertension.

>With the client taking both spironolactone and lisinopril, which of the following labs is most important for the nurse to monitor?

1. Serum creatinine
Correct Incorrect Correct answer

2. Sodium
Correct Incorrect Correct answer

3. Serum glucose
Correct Incorrect Correct answer

4. Potassium
Correct Incorrect Correct answer

Correct

Incorrect
Question 58 of 85

58. Question

A concerned new mother is watching the nurse take vital signs on an active newborn. She asks, “What are the normal ranges for vital signs in a baby?”

>Which of the following parameters is incorrect and would be considered out of range for the newborn?

1. Blood pressure of 68/40
Correct Incorrect Correct answer

2. Pulse of 130bpm
Correct Incorrect Correct answer

3. Respiratory rate of 22 breaths per minute
Correct Incorrect Correct answer

4. Temperature of 98.4 degrees
Correct Incorrect Correct answer

Correct

Incorrect
Question 59 of 85

59. Question

A client has arrived in the post anesthesia care unit (PACU) after undergoing general anesthesia with halothane for a surgical procedure.

Nurse Notes:

Time 1000.
Client received to PACU with oral airway in place. IV infusing per order and IV site within normal limits. Surgical abdominal dressing clean, dry and intact. See flowsheet for vitals.

1015.
Client assessed and noted to be tachypneic and tachycardic. Generalized muscle rigidity noted. Peaked T waves noted on cardiac monitor.

1017.
Anesthesiologist called to bedside for further assessment. Oxygen per face mask applied and cooling measures commenced.

1020.
Anesthesia present at bedside.

Vital Signs:

1000 1015 1020

Blood pressure 130/70 148/90 154/94

Pulse 90 115 124

Respirations 20 28 32

Temperature 99.7 degrees F 103 degrees F 104 degrees F

Oxygen saturation 96% 92% 94%

>Complete the sentence from the list of options below.

The nurse should recognize that the client is most likely experiencing (choose a, b, c, or d). And she anticipates administering (choose e, f, g, or h).

a. sepsis
Correct Incorrect Correct answer

b. anaphylaxis
Correct Incorrect Correct answer

c. malignant hyperthermia
Correct Incorrect Correct answer

d. thyroid storm
Correct Incorrect Correct answer

e. Vancomycin
Correct Incorrect Correct answer

f. Dantrolene
Correct Incorrect Correct answer

g. Epinephrine
Correct Incorrect Correct answer

h. Methimazole
Correct Incorrect Correct answer

Correct

Incorrect
Question 60 of 85

60. Question

A 15-year-old female is brought to the emergency room after being rescued from a house fire. She is having some shortness of breath from smoke inhalation and the nurse notes that her hands are burned. Further assessment reveals that the burn has destroyed the epidermis and dermis. The skin is bright red and leathery in appearance and does not blanche under pressure.

The client asks, “Why doesn’t it hurt very much?”

>Which of the following descriptions is the appropriate response?

1. “You’re still in shock from the house fire and your adrenaline level is high.”
Correct Incorrect Correct answer

2. “Those are first degree burns; they aren’t as painful as other types of burns.”
Correct Incorrect Correct answer

3. “You have what is called a third-degree burn; with this type of burn, the nerve endings are destroyed, and you may not feel much pain.”
Correct Incorrect Correct answer

4. “Don’t worry about that right now; the pain will come later.”
Correct Incorrect Correct answer

Correct

Incorrect
Question 61 of 85

61. Question

A 5-year-old boy is admitted to the pediatric floor and is scheduled for a tonsillectomy. His 7-year-old sister is very anxious and keeps telling her mother that she is afraid something bad will happen to her brother.

>Which of the following actions by the nurse is most appropriate in easing the older sister’s fears?

1. Assure her that the best surgeons will be taking care of her brother.
Correct Incorrect Correct answer

2. Have the child life specialist visit with the family.
Correct Incorrect Correct answer

3. Offer the child a lollipop and coloring book.
Correct Incorrect Correct answer

4. Tell her that her brother is very lucky to have such a concerned big sister.
Correct Incorrect Correct answer

Correct

Incorrect
Question 62 of 85

62. Question

A nursing instructor is watching a student perform a sterile procedure.

>Which of the following would require action by the nursing instructor?

1. The student maintains a 1-inch non-sterile border and drops items into the middle of the sterile field.
Correct Incorrect Correct answer

2. The student turns briefly away from the sterile field while reaching for another sterile package, her hands or body do not touch or cross the sterile field.
Correct Incorrect Correct answer

3. The student slowly pours normal saline into a sterile container, holding the normal saline bottle about 2 inches above the sterile container while pouring.
Correct Incorrect Correct answer

4. The student opens a sterile package by first opening the flap away from her, then the two side flaps, then the last flap toward her.
Correct Incorrect Correct answer

Correct

Incorrect
Question 63 of 85

63. Question

A client is ordered 2 units of packed red blood cells.

>Which of the following steps should the nurse take before and during the transfusion? Select all that apply.

1. Identify the client and check the blood with verification by a second nurse.
Correct Incorrect Correct answer

2. Start the IV before going to the blood bank to pick up the blood.
Correct Incorrect Correct answer

3. Hang the blood with a liter of Lactated Ringer’s.
Correct Incorrect Correct answer

4. Use an 18-gauge IV catheter to administer the transfusion.
Correct Incorrect Correct answer

5. Administer the blood over 6 hours.
Correct Incorrect Correct answer

Correct

Incorrect
Question 64 of 85

64. Question

A 28-year-old male currently home for semester break is admitted through the emergency room with complaints of a headache and neck stiffness.

Nurse Notes:

Time 1600.
Client placed into bed. He reports a headache that started yesterday and has steadily worsened, with little relief from pain medications. He also complains of neck stiffness and reports his last temperature was 99.8 degrees Fahrenheit at home. He states, “I think I am coming down with a cold or the flu, but the neck stiffness really bothers me, so I wanted to check it out.”

Nuchal rigidity noted on exam. Positive Kernig’s sign with attempted knee extension.

CBC, blood cultures drawn.

1620.
Lumbar puncture performed, with cloudy CSF collected.

1630.
Suspected diagnosis of meningitis made. Droplet precautions instituted.

1640.
Antibiotics hung. Client now appearing confused and agitated. Vomited x 1. Fundoscopic exam reveals papilledema.

1700.
Client noted to have generalized tonic-clonic seizure activity and is unresponsive

Vital Signs Initial:

Time 1600

Temp 101 F

P 112

RR 20

Oxygen saturation 98% on RA

B/P 115/72

Pain 8/10

Lab Report Initial:

Lab Results Reference Range

White Blood Cells (WBC) 18 x 10³cells/mm³ 4.5 – 10.5 x 10³cells/mm³

C-reactive protein 120 mg/dL Less than 0.8mg/dl

Diagnostic Reports:

Lumbar puncture shows cloudy CSF, elevated protein, elevated WBC, and low glucose

>Complete the following sentence by choosing from the list of options.

Based on the data, the nurse determines the client’s status is (choose a, b, or c), with the likely reasoning being (choose d, e, or f).

a. improving
Correct Incorrect Correct answer

b. deteriorating
Correct Incorrect Correct answer

c. unchanged
Correct Incorrect Correct answer

d. high fever
Correct Incorrect Correct answer

e. allergic reaction
Correct Incorrect Correct answer

f. increased intracranial pressure
Correct Incorrect Correct answer

Correct

Incorrect
Question 65 of 85

65. Question

A nurse is caring for a woman in labor. She reviews the fetal strip and notes moderate variability with occasional decelerations. The decelerations occur with a contraction, show a gradual decrease in fetal heart rate to its lowest point over 30 seconds, and the shape of the deceleration mirrors the contraction.

>Which of the following is the correct course of action for the nurse to take?

1. Apply oxygen per face mask
Correct Incorrect Correct answer

2. Administer terbutaline
Correct Incorrect Correct answer

3. Give IV fluid bolus
Correct Incorrect Correct answer

4. Continue to monitor fetal and maternal status.
Correct Incorrect Correct answer

Correct

Incorrect
Question 66 of 85

66. Question

A nurse is educating a pregnant client about vaccines recommended in pregnancy, including the influenza and Tdap vaccines.

>Which type of immunity does the fetus receive from maternal administration of these vaccines?

1. Artificial active immunity
Correct Incorrect Correct answer

2. Natural active immunity
Correct Incorrect Correct answer

3. Passive natural immunity
Correct Incorrect Correct answer

4. Passive artificial immunity
Correct Incorrect Correct answer

Correct

Incorrect
Question 67 of 85

67. Question

A nurse is teaching a class about information security and client confidentiality. Using a PowerPoint presentation, the nurse reviews a number of scenarios that address client privacy.

>Which of the following scenarios would be considered a violation of client privacy?

1. The nurse closes all screens on her computer and logs out before attending to a call light.
Correct Incorrect Correct answer

2. The dietician is reviewing lab results in a client’s chart.
Correct Incorrect Correct answer

3. Two nurses step into an empty room and close the door to exchange shift report.
Correct Incorrect Correct answer

4. The nurse shows a client’s CT scan results to a worried visitor who stops by the desk on her way to the client’s room.
Correct Incorrect Correct answer

Correct

Incorrect
Question 68 of 85

68. Question

A postpartum nurse is making rounds on her clients. When she enters the room of her 17-year-old client, the client asks “Where is the other nurse with my baby? It’s been a while since she took the baby to the nursery to do labs.” The postpartum nurse is alarmed as the nursery is currently empty.

>Which of the following actions takes priority?

1. Ask the mother to describe the nurse who took the baby.
Correct Incorrect Correct answer

2. Review security camera footage.
Correct Incorrect Correct answer

3. Search the entire postpartum floor for the baby while asking visitors and employees if they have seen the child.
Correct Incorrect Correct answer

4. Call a Code Pink and allow no one to enter or leave the postpartum unit.
Correct Incorrect Correct answer

Correct

Incorrect
Question 69 of 85

69. Question

Case Study Question 1 of 6

A 35-year-old female is brought to the emergency room via ambulance complaining of constant trembling and nausea/vomiting/diarrhea.

Nurse Notes:

1200.
Client with history of anxiety disorder and major depressive disorder, currently on paroxetine daily. She reports she was recently given a prescription for cyclobenzaprine for muscle spasms in her back from old tennis injury and has been using it around the clock for several days. No other significant medical history.

Client reports feeling palpitations; general diaphoresis noted upon exam. Also reports nausea, vomiting, and diarrhea since yesterday evening. Hyperactive bowel sounds noted. She has a mild tremor in her hands. Reflexes +3 bilaterally and ankle clonus noted.

18-gauge IV started x2.

CBC, electrolytes, BUN and creatinine, creatinine phosphokinase, liver enzymes, drug screen collected.

1300.
Client becoming increasingly agitated and now disoriented to place and time. Cries out “my heart is beating so fast!” Significant muscle rigidity noted.

Vital Signs:

Time: Admit 1200 1300

T 100F 104 F

P 98 140

RR 20 26

B/P 130/80 170/100

Pulse oximeter 98% on RA 96% on RA

Pain none none

>Select the 5 findings that are most significant from the options below.

a. Blood pressure
Correct Incorrect Correct answer

b. Tremor
Correct Incorrect Correct answer

c. Diaphoresis
Correct Incorrect Correct answer

d. Heart rate
Correct Incorrect Correct answer

e. Temperature
Correct Incorrect Correct answer

f. Oxygen saturation
Correct Incorrect Correct answer

g. Hyperreflexia
Correct Incorrect Correct answer

h. Muscle rigidity
Correct Incorrect Correct answer

i. Altered mental status
Correct Incorrect Correct answer

Correct

Incorrect

Question 70 of 85

70. Question

Case Study Question 2 of 6

A 35-year-old female is brought to the emergency room via ambulance complaining of constant trembling and nausea/vomiting/diarrhea.

Nurse Notes:

1200.
Client with history of anxiety disorder and major depressive disorder, currently on paroxetine daily. She reports she was recently given a prescription for cyclobenzaprine for muscle spasms in her back from old tennis injury and has been using it around the clock for several days. No other significant medical history.

Client reports feeling palpitations; general diaphoresis noted upon exam. Also reports nausea, vomiting, and diarrhea since yesterday evening. Hyperactive bowel sounds noted. She has a mild tremor in her hands. Reflexes +3 bilaterally and ankle clonus noted.

18-gauge IV started x2.

CBC, electrolytes, BUN and creatinine, creatinine phosphokinase, liver enzymes, drug screen collected.

1300.
Client becoming increasingly agitated and now disoriented to place and time. Cries out “my heart is beating so fast!” Significant muscle rigidity noted.

Vital Signs:

Time: Admit	1200	1300
T	100F	104 F
P	98	140
RR	20	26
B/P	130/80	170/100
Pulse oximeter	98% on RA	96% on RA
Pain	none	none

Labs:

Lab	Results	Reference range
Hematocrit	35%	Males: 42-52% Females: 35-47%
Hemoglobin	12 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	15,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Creatinine phosphokinase	375mcg/L	10-120mcg/L
AST	50 U/L	8-33 U/L
ALT	80 U/L	7-56 U/L
Drug screen	Negative	Negative

>For each client finding, click to indicate if the finding is consistent with neuroleptic malignant syndrome, serotonin syndrome, or anticholinergic toxicity. Each finding may support more than one type of respiratory condition.

Correct Incorrect Correct answer

Correct

Incorrect

Question 71 of 85

71. Question

Case Study Question 3 of 6

A 35-year-old female is brought to the emergency room via ambulance complaining of constant trembling and nausea/vomiting/diarrhea.

Nurse Notes:

18-gauge IV started x2.

CBC, electrolytes, BUN and creatinine, creatinine phosphokinase, liver enzymes, drug screen collected.

1300.
Client becoming increasingly agitated and now disoriented to place and time. Cries out “my heart is beating so fast!” Significant muscle rigidity noted.

Vital Signs:

Time: Admit	1200	1300
T	100F	104 F
P	98	140
RR	20	26
B/P	130/80	170/100
Pulse oximeter	98% on RA	96% on RA
Pain	none	none

Labs:

Lab	Results	Reference range
Hematocrit	35%	Males: 42-52% Females: 35-47%
Hemoglobin	12 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	15,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Creatinine phosphokinase	375mcg/L	10-120mcg/L
AST	50 U/L	8-33 U/L
ALT	80 U/L	7-56 U/L
Drug screen	Negative	Negative

>Choose the most appropriate word from the choices below to fill in the blank of the following sentences.

The nurse suspects that the client has (choose a, b, c, or d). The nurse must intervene quickly to prevent (choose e, f, g, or h).

a. Serotonin syndrome

Correct Incorrect Correct answer

b. Neuroleptic malignant syndrome

Correct Incorrect Correct answer

c. Anticholinergic toxicity

Correct Incorrect Correct answer

d. Extra pyramidal symptoms

Correct Incorrect Correct answer

e. Congestive heart failure

Correct Incorrect Correct answer

f. Coma and death

Correct Incorrect Correct answer

g. Rhabdomyolysis

Correct Incorrect Correct answer

h. Irreversible extra pyramidal symptoms

Correct Incorrect Correct answer

Correct

Incorrect

Question 72 of 85

72. Question

Case Study Question 4 of 6

A 35-year-old female is brought to the emergency room via ambulance complaining of constant trembling and nausea/vomiting/diarrhea.

Nurse Notes:

18-gauge IV started x2.

CBC, electrolytes, BUN and creatinine, creatinine phosphokinase, liver enzymes, drug screen collected.

1300.
Client becoming increasingly agitated and now disoriented to place and time. Cries out “my heart is beating so fast!” Significant muscle rigidity noted.

Vital Signs:

Time: Admit	1200	1300
T	100F	104 F
P	98	140
RR	20	26
B/P	130/80	170/100
Pulse oximeter	98% on RA	96% on RA
Pain	none	none

Labs:

Lab	Results	Reference range
Hematocrit	35%	Males: 42-52% Females: 35-47%
Hemoglobin	12 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	15,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Creatinine phosphokinase	375mcg/L	10-120mcg/L
AST	50 U/L	8-33 U/L
ALT	80 U/L	7-56 U/L
Drug screen	Negative	Negative

The physician makes a working diagnosis of serotonin syndrome.

>Select the orders from each of the categories the nurse should include in the plan of care. Each category may have more than one order.

Order Categories	Orders
Transfer Orders	a. Transfer to Intensive Care Unit
Transfer Orders	b. Transfer to Medical Surgical Unit
Fever Management	c. Apply cooling blanket
	d. Obtain vitals every hour
	e. Administer Tylenol 650mg PO
	f. Administer Dantrolene
Blood Pressure Management	g. Administer propranolol
Blood Pressure Management	h. Start esmolol IV infusion
Other Orders	i. Administer cyproheptadine
	j. Increase paroxetine dose
	k. Administer diazepam IV
	l. Continuous cardiac monitor

a. Transfer to Intensive Care Unit

Correct Incorrect Correct answer

b. Transfer to Medical Surgical Unit

Correct Incorrect Correct answer

c. Apply cooling blanket

Correct Incorrect Correct answer

d. Obtain vitals every hour

Correct Incorrect Correct answer

e. Administer Tylenol 650mg PO

Correct Incorrect Correct answer

f. Administer Dantrolene

Correct Incorrect Correct answer

g. Administer propranolol

Correct Incorrect Correct answer

h. Start esmolol IV infusion

Correct Incorrect Correct answer

i. Administer cyproheptadine

Correct Incorrect Correct answer

j. Increase paroxetine dose

Correct Incorrect Correct answer

k. Administer diazepam IV

Correct Incorrect Correct answer

l. Continuous cardiac monitor

Correct Incorrect Correct answer

Correct

Incorrect

Question 73 of 85

73. Question

Case Study Question 5 of 6

A 35-year-old female is brought to the emergency room via ambulance complaining of constant trembling and nausea/vomiting/diarrhea.

Nurse Notes:

18-gauge IV started x2.

CBC, electrolytes, BUN and creatinine, creatinine phosphokinase, liver enzymes, drug screen collected.

1300.
Client becoming increasingly agitated and now disoriented to place and time. Cries out “my heart is beating so fast!” Significant muscle rigidity noted.

Vital Signs:

Time: Admit	1200	1300
T	100F	104 F
P	98	140
RR	20	26
B/P	130/80	170/100
Pulse oximeter	98% on RA	96% on RA
Pain	none	none

Labs:

Lab	Results	Reference range
Hematocrit	35%	Males: 42-52% Females: 35-47%
Hemoglobin	12 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	15,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Creatinine phosphokinase	375mcg/L	10-120mcg/L
AST	50 U/L	8-33 U/L
ALT	80 U/L	7-56 U/L
Drug screen	Negative	Negative

Orders:

Transfer client to the ICU
Vital signs and core temp hourly
Stop paroxetine and cyclobenzaprine
Cooling blanket now to bring core temp to <100.4
Start esmolol IV with loading dose of 500mcg/kg and then maintenance infusion of 50mcg/kg/min
Start 0.9% normal saline @ 150ml/hr
Administer 3 mg diazepam IVP for muscle rigidity
Insert Foley catheter
Administer cyproheptadine 8mg PO

The nurse manages the transfer to the ICU.

>Of the orders listed below, select the 4 orders the nurse should implement first

a. Stop paroxetine and cyclobenzaprine

Correct Incorrect Correct answer

b. Cooling blanket now to bring core temp to <100.4*

Correct Incorrect Correct answer

c. Start esmolol IV with loading dose of 500mcg/kg and then maintenance infusion of 50mcg/kg/min

Correct Incorrect Correct answer

d. Start 0.9% normal saline @ 150ml/hr

Correct Incorrect Correct answer

e. Administer 3 mg diazepam IVP for muscle rigidity

Correct Incorrect Correct answer

f. Insert Foley catheter

Correct Incorrect Correct answer

g. Administer cyproheptadine 8mg PO

Correct Incorrect Correct answer

Correct

Incorrect

Question 74 of 85

74. Question

Case Study Question 6 of 6

A 35-year-old female is brought to the emergency room via ambulance complaining of constant trembling and nausea/vomiting/diarrhea.

Nurse Notes:

18-gauge IV started x2.

CBC, electrolytes, BUN and creatinine, creatinine phosphokinase, liver enzymes, drug screen collected.

1300.
Client becoming increasingly agitated and now disoriented to place and time. Cries out “my heart is beating so fast!” Significant muscle rigidity noted.

1315.
Cooling blanket applied.

1320.
Esmolol loading dose of 500mcg/kg IVP over 1 minute.

1323.
Esmolol maintenance infusion of 50mcg/kg/min started.

1325.
Cyproheptadine 8mg PO given.

1330.
Transferred to ICU

1345.
Patient less diaphoretic. Diazepam 3mg IVP given. Foley catheter inserted

Vital Signs:

Time: Admit	1200	1300	1345	1530
T	100F	104 F	103 F	101.8 F
P	98	140	125	110
RR	20	26	22	18
B/P	130/80	170/100	150/96	138/88
Pulse oximeter	98% on RA	96% on RA	96% on RA	97% on RA
Urine Output	–	–	–	70ml
Muscle Rigidity	–	Significant	Significant	Significant

Labs:

Lab	Results	Reference range
Hematocrit	35%	Males: 42-52% Females: 35-47%
Hemoglobin	12 g/dL	Males: 13-18 g/dL Females:12-16 g/dL
WBC	15,000 cell/mm3	4.5 – 10.5 x 10³cells/mm³
Creatinine phosphokinase	375mcg/L	10-120mcg/L
AST	50 U/L	8-33 U/L
ALT	80 U/L	7-56 U/L
Drug screen	Negative	Negative

Orders:

Transfer client to the ICU
Vital signs and core temp hourly
Stop paroxetine and cyclobenzaprine
Cooling blanket now to bring core temp to <100.4
Start esmolol IV with loading dose of 500mcg/kg and then maintenance infusion of 50mcg/kg/min
Start 0.9% normal saline @ 150ml/hr
Administer 3 mg diazepam IVP for muscle rigidity
Insert Foley catheter
Administer cyproheptadine 8mg PO

The nurse re-evaluates the client’s status at 1530.

>Complete the following sentence by choosing from the list of options.

The nurse determines the client’s status is (choose a, b, or c). As evidenced by (choose d, e, or f).

a. improving

Correct Incorrect Correct answer

b. deteriorating

Correct Incorrect Correct answer

c. unchanged

Correct Incorrect Correct answer

d. urine output

Correct Incorrect Correct answer

e. muscle rigidity

Correct Incorrect Correct answer

f. vital signs

Correct Incorrect Correct answer

Correct

Incorrect

Question 75 of 85

75. Question

The nurse is taking care of a client who used to work in construction. As a result, the client has significant hearing loss in both ears.

>Which of the following nursing interventions would be inappropriate to use with this client?

1. Speak to the client face-to-face at eye level.
Correct Incorrect Correct answer

2. Communicate orally each time the nurse enters the room so the client can practice reading lips.
Correct Incorrect Correct answer

3. Ensure there are no distractions or background noise when speaking to the client.
Correct Incorrect Correct answer

4. Make sure any assistive devices, such as hearing aids, are working properly.
Correct Incorrect Correct answer

Correct

Incorrect
Question 76 of 85

76. Question

The nursing student is observing a nurse change the dressing on a central venous catheter.

>Which of the following steps should the nurse take while performing the dressing change? Select all that apply.

1. Maintain clean technique throughout the dressing change.
Correct Incorrect Correct answer

2. Clean skin using isopropyl alcohol, scrubbing for 30 seconds and allowing to dry completely.
Correct Incorrect Correct answer

3. Ensure the client wears a mask and turns his or her head away from the insertion site.
Correct Incorrect Correct answer

4. Measure the length of the catheter at the insertion site.
Correct Incorrect Correct answer

5. Assess the catheter site for redness or drainage.
Correct Incorrect Correct answer

Correct

Incorrect
Question 77 of 85

77. Question

A nurse is caring for a client that had a bronchoscopy and has been cleared for discharge home.

>Which of the following should be included in discharge teaching about concerning signs to immediately report? Select all that apply.

1. Sore, dry throat.
Correct Incorrect Correct answer

2. Coughing up small amounts of blood-tinged mucus.
Correct Incorrect Correct answer

3. Experiencing significant shortness of breath
Correct Incorrect Correct answer

4. Mild fever for 12 hours in duration
Correct Incorrect Correct answer

5. Sudden, severe chest pain
Correct Incorrect Correct answer

6. Fatigue and hoarseness
Correct Incorrect Correct answer

7. Wheezing and neck swelling
Correct Incorrect Correct answer

Correct

Incorrect
Question 78 of 85

78. Question

The nurse is assigned to a client with a history of human immunodeficiency virus (HIV) who has been on antiretroviral therapy for years.

>Which of the following would the nurse expect to see if the client is following the treatment plan?

1. A viral load of less than 20 copies/mL of blood and a CD4 count of 600 cells/microliter.
Correct Incorrect Correct answer

2. A viral load of 1000 copies/mL of blood and a CD4 count of 150 cells/microliter.
Correct Incorrect Correct answer

3. A viral load of more than 1000 copies/mL of blood and a CD4 count of 700 cells/microliter.
Correct Incorrect Correct answer

4. A viral load of less than 20 copies/mL of blood and a CD4 count of 190 cells/microliter.
Correct Incorrect Correct answer

Correct

Incorrect

Question 79 of 85

79. Question

An ambulance brings in a 50-year-old male who is complaining of nausea/vomiting and gastrointestinal cramping.

Nurse Notes:

1405.
Client placed in bed. Client with history of type 2 diabetes and myasthenia gravis. He takes insulin and pyridostigmine at home. He complains of nausea/vomiting, diarrhea, and lower abdominal cramping. Drooling from mouth and tearing of eyes noted. Constricted pupils noted on exam. Wheezing heard bilaterally on auscultation. Pain level 6/10.

Second large bore IV started. IV fluids infusing.

CXR and EKG ordered. CBC, electrolytes drawn.

1420.
Client continues to complain of significant abdominal cramping and has vomited x2 since arriving. Noted to be diaphoretic. Slight slurring of speech noted. Client restless and exhibiting confusion, pulling at IV lines. Shallow breathing and labored effort noted. Suctioning of mouth done secondary to excessive oral secretions. Oxygen applied per face mask.

1425.
Labs and diagnostic tests return.

Vital Signs:

Time	1405	1420
Blood pressure	90/60	80/55
Pulse	48	44
Respirations	16	10
Temperature	98.9 degrees F	99 degrees F
Oxygen saturation	95% on RA	87% on RA

Lab Report:

Lab	Results	Reference Range
White Blood Cells (WBC)	9 x 10³cells/mm³	4.5 – 10.5 x 10³cells/mm³
Hematocrit	40%	Males: 42-52% Females: 35-47%
Hemoglobin	13.5g/dL	Males: 13-18 g/dL Females:12-16 g/dL
Glucose (serum)	165mg/dL	70-100 mg/dL
Potassium (serum)	4.0 mEq/L	3.5 to 5 mEq/L
Sodium (serum)	140 mEq/L	135 to 145 mEq/L

Diagnostic Reports:

Electrocardiogram shows sinus tachycardia.
Chest X-ray shows hyperexpanded lung fields.

>Using the diagram below, select 2 actions to take, 1 potential condition, and 2 parameters to monitor.

Actions to Take	Potential Conditions	Parameters to Monitor
a. Administer atropine and pralidoxime	f. Gastroenteritis	j. Respiratory secretions
b. Give additional dose of pyridostigmine	g. Multiple Sclerosis	k. Blood glucose
c. Administer antibiotics per order	h. Cholinergic Crisis	l. Cardiorespiratory status
d. Assist with intubation	i. Autonomic Neuropathy	m. Bowel sounds
e. Administer insulin		n. Urinary output

a. Administer atropine and pralidoxime

Correct Incorrect Correct answer

b. Give additional dose of pyridostigmine

Correct Incorrect Correct answer

c. Administer antibiotics per order

Correct Incorrect Correct answer

d. Assist with intubation

Correct Incorrect Correct answer

e. Administer insulin

Correct Incorrect Correct answer

f. Gastroenteritis

Correct Incorrect Correct answer

g. Multiple Sclerosis

Correct Incorrect Correct answer

h. Cholinergic Crisis

Correct Incorrect Correct answer

i. Autonomic Neuropathy

Correct Incorrect Correct answer

j. Respiratory secretions

Correct Incorrect Correct answer

k. Blood glucose

Correct Incorrect Correct answer

l. Cardiorespiratory status

Correct Incorrect Correct answer

m. Bowel sounds

Correct Incorrect Correct answer

n. Urinary output

Correct Incorrect Correct answer

Correct

Incorrect

Question 80 of 85

80. Question

The nurse is teaching a community workshop about infant care. One of the mothers asks, “Can you tell us about safe sleep guidelines?”

>Which of the following is a correct response by the nurse?

1. A baby can be placed on their belly to sleep if they have been diagnosed with reflux.
Correct Incorrect Correct answer

2. It is ok to use a blanket to cover baby if he or she is cold.
Correct Incorrect Correct answer

3. The baby should be placed to sleep on a firm, flat mattress with a fitted sheet.
Correct Incorrect Correct answer

4. It is recommended that baby remain in your room for the first 3 months of life.
Correct Incorrect Correct answer

Correct

Incorrect
Question 81 of 85

81. Question

A client reports that her daughter died 7 months ago, soon after Christmas, and she sometimes still gets depressed. The nurse asks further questions to assess for dysfunctional grieving, and the client reports normal sleep and eating habits, and is clean and appropriately dressed in appearance. She is still attending church weekly. The client further states she is not looking forward to her daughter’s upcoming birthday as they always went on a trip together.

>Which of the following would be considered a therapeutic response by the nurse?

1. “It’s been 7 months, it’s time for you to move on.”
Correct Incorrect Correct answer

2. “You just need to get past this birthday, and it’ll get better with each passing birthday. You won’t feel as sad.”
Correct Incorrect Correct answer

3. “Tell me about some of the trips that you took with your daughter on her birthday.”
Correct Incorrect Correct answer

4. “I will have the doctor prescribe you Zoloft to help you with your depression.”
Correct Incorrect Correct answer

Correct

Incorrect
Question 82 of 85

82. Question

After being diagnosed with iron deficiency anemia, a client is taking oral iron and eating foods rich in iron.

>Which of the following foods may help increase the body’s absorption of iron when consumed at the same time as iron?

1. Orange juice, cantaloupe, broccoli
Correct Incorrect Correct answer

2. Salmon, eggs, tofu
Correct Incorrect Correct answer

3. Liver and red meat
Correct Incorrect Correct answer

4. Shrimp and tuna
Correct Incorrect Correct answer

Correct

Incorrect
Question 83 of 85

83. Question

The physician orders heparin 7,500 units subcutaneously every 12 hours on a client for DVT prophylaxis. The heparin is sent from the pharmacy in a vial of 10,000 units/mL.

>How much will the nurse administer for one dose?

1. 2.5ml
Correct Incorrect Correct answer

2. 1.3ml
Correct Incorrect Correct answer

3. 0.75ml
Correct Incorrect Correct answer

4. 0.5ml
Correct Incorrect Correct answer

Correct

Incorrect
Question 84 of 85

84. Question

A 58-year-old female is recovering from a colon resection. She has a BMI of 40 and type 2 diabetes. Her most recent labs indicate albumin level of 2.5 g/dL.

>With the client at risk for wound dehiscence, which of the following should not be included in the plan of care?

1. Discourage the client from eating chicken breast, salmon, and eggs
Correct Incorrect Correct answer

2. Keep tight control of glucose.
Correct Incorrect Correct answer

3. Teach client how to splint incisional site when coughing, deep breathing, sneezing, or vomiting.
Correct Incorrect Correct answer

4. Administer stool softeners.
Correct Incorrect Correct answer

Correct

Incorrect

Question 85 of 85

85. Question

A 40-year-old male is brought to the emergency room via ambulance with facial drooping.

Nurse Notes:

0700.
Client noted to have facial drooping on right side, with inability to close eye or lips on right side. Complains of mild headache along with general facial pain on right side. Decreased sensation to light touch on the right side with normal sensation on the left. Has slight slurring of speech. Strength equal bilaterally in extremities. No rashes, sores, ulcers noted on skin assessment. Lung sounds clear bilaterally. S1 and S2 auscultated clearly.

Client’s wife reports that client had complained of forehead numbness yesterday along with right ear pain and had complained of his food having “no taste” last night during dinner. Previous medical history is hypertension x 3 years and history of frequent cold sores.

CBC, complete metabolic panel, Lyme antibody, RPR drawn. COVID-19 swab done.

0725.

CT scan of the head completed.

Vital Signs:

Time	0700
Blood pressure	150/95
Pulse	92
Respirations	20
Temperature	98.9 degrees F
Oxygen saturation	98% on RA

Lab Report:

Lab	Results	Reference Range
White Blood Cells (WBC)	9.5 x 10³cells/mm³	4.5 – 10.5 x 10³cells/mm³
Hematocrit	44%	Males: 42-52% Females: 35-47%
Hemoglobin	14g/dL	Males: 13-18 g/dL Females:12-16 g/dL
Glucose (serum)	120mg/dL	70-100 mg/dL
Potassium (serum)	4.0 mEq/L	3.5 to 5 mEq/L
Sodium (serum)	140 mEq/L	135 to 145 mEq/L
RPR	Negative	Negative
COVID-19	Negative	Negative

Diagnostic Reports:

CT scan is unremarkable

>Using the diagram below, select 2 actions to take, 1 potential condition, and 2 parameters to monitor.

Actions to Take	Potential Conditions	Parameters to Monitor
a. Administer prednisone	f. Lyme disease	j. Blood pressure
b. Injection of TPA	g. Ischemic stroke	k. Pain
c. Administer antibiotics	h. Neurosyphilis	l. Facial function
d. Give an analgesic for pain	i. Bell’s Palsy	m. Lymph nodes
e. Administer Penicillin G via IV		n. Facial sensation

a. Administer prednisone

Correct Incorrect Correct answer

b. Injection of TPA

Correct Incorrect Correct answer

c. Administer antibiotics

Correct Incorrect Correct answer

d. Give an analgesic for pain

Correct Incorrect Correct answer

e. Administer Penicillin G via IV

Correct Incorrect Correct answer

e. Administer Penicillin G via IV

Correct Incorrect Correct answer

g. Ischemic stroke

Correct Incorrect Correct answer

h. Neurosyphilis

Correct Incorrect Correct answer

i. Bell’s Palsy

Correct Incorrect Correct answer

j. Blood pressure

Correct Incorrect Correct answer

k. Pain

Correct Incorrect Correct answer

l. Facial function

Correct Incorrect Correct answer

m. Lymph nodes

Correct Incorrect Correct answer

n. Facial sensation

Correct Incorrect Correct answer

Correct

Incorrect

	1100	1105	1115	1125
Blood pressure	115/78	112/80	90/55	82/48
Pulse	90	94	105	110
Respirations	18	18	20	20
Temperature	97.9 degrees F	98 degrees F	98 degrees F	98.1 degrees F

Lab	Results
Color	Dark Yellow
Ketones	1+
Glucose	3+
Bilirubin	Negative
Blood	Negative
Bacteria	None
Specific gravity	1.020

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NCLEX Practice Test 1

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