Psychosocial
A nursing student reports feeling overwhelmed by exams, clinicals, and work responsibilities. Which statement by the student indicates a positive adaptation to stress?
A. "I've stopped attending classes because I can't handle everything."
B. "I've started making a schedule and prioritizing my tasks."
C. "I stay up all night worrying about my grades."
D. "I ignore my stress and hope it goes away."
Answer: B. "I've started making a schedule and prioritizing my tasks."
Rationale:
A nurse is assessing a client for urinary retention. Which finding is most concerning?
A. Voiding 300 mL every 4 hours
B. Strong urge to void with inability to urinate
C. Clear yellow urine
D. Urine specific gravity of 1.020
Answer: B. Strong urge to void with inability to urinate
Rationale: Urinary retention occurs when the bladder cannot empty completely despite the urge to void. The client may report bladder fullness, discomfort, and inability to urinate.
A nurse is assessing a client for constipation. Which finding is most consistent with constipation?
A. Frequent loose stools
B. Hard, dry stools that are difficult to pass
C. Abdominal pain relieved by vomiting
D. Passage of stool after every meal
B. Hard, dry stools that are difficult to pass
Rationale:
Which assessment finding requires immediate intervention in a client with impaired circulation?
A. Capillary refill of 2 seconds B. Warm extremities C. Blood pressure 88/50 mm Hg D. Heart rate 82 beats/min
Answer: C. Blood pressure 88/50 mm Hg
Rationale:
A nurse reviews the following ABG results:
How should the nurse interpret these results?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A. Respiratory acidosis
Rationale: The pH is below 7.35 (acidotic), and the PaCO₂ is elevated (>45 mm Hg). CO₂ is an acid, so increased CO₂ causes respiratory acidosis.
A nurse is teaching a client about stress management. Which activity should the nurse identify as an effective stress-reduction technique?
A. Increasing caffeine consumption
B. Avoiding social interactions
C. Practicing deep-breathing exercises
D. Working longer hours to stay distracted
Answer: ✅ C. Practicing deep-breathing exercises
Rationale:
Which client is at greatest risk for developing a urinary tract infection (UTI)?
A. A client who ambulates daily
B. A client with an indwelling urinary catheter
C. A client who drinks 2 liters of water daily
D. A client who voids every 3 to 4 hours
B. A client with an indwelling urinary catheter
Rationale: Indwelling urinary catheters are the leading risk factor for healthcare-associated UTIs because they provide a pathway for microorganisms to enter the urinary tract.
A nurse is teaching a client about preventing constipation. Which statement by the client indicates understanding?
A. "I should drink fewer fluids to reduce bloating."
B. "I should avoid physical activity."
C. "I should increase my intake of high-fiber foods."
D. "I should ignore the urge to have a bowel movement."
Answer: C. "I should increase my intake of high-fiber foods."
Rationale:
A postoperative client suddenly develops shortness of breath, tachycardia, and decreased oxygen saturation. Which action should the nurse take first?
A. Obtain a prescription for pain medication. B. Encourage the client to ambulate. C. Assess airway, breathing, and circulation. D. Document the findings.
Answer: C. Assess airway, breathing, and circulation.
Rationale:
Which client is at greatest risk for metabolic acidosis?
A. Client with prolonged vomiting
B. Client with diabetic ketoacidosis
C. Client with hyperventilation
D. Client taking antacids
Answer: B. Client with diabetic ketoacidosis
Rationale: Diabetic ketoacidosis leads to accumulation of ketones, causing metabolic acidosis.
A client experiencing chronic stress is being assessed by the nurse. Which finding would the nurse expect?
A. Improved concentration and memory
B. Decreased blood pressure
C. Frequent headaches and fatigue
D. Increased immune function
Answer: ✅ C. Frequent headaches and fatigue
Rationale:
A nurse is caring for a client with an indwelling urinary catheter. Which action is most important to prevent a catheter-associated urinary tract infection (CAUTI)?
A. Empty the drainage bag every 24 hours.
B. Irrigate the catheter routinely.
C. Maintain a closed drainage system.
D. Clamp the catheter before ambulation.
Answer: C. Maintain a closed drainage system.
Rationale:
A postoperative client reports abdominal cramping and has not had a bowel movement for 3 days. Which nursing action should the nurse perform first?
A. Administer a laxative immediately
B. Assess bowel sounds and abdominal distention
C. Restrict oral fluids
D. Encourage bed rest
Answer: B. Assess bowel sounds and abdominal distention
Rationale:
he nurse is teaching a client about a nasal cannula. Which statements are correct? Select all that apply.
A. It is commonly used for clients requiring low-flow oxygen.
B. The client can eat and talk while wearing the device.
C. Oxygen flow rates are typically 1 to 6 L/min.
D. It delivers precise oxygen concentrations.
E. Petroleum-based products should be avoided around the nares.
Answer:
✅ A, B, C, E
Rationales
✅ A. It is commonly used for clients requiring low-flow oxygen. A nasal cannula is the most common low-flow oxygen delivery device.
✅ B. The client can eat and talk while wearing the device. Unlike masks, the nasal cannula does not interfere with eating or speaking.
✅ C. Oxygen flow rates are typically 1 to 6 L/min. Flow rates greater than 6 L/min can cause mucosal drying and discomfort.
❌ D. It delivers precise oxygen concentrations. A Venturi mask, not a nasal cannula, provides precise oxygen concentrations.
✅ E. Petroleum-based products should be avoided around the nares. Petroleum products increase fire risk when oxygen is in use.
Which assessment finding is most consistent with respiratory acidosis?
A. Deep rapid respirations
B. Bradypnea and confusion
C. Anxiety and tingling fingers
D. Tachypnea and dizziness
Answer: B. Bradypnea and confusion
Rationale: Respiratory acidosis occurs when the lungs retain CO₂, often due to hypoventilation. Confusion and decreased respiratory rate are common findings.
A client expresses feelings of hopelessness. Which nursing responses are therapeutic? SATA
A. "Tell me more about how you're feeling."
B. "Everything will be fine."
C. Active listening
D. Acknowledging feelings
E. Changing the subject
Answer: A, C, D
A. "Tell me more about how you're feeling."
Rationale: This is a therapeutic communication technique that encourages the client to express emotions and elaborate on their feelings. It demonstrates interest and allows the nurse to further assess the client's emotional state.
B. "Everything will be fine."
Rationale: This is an example of false reassurance. The nurse cannot guarantee the outcome, and this statement may minimize the client's feelings or discourage further discussion.
C. Active listening
Rationale: Active listening conveys acceptance, respect, and genuine interest. It encourages the client to continue sharing thoughts and feelings and helps build trust in the nurse-client relationship.
D. Acknowledging feelings
Rationale: Acknowledging or validating feelings communicates empathy and understanding. Statements such as, "It sounds like you're feeling overwhelmed right now" help clients feel heard and supported.
E. Changing the subject
Rationale: Changing the subject is a nontherapeutic communication technique because it redirects attention away from the client's concerns and may make the client feel dismissed or unimportant.
A nurse is assessing a client with a urinary tract infection (UTI). Which findings should the nurse expect? Select all that apply.
A. Urinary frequency
B. Dysuria
C. Clear urine with no odor
D. Urgency
E. Hematuria
Answer
A, B, D, E
Rationales
A. Urinary frequency The client may experience frequent urges to urinate due to bladder irritation caused by infection.
B. Dysuria Painful or burning urination is a hallmark symptom of a UTI.
C. Clear urine with no odor UTIs commonly cause cloudy urine, foul odor, or blood in the urine.
D. Urgency Inflammation of the urinary tract often produces a sudden strong urge to void.
E. Hematuria Blood may be present in the urine due to irritation of the urinary tract lining.
A nurse is caring for a client with diarrhea. Which nursing interventions are appropriate? Select all that apply.
A. Monitor skin integrity
B. Assess fluid intake and output
C. Restrict fluids
D. Monitor electrolyte levels
E. Provide frequent perineal care
Answers: A, B, D, E
Rationale:
Which statements about a nonrebreather mask are correct? Select all that apply.
A. It can deliver high concentrations of oxygen. B. The reservoir bag should remain partially inflated. C. It is often used during emergencies. D. It is appropriate for a client eating meals. E. Flow rates are generally set between 10 and 15 L/min.
A. It can deliver high concentrations of oxygen.
B. The reservoir bag should remain partially inflated.
C. It is often used during emergencies.
D. It is appropriate for a client eating meals.
E. Flow rates are generally set between 10 and 15 L/min.
Answer:
✅ A, B, C, E
Rationales
✅ A. It can deliver high concentrations of oxygen. A nonrebreather mask delivers the highest oxygen concentration without intubation.
✅ B. The reservoir bag should remain partially inflated. A deflated reservoir bag indicates inadequate oxygen flow.
✅ C. It is often used during emergencies. Clients with severe hypoxemia often require this device.
❌ D. It is appropriate for a client eating meals. The mask must be removed for eating.
✅ E. Flow rates are generally set between 10 and 15 L/min. High flow rates are necessary to keep the reservoir bag inflated.
A client has metabolic acidosis. Which assessment findings should the nurse expect? Select all that apply.
A. Kussmaul respirations
B. Hyperkalemia
C. Confusion
D. pH below 7.35
E. Bradycardia as an early sign
Answer: ✅ A, B, C, D
Rationales
✅ A. Kussmaul respirations The body compensates by breathing rapidly to eliminate CO₂.
✅ B. Hyperkalemia Hydrogen ions move into cells while potassium moves out.
✅ C. Confusion Decreased pH can affect neurological function.
✅ D. pH below 7.35 Acidosis is defined by a low pH.
❌ E. Bradycardia as an early sign Tachycardia is more common initially.
The nurse is caring for a client who has just died. Which actions should the nurse perform? Select all that apply.
A. Document the time of death.
B. Provide privacy for the family.
C. Respect cultural and religious practices.
D. Remove all tubes and lines immediately.
E. Prepare the body according to agency policy.
A, B, C, E
Rationales
✅ A. Document the time of death. Accurate documentation is a legal responsibility of the nurse and includes the time of death and assessments performed.
✅ B. Provide privacy for the family. Family members should be given time to grieve and say their goodbyes in a private environment.
✅ C. Respect cultural and religious practices. End-of-life and postmortem care should incorporate the client's and family's cultural and religious beliefs whenever possible.
❌ D. Remove all tubes and lines immediately. This is incorrect. Tubes and lines may need to remain in place in cases involving a coroner, medical examiner, autopsy, or organ donation. The nurse should follow agency policy and provider orders.
✅ E. Prepare the body according to agency policy. Postmortem care includes preparing the body, applying identification tags, and arranging transport according to facility procedures.
Additional NCLEX Question
The nurse is assessing a client with urinary retention. Which findings would the nurse expect? Select all that apply.
A. Frequent voiding of small amounts
B. Bladder distention
C. Feelings of incomplete emptying
D. Large urine output with each void
E. Suprapubic discomfort
A, B, C, E
Rationales
A. Frequent voiding of small amounts Clients with retention often void small amounts due to incomplete bladder emptying.
B. Bladder distention Urine accumulates in the bladder, causing distention.
C. Feelings of incomplete emptying A common complaint among clients experiencing retention.
D. Large urine output with each void Urinary retention usually results in small, frequent voids rather than complete emptying.
E. Suprapubic discomfort Bladder pressure from retained urine often causes discomfort.
Which factors place a client at risk for constipation? Select all that apply.
A. Opioid use
B. Immobility
C. Low-fiber diet
D. Increased fluid intake
E. Habitual laxative use
Answers: A, B, C, E
Rationale:
Which assessments indicate a client may need oxygen therapy? Select all that apply.
A. Oxygen saturation of 86%
B. Restlessness
C. Cyanosis D. Confusion
E. Warm pink skin with SpO₂ 98%
Answer:
✅ A, B, C, D
Rationales
✅ A. Oxygen saturation of 86% This level indicates significant hypoxemia.
✅ B. Restlessness Often an early sign of hypoxia.
✅ C. Cyanosis Bluish discoloration may indicate inadequate oxygenation.
✅ D. Confusion Changes in cognition can result from decreased oxygen delivery to the brain.
❌ E. Warm pink skin with SpO₂ 98% These findings suggest adequate oxygenation.
The nurse reviews arterial blood gas results. Which values indicate respiratory acidosis? Select all that apply.
A. pH 7.30
B. PaCO₂ 52 mm Hg
C. HCO₃⁻ 24 mEq/L
D. pH 7.48
E. PaCO₂ 30 mm Hg
Answer: ✅ A, B, C
Rationales
✅ A. pH 7.30 A pH below 7.35 indicates acidosis.
✅ B. PaCO₂ 52 mm Hg Normal PaCO₂ is 35-45 mm Hg. A value of 52 indicates CO₂ retention.
✅ C. HCO₃⁻ 24 mEq/L This normal bicarbonate level suggests an uncompensated respiratory problem.
❌ D. pH 7.48 A pH greater than 7.45 indicates alkalosis.
❌ E. PaCO₂ 30 mm Hg Low CO₂ is associated with respiratory alkalosis.