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Question 1: A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion.^1 He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now.^2 What action is best for the nurse to take? A) Stop the feeding pump and notify the healthcare provider immediately. B) Aspirate a large volume of fluid from the tube to check for placement. C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D) Resume the feeding at a slower rate and monitor for further coughing. Rationale: The correct answer is C. Severe coughing can dislodge the nasogastric tube.^3 Checking the pH of aspirated fluid is a reliable bedside method to assess tube placement in the stomach (pH should be acidic, typically 1-5). Clearing the tube with a small amount of air helps to ensure that the aspirated fluid is from the stomach and not residual feeding in the tube itself. Stopping the feeding and notifying the provider (A) is premature without assessing placement. Aspirating a large volume (B) may not be necessary if a pH check can be obtained. Resuming feeding without checking placement (D) could lead to aspiration if the tube is misplaced. Question 2: A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered.^4 The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A) Hold the dose until the next scheduled time (0900 the following day). B) Give the missed dose at 1300 and change the schedule to administer daily at 1300. C) Administer half the dose (250 mg) at 1300 and the other half at 0900 the next day. D) Consult with the healthcare provider before administering the medication. Rationale: The correct answer is B. For a medication administered once daily, if a dose is missed by several hours, it is generally best to administer the dose as soon as possible and then
adjust the administration time accordingly to maintain a 24-hour interval. Holding the dose (A) could reduce the therapeutic effect. Splitting the dose (C) is not a standard practice for once-daily medications without specific orders. Consulting the provider (D) is an option, but administering the dose and adjusting the schedule is a common and acceptable practice in this scenario. Question 3: A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A) Administer the analgesic only when the client reports pain. B) Offer the analgesic every six hours to avoid over-sedation. C) Give an around-the-clock schedule for administration of analgesics. D) Provide non-pharmacological pain relief measures more frequently. Rationale: The correct answer is C. In hospice care, the focus is on comfort and quality of life. An "as needed" (PRN) schedule for increasing pain can lead to undertreatment and breakthrough pain. An around-the-clock schedule helps to maintain a consistent level of analgesia and prevent pain from escalating. Administering only when reported (A) and extending the interval (B) can lead to inadequate pain control. Non-pharmacological measures (D) are important adjuncts but may not be sufficient for increasing pain. Question 4: After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Establish nursing goals. B) Implement nursing interventions. C) Determine the etiology of the problem. D) Evaluate the client's response. Rationale: The correct answer is C. The nursing process involves several steps. After assessment and identifying a problem (nursing diagnosis), the next step is to analyze the data to determine the underlying cause or contributing factors (etiology) of the problem. This understanding guides the development of appropriate goals and interventions. Question 5:
D) Apply warm compresses to the lower abdomen. Rationale: The correct answer is C. Urinary retention is the inability to empty the bladder.^5 The most important initial action is to assess the bladder for distention, which indicates urine accumulation and confirms the retention. This assessment guides further interventions, such as catheterization if the bladder is distended and the client cannot void. Question 8: A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A) Dietary restrictions related to meat consumption. B) Restrictions on the use of certain pain medications. C) Blood transfusions are forbidden. D) Limitations on diagnostic testing procedures. Rationale: The correct answer is C. A central tenet of the Jehovah's Witness faith is the refusal of blood transfusions, even in life-threatening situations.^6 This belief has significant implications for medical treatment planning, especially in situations involving potential blood loss. Question 9: While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow.^7 What nursing action should the nurse implement? A) Correct her grip by placing her hands at the wrist and upper arm. B) Advise her to support the joint directly to prevent injury. C) Acknowledge that she is supporting the arm correctly. D) Demonstrate a different technique using a wider grasp. Rationale: The correct answer is C. Supporting the limb above and below the joint being exercised provides adequate support and prevents undue stress on the joint. The wife's technique is correct and the nurse should acknowledge this to reinforce proper technique. Question 10:
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Supine. B) Trendelenburg. C) Fowler's. D) Side-lying. Rationale: The correct answer is C. Fowler's position (head of the bed elevated 30-45 degrees or higher) is the best position for administering enteral feedings to an unresponsive client. This position helps to prevent aspiration by promoting gravity flow of the feeding into the stomach and reducing the risk of regurgitation. Question 11: An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead.^8 What should be the nurse's first response? A) "That sounds like a good way to manage your stress." B) "It is important that you continue your medication while learning to meditate." C) "Many people have been able to stop their medications with meditation." D) "You should discuss that decision with your doctor." Rationale: The correct answer is B. While spiritual meditation can be a beneficial complementary therapy for stress reduction and overall well-being, abrupt cessation of antihypertensive medication can be dangerous.^9 The nurse's first response should emphasize the importance of continuing prescribed medications while exploring other modalities. The client should then be encouraged to discuss their desire to change treatment with their healthcare provider (which is also a good subsequent step). Question 12: A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion? A) 25 ml/hr B) 50 ml/hr
B) Apply a warm compress to the IV site. C) Initiate an alternate site for the IV infusion of the medication. D) Administer an antihistamine to reduce inflammation. Rationale: The correct answer is C. The signs and symptoms (pain, irritation, erythema, swelling, red streak along the vein) indicate phlebitis, an inflammation of the vein.^12 Continuing the infusion at the affected site can worsen the inflammation and potentially lead to further complications. The IV infusion should be discontinued, and a new IV access site should be initiated in a different location. Slowing the rate (A) or applying a warm compress (B) might provide some comfort but does not address the underlying problem. Antihistamines (D) are used for allergic reactions, which is not the likely cause here.^13 Question 15: A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A) Ask a family member to translate the client's concerns. B) Use a medical dictionary to look up key terms in the client's language. C) Request and document the name of the certified translator. D) Speak slowly and loudly to ensure the client understands. Rationale: The correct answer is C. When a client has communication barriers due to language, it is essential to use a qualified medical interpreter to ensure accurate and unbiased communication, especially regarding treatment concerns. Requesting a certified translator is the appropriate step. Family members (A) may not be fluent in medical terminology or may have their own biases. Medical dictionaries (B) are insufficient for complex communication. Speaking slowly and loudly (D) does not overcome language barriers. Documenting the use of a translator is also crucial for legal and communication purposes. Question 16: A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall.^14 In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A) Avoid bending at the waist more than 90 degrees. B) Sit only on low chairs or toilet seats. C) Pivot on your operated leg when turning.
D) Sleep on your non-operated side without any pillows. Rationale: The correct answer is A. Following a hemiarthroplasty (partial hip replacement), specific hip precautions are crucial to prevent dislocation of the new hip joint. Bending at the waist more than 90 degrees can cause the hip to dislocate.^15 Clients should sit on high chairs and use elevated toilet seats (B is incorrect). Pivoting on the operated leg (C) can also lead to dislocation. Sleeping on the non-operated side with a pillow between the knees (to maintain abduction) is recommended (D is incorrect). Question 17 An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Arrange for spiritual counseling for the family. B. Initiate the hospice admission process immediately. C. Notify the healthcare provider of the family's request. D. Discuss the implications of hospice care with the resident. Rationale: The nurse's first action should be to communicate the family's request for hospice care, which aligns with the resident's prior wishes for no resuscitative efforts, to the healthcare provider. This ensures that the medical team is aware and can issue the necessary orders for hospice admission. Question 18 A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Her social support system. B. Her coping mechanisms. C. Nutritional history. D. Any recent stressful life events. Rationale: While all options are relevant to assessing anxiety, nutritional history is a fundamental and often overlooked area that can significantly impact mental health. Deficiencies or imbalances can directly contribute to anxiety, making it a critical initial assessment.
C. "It's normal for it to be this size after surgery." D. "Would you like me to call the ostomy nurse to talk to you?" Rationale: It is common for new stomas to be swollen post-operatively. Providing accurate information that the swelling is temporary and will decrease helps alleviate the client's immediate concerns and provides realistic expectations. Question 21 The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/ ml. How many milliliters should the nurse administer? A. 0.75 ml B. 1.0 ml C. 1.5 ml D. 2.0 ml Rationale: To calculate the volume to administer, use the formula: Volume to administer=Dose on HandDesired Dose×Volume on Hand Given: Desired Dose = 15 mg Dose on Hand = 20 mg Volume on Hand = 2 ml Volume to administer=20 mg15 mg×2 ml Volume to administer=0.75×2 ml Volume to administer=1.5 ml Question 22 Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?
A. Aspirating gastric contents and testing pH. B. Auscultating for an air bolus over the epigastrium. C. Examining a chest x-ray obtained after the tubing was inserted. D. Observing for respiratory distress or coughing. Rationale: While other methods can provide indications, examining a chest x-ray is considered the gold standard for confirming accurate placement of a nasogastric tube, as it directly visualizes the tube's position. Question 23 The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 62 gtt/min B. 98 gtt/min C. 124 gtt/min D. 150 gtt/min Rationale:
- Convert client weight to kg: 182 lbs / 2.2 lbs/kg = 82.73 kg
- Calculate total mcg/min needed: 5 mcg/kg/min * 82.73 kg = 413.65 mcg/min
- Convert Nipride concentration to mcg/mL: 50 mg = 50,000 mcg 50,000 mcg / 250 mL = 200 mcg/mL
- Calculate mL/min needed: 413.65 mcg/min / 200 mcg/mL = 2.068 mL/min
A. Keep windows open to air out the house. B. Use feather pillows and down comforters. C. Avoid any types of sprays, powders, and perfumes. D. Dust with a dry cloth daily. Rationale: Sprays, powders, and perfumes often contain irritants and allergens that can trigger allergic reactions. Avoiding them is a key strategy for allergy management. Question 27 A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Administer oxygen via nasal cannula. B. Encourage the client to take deep breaths. C. Assist the ambulating client back to the bed. D. Notify the healthcare provider immediately. Rationale: The immediate priority is client safety. A significant drop in oxygen saturation during ambulation indicates that the client is becoming desaturated and needs to cease the activity and rest to improve oxygenation. Question 28 The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Before exhaling completely. B. During the exhalation. C. During the inhalation. D. After holding breath for a few seconds. Rationale: To ensure the medication reaches the lungs effectively, the client should activate the inhaler and inhale slowly and deeply at the same time. Question 29
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. "I will eat more fried foods since they fill me up." B. "I will limit my intake of beef to 4 ounces per week." C. "I can eat as much cheese as I want because it's dairy." D. "I will stop exercising because it raises my heart rate." Rationale: Limiting red meat intake is a key dietary modification for managing high cholesterol due to its saturated fat content. Question 30 When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Document the finding in the client's chart. B. Notify the healthcare provider. C. Loosen the right wrist restraint. D. Apply a warm compress to the hand. Rationale: Blue fingers (cyanosis) indicate impaired circulation. The immediate priority is to restore circulation by loosening the restraint. This is a critical safety intervention. Question 31 A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 6 a.m., 2 p.m., and 10 p.m. B. 8 a.m., 4 p.m., and midnight. C. 9 a.m., 3 p.m., and 9 p.m. D. With meals and at bedtime.
D. The charge nurse on duty at the time of the fall. Rationale: The nurse directly involved in the action (transferring the client) that immediately preceded the injury (the fall) is at the greatest risk for a malpractice judgment, as their direct action or inaction would be most scrutinized for negligence. Question 34 The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The nurse verified that the client understood the procedure. B. The nurse ensured the client felt no pressure to sign. C. The client voluntarily signed the form. D. The nurse explained the risks and benefits of the procedure. Rationale: When witnessing a signature on an informed consent, the nurse is primarily verifying that the client was indeed the one who signed the document and that they appeared to do so voluntarily. It is the healthcare provider's responsibility to ensure the client understands the procedure, risks, and benefits. Question 35 The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the NGT for 30 minutes after medication administration. B. Administer each medication mixed together with water. C. Flush the tube with water. D. Place the client in a Trendelenburg position. Rationale: Flushing the tube with water before administering medications helps to clear the tube, preventing medication adherence to the tube walls and ensuring proper delivery of the medication. Question 36 An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program
3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. "Make sure to set realistic weight loss goals." B. "Be sure to have a complete physical examination before beginning your planned exercise program." C. "Consider joining a support group for weight loss." D. "Remember to drink plenty of water during your exercise." Rationale: Given the client's obesity and the intensity of the planned exercise program, a thorough physical examination is essential to rule out any underlying conditions that could be exacerbated by exercise or to identify potential risks. Question 37 When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the: A. Hips B. Lower abdomen C. Upper torso D. Knees Rationale: Due to age-related changes such as kyphosis and loss of muscle mass, the center of gravity in older adults tends to shift upwards towards the upper torso, affecting balance and increasing the risk of falls. Question 38 Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Weight-for-height ratio B. Body Mass Index (BMI) C. Upper arm circumference D. Skinfold thickness measurements
C. Position the client with pillows to prevent external rotation of the hip. D. Turn the client every two hours using the log-roll technique. Rationale: Gently lifting the client rather than dragging or pulling helps prevent skin shearing and breakdown, which is crucial for bedridden clients, especially those with fractures who are at increased risk for skin integrity issues. Question 42 During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A. Stop the assessment and reschedule for another day. B. Tell the client that there is nothing to cry about. C. Acknowledge the client's distress and tell her it is all right to cry. D. Offer the client a tissue and change the subject. Rationale: Acknowledging the client's emotional state and providing reassurance creates a therapeutic environment, allowing the client to express her feelings without judgment. This promotes trust and open communication. Question 43 Which action is most important for the nurse to implement when donning sterile gloves? A. Ensure the inner glove package is opened away from the body. B. Touch only the inside cuff of the first glove. C. Keep gloved hands above the elbows. D. Avoid touching anything non-sterile. Rationale: Keeping gloved hands above the elbows (and at or above waist level) prevents accidental contamination by touching non-sterile surfaces or allowing gravity to pull contaminants down. Question 44 The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?
A. Canned chicken noodle soup, crackers, and fruit cocktail. B. Skim milk, turkey salad, roll, and vanilla ice cream. C. Hot dog on a bun with ketchup and potato chips. D. Pizza with pepperoni and extra cheese. Rationale: Canned soups, hot dogs, and processed meats like pepperoni are typically very high in sodium. Skim milk, fresh turkey (as in a salad), a plain roll, and vanilla ice cream are generally lower in sodium, indicating better understanding. Question 45 An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. "Ensure the client's knees are straight." B. "Reposition in a Sim's position with the client's weight on the anterior ilium." C. "Place a pillow under the client's head." D. "Elevate the head of the bed to 45 degrees." Rationale: For enema administration, the Sim's position (left lateral with the right leg flexed) is preferred as it allows gravity to assist the flow of the enema into the sigmoid colon and rectum. The instruction correctly guides the UAP to the appropriate positioning. Question 46 An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Assess for signs of a respiratory infection. B. Inquire about the source and type of pain. C. Check for symptoms of a gastrointestinal upset. D. Ask about the child's sleep patterns. Rationale: "Miseries" is a common cultural term used to describe general discomfort or pain. Therefore, the nurse should directly inquire about the characteristics and location of the child's pain to understand the underlying issue.
