Cumulative NCLEX Practice Test

1. A client has been admitted to the hospital with findings of urinary tract infection and
dehydration. The nurse determines that the client has received adequate volume
replacement and has returned to normal hydration status if the blood urea nitrogen level is:
5 mg/dL
15 mg/dL
27 mg/dL
34 mg/dL

2. A client newly diagnosed with diabetes mellitus has a glycosylated hemoglobin A1c level of
10%. The nurse ensures that client teaching includes which of the following:
Avoiding infection
Taking in adequate fluids
Preventing and recognizing hypoglycemia
Preventing and recognizing hyperglycemia

3. The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the
following prescriptions should the nurse anticipate from the primary healthcare provider
(PHCP)? Select all that apply.
Furosemide
Neomycin
Naproxen
Lactulose
Diazepam

4. The client is admitted for having unstable angina. The nurse caring for the client understands
that nitroglycerin should not be given to the client if he manifests which sign or symptom?
Atrial fibrillation
A blood pressure of 78/59 mm Hg.
Headache
A warm flushed feeling

5. The nurse is caring for a client in the Intensive Care Unit with acute respiratory failure. The
nurse should expect which ABG results?
pH: 7.29; PCO2: 56; PaO2: 83; HCO3: 22
pH: 7.38; PCO2: 40; PaO2: 92; HCO3: 25
pH: 7.49; PCO2: 34; PaO2: 96; HCO3: 28
pH: 7.40; PCO2: 65; PaO2: 85; HCO3: 16
 6. A client in his early 60s is brought to the ER complaining of shortness of breath. Initial
assessment findings include crackles, finger clubbing, and dry cough. The client states that he has
previously worked in construction for 15 years. The ER physician suspects asbestosis. Which
nursing problem should the nurse prioritize in the client?
Impaired gas exchange
Imbalanced nutrition: Less than body requirements
Fatigue
Ineffective airway clearance

7. The nurse cares for a 58-year-old client in the emergency department.

History &
Physical

1600 – 58-year-old client with a history of hypertension and diabetes mellitus type I reports headaches
and elevated blood pressure. The client reported the headaches started one day ago and have
worsened. The client reports not taking his prescribed medications because he lost his health insurance.
His prescribed antihypertensive medications were clonidine and enalapril. The client has a flushed
appearance on exam, endorses a generalized headache, and blurred vision.

Vital Signs

Oral temperature 99.5 F (37.5o C); Pulse 114 bpm; Respirations 16.
BP 207/124 mm Hg; Oxygen saturation 95% on room air.

Laboratory

Laboratory Result Reference Range

Capillary Blood Glucose 225 mg/dL
BUN 25 mg/dL
Creatinine 1.3 mg/dL

Orders

● Nitroprusside via continuous infusion

● Timolol 0.25% to both eyes

Diagnostic
Testing

Diagnostic Test Result Reference Range

 Tonometry 19 mmHg 10 – 21 mmHg

➣Complete the diagram by dragging from the choices below to specify what condition the client
is most likely experiencing, two (2) actions the nurse should take to address that condition, and
two (2) parameters the nurse should monitor to assess the client’s progress.

Action to Take Potential Conditions Parameters to Monitor

Administer prescribed timolol Myocardial infarction Troponin

ophthalmic

Obtain hourly blood glucose Hypertensive Emergency Blood Glucose

levels
Obtain a prescription for regular Migraine Headache Thiocyanate levels
insulin infusion
Position the client Diabetic ketoacidosis Blood Pressure
Semi-fowler’s
Administer prescribed Angle Closure Glaucoma Intraocular pressure (IOP)
nitroprusside

8. A nurse is reviewing a client's arterial blood gas results and notes the following: pH 7.45,
PCO2 of 30 mm Hg, and HCO3-of 22 mEq/L. Which of the following conditions do these
results indicate?
Metabolic acidosis, compensated
Respiratory alkalosis, compensated
Metabolic alkalosis, uncompensated
Respiratory acidosis, uncompensated

9. A middle-aged African American is being treated in the emergency room for a sickle cell
crisis. Which position should the nurse place the patient in?
Side-lying with flexed knees
Fetal position
Semi-Fowler’s position with knees and hips bent
Semi-Fowler’s with legs extended on the bed
 10. The nurse is providing discharge instructions to a client prescribed nasal cannula oxygen.
Which of the following instructions should the nurse include? Select all that apply.
Keep a pulse oximetry device readily available.
Pad the tubing in areas that put pressure on the skin.
Have a sign on your door indicating the presence of oxygen.
I should use the oven and not the stovetop to cook.
You may apply petroleum jelly to your nares to prevent drying.

11. During handoff, the nurse was informed that a patient’s serum potassium is 2.8 mEq/L. During
rounds, the first thing that the nurse should assess in this client should be:
Ability to balance while walking
Quality of peripheral pulses
Respiratory status looking out for shallow respirations
Frequency of bowel movement

12. The nurse working in the clinic reviews laboratory data for a client prescribed lithium.
➢ Click to highlight the findings in the laboratory data that requires follow-up.

Laboratory

Laboratory Test Result Reference Range

White Blood Cell 10,500 mm3 5,000 – 10,000 mm3
Sodium 130 mEq/L 135-145 mEq/L
Potassium 3.7 mEq/L 3.5 – 5.0 mEq/L
Blood Urea Nitrogen 29 mg/dL 10-20 mg/dL
Creatinine 1.0 mg/dL 0.6-1.2 mg/dL
Lithium Level 1.5 mEq/L 0.6 – 1.2 mEq/L

13. The infant just finished surgery for the repair of a malfunctioning ventriculoperitoneal shunt.
Which symptom would indicate to the nurse that a problem could be arising?
Increased urine output

Depressed fontanels
A decreased heart rate
Irritability

14. A nurse calls the physician regarding a new medication order because the prescribed dosage
is higher than the recommended dosage. The nurse, however, is unable to locate the physician,
and the medication is due to be administered. Which action should the nurse implement first?
Contact the unit’s nursing supervisor
 Administer the dose as prescribed since the nurse is protected by a written order
Hold the medication until the physician can be contacted, and the order is
clarified
Administer what the nurse knows as the recommended dose until the physician can be
located

15. The nurse is teaching a client about newly prescribed insulin glargine. The nurse recognizes the
need for further instruction when the client makes the following statement? Select all that
apply.
"I will take this insulin right before my meals."
"I should roll this vial of insulin before removing it with the syringe."
"This insulin will help control my glucose for 24 hours."
"I can only inject this insulin into my abdomen."
"I'm glad to know I can mix this with my regular insulin."

16. A client has just been transferred back to his room following a below-knee amputation of the
right leg. The nurse is closely monitoring the client. Which sign would prompt the nurse to
assess further, as it could indicate a developing complication?
The client is growing increasingly restless
The client has a blood pressure of 127/78 mmHg
The client has a pulse rate of 89 bpm
Hypoactive bowel sounds were found upon auscultation of 4 quadrants

17. A nurse is conducting client teaching on a client receiving a monoamine oxidase inhibitor
(MAOI) about his drug therapy. The client has demonstrated understanding by stating I should
avoid tyramine-containing foods, or I may go into a hypertensive crisis. When asked to list
specific tyramine-containing foods, the client would be correct by including which food?
Cream cheese
Swiss cheese
Milk
Ice cream

18. A client with thrombocytopenia is currently having epistaxis. The most appropriate nursing
intervention should be:
Instruct the client to lie flat with his neck suspended
Ask the client to sit upright, leaning slightly forward
Ask the client to blow his nose, then put lateral pressure on his nose
Ask the client to hold his nose while bending forward from the waist

19. The nurse is caring for a client with a major thermal burn. Which initial laboratory
abnormalities does the nurse anticipate in response to the burn? Select all that apply.
Hemodilution
Hyperkalemia
 Metabolic Acidosis
Hyperglycemia
Hemoconcentration

20. The client in a psychiatric clinic tells the nurse, I want to kill my wife. The moment I see, I am
going to kill her. What should be the nurse’s next action?
Respect the client’s right to privacy and confidentiality.
Document the client’s statements
Notify the client’s psychiatrist of the comments.
Explore the client’s feelings about his wife

21. A client arrives at the clinic with his daughter reporting memory impairments.

Nurses’ Note

A 71-year-old male arrives with his daughter with concerns about memory loss. The client’s daughter
reports that he has forgotten key dates, such as birthdays and his wedding anniversary, over the past six
months. She emphasized that he would never forget these dates. Further, the client’s daughter also
reports that driving has become more difficult and that the client has been involved in two minor
accidents over the past six months. He has also misplaced three sets of keys. The daughter describes
her father’s judgment as ‘declining’ along with his memory. The client’s daughter is concerned that her
father may have dementia.

The client is alert and fully oriented. The client had difficulty with remote memory questioning.
Immediate and recent memory was intact. The client denied any pain or physical symptoms, stating, “I’m
here because my daughter insisted.”

➢ Click to specify if the clinical feature is consistent with delirium or dementia. Each finding
may support more than one disease process.

Clinical Feature Delirium Dementia

The onset of symptoms is
months to years
May be caused by uncontrolled
hypertension and diabetes
Progressively worsens
Memory impairments
It may be caused by fluid and
electrolyte imbalances or
infection
May cause impairments in
judgment
Altered level of consciousness
 22. The primary healthcare provider prescribes 30 mL/kg of 0.9% saline to a client with
suspected sepsis. The client weighs 236 pounds. How many mL will the nurse infuse into the
client? Fill in the blank. Round your answer to the nearest whole number.

mL

23. The nurse is assessing a client who has developed cardiac tamponade. Which of the
following findings would the nurse expect to observe? Select all that apply.
Bibasilar crackles
A systolic murmur
Bradycardia
Jugular venous distention
Hypotension

24. The nurse is caring for a client newly admitted to the medical-surgical unit.

Primary Healthcare Provider

Nurse’s Note (PHCP) Prescriptions

2100 –A 17-year-old female was admitted with - 0.9% saline at 150 mL/hr
severe dehydration. The client was at school and - Psychiatry consultation
‘blacked out.’ The client is underweight and - Fluoxetine 40 mg PO daily
appears malnourished. She was diagnosed with - Daily weights
anorexia nervosa two years ago. She endorsed - Dietician consultation
suicidal ideations saying, ‘She is tired of her body - Supervise mealtimes
and wants to end it all.’ She reports persistent
dizziness and a headache.

Drag one (1) prescription and one (1) nurse’s note finding to complete the sentence.

Based on the client’s clinical data, the nurse should immediately _______________ based on the client’s
_________________.

PHCP’s Prescriptions Health History Findings

administer olanzapine suicidal ideations
initiate 0.9% saline infusion severe dehydration
weigh the client altered nutrition
establish a therapeutic rapport underweight appearance
25. A 78-year-old man is admitted with sepsis. Which of the following should the nurse expect
the health care provider to order? Select all that apply.
Crystalloids
Blood cultures
Abdominal x-ray
Antibiotics
Two large-bore IVs
Vasopressors if shock persists

26. Which EKG rhythm represents a third-degree heart block?

a.

b.

c.

d.

27. The nurse is caring for a client experiencing variable decelerations. The nurse observes the
umbilical cord protruding through the vagina. Place the priority actions in the correct order.
Place the client in the Trendelenburg position
Prepare for delivery
Apply pressure to lift the presenting fetal part
Administer oxygen
Stay with the client and call for help
 28. A 3-month-old infant is in the emergency room for acute abdominal pain. The nurse
suspects intussusception. Which assessment data would further support the nurse’s
suspicion?
Black tarry stool
Ribbon-like stool
Red, currant jelly-like stool
Frothy, foul-smelling stool

29. The nurse is assessing a client experiencing psychosis. The client states, "I am
convinced my wife and brother-in-law want to kill me." The nurse interprets this
statement as a:
Delusion of reference
Delusion of persecution
Delusion of grandeur
Delusion of erotomania

Unfolding Case Study

The nurse cares for a 29-year-old male in the emergency department (ED).

Nurses' Note
2115 – Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a
fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire
then spread to his back and part of his chest.
The client has sustained full thickness burns to this right hand and entire arm. Superficial partial
thickness burns were observed to his right torso and entire back.
The client arrives screaming in pain that he states are in his torso and back. He endorses no pain in his
right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in
the left antecubital space.

Vital Signs
Oral Temperature 99 o F (37o C)
Heart rate 114/minute
Respirations 22/minute
Blood pressure 98/62 mm Hg
Oxygen saturation 95% on room air
 Assessment

Neurological Alert and completely oriented. Appears

distressed.
Cardiovascular Thready peripheral pulses, no edema, no jugular
venous distention (JVD)
Respiratory Clear lung fields, unlabored respirations,
tachypnea
GI/GU Normoactive bowel sounds
Skin Full thickness burns to the right hand and entire
arm; Superficial partial thickness burns to his
right torso and entire back. The client is
diaphoretic and pale elsewhere.

30. Which two (2) assessment findings is the nurse most concerned with?
Respiratory status
Extent of injury
Oral temperature
Type of burns
Sensation in the right arm
31. Complete the sentence from the list of options.

Select
18%
27%
36%

Based on the client’s injuries, the client has sustained a total body surface area burn.

32. Based on the clinical data, the nurse’s immediate concern is the client’s
risk for infection.
thermoregulation.
airway patency.
fluid volume deficit.

33. Which interventions should the nurse anticipate being incorporated into the client’s plan of care?

Intervention Anticipated Not Anticipated

Insertion of indwelling urinary
catheter
Irrigate wounds with cool saline
solution
Implement fluid restrictions
Remove any jewelry from
affected extremity
Administer tetanus prophylaxis
(Tdap)
 34. Complete the sentences from the list of options.

The nurse should plan to obtain a prescription for __________to restore circulating volume.

Select
0.45% saline
Dextrose 5% Water (D5W)
Lactated ringers

The __________ will be used to determine the 24-hour fluid requirement.

Select
Parkland formula
pulmonary function tests
TNM staging

To measure the effectiveness of the fluid replacement, the nurse plans to __________.

Select
Insert an indwelling urinary catheter.
Collect serial complete blood counts.
Monitor the serum potassium level.

35. The nurse has initiated prescribed intravenous Lactated Ringers (LR) and inserted an indwelling
urinary catheter.

The nurse assesses the urine output and determines whether the client is meeting the treatment
goal when it is
a. 0.10 mL/kg/hr.
b. 0.25 mL/kg/hr.
c. 0.6 mL/kg/hr.
d. 0.5 mL/kg/hr.
 Cumulative NCLEX Practice Test Answer Key
1. A client has been admitted to the hospital with findings of urinary tract infection and
dehydration. The nurse determines that the client has received adequate volume
replacement and has returned to normal hydration status if the blood urea nitrogen level is
a. 5 mg/dL
b. 15 mg/dL
c. 27 mg/dL
d. 34 mg/dL

Correct Answer: B

Rationale: The average blood urea nitrogen level is 8 to 25 mg/dL. Values such as those in
options C and D indicate continued dehydration. Option A reflects a lower than average cost,
which may occur with fluid volume overload, among other conditions. 27 mg/dL indicates a
normal BUN, showing that the client has received adequate volume replacement and has
returned to normal hydration status.

2. A client newly diagnosed with diabetes mellitus has a glycosylated hemoglobin A1c level of
10%. The nurse ensures that client teaching includes which of the following:
a. Avoiding infection
b. Taking in adequate fluids
c. Preventing and recognizing hypoglycemia
d. Preventing and recognizing hyperglycemia

Correct Answer: D

Rationale: Glycosylated Hemoglobin is tested to monitor the long-term control of diabetes

mellitus. It measures the amount of glucose that has become permanently bound to the red
blood cells from circulating glucose. If the blood glucose level rises, the amount of
glycosylation is also elevated. This indicates that the client has had periods of undetected
hyperglycemia. For glycosylated hemoglobin A1c, 7% or less indicates reasonable control, 7%
to 8% indicates good power, and 8% or higher indicates poor control. The test result helps the
nurse identify the continued need for teaching related to the prevention of hyperglycemic
episodes. Therefore, options A, B, and C are incorrect, while option D is the correct answer.
3. The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the
following prescriptions should the nurse anticipate from the primary healthcare provider
(PHCP)? Select all that apply.
a. Furosemide
b. Neomycin
c. Naproxen
d. Lactulose
e. Diazepam

Choices B and D are correct. Neomycin is an antibiotic and is indicated for hepatic
encephalopathy. This oral medication is taken to decrease ammonia's gastrointestinal
production, which contributes to encephalopathy. Lactulose is central in treating hepatic
encephalopathy because it traps ammonia in the colon and increases its transit. Thereby
decreasing serum ammonia levels.

Choices A, C, and E are incorrect. Potassium-wasting diuretics such as furosemide should be

avoided because it contributes to hypokalemia. Hypokalemia contributes to the production of
ammonia. Thus, a highly preferred diuretic in mitigating ascites is potassium-sparing diuretic
spironolactone. NSAIDs should be avoided because of their nephrotoxic and anticoagulation
effects. Low doses of acetaminophen may be approved for mild to moderate pain.
Benzodiazepines, such as diazepam, should be avoided for a client with hepatic encephalopathy.
These medications can worsen a client's sensorium, putting the client at high risk for falls and
injury.

Treatment options for hepatic encephalopathy would include prescribed

potassium-sparing diuretics, lactulose, and antibiotics such as neomycin or rifaximin. Nursing
care aims to assist the client in achieving and maintaining treatment adherence and the
avoidance of medication such as NSAIDs and benzodiazepines that could worsen the
encephalopathy.

4. The client is admitted for having unstable angina. The nurse caring for the client understands
that nitroglycerin should not be given to the client if he manifests which sign or symptom?
a. Atrial fibrillation
b. A blood pressure of 78/59 mm Hg.
c. Headache
d. A warm flushed feeling

Correct Answer: B
 A is incorrect. Nitroglycerin is not contraindicated in atrial fibrillation. Therefore, it is safe to
administer the drug even if there is atrial fibrillation. B is correct. Nitroglycerin is a vasodilator
that causes a decrease in blood pressure. The nurse should not administer any drug that causes
the blood pressure to drop when the client’s systolic blood pressure is below 90 mm Hg. C is
incorrect. Headaches are a common side effect of nitroglycerin and should not be a reason to
withhold the drug. D is incorrect. A warm flushed feeling is also a side effect of Nitroglycerin,
which is caused by its vasodilatory effects.

5. The nurse is caring for a client in the Intensive Care Unit with acute respiratory failure. The
nurse should expect which ABG results?
a. pH: 7.29; PCO2: 56; PaO2: 83; HCO3: 22
b. pH: 7.38; PCO2: 40; PaO2: 92; HCO3: 25
c. pH: 7.49; PCO2: 34; PaO2: 96; HCO3: 28
d. pH: 7.40; PCO2: 65; PaO2: 85; HCO3: 16

Correct Answer: A

A is correct. A client in respiratory distress should be expected to exhibit acidosis, hypoxemia,

and hypercapnia (respiratory acidosis) in his ABGs. Option A indicates respiratory acidosis. B is
incorrect. This is indicative of a normal Arterial blood gas result. C is incorrect. This is an arterial
blood gas result showing respiratory alkalosis. Respiratory alkalosis commonly occurs in
hyperventilation, wherein more carbon dioxide is eliminated. D is incorrect. This is an example of
compensated respiratory acidosis.

6. A client in his early 60s is brought to the ER complaining of shortness of breath. Initial
assessment findings include crackles, finger clubbing, and dry cough. The client states that he
has previously worked in construction for 15 years. The ER physician suspects asbestosis.
Which nursing problem should the nurse prioritize in the client?
a. Impaired gas exchange
b. Imbalanced nutrition: Less than body requirements
c. Fatigue
d. Ineffective airway clearance

Correct Answer: A

A is correct. In asbestosis, there is filling and inflammation of lung spaces with asbestos fibers.
These fibers move into the alveolar space and cause fibrosis, leading to increased production in
secretions and impairing gas exchange. This should be a priority problem for the nurse. B is
incorrect. The patient has imbalanced nutrition because of his difficulty of breathing and
intolerance to activity. However, it should not be prioritized over the gas exchange. C is incorrect.
Because of the client’s impaired oxygenation, insufficient oxygen reaches the muscles to sustain
activity.
 However, this problem must not take priority over the gas exchange. D is incorrect. Due to the
increased secretions brought about by the asbestos fibers, there is an ineffective airway
clearance. Although equally crucial with gas exchange, the nurse should prioritize impaired gas
exchange over airway clearance because treatment for asbestosis focuses on relieving
symptoms. Oxygen delivery to the cells holds more importance.

7. Correct Responses

Potential Conditions
This client is experiencing a hypertensive emergency and is at risk for end-organ damage. The
client is hypertensive and is symptomatic (headache, blurred vision, flushing). This is supported
by the client reporting that he was unable to take his prescribed medications and likely is
experiencing rebound hypertension from the abrupt discontinuation of the medication. The
hypertension is causing end-organ damage, as evidenced by the increased creatinine.
It is unlikely that the client is experiencing a myocardial infarction. The client did not endorse any
angina, nor is the client reporting atypical manifestations such as indigestion or profound fatigue.
Diabetic ketoacidosis is not a condition experienced by the client because the blood sugar is not
hyperglycemic (greater than 250 mg/dL). The client reporting blurred vision and a headache is a
concern for acute angle-closure glaucoma, but the tonometry reading, which measures
intraocular pressure was normal. The intraocular pressure would be greater than 30 mmHg for
acute angle-closure glaucoma. Migraine headaches are not likely because having a headache
with this significantly elevated blood pressure is uncommon for a migraine.

Action to Take
Priorities for a client experiencing a hypertensive emergency/crisis is to administer the prescribed
antihypertensive. A prescription was provided for nitroprusside, and the nurse should administer
the drug via an infusion pump. The nurse should also position the client semi-Fowlers. This
position is preferred because this position slightly decreases intracerebral blood pressure. The
supine position would not be recommended because this increases blood flow to the brain and is
not recommended for a client with extremely high blood pressure.

Parameters to Monitor
The client taking nitroprusside should have their blood pressure carefully watched. Nitroprusside
is a potent vasodilator; monitoring blood pressure every five to fifteen minutes is required. A
complication of not watching the blood pressure closely during this therapy would be significant
hypotension.
8. A nurse is reviewing a client's arterial blood gas results and notes the following: pH 7.45,
PCO2 of 30 mm Hg, and HCO3-of 22 mEq/L. Which of the following conditions do these
results indicate?
a. Metabolic acidosis, compensated
b. Respiratory alkalosis, compensated
c. Metabolic alkalosis, uncompensated
d. Respiratory acidosis, uncompensated

Correct Answer: B

The normal pH ranges between 7.35-7.45. As seen in this case, a respiratory condition would
show an inverse relationship between the PCO2 and the pH. In a metabolic state, the HCO3-
would have direct contact with the pH. Because the pH is at 7.45, which is within the normal
range, this is an indication that compensation has occurred. Therefore, option B is the correct
answer, while options A, C, and D are incorrect.

9. A middle-aged African American is being treated in the emergency room for a sickle cell
crisis. Which position should the nurse place the patient in?
a. Side-lying with flexed knees
b. Fetal position
c. Semi-Fowler’s position with knees and hips bent
d. Semi-Fowler’s with legs extended on the bed

Correct Answer: D

A is incorrect. The nurse should facilitate oxygenation and adequate circulation for the client.
Knee flexion impedes the flow of the client. B is incorrect. In a fetal position, the client’s knees
and hips are flexed. Knee and hip flexion impede circulation in the patient. The nurse should
ensure that flow is optimal when positioning the client. C is incorrect. Semi-Fowler’s position
facilitates lung expansion; however, the bent knees and hips impede the client’s circulation. The
nurse should not place the client in this position. D is correct. The client in sickle cell crisis
should be positioned to optimize circulation and oxygenation. The nurse should place the client
in Semi-Fowler’s position with his extremities relaxed and straightened.
10. The nurse is providing discharge instructions to a client prescribed nasal cannula oxygen.
Which of the following instructions should the nurse include? Select all that apply.
a. Keep a pulse oximetry device readily available.
b. Pad the tubing in areas that put pressure on the skin.
c. Have a sign on your door indicating the presence of oxygen.
d. I should use the oven and not the stovetop to cook.
e. You may apply petroleum jelly to your nares to prevent drying.

Choices A, B, and C are correct. A pulse oximetry device should be provided to the client, and
they should be encouraged to log their oxygen saturations as directed. If the client experiences
dyspnea or tachypnea, the client should be instructed to seek medical attention for a level less
than 95% (unless otherwise directed). Padding the tubing around pressure ears (back of the
ears) is recommended to avoid injury. A sign posted on the door should be visible to alert
visitors of the oxygen and extinguish and open flames.

Choices D and E are incorrect. Stovetop and oven cooking is highly discouraged as the presence
of oxygen may accelerate any fire that may ignite. Rather, if cooking is to be done using heat or
flames, another individual should do the cooking, and the oxygen should be greater than six feet
away from the flame source. Petroleum jelly should not lubricate the nares as it may be aspirated.
Water-soluble jelly is recommended.

11. During handoff, the nurse was informed that a patient’s serum potassium is 2.8 mEq/L. During
rounds, the first thing that the nurse should assess in this client should be:
a. Ability to balance while walking
b. Quality of peripheral pulses
c. Respiratory status looking out for shallow respirations
d. Frequency of bowel movement

Correct Answer: C

Rationale: Hypokalemia affects the musculoskeletal, cardiovascular, neurologic, and respiratory

systems. The skeletal muscles become weak, which may make ambulation difficult. The
peripheral pulses may become weak and thready. One of the muscles that will become weak is
the diaphragm, which can lead to weak and shallow respirations. There may be decreased
peristalsis in the GI system leading to constipation.

So, all of these assessment findings are possible with hypokalemia! However, the respiratory
system is the first thing that the nurse should assess. Remember, airway, breathing, circulation!!
Hypokalemia causes diaphragm muscle weakness,
 which may lead to shallow respirations and respiratory insufficiency. This is the priority.
Therefore, respiratory status should be assessed first in any client with hypokalemia, making
option C the correct answer. Options A, B, and D should also be included in the assessment but
are not the utmost priority and are incorrect.

12. The nurse working in the clinic reviews laboratory data for a client prescribed lithium.
➢ Click to highlight the findings in the laboratory data that requires follow-up.

Laboratory

Laboratory Test Result Reference Range

White Blood Cell 10,500 mm3 5,000 – 10,000 mm3
Sodium 130 mEq/L 135-145 mEq/L
Potassium 3.7 mEq/L 3.5 – 5.0 mEq/L
Blood Urea Nitrogen 29 mg/dL 10-20 mg/dL
Creatinine 1.0 mg/dL 0.6-1.2 mg/dL
Lithium Level 1.5 mEq/L 0.6 – 1.2 mEq/L

The findings requiring follow-up include the decreased sodium level, which is concerning because
hyponatremia facilitates lithium toxicity. The elevated BUN requires follow-up because this is further
evidence of dehydration. The lithium level is elevated, which is quite concerning for toxicity.

The white blood cell (WBC) count is elevated, but this is not a concern. Lithium causes leukocytosis,
which is a benign side effect. While this could mask acute infection and inflammation, this is an expected
finding.

Additional information: Lithium is a salt and is utilized to treat bipolar disorder. Key teaching points for a
patient taking lithium include the avoidance of dehydration, adhering to the dosing schedule to maintain
a therapeutic level of 0.6-1.2 mEq/L, and reporting signs of toxicity such as nausea, vomiting, and ataxia.
The patient should be instructed that the drug level should be obtained twelve hours after the last dose.

13. The infant just finished surgery to repair a malfunctioning ventriculoperitoneal shunt. Which
symptom would indicate to the nurse that a problem could be arising?
a. Increased urine output
b. Depressed fontanelle
c. A decreased heart rate
d. Irritability

Correct Answer: D

A is incorrect. Increased urine output is not related to problems with VP shunting.

B is incorrect. Depressed fontanels are a sign that the VP shunt is draining the CSF from the
 child’s cranial cavity. A bulging fontanel is a sign of a problem.

C is incorrect. Bradycardia is not an initial sign of increased ICP. Tachycardia should be observed
with increased intracranial pressure.

D is correct. Irritability in an infant is a sign of increased intracranial pressure.

14. A nurse calls the physician regarding a new medication order because the prescribed dosage
is higher than the recommended dosage. The nurse, however, is unable to locate the
physician, and the medication is due to be administered. Which action should the nurse
implement first?
a. Contact the unit’s nursing supervisor
b. Administer the dose as prescribed since the nurse is protected by a written order
c. Hold the medication until the physician can be contacted and the order is
clarified
d. Administer what the nurse knows as the recommended dose until the physician can be
located

Correct Answer: A

The correct answer is A. If the physician writes a prescription that is questionable or requires
clarification, the nurse's responsibility is to contact the physician. If there is no resolution
regarding the order because the physician cannot be located or because the physician insists on
keeping the medicine as it was written, the nurse should contact the nurse manager or nursing
supervisor for further clarification as to the proper steps that should be taken. Under no
circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

15. The nurse is teaching a client about newly prescribed insulin glargine. The nurse
recognizes the need for further instruction when the client makes the following
statement? Select all that apply.
a. "I will take this insulin right before my meals."
b. "I should roll this vial of insulin before removing it with the syringe."
c. "This insulin will help control my glucose for 24 hours."
d. "I can only inject this insulin into my abdomen."
e. "I'm glad to know I can mix this with my regular insulin."

Choices A, B, D, and E are correct. These statements are incorrect and require
follow-up. Insulin glargine is a long-acting insulin that has no peak effect. Thus, it is not taken
with meals. It is dosed once a day to provide glucose control for 24 hours. Insulin glargine is not a
suspension; thus, it does not need to be rolled like NPH. This insulin is not mixed with any other
insulin. Insulin glargine does not have only to be injected into the abdomen.

Choice C is incorrect. This statement is factual and does not require additional teaching. Insulin
glargine provides basal glucose control for up to 24 hours. Combined with a
carbohydrate-controlled diet, this should decrease the client's reliance on correctional insulin.
16. A client has just been transferred back to his room following a below-knee amputation of the
right leg. The nurse is closely monitoring the client. Which sign would prompt the nurse to
assess further, as it could indicate a developing complication?
a. The client is growing increasingly restless
b. The client has a blood pressure of 127/78 mmHg
c. The client has a pulse rate of 89 bpm
d. Hypoactive bowel sounds were found upon auscultation of 4 quadrants

Correct Answer: A

A postoperative client who is growing increasingly restless should prompt the nurse to monitor
closely and assess further as it can indicate hemorrhage, shock, or pulmonary embolism. A blood
pressure of 127/78mmHg is healthy, as well as a pulse rate of 89 bpm. Hypoactive bowel sounds
are expected postoperatively. The correct answer, therefore, is option A, while options B, C, and D
are incorrect.

17. A nurse is conducting client teaching on a client receiving a monoamine oxidase inhibitor
(MAOI) about his drug therapy. The client has demonstrated understanding by stating, “I should
avoid tyramine-containing foods, or I may go into a hypertensive crisis.” When asked to list
specific tyramine-containing foods, the client would be correct by including which foods?
a. Cream cheese
b. Swiss cheese
c. Milk
d. Ice cream

Correct Answer: B

Fermented, aged, or smoked foods are high in tyramine and should be avoided; thus, Swiss
cheese. Cream cheese, milk, and ice cream are unfermented milk products and may be taken by
patients on MAOIs without incident. The correct answer, therefore, is option B. Options A, C, and
D are incorrect.

18. A client with thrombocytopenia is currently having epistaxis. The most appropriate nursing
intervention should be:
a. Instruct the client to lie flat with his neck suspended
b. Ask the client to sit upright, leaning slightly forward
c. Ask the client to blow his nose, then put lateral pressure on his nose
d. Ask the client to hold his nose while bending forward from the waist

Correct Answer: B

In the event of epistaxis, the client should be instructed to assume an upright position, leaning
slightly forward to help prevent an increase of vascular pressure in the nose and help prevent
the aspiration of blood. Option B is, therefore the correct answer. Lying in the supine position
 would predispose the client to aspiration. Blowing the nose would risk dislodging any clotting
that has occurred and promote further bleeding. Bending at the waist increases the vascular
pressure in the nose, which would lead to further bleeding instead of stopping it. Options A, C,
and D are therefore incorrect.

19. The nurse is caring for a client with a major thermal burn. Which initial laboratory
abnormalities does the nurse anticipate in response to the burn? Select all that apply.
a. Hemodilution
b. Hyperkalemia
c. Metabolic Acidosis
d. Hyperglycemia
e. Hemoconcentration

Choices B, C, D, and E are correct. Following a major burn, significant fluid and electrolyte
changes occur from cellular damage, which causes potassium to leak into the extracellular
space. Thus, life-threatening hyperkalemia may occur. Metabolic acidosis is likely because of
the impairment the burn causes to the kidney's ability to cycle bicarbonate. The discharge of
catecholamines causes glucose release from the liver, raising the blood glucose. Finally, the
loss of fluid causes hemoconcentration, illustrated by an elevated hematocrit.

Choice A is correct. Initially, the client with a major thermal burn will have hemoconcentration
from all of the fluid loss. Hemodilution may occur later in the process from the fluid shift.

20. The client in a psychiatric clinic tells the nurse, I want to kill my wife. The moment I see, I am
going to kill her. What should be the nurse's next action?
a. Respect the client’s right to privacy and confidentiality.
b. Document the client’s statements
c. Notify the client’s psychiatrist of the comments.
d. Explore the client’s feelings about his wife

Correct Answer: C

A is incorrect. Although the nurse should respect the confidentiality of the subject, the nurse
should make arrangements so that the wife is informed of the threat to her safety.

B is incorrect. The nurse needs to document what the client said in the conversation; however, the
nurse should implement measures to ensure the safety of the client’s wife.

C is correct. Mental health staff must report identifiable third parties of threats made by a
person, even if these threats were discussed in a private therapy session.

D is incorrect. Exploring the client’s feelings regarding his wife would further increase the
client’s anger toward her. This is not an appropriate action for the nurse to take.
 21.
Clinical Feature Delirium Dementia
The onset of symptoms is x
months to years
May be caused by uncontrolled x
hypertension and diabetes
Progressively worsens x
Memory impairments x x
May be caused by fluid and x
electrolyte imbalances or
infection
May cause impairments in x x
judgment
Altered level of consciousness x

This client is likely experiencing the early stages of dementia. Although more testing needs to be
completed, the onset of symptoms being months ago, the client having a disturbance in his executive
functioning, and lack of insight point to dementia. It is common for clients with memory loss to have
limited insight and rely on denial as a defense mechanism. Thus, having a family member identify the
issue is common.

22. The primary healthcare provider prescribes 30 mL/kg of 0.9% saline to a client with
suspected sepsis. The client weighs 236 pounds. How many mL will the nurse infuse into the
client? Fill in the blank. Round your answer to the nearest whole number.

mL

First, convert the pounds to kilograms by dividing the weight in pounds by 2.2 236 / 2.2

= 107.27 kg

Next, multiply the prescribed amount of fluid by the client's weight in kilograms 30 mL x

107.27 kg = 3218.1 mL

Finally, round the amount of fluid to a whole number of 3218

23. The nurse is assessing a client who has developed cardiac tamponade. Which of the
following findings would the nurse expect to observe? Select all that apply.
a. Bibasilar crackles
b. A systolic murmur
c. Bradycardia
d. Jugular venous distention
e. Hypotension

Choices D and E are correct. Classic manifestations of cardiac tamponade include tachycardia,
 tachypnea, pericardial rub, jugular venous distention, and hypotension with a narrowed pulse
pressure.

Choices A, B, and C are incorrect. Bibasilar crackles, a systolic murmur, and bradycardia would
not be consistent with cardiac tamponade. The client with cardiac tamponade would have
tachycardia to increase cardiac output, coupled with a pericardial friction rub if the tamponade is
caused by inflammation.

An array of infectious and noninfectious reasons may cause cardiac tamponade. Immediate
treatment of cardiac tamponade would be pericardiocentesis. A needle is inserted to aspirate
the pericardial fluid in this ultrasound-guided procedure. The provider may elect to leave a
temporary catheter in place in the pericardium to drain more fluid. Nursing care involves
reporting any suspicion of cardiac tamponade promptly to the provider.

24. Based on the client’s clinical data, the nurse should immediately initiate a 0.9% saline infusion
based on the client’s severe dehydration.
Rationale –
The client is exhibiting concerning signs of severe dehydration (persistent dizziness and an
episode of syncope). The nurse must prioritize physical needs and interventions, which is
initiating intravenous fluids. The intravenous fluids will positively affect severe dehydration.
The nurse should then address the client’s suicidal ideations by ensuring the environment is safe
and then establishing a therapeutic rapport. While no approved medication is available for
anorexia, olanzapine has shown some benefits as it increases weight. This medication will take
several days to gain efficacy and is not the priority. Weighing the client will not correct the
client’s severe dehydration, which is causing her dizziness and syncope. Physical needs are still a
priority if a client has a mental health disorder.

25. A 78-year-old man is admitted with sepsis. Which of the following should the nurse expect
the health care provider to order? Select all that apply.
a. Crystalloids
b. Blood cultures
c. Abdominal x-ray
d. Antibiotics
e. Two large-bore IVs
f. Vasopressors if shock persists

Choices A, B, D, E, and F are correct. When treating sepsis, inserting intravenous access (2
large-bore IVs, 16-gauge), obtaining blood cultures, and starting crystalloid fluids are critical
initial interventions. Vasopressors are administered if the shock persists despite the initial
interventions and aggressive fluid resuscitation
Intravenous access: When sepsis is suspected, adequate venous access with two large-bore
IVs (16-gauge) (Choice E) must be placed as soon as possible. This allows the administration
of aggressive volume resuscitation (crystalloids) and
broad-spectrum antibiotics.

Blood cultures: Blood cultures (Choice B) must be obtained once sepsis is suspected. Blood
cultures help to confirm the sepsis diagnosis, identify the causative organism, and tailor the
antibiotic coverage. Per the 'Surviving Sepsis Campaign guidelines, at least two blood cultures
should be obtained before initiating antibiotics (one percutaneously drawn and the other from
peripheral vascular access.)

Crystalloids: Sepsis often results in systemic inflammatory response syndrome (SIRS), leading to
systemic vasodilation. Isotonic fluids (crystalloids such as normal saline, Choice A) are given
intravenously to help maintain systemic vascular resistance (SVR) and blood pressure.

Antibiotics: Antibiotics (Choice D) must be given early to improve the outcomes of sepsis.
Guidelines mandate starting antibiotics within 1 hour of a suspected sepsis diagnosis. Int
empiric broad-spectrum antibiotics are initially used, but they are later tailored to the specific
organism identified on blood cultures.

Vasopressors: Initial intervention in all cases of sepsis includes aggressive volume resuscitation
(crystalloid fluid bolus of 30 mL/kg [1-2 L] over 30-60 minutes).
Vasopressors are indicated if the hypotension persists despite aggressive volume resuscitation
with several liters (4 or more liters) of the isotonic crystalloid solution. Persistent hypotension
(shock) is defined as systolic blood pressure lower than 90 mmHg or mean arterial pressure
(MAP) lower than 65 mmHg with decreased tissue perfusion. When vasopressors are indicated,
a central venous catheter should be placed in the internal jugular or subclavian vein. While
helpful in administering large-volume crystalloids and adequate vasopressors, primary venous
access also allows the measurement of central venous pressure (CVP). The preferred
vasopressor in sepsis is norepinephrine. Dopamine increases heart rate and is not the preferred
vasopressor and is only used if there is concomitant bradycardia.

Choice C is incorrect. There is no indication to perform an abdominal X-ray in all cases of

sepsis. However, if an abdominal source of infection (abdominal perforation, peritonitis, or
bowel obstruction) is suspected, an abdominal X-ray should be obtained.
26. Which EKG rhythm represents a third-degree heart block?

a.

b.

c.

d.

Choice A is correct. This rhythm represents a 3rd-degree heart block because there is no QRS
complex after every other p wave. This is because the AV node has no conduction during a
3rd-degree heart block. Therefore, the p waves and QRS complexes are not interacting with
each other.

Choice B is incorrect. This rhythm represents a 1st-degree heart block. This rhythm occurs when
the AV conduction is slowed, therefore creating a more extended time between the p wave and
the QRS complex.

Choice C is incorrect. This rhythm represents a 2nd-degree heart block or Mobitz type
2. This occurs when the AV node is taking longer to conduct. The PR interval may be regular or
lengthened. This rhythm indicates problems in the Purkinje system.

Choice D is incorrect. This rhythm is sinus tachycardia, which is a heart rate over 100 bpm.
27. The nurse is caring for a client experiencing variable decelerations. The nurse observes the
umbilical cord protruding through the vagina. Place the priority actions in the correct order.
a. Place the client in the Trendelenburg position
b. Prepare for delivery
c. Apply pressure to lift the presenting fetal part
d. Administer oxygen
e. Stay with the client and call for help

Answer: C, E, A, D, B

The priority nursing action is to apply pressure to the presenting fetal part. This will lift the fetus
off the prolapsed umbilical cord and restore blood flow to the fetus. The nurse cannot let go until
the health care provider arrives to deliver the fetus. The nurse should stay with the client and
call for help. This is a medical emergency, and the nurse must remain with the client to ensure
safety. Next, the nurse needs someone to place the client in Trendelenburg’s position. This will
assist with keeping the presenting fetal part off of the umbilical cord, so that blood flow to the
fetus continues. Next, the nurse needs someone to administer oxygen to the mother via a simple
face mask at 8-10 L/min. This will optimize oxygenation to the fetus. Lastly, the nurse needs to
prepare for the immediate delivery of the fetus. This is the only way to resolve this medical
emergency.

28. A 3-month-old infant is in the emergency room for acute abdominal pain. The nurse
suspects intussusception. Which assessment data would further support the nurse’s
suspicion?
a. Black tarry stool
b. Ribbon-like stool
c. Red, currant jelly-like stool
d. Frothy, foul-smelling stool

Choice C is correct. Red, currant jelly-like stools are characteristic of intussusception. Choice A is

incorrect. Black, tarry stools indicate upper GI bleeding in a patient.

Choice B is incorrect. Ribbon-like stools are characteristic of Hirschsprung’s disease.

Choice D is incorrect. Frothy, foul-smelling stools are a characteristic stool pattern for
cystic fibrosis.

29. The nurse is assessing a client experiencing psychosis. The client states, "I am
convinced my wife and brother-in-law want to kill me." The nurse interprets this
statement as a:
a. Delusion of reference
 b. Delusion of persecution
c. Delusion of grandeur
d. Delusion of erotomania

Choice B is correct. Delusion of persecution is when an individual is falsely convinced someone is

out to get them or intends to cause them harm. This is a serious delusion because the client may
react with violence.

Choices A, C, and D are incorrect. A delusion of reference is when an individual is convinced

that something they are observing is explicitly meant for them. For example, a client is
watching a television newscast about a wanted individual and is convinced that the individual
is them. Delusion of erotomania occurs when an individual is convinced that someone is in love
with them. Delusion of grandeur is when an individual has a self-inflated view of themselves.

30. Which two (2) assessment findings is the nurse most concerned with?

a. Respiratory status
b. Extent of injury
c. Oral temperature
d. Type of burns
e. Sensation in the right arm

The client’s burn severity (both the extent and type) is of serious concern. A full-thickness burn ranging
from two to ten percent of the total body surface area is a severe burn injury requiring immediate medical
attention. This client has sustained 36% TBSA burns (9% to the arm, 18% to the back, 9% to the right
side of the torso). The client’s decreased sensation in his arm is a characteristic finding of a full-thickness
burn, as this type of burn causes nerve damage.

31.
Select
18%
27%
36%

Based on the client’s injuries, the client has sustained a 36 % total body surface area burn. This client
has sustained a total body surface area burn of 36%.

Entire back, 18%

Right arm, 9%
Right side of the torso, 9%

32. Based on the clinical data, the nurse’s immediate concern is the client’s
a. risk for infection.
b. thermoregulation.
c. airway patency.
d. fluid volume deficit.

The immediate concern for this client is their fluid volume status. The client is experiencing
tachycardia and suboptimal blood pressure suggesting significant hypovolemia. Additionally, the
extent and type of burn injury are severe. The client’s airway is patent and does not require
 follow-up. The risk for infection is a concern with a major burn, but the client’s hemodynamic
instability needs to be addressed first.

33. Which interventions should the nurse anticipate being incorporated into the client’s plan of care?

Intervention Anticipated Not Anticipated

Insertion of indwelling urinary x
catheter
Irrigate wounds with a cool x
saline solution
Implement fluid restrictions x
Remove any jewelry from the x
affected extremity
Administer tetanus prophylaxis x
(Tdap)

This client has sustained a major thermal burn and fluid repletion will be necessary. An
indwelling catheter will be needed to determine if the fluid repletion is successful. The wounds
should be irrigated with a cool (not cold) saline solution and wrapped lightly in sterile gauze. Any
jewelry should be removed from the affected extremity because the area will swell, and this may
cause vascular compromise. Tdap prophylaxis is commonly administered for any non-superficial
burn.

34. Complete the sentences from the list of options.

The nurse should plan to obtain a prescription for __________to restore circulating volume.
Select
0.45% saline
Dextrose 5% Water (D5W)
Lactated ringers

The __________ will be used to determine the 24-hour fluid requirement.

Select
Parkland formula
pulmonary function tests
TNM staging

To measure the effectiveness of the fluid replacement, the nurse plans to __________.

Select
insert an indwelling urinary catheter.
collect serial complete blood counts.
monitor the serum potassium level.

Isotonic fluids are used when providing fluid resuscitation to a client who sustained a major burn.
Thus, LR is an appropriate choice for treating the hypovolemia caused by the burn. The Parkland
formula (4 mL x client’s weight in kilograms x total body surface area burned) will determine the
24-hour fluid requirement. An indwelling catheter is necessary to determine if the client is
 responding to the fluid volume replacement. While weight is the gold standard in determining a
client’s fluid status, urine output should be monitored closely during acute fluid resuscitation.

35. The nurse assesses the urine output and determines whether the client is meeting the treatment
goal when it is
a. 0.10 mL/kg/hr.
b. 0.25 mL/kg/hr.
c. 0.6 mL/kg/hr.
d. 0.5 mL/kg/hr.

The nurse should monitor the client's hourly urine output to determine if the client is responding
to the fluid replacement. To determine the client’s hourly urine output, the nurse should multiply
the weight in kilograms by 0.5 mL. If the UOP is less than 0.5 mL/kg/hr, the physician should be
notified.