Category 1
The charge nurse receives report on four clients. Which client should the nurse assess first?
A. A 72-year-old client with heart failure who gained 1.5 kg (3.3 lb) over 3 days and reports needing two pillows at night
B. A 64-year-old client with pneumonia whose temperature is 38.2°C (100.8°F) and respiratory rate is 24/min
C. A 58-year-old client 6 hours after a thyroidectomy who reports tingling around the mouth and has a newly documented positive Chvostek sign
D. A 45-year-old client with pancreatitis who reports abdominal pain of 8/10 despite receiving IV morphine 30 minutes ago
Answer: C.
Short rationale: Tingling around the mouth and a positive Chvostek sign after thyroidectomy suggest acute hypocalcemia, which can progress to tetany, laryngospasm, and airway compromise.
A client is being transferred from a medical-surgical unit to a rehabilitation facility. Which action is most important for preventing an interruption in care?
A. Send the client's current medication administration record with the transport team
B. Provide a complete handoff that includes current status, recent changes, medications, lines, wounds, and pending results
C. Remove all peripheral IV access before transportation
D. Ask the receiving facility to obtain the client's medical history independently
Answer: B.
Short rationale: A complete handoff communicates the information the receiving team needs to continue safe, uninterrupted care
A 68-year-old client tells the nurse, "I'm healthy, so I don't really need preventive visits anymore." Which response is best?
A. "Preventive screening generally stops after age 65."
B. "Preventive care remains important, although recommendations are individualized according to age, health status, and prior screening."
C. "You only need to seek care if you develop symptoms."
D. "At your age, preventive care should focus primarily on medications."
Answer: B.
Short rationale: Preventive care continues in older adulthood, but screening recommendations should be individualized based on health status, previous screening, life expectancy, and preferences.
Question:
A client with metastatic cancer is receiving comfort-focused care. Which nursing interventions are appropriate? Select all that apply.
A. Assess and treat pain regularly
B. Explain that decreased appetite can occur near the end of life
C. Force oral fluids whenever the client refuses food
D. Provide frequent oral care
E. Reposition according to comfort and tolerance
F. Explain that some changes in breathing may occur as death approaches
G. Withhold opioids because they may cause respiratory depression
Answer: A, B, D, E, F.
Short rationale: End-of-life care focuses on comfort and symptom management. Pain control, oral care, comfortable repositioning, and education about expected changes are appropriate.
A postoperative client has not voided for 8 hours and reports increasing suprapubic pressure. Which actions are appropriate? Select all that apply.
A. Assess for bladder distention
B. Review intake and output
C. Obtain a bladder scan if available
D. Encourage the client to ignore the urge until the next scheduled toileting time
E. Assess for medications that may contribute to urinary retention
F. Insert an indwelling catheter immediately without further assessment
.
Answer: A, B, C, E.
Short rationale: Assessment should identify the cause and severity of urinary retention before intervention. Bladder scanning and medication review are appropriate.
A provider enters the following orders for a client admitted with acute kidney injury:
The client's current laboratory results are potassium 6.2 mEq/L, creatinine 3.4 mg/dL, and urine output 15 mL/hr. Which action should the nurse take first?
A. Administer the potassium chloride after confirming the client's IV patency
B. Hold the potassium chloride and contact the provider to clarify the order
C. Administer furosemide and then give the potassium chloride
D. Implement all orders as written
Answer: B.
Short rationale: A potassium of 6.2 mEq/L indicates severe hyperkalemia. Giving 40 mEq of IV potassium could cause life-threatening dysrhythmias. The nurse must clarify the unsafe order.
A client is scheduled for a thoracentesis. Which findings should cause the nurse to pause the procedure and address the issue before proceeding? Select all that apply.
A. The client states, "I don't understand why this procedure is necessary."
B. The signed consent is present, but the client says, "I signed because my daughter told me I had to."
C. The client asks whether the procedure will improve breathing.
D. The provider has not yet discussed the major risks and benefits with the client.
E. The client correctly explains that fluid will be removed from the pleural space.
F. The client asks whether local anesthesia will be used.
Answer: A, B, D.
Short rationale: The client must understand the procedure and provide voluntary informed consent. The provider performing the procedure is responsible for explaining risks, benefits, and alternatives.
A 42-year-old client reports that both parents developed type 2 diabetes in their 50s. The client has a BMI of 32 kg/m² and a sedentary lifestyle. Which nursing response demonstrates the best use of family and individual risk information?
A. "Because you have a family history, developing diabetes is unavoidable."
B. "Your family history increases your risk, so screening and lifestyle modification are particularly important."
C. "You do not need screening unless you develop polyuria and polydipsia."
D. "Your BMI is more important than your family history."
Answer: B.
Short rationale: Family history increases risk, while obesity and inactivity are modifiable risk factors. Screening and lifestyle changes can reduce risk
A client newly diagnosed with cancer says, "I know everyone is telling me to stay positive, but I'm terrified." Which response is best?
A. "You have to stay positive to get through this."
B. "At least they found the cancer early."
C. "Tell me more about what feels most frightening right now."
D. "Try not to think about the diagnosis until you know more."
Answer: C.
Short rationale: An open-ended response encourages the client to express feelings and identify specific concerns without minimizing fear.
A client with sickle cell disease reports severe generalized pain rated 9/10. The client received an opioid 30 minutes ago and states, "It still hurts." Respiratory rate is 16/min and oxygen saturation is 97%. Which action is best?
A. Withhold further analgesia because the client may become dependent
B. Reassess the pain and administer additional prescribed analgesia according to the pain-management plan
C. Tell the client that opioids should have eliminated the pain by now
D. Wait until the next scheduled medication time regardless of the pain score
Answer: B.
Short rationale: Severe sickle-cell pain may require titrated/repeated analgesia. The client should be reassessed and treated according to the prescribed pain-management plan.
Question:
A nurse caring for an older adult notices multiple bruises in different stages of healing on the client's upper arms and back. The client's adult child states, "She falls all the time," but the client becomes tearful and avoids eye contact when the child enters the room. Which action is most appropriate?
A. Ask the adult child to explain the cause of each bruise
B. Document the findings and report the suspected abuse according to required reporting procedures
C. Wait until the client independently states that abuse has occurred
D. Ask another nurse whether the bruising appears consistent with accidental injury
Answer: B.
Short rationale: Nurses must report suspected abuse according to applicable reporting requirements. Proof or a client admission is not required before reporting reasonable suspicion.
The RN is caring for four clients. Classify each task as "Appropriate to delegate to UAP, Appropriate to delegate to LPN/VN, or RN responsibility".
A. Obtain routine vital signs on a stable client 24 hours after surgery
B. Reinforce teaching about a prescribed low-sodium diet after the RN has provided initial teaching
C. Assess a client who reports new crushing chest pressure
D. Assist a stable client with bathing and oral hygiene
E. Perform a sterile dressing change on an uncomplicated postoperative wound
F. Evaluate whether a newly administered IV antihypertensive achieved the desired response
A. Obtain routine vital signs on a stable client 24 hours after surgery
Answer: UAP
Short rationale: Routine vital signs on a stable client are predictable and can be delegated to UAP.
B. Reinforce teaching about a prescribed low-sodium diet after the RN has provided initial teaching
Answer: LPN/VN
Short rationale: The RN provides the initial teaching; the LPN/VN may reinforce established teaching.
C. Assess a client who reports new crushing chest pressure
Answer: RN
Short rationale: New chest pressure requires assessment and clinical judgment, which remain the RN's responsibility.
D. Assist a stable client with bathing and oral hygiene
Answer: UAP
Short rationale: Basic ADLs for a stable client are appropriate UAP tasks.
E. Perform a sterile dressing change on an uncomplicated postoperative wound
Answer: LPN/VN
Short rationale: A predictable sterile dressing change on an uncomplicated wound may be within LPN/VN scope, depending on state law and facility policy.
F. Evaluate whether a newly administered IV antihypertensive achieved the desired response
Answer: RN
Short rationale: Evaluating a medication's therapeutic response requires nursing judgment and evaluation.
A 51-year-old client asks why preventive screening is necessary when the client feels well. Which response is best?
A. "Screening is primarily used to diagnose conditions after symptoms appear."
B. "Preventive screening can identify certain conditions during an earlier stage when intervention may be more effective."
C. "Screening eliminates the possibility of developing chronic disease."
D. "Screening is recommended only when there is a strong family history."
Answer: B.
Short rationale: Screening can identify certain diseases before symptoms occur, allowing earlier evaluation and treatment.
A client with chronic alcohol use disorder is admitted 12 hours after the last alcohol intake. Which findings require immediate attention because they may indicate worsening withdrawal? Select all that apply.
A. New visual hallucinations
B. Tremor
C. Severe diaphoresis
D. Blood pressure 178/102 mm Hg
E. Mild anxiety
F. Generalized tonic-clonic seizure
G. Disorientation to person and place
Answer: A, B, C, D, F, G.
Short rationale: Tremor, diaphoresis, hypertension, hallucinations, seizures, and disorientation can occur with escalating alcohol withdrawal. Seizures and delirium are particularly serious complications
An older adult hospitalized with pneumonia becomes fatigued while bathing and requires increasing assistance to stand. Which action best promotes safety while maintaining independence?
A. Complete all bathing and mobility tasks for the client
B. Encourage the client to perform tasks independently despite fatigue
C. Assess functional ability and provide assistance for tasks the client cannot safely complete
D. Restrict all activity until pneumonia has resolved
Answer: C.
Short rationale: The nurse should promote as much independence as safely possible while assisting with activities the client cannot safely perform.
A client hospitalized with heart failure has a nursing care plan that includes daily weights and monitoring for peripheral edema. Over the past 48 hours, the client's weight has increased by 2.2 kg (4.8 lb), oxygen requirement has increased from 2 L/min to 4 L/min, and bilateral crackles are now present. Which action best demonstrates appropriate evaluation and updating of the plan of care?
A. Continue the existing plan because daily weights are already prescribed
B. Remove the fluid-volume monitoring interventions because the client is already receiving a diuretic
C. Revise the plan to address worsening fluid overload and increased respiratory support needs
D. Wait for the next scheduled care-plan review before making changes
Answer: C.
Short rationale: Rapid weight gain, increasing oxygen needs, and crackles indicate worsening fluid overload. The plan of care should be updated when the client's condition changes.
A client with suspected Clostridioides difficile infection has frequent watery stools. Which interventions should the nurse implement? Select all that apply.
A. Perform hand hygiene with soap and water after client care
B. Place the client on appropriate contact precautions
C. Use dedicated equipment when possible
D. Use alcohol-based hand sanitizer as the preferred method after removing gloves
E. Clean the environment with an appropriate sporicidal disinfectant
F. Wear an N95 respirator for all interactions with the client
G. Remove contaminated gloves before touching clean environmental surfaces
Answer: A, B, C, E, G.
Short rationale: C. difficile forms spores that are not reliably eliminated by alcohol-based sanitizer. Soap and water, contact precautions, dedicated equipment, and sporicidal environmental cleaning reduce transmission.
A nurse is teaching an adult client about reducing cardiovascular risk. Which behaviors should the nurse identify as modifiable risk factors? Select all that apply.
A. Cigarette smoking
B. Physical inactivity
C. Excessive sodium intake
D. Uncontrolled hypertension
E. Age
F. Family history of premature cardiovascular disease
G. Excessive alcohol consumption
Answer: A, B, C, D, G.
Short rationale: Smoking, inactivity, excessive sodium, uncontrolled hypertension, and excessive alcohol use are modifiable. Age and family history are nonmodifiable.
A hospitalized client tells the nurse that a cultural practice requires a family member to remain present during important healthcare decisions. The client is alert and has decision-making capacity. What should the nurse do?
A. Explain that hospital policy requires the client to make all decisions independently
B. Determine the client's preferences and incorporate the requested family participation when possible
C. Ask the family to make decisions because the practice requires it
D. Tell the client cultural practices cannot alter medical treatment
Answer: B.
Short rationale: The client—not the family or culture—retains decision-making authority when capable. The nurse should respect the client's preference for family involvement.
A client with chronic heart failure has lost 8% of body weight over 2 months, reports early satiety, and has a serum albumin that has decreased from 3.6 to 2.8 g/dL. Which finding is most concerning?
A. The client prefers smaller meals
B. The client has unintended weight loss with decreased intake
C. The client avoids adding salt to meals
D. The client drinks water between meals
Answer: B.
Short rationale: Significant unintentional weight loss and decreased intake indicate nutritional risk and require intervention.
A nurse is caring for a hospitalized client who is a local public official. During the shift, another employee who is not involved in the client's care asks, "I heard she was admitted. What happened?" Which response by the nurse is best?
A. "I can't discuss any information about a client who is receiving care here."
B. "She is stable, but I cannot give you any additional details."
C. "Her family has been informed, so you should ask them."
D. "You can check the electronic health record if you have access."
Answer: A.
Short rationale: Client information is confidential. A person who is not involved in the client's care does not have a need to know.
A community health nurse is developing an educational program for adults in an area with a high incidence of hypertension, obesity, and uncontrolled type 2 diabetes. Which intervention is most likely to have the greatest population-level impact?
A. Provide printed information about complications of diabetes
B. Offer individualized medication teaching only to residents who already have diabetes
C. Develop a culturally appropriate program addressing nutrition, physical activity, blood-pressure screening, and access to primary care
D. Focus the program on identifying residents who require emergency medical evaluation
Answer: C.
Short rationale: A population-based program addressing multiple modifiable risk factors and access to care has greater potential community impact than education directed only at individuals who already have disease.
A client whose spouse died 3 weeks ago tells the nurse, "Sometimes I still set two places at the table. Then I remember she's gone and I start crying." Which response is most therapeutic?
A. "You need to begin moving forward."
B. "It sounds like you are still having difficulty accepting the loss."
C. "Grief takes time, and it is understandable to continue experiencing reminders of your spouse."
D. "Try to keep yourself busy so you don't dwell on the loss."
Answer: C.
Short rationale: This response acknowledges and normalizes grief without judging the client or rushing the grieving process.
A client receiving continuous enteral feeding suddenly develops coughing, tachypnea, oxygen saturation of 88%, and coarse bilateral breath sounds. Which action should the nurse take first?
A. Increase the feeding rate to compensate for missed nutrition
B. Stop the feeding and assess the client's airway and respiratory status
C. Flush the tube with 60 mL of sterile water
D. Place the client flat and obtain a residual volume
Answer: B.
Short rationale: These findings suggest aspiration. Stop the feeding and immediately assess airway and breathing.
A hospitalized client with delirium becomes increasingly agitated at night and repeatedly attempts to get out of bed. Which intervention is most appropriate?
A. Apply physical restraints immediately
B. Keep the room completely dark to encourage sleep
C. Provide frequent reorientation, reduce unnecessary stimuli, and address reversible causes
D. Ask family members to leave because their presence may increase confusion
Answer: C.
Short rationale: Delirium management includes reorientation, reducing excess stimuli, promoting safety, and identifying reversible causes.