NCLEX quizzes

Question 1

A new graduate nurse and their preceptor must collect several urine specimens for laboratory testing. Which techniques for urine collection by the graduate nurse are performed incorrectly, requiring the preceptor to intervene? Select all that apply.

Catheterizing a patient to collect a sterile urine sample for routine urinalysis

Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up

Collecting a sterile urine specimen from the collection bag of a patient’s indwelling catheter

Collecting about 3 mL of urine from a patient’s indwelling catheter to send for a urine culture

Planning to collect a sterile specimen from a patient with a urinary diversion by catheterizing the stoma

Discarding the first urine of the day when performing a 24-hour urine specimen collection on a patient

Answer 1

A. Catheterizing a patient to collect a sterile urine sample for routine urinalysis
B. Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up
C. Collecting a sterile urine specimen from the collection bag of a patient’s indwelling catheter

Question 2

A nurse caring for older adults in an extended-care facility performs regular assessments of the patients’ urinary functioning. Which patients would the nurse identify as at risk for urinary retention? Select all that apply.
A. Patient who is diagnosed with an enlarged prostate B. Patient who is on bedrest
C. Patient who is diagnosed with vaginal prolapse
D. Older adult patient with dementia
E. Patient who is taking antihistamines to treat allergies
F. Patient who has difficulty walking to the bathroom

Answer 2

A, C, E

Question 3

A nurse in the gynecology clinic is preparing an educational brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include?
Select all that apply.
A. Wear underwear with a cotton crotch.
B. Take baths rather than showers.
C. Drink six to eight 8-oz glasses of liquid per day.
D. Urinate before and after intercourse.
E.After defecation, dry the perineal area from the front to the back.
F. Observe the urine for color, amount, odor, and frequency.

Answer 3

A, C, E, F

Question 4

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient’s urine output?
A.Decreased amount and highly concentrated
B. Decreased amount and very pale like water
C. Increased amount and very concentrated D.Increased amount and dilute appearing

Answer 4

A.

Question 5

The health care provider has ordered an indwelling catheter to be inserted to relieve urinary retention in a male patient with prostate enlargement. What consideration will the nurse keep in mind when performing this procedure?
A.The male urethra is more vulnerable to injury during insertion.
B.In the hospital, a clean technique is used for catheter insertion.
C.The catheter is inserted 2 to 3 inches into the meatus.
D.Since it uses a closed system, the risk for UTI is absent.

Answer 5

A.

Question 6

A nurse is caring for a patient with an enlarged prostate who has had an indwelling catheter for several weeks. A prescription for continuous bladder irrigation (CBI) is written after the patient developed hematuria post cystoscopy. The nurse teaches the patient the purpose of CBI is to prevent what situation?
A.Catheter infection due to long-term use
B. Need to flush the catheter of organisms post procedure
C. Blood clots that could block the catheter
D. Need for increased fluid intake

Answer 6

C.

Question 7

A nurse is caring for a patient who has a urinary diversion (urostomy) after cystectomy (removal of the bladder) to treat bladder cancer. What interventions are indicated for this patient? Select all that apply. A.Measuring the patient’s fluid intake and output B.Keeping the skin around the stoma moist
C.Emptying the appliance frequently
D. Reporting any mucus in the urine to the primary care provider
E. Encouraging the patient to look away when changing the appliance
F. Monitoring the return of intestinal function and peristalsis

Answer 7

A, C, F

Question 8

A nurse is changing the stoma appliance on a patient’s ileal conduit. Which finding requires the nurse to follow up with the provider?
A.Stoma is moist.
B. Skin around the stoma is irritated.
C. Urine is leaking from the stoma.
D. Stoma is a purple-black color.

Answer 8

D

Question 9

A postoperative patient is having difficulty voiding and reports suprapubic pressure. What action can the nurse take to promote voiding?
A. Pouring cold water over the patient’s fingers and perineum
B. Assessing bladder residual using the bladder scanner
C. Immediately encouraging the patient to void
D. Recommending an indwelling catheter

Answer 9

C

Question 10

A nurse caring for a patient who just began hemodialysis assesses the patient’s AV fistula. Nursing documentation includes: “5/10/25 0930 AV fistula in the right forearm negative for thrill and bruit. Patient denies pain and tenderness.” Which finding is essential for the nurse report to the health care provider?
A. Thrill and bruit are absent.
B. Area is without redness or swelling.
C. Patient denies pain and tenderness.
D. Trace edema of the fingers is present.

Answer 10

A

Question 11

A nurse is caring for an alert, ambulatory, older adult with urinary frequency who has difficulty making it to the bathroom in time. Which nursing intervention is most appropriate to include in the care plan for this patient?
A. Explaining that incontinence is an expected occurrence with aging
B. Asking the patient’s family/caregivers to purchase incontinence pads for the patient
C. Teaching the patient how to perform PFMT exercises at regular intervals
D. Inserting an indwelling catheter to prevent skin breakdown

Answer 11

C

Question 12

A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic) for a UTI. The patient states, “My urine was bright orange-red today; I think I’m bleeding. Something is terribly wrong.” How will the nurse best respond?
A. “The medication causes a red-orange tinge to the urine; it is expected.”
B. “I will test your urine for blood.”
C. “This may be the result of an injury to your bladder.”
D. “I’ll hold the medication and let the provider know you are allergic to the drug.”

Answer 12

A.

Question 13

A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What nursing interventions are appropriate to include when caring for this patient?
Select all that apply.
A. Preventing the tubing from kinking to maintain free urinary drainage
B. Changing the sheath weekly and provide hygiene C. Fastening the sheath tightly to prevent the possibility of leakage
D. Having the patient maintain bedrest to prevent the sheath from slipping off
E. Leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis
F. Ensuring the device does not restrict blood flow.

Answer 13

a
e
f

Question 14

A nurse receives a prescription to catheterize a patient following surgery. What nursing action reflects correct technique?
a. Planning to use different equipment for catheterization of male versus female patients
b. Selecting the smallest appropriate size indwelling urinary catheter
c. Sterilizing the equipment prior to insertion
d. Avoiding filling the balloon with sterile water to prevent pressure on tissues

Answer 14

b

Question 15

A nurse in the emergency room is teaching a patient how to collect a midstream urine specimen. What instructions will the nurse give the patient?
Select all that apply.
a. Wash your hands with soap and water.
b. Open the container and place the lid face down on the counter.
c. Separate your labia and wipe with the antiseptic towelettes in the kit.
d. Without letting go of the labia, void a small amount into the toilet or collection hat.
e. Lean the collection container against the urinary opening and void into the container.
f. Void an ounce, then remove the container and finish voiding in the toilet.

Answer 15

a
c
d
e

Question 16

A nurse on a pediatric surgical unit notes a 10-year-old child has developed nocturnal enuresis. What health concern will the nurse plan for?
a. Constipation
b. Bedwetting after the age of toilet training
c. Patient who is manipulative
d. Infection

Answer 16

b

Question 17

A nursing student hears in report that their patient is receiving a nephrotoxic medication. The student plans care to include what action?
a. Teaching the patient to expect increased voiding
b. Assessing for kidney damage
c. Preventing urinary incontinence
d. Observing for nocturia

Answer 17

b

Question 18

A nurse at a health fair calculates the body mass index (BMI) of a person who weighs 68 kg and is 165 cm (1.65 m) tall. How will the nurse document the BMI?
A.25 kg/m2
B.46 kg/m2
C. 68 kg/m2
D. 165 kg/m2

Answer 18

A

Question 19

After administering an enteral feeding, a nurse evaluates the patient’s tolerance of the feeding. Which findings suggesting intolerance require collaboration with the dietician and health care provider? Select all that apply.
A.Nausea and/or vomiting
B. Weight gain
C. Bowel sounds 20/min
D. 200-mL gastric residual
E. Absence of diarrhea and constipation
F. Slight abdominal pain and distention

Answer 19

B, F

Question 20

A nurse is feeding an older adult patient with dementia. What intervention will best promote nutritional intake?
A.Stroke the underside of the patient’s chin to promote swallowing.
B. Serve meals in different places and at different times.
C. Offer a whole tray of various foods to choose from. D. Avoid between-meal snacks to ensure hunger at mealtime.

Answer 20

A.

Question 21

A patient with COPD is experiencing anorexia and weight loss. Which intervention would be most helpful in stimulating appetite in this patient?
A. Administering pain medication after meals.
B. Encourage the patient’s family to bring food from home when possible.
C. Scheduling respiratory therapy nebulizer treatments before each meal.
D. Reinforcing the importance of eating what is delivered to them.

Answer 21

b

Question 22

A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention will best prevent aspiration?
A. Feed the patient solids first and liquids last.
B. Place the bed in the semi-Fowler position during feeding.
C. Provide a 30-minute rest period prior to mealtime. D. Provide a straw for the patient’s beverages and soups.

Answer 22

C

Question 23

During interprofessional rounds, the charge nurse and health care provider evaluate patients to determine their need for parenteral nutrition (PN). Which patients will be identified as candidates for this type of nutritional support? Select all that apply.
A. Patient with irritable bowel syndrome and intractable diarrhea
B. Patient with celiac disease not absorbing nutrients from the GI tract
C. Patient who is underweight and needs short-term nutritional support
D. Patient who is comatose and needs long-term nutritional support
E. Patient who has anorexia and refuses to take foods via the oral route
F.Patient with burns who has not been able to eat adequately for 5 days

Answer 23

A, B, F

Question 24

A nurse is feeding a patient who reports feeling nauseated and unable to eat what is being offered. What would be the most appropriate initial action of the nurse in this situation?
A. Remove the tray from the room.
B. Administer an antiemetic and encourage the patient to take small amounts.
C. Explore why the patient does not want to eat the food.
D. Offer high-calorie snacks such as pudding and ice cream.

Answer 24

A

Question 25

A nurse is receiving report on a patient with alcoholism who will be transferred to the medical-surgical unit. Due to long-term alcohol exposure, the nurse plans for administration of which nutrient?
A. B vitamins
B. Lipids
C. Fluids
D. C vitamins

Answer 25

A

Question 26

A nursing student is caring for a patient who had a gastrostomy tube placement 12 hours ago. Which action by the student is correct?
A. Using a cotton-tipped applicator dipped into sterile saline solution and gently cleaning around the insertion site
B. Washing the area surrounding the tube with a wet washcloth and with soap and water.
C. Adjusting the external disk every 3 hours to avoid crusting around the tube.
D. Taping a gauze dressing over the site after cleansing it.
E. Assessing the gastric residual every 4 hours.
F. Discontinuing feedings when gastric residual volume is 120 mL.

Answer 26

A

Question 27

A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient’s diet should not be advanced?
A. The patient consumed 75% of the liquids on the breakfast tray.
B. The patient tells you they are hungry.
C. The patient’s abdomen is soft, nondistended, with bowel sounds.
D. The patient reports fullness and diarrhea after breakfast.

Answer 27

D

Question 28

A patient hospitalized for a stroke has a prescription for continuous tube feedings through a small-bore nasogastric tube. Following tube placement, which action by the nurse best confirms correct tube placement?
A. Auscultating the bowel sounds
B. Measuring the pH of gastric aspirate
C. Measuring the amount of residual in the stomach D. Ensuring validation of tube placement by x-ray

Answer 28

D

Question 29

A nurse specializing in care of older adults speaks to a group of nursing students about that population’s challenge with obtaining sufficient nutrition. Which points will the nurse include in the discussion? Select all that apply.
A. An increase in BMR and physical activity require additional calories.
B. Tooth loss and periodontal disease may make chewing more difficult.
C. Decreased peristalsis can result in constipation, requiring additional fiber and fluid.
D. Loss of taste between sweet and salty occurs with a preference for sweets.
E. Older adults express an increase thirst sensation. F. Caloric needs decrease, and the need for nutrients increases, especially protein.

Answer 29

B, C, D, F

Question 30

A nurse in the intensive care unit is reviewing diagnostic studies to evaluate a patient’s nutritional status. What findings consistent with inadequate nutrition require follow-up by the nurse? Select all that apply.
A.Decreased hemoglobin
B. Low prealbumin level
C. Increased transferrin
D. Anemia
E. Elevated lymphocytes

Answer 30

A, B, D

Question 31

A nurse plans to administer a bolus tube feeding for a patient but is unable to aspirate gastric contents due to a clogged tube. What action will the nurse take next?
A. Use warm water or air, applying gentle pressure to remove the clog.
B. Use the tube’s stylet to unclog the tubes.
C. Administer a cola beverage to remove the clog.
D. Replace the tube with a new one.

Answer 31

a

Question 32

A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient assessment requires collaboration with the surgeon, as the procedure could need to be postponed?
A. 19-year-old patient who is a vegan
B. Older adult patient who takes daily nutritional drinks
C. 43-year-old patient who takes ginkgo biloba and an aspirin daily
D. Infant who is breastfeeding

Answer 32

C

Question 33

A nurse is caring for a patient with ill-fitting dentures. What modification to their diet will the nurse suggest? A. Clear liquid
B. Full liquid
C.Mechanically altered
D. Honeylike liquids

Answer 33

C

Question 34

A nurse is performing an abdominal assessment on a patient experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action will the nurse perform next?
A. Auscultating the abdomen using an orderly clockwise approach in all abdominal quadrants
B. Percussing all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen
C. Lightly palpating over the abdominal quadrants; first checking for any areas of pain or discomfort
D. Deeply palpating over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses

Answer 34

A

Question 35

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. When the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next?
A. Elevating the head of the bed 30 degrees and repositioning the rectal tube
B. Placing the patient in a supine position and modifying the amount of solution
C. Lowering the solution container and checking the temperature and flow rate
D. Removing the rectal tube and notifying the primary care provider

Answer 35

C

Question 36

A nurse working on a GI unit is caring for a group of patients. In patients with which health problems or issues could the assessment possibly reveal decreased or absent bowel sounds after listening for 2 minutes? Select all that apply.
A. Peritonitis
B. Prolonged bedrest
C. Diarrhea
D. Gastroenteritis
E. Early bowel obstruction
F. Postoperative paralytic ileus

Answer 36

A, B, F

Question 37

A nurse in a long-term care facility is assessing a group of patients. In which patients would the nurse anticipate increased risk for developing diarrhea? Select all that apply.
A. Patient taking opioids for pain
B. Patient taking metformin for type 2 diabetes C.Patient taking diuretics
D. Patient who developed dehydration
E. Patient taking amoxicillin clavulanate for infection F. Patient taking magnesium-containing antacids

Answer 37

B, E ,F

Question 38

A nurse plans to administer a retention enema to a patient with a fecal impaction. Which nursing action is appropriate for this procedure?
A. Administering a large volume of solution (500 to 1,000 mL)
B. Mixing milk and molasses in equal parts for an enema
C. Instructing the patient to retain the enema for at least 30 minutes
D. Administering the enema while the patient is sitting on the toilet

Answer 38

C

Question 39

A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply.
A. “When you inspect the stoma, it should be dark purple-blue.”
B. “The size of the stoma will stabilize within 2 weeks.” C. “Keep the skin around the stoma site clean and moist.”
D. “The stool from an ileostomy is normally liquid.”
E. “Eat dark-green vegetables to control the odor of the stool.”
F. “You may have a tendency to develop food blockages.”

Answer 39

D, E, F

Question 40

A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test?
A. Having the patient consume a low-fiber diet several days before the test
B. Having the patient take bisacodyl and ingest a gallon oral polyethylene glycol solution (PEG)
C. Preparing the patient for the use of general anesthesia during the test
D. Explaining that barium contrast mixture will be given to drink before the test

Answer 40

a

Question 41

A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure, the patient tells the nurse they are feeling dizzy and nauseated and then vomits. What should be the nurse’s next action?
A. Reassuring the patient that this is a normal reaction to the procedure
B. Stopping the procedure, preparing to administer CPR, and notifying the primary care provider
C. Stopping the procedure, assessing vital signs, and notifying the health care provider
D. Pausing the procedure, waiting 5 minutes, and then resuming the procedure

Answer 41

C

Question 42

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) an upper GI series. What is the correct order for performing the tests?
A. c, b, d, a
B d, c, a, b
C. a, b, d, c
D. b, a, d, c

Answer 42

D

Question 43

A nurse is caring for a patient who had abdominal surgery and has a nasogastric tube attached to low suction. Which nursing actions are appropriate when caring for this patient? Select all that apply.
A. Irrigating the tube with 30-mL normal saline solution
B. Confirming tube placement via pH testing of gastric secretions
C. Positioning the air vent at the level of the patient’s umbilicus
D. Instilling irrigation via the blue air vent
E. Monitoring the patient’s abdomen for distention
F. Documenting the nasogastric irrigation and drainage with I & O

Answer 43

A, B, D, E, F

Question 44

A nurse is planning a bowel program for a patient with frequent constipation after sustaining a spinal cord injury. What is the first step the nurse will take? A.Offering a diet that is low in residue
B. Increasing fluid intake to 3,000 mL daily C.Administering daily enemas to stimulate peristalsis D.Assessing the patient’s bowel patterns

Answer 44

D

Question 45

A community health nurse is providing an adult education session about colon cancer. Which signs and symptoms of this cancer will the nurse include? Select all that apply.
A. Blood in the stool
B. Previous colonoscopy
C. Passing two large bowel movements daily D.Unintentional weight loss
E. Upper abdominal cramping
F. Previous opioid use

Answer 45

A, D

Question 46

For a patient with which health problem or issue would a nurse expect the health care provider to order colostomy irrigation?
A. IBS
B. Left-sided end colostomy in the sigmoid colon C.Postradiation damage to the bowel
D. Crohn disease

Answer 46

B

Question 47

A nurse is assisting a patient to change an ostomy appliance when they note the stoma is protruding into the bag. What would be the nurse’s first action in this situation?
A. Reassuring the patient that this is a normal with a new ostomy
B. Notifying the health care provider that the stoma is prolapsed
C. Having the patient rest for 30 minutes to see if the prolapse resolves
D. Replacing the appliance with a larger appliance

Answer 47

C

Question 48

A nurse is caring for an older adult who reports persistent constipation and has a number of laxative prescriptions on the MAR. Which medication would the nurse avoid for this patient?
A. Saline osmotic laxative
B. Bulk-forming laxative
C. Methylcellulose
D. Stool softener

Answer 48

A

Question 49

A nurse caring for a patient who reports frequent constipation learns the patient uses phosphate and sodium citrate enemas several times weekly. What education would the nurse provide?
Electronic Health Record
PMH: Hypertension, chronic kidney disease
A.“Avoid consuming fiber or roughage in the diet.”
B. “Sedentary activities will be helpful.”
C. “These enemas should be avoided with kidney failure.”
D. “Restrict your fluids to 1,000 mL daily.”

Answer 49

C

Question 50

A nurse asks a patient for a stool sample to perform the guaiac test. How does the nurse best explain the purpose of this test?
A. “This test replaces the need for screening colonoscopy.”
B. “We are looking for infectious organisms in your stool.”
C. “The screening assesses for blood in your stool.” D.“This test assesses for antibodies to colon cancer.”

Answer 50

C

Question 51

A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What action will the nurse take first?
A. Readminister the medication and notify the health care provider.
B. Obtain the pill in a liquid form for administration.
C. Assess the emesis, looking for the pill.
D. Notify the primary care provider.

Answer 51

C

Question 52

A nurse caring for a group of patients uses measures to reduce discomfort for the patients during injections. Which technique is recommended?
A. Selecting a needle of the largest gauge that is appropriate for the site and solution to be injected B.Injecting the medication into contracted muscles to reduce pressure and discomfort at the site
C. Using the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track
D. Applying vigorous pressure in a circular motion after the injection to distribute the medication to the intended site

Answer 52

C

Question 53

A nurse is preparing medications for patients in the ICU. The nurse is aware that patient variables may affect the absorption of these medications. Which statements accurately describe these variables the nurse will use as a basis for practice? Select all that apply.
A. Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed.
B. Some people experience the same response with a placebo as with the active drug used in studies. C.People with liver disease metabolize drugs more quickly than people with normal liver functioning.
D. A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication’s effects.
E. Oral medications should not be given with food as the food may delay the absorption of the medications.
F. Circadian rhythms and cycles may influence drug action.

Answer 53

A, B, D, F

Question 54

A nurse is administering a pain medication to a patient. In addition to checking the identification bracelet, which active identification strategy reflects best practice? A.Asking the patient their name and birthdate B.Reading the patient’s name on the sign over the bed
C. Asking the patient’s roommate to verify the patient’s name
D. Asking, “Are you Mr. Brown?”

Answer 54

A

Question 55

A nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure? Select all that apply.
A. Crushing the enteric-coated pill and mix it in a liquid
B. Initially flushing the tube with 60 mL of very warm water
C. Using the recommended policy to check tube placement in the stomach or intestine
D. Giving each medication separately and flush with water between each drug E.Lowering the head of the bed to prevent reflux F.Adjusting the amount of water used if patient’s fluid intake is restricted

Answer 55

C, D, F

Question 56

A medication prescription reads: “Hydromorphone, 2 mg IV every 3 to 4 hours PRN pain.” The prefilled cartridge is available with a label reading “Hydromorphone 2 mg/1 mL” and a statement that the cartridge contains 1.2 mL of hydromorphone. How should the nurse proceed?
A. Give the entire contents of the cartridge sent by the pharmacy
B. Call the pharmacy and request the proper dose C.Refuse to give the medication and document refusal in the EHR
D. Discard 0.2 mL before administration; verify the waste with another nurse

Answer 56

D

Question 57

A nurse prepares to administer insulin to a patient with diabetes. What is the correct procedure to carry out this prescription? MAR 7:30 AM: 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously.
A. Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin.
B. Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; followed by withdrawal of 40 units of NPH insulin
C. Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin. D.Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin.

Answer 57

B

Question 58

A nurse is administering heparin subcutaneously to a patient. What technique is appropriate for this injection?
A. Aspirating before giving and gently massage after the injection
B. Avoiding aspirating; massaging the site for 1 minute
C. Avoiding aspirating before and massaging after the injection
D. Massaging the injection site; aspirating is unnecessary but will do no harm

Answer 58

C

Question 59

A nurse discovers that a medication error occurred. What is the nurse’s priority? A. Recording the error on the medication sheet
B. Notifying the physician regarding course of action C. Assessing the patient for adverse effects of the error D. Completing an event report, explaining how the mistake was made

Answer 59

C

Question 60

A nurse is teaching a patient how to use a meter-dosed inhaler to control asthma. What are appropriate guidelines for this procedure? Select all that apply.
A. Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer.
B. Take shallow breaths when breathing through the spacer.
C. Depress the canister releasing one puff into the spacer and inhale slowly and deeply.
D. After inhaling, exhale quickly through pursed lips. E.Wait 1 to 5 minutes as prescribed before administering the next puff. F.Gargle and rinse with salt water after using the MDI.

Answer 60

A, C, D

Question 61

A nurse in a rehabilitation facility is preparing to administer a skeletal muscle relaxant to a patient recovering from a motor vehicle accident. When the patient states, “I don’t want that pill,” what action will the nurse take next?
A. Encourage the patient to take the pill to help reduce muscle spasm.
B. Explain that the health care provider prescribes only necessary medications.
C. Ask the patient to explain their concern about the medication.
D. Question the patient about allergies and previous medication reactions.

Answer 61

C

Question 62

A nurse is preparing to administer medications to a patient transferred from the intensive care unit just as lunch is served. Prior to administering medications to the patient, the nurse takes which action? A.Performing medication reconciliation
B morning care has been administered
C.Ordering the patient a meal
D. Taking a report from the nurse sending the patient

Answer 62

A

Question 63

When administering an IVPB medication using gravity, what action is appropriate for the nurse take?
A. Placing the primary IV bag below the level of the piggyback bag B.Disconnecting the tubing closest to the patient and flushing the intravenous access
C. Ensuring the piggyback bag is below the main IV bag
D. Closing the roller clamp to the secondary infusion

Answer 63

A

Question 64

A nurse is administering enoxaparin subcutaneously using the manufacturer’s prefilled syringe. Which action reflects correct practice?
A. Administering the medication in the posterolateral abdomen B.Removing air bubble prior to injecting
C. Gently rubbing the abdomen after injection to promote absorption
D. Replacing the cap on the syringe before discarding it in the sharps contain

Answer 64

A

Question 65

A nurse is administering medications to an older adult with dysphagia. After crushing the pills, which action is most appropriate? A.Mixing the crushed medications with 120 mL of water before administering B.Mixing the medications into the patient’s bowl of pudding
C.Crushing each pill separately and administering each in a teaspoon of applesauce D.Asking the patient to chew the pills and providing juice after swallowing

Answer 65

C

Question 66

A patient experiencing chest pain asks the nurse why a nitroglycerin tablet must be placed under their tongue instead of swallowed. Which answer by the nurse is appropriate?
A. “We could put the tablet between the cheek and gum, instead.”
B. “The area is rich in superficial blood vessels, and helps with absorption.” C.“Swallowing interferes with quick systemic effects.” D.“This is an enteric-coated tablet, designed for absorption outside the stomach.”

Answer 66

B

Question 67

A nurse in the pediatric unit of an acute care hospital is awaiting a prescription for antibiotics for a toddler with a severe infection. Which information about the child is essential to document immediately? A.Beverage preference B.Whether a parent/guardian is present at the bedside
C. Weight in kilograms D.Intake and output

Answer 67

C

Question 68

A nurse in a pediatric practice teaches the mother of a toddler to administer antibiotic ear drops. What education by the nurse is correct?
A. “It is best to pull the pinna of the affected ear up and back.”
B. “Place the child on their side of the affected ear and pull the pinna straight back.”
C. “When administering the ear drop, gently pull the pinna down and back.” D.“Cleanse the ear canal with a cotton swab before administering.”

Answer 68

C

Question 69

A nurse is planning to administer digoxin to a patient. After reviewing the medical record, what action will the nurse take? Electronic Health Record Prescriptions 11/22/2025 digoxin loading dose 0.25 mg IV twice today only 11/23/2025 begin digoxin 0.125 mg orally daily Laboratory Studies Digoxin level: 2.7 ng/mL (reference range 0.5–2 ng/mL) A.Administer the medication, recording the level in the MAR.
B. Hold the medication and confer with the prescriber. C.Give the patient one half the dose.
D. Evaluate the patient’s kidney function studies.

Answer 69

B

Question 70

A nurse notices that an older adult patient is malnourished, and blood tests reveal reduced plasma protein levels. For which of these pharmacodynamic effects will the nurse observe? A.Medication toxicities B.Failure to thrive
C. Weight gain
D. Mental confusion

Answer 70

A

Question 71

A nurse on a medical-surgical unit is planning to administer an antibiotic to a patient with a kidney infection who is 10 weeks’ pregnant. The drug reference states that the medication is teratogenic. Which action will the nurse take?
A. Administer the medication, because the risk of illness is greater than the benefit of the medication.
B. Hold the medication and collaborate with the health care provider to find an alternative.
C. Ask the patient if they consent to receive the medication and document the response in the electronic health record.
D. Collaborate with the pharmacist on dose reduction.

Answer 71

B

Question 72

At 8 AM, a nurse receives a prescription for an analgesic to be administered every 4 hours PRN. The nurse plans to administer this medication at what times?
A. 0800, 1200, 1600, 2000, 0000, 0400 hours
B. Around the clock on even hours
C. Six times daily
D. Upon patient request, within prescribed time intervals

Answer 72

D

Question 73

A nurse on the respiratory unit is interpreting ABGs for several patients. The patient with which problem will the nurse suspect may have developed respiratory alkalosis?
A. Hypoxia
B. Atelectasis
C. Chronic respiratory illness
D. Sedative overdose

Answer 73

A

Question 74

A nurse is caring for a group of patients. The patient with which problem would the nurse identify is at high risk for fluid volume excess?
A. Renal failure
B. Vomiting
C. Hypernatremia
D.NPO for surgery

Answer 74

A

Question 75

A nurse is caring for a patient who has developed hypernatremia. For which intravenous solution would the nurse anticipate a prescription?
A. 5% dextrose in 0.9% NaCl
C. 0.9% NaCl (normal saline)
C. 0.45% NaCl (½-strength normal saline)
D. 5% dextrose in lactated Ringer’s solution

Answer 75

C

Question 76

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient’s fluid balance status?
A. Recording intake and output
B. Testing skin turgor
C. Reviewing the complete blood count
D. Measuring weight daily

Answer 76

D

Question 77

A nurse is caring for a patient in the intensive care unit. How will the nurse interpret the patient’s arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3–, 14 mEq/L?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

Answer 77

C

Question 78

A patient with dehydration has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement?
A. Explaining the mechanisms of fluid transport in cellular compartments
B. Keeping the patient’s preferred fluids readily available for the patient
C. Emphasizing the long-term benefit of increasing fluids
D. Planning to offer most daily fluids in the evening

Answer 78

B

Question 79

A nurse is flushing a patient’s peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What action will the nurse take next?
A. Removing the IV from the site and start at another location
B. Immediately notifying the primary care provider C.Outlining the affected area in ink and monitoring for changes
D. Aspirating the catheter and attempting to flush again

Answer 79

A

Question 80

A nurse is monitoring a patient who is receiving an IV infusion of normal saline at 250 mL /hr. The patient is apprehensive and presents with a pounding headache, rapid pulse, chills, and dyspnea. What would be the nurse’s priority intervention related to these symptoms?
A. Discontinuing the infusion immediately, monitoring vital signs, and reporting findings to the primary care provider immediately
B. Slowing the rate of infusion, notifying the primary care provider immediately, and monitoring vital signs C.Pinching off the catheter or securing the system to prevent entry of air, placing the patient in the Trendelenburg position, and calling for assistance D.Discontinuing the infusion immediately, applying warm compresses to the site, and restarting the IV at another site

Answer 80

A.

Question 81

A nurse carefully assesses the acid–base balance of a patient whose bicarbonate (HCO3–) level is decreased on the ABG results. This typically occurs in patients with damage to which organ?
A. Kidneys
B. Lungs
C. Adrenal glands
D. Brain

Answer 81

B.

Question 82

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?
A. Encouraging foods and fluids with higher sodium content
B. Administering oral potassium supplements as prescribed
C. Cautioning the patient about eating foods high in potassium content
D. Discussing calcium-losing aspects of nicotine and alcohol use

Answer 82

B

Question 83

A nurse has begun administering an intravenous antibiotic via the patient’s peripheral venous access. Immediately, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse’s next action related to these findings?
A. Repositioning the extremity and raise the height of the IV pole
B. Applying pressure to the dressing on the IV
C. Pulling the catheter out slightly and reinserting it
D. Putting on gloves; removing the catheter

Answer 83

D

Question 84

When caring for a patient receiving hemodialysis through an arteriovenous fistula, which action is essential for the nurse to take?
A. Avoiding IM injections
B. Not assessing the radial pulse on the same side as the access
C. Performing BP and venipuncture on the opposite extremity
D. Using the distended portion of the fistula for IV medications

Answer 84

C.

Question 85

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse’s priority actions related to these symptoms?
A. Slowing or stopping the infusion; monitoring vital signs, notifying the health care provider, and placing the patient in an upright position with their feet dependent
B. Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care provider immediately, and administering antihistamine parenterally as needed
C, Stopping the transfusion immediately and keeping the vein open with normal saline, notifying the health care provider, and treating symptoms with acetaminophen
D. Stopping the infusion immediately, obtaining a culture of the patient’s blood, monitoring vital signs, notifying the health care provider, and administering antibiotics immediately

Answer 85

A

Question 86

A nurse is performing physical assessments for patients with fluid imbalance. Which findings indicate a fluid volume excess? Select all that apply.
A. Pinched and drawn facial expression
B. Deep, rapid respirations
C. Moist crackles heard upon auscultation D.Tachycardia
E. Distended neck veins
F. Sluggish skin turgor

Answer 86

C,D,E

Question 87

A nurse is caring for a patient experiencing a fluid volume deficit. What should be included in the recorded intake and output for the patient? Select all that apply.
A. Urine
B. Carbonated beverage
C. Formed stool
D. Vomitus
E. Chicken noodle soup
F. Pressure wound irrigant

Answer 87

A,BDE

Question 88

A nurse is caring for an older adult with a fluid volume deficit related to decreased thirst sensation. For which signs and symptoms of this health problem will the nurse assess?
A. Dependent edema
B, Crackles in the lungs
C. Neck vein distention
D. Weight loss

Answer 88

D

Question 89

A nurse on the IV team is making rounds to assess patients receiving IV therapy. Under which circumstance will the nurse recommend an intravenous catheter be discontinued?
A. The area surrounding the catheter is bruised.
B. The patient’s extremity is cool to touch.
C. The site is red, warm, and swollen.
D. Part of the catheter (1 mm) is visible under the dressing.

Answer 89

C