Oxygenation and Circulation
Which finding best indicates adequate oxygenation in an adult patient?
A. Respiratory rate of 24 breaths/min
B. Oxygen saturation of 96%
C. Cyanosis of the lips
D. Use of accessory muscles
Correct Answer: B. Oxygen saturation of 96%
Rationale:
Normal oxygen saturation for a healthy adult is typically 95–100%, indicating adequate oxygenation.
The nurse understands that THIS type of stress response is exhibited when she applies nail bed pressure to her patient's fingernails and she withdraws from the painful stimulation.
A. General adaptation syndrome
B. Local adaptation syndrome
C. Selective affect response
D. Fight or flight
What is B- local adaptation?
Which factor is most important for promoting normal bowel elimination?
A. Increased protein intake
B. Adequate fluid intake
C. Limiting physical activity
D. Taking daily laxatives
Correct Answer: B. Adequate fluid intake
Rationale:
Fluids help soften stool and promote intestinal motility, making bowel movements easier.
Which amount of urine output indicates adequate kidney function in an adult?
A. 10 mL/hr
B. 20 mL/hr
C. 30 mL/hr
D. 50 mL/hr
Correct Answer: C. 30 mL/hr
Rationale:
Normal urine output for an adult is at least 30 mL/hr. Output below this may indicate decreased renal perfusion or kidney dysfunction.
Which nursing intervention best promotes sleep in a hospitalized patient?
A. Administering IV fluids at bedtime
B. Limiting nighttime interruptions
C. Keeping lights on for safety
D. Encouraging daytime naps
Correct Answer: B. Limiting nighttime interruptions
Rationale:
Reducing noise, lighting, and interruptions supports the patient’s circadian rhythm and promotes restorative sleep.
Which position is most appropriate to improve lung expansion in a patient with shortness of breath?
A. Supine
B. Prone
C. Semi-Fowler’s
D. Trendelenburg
Correct Answer: C. Semi-Fowler’s
Rationale:
Semi‑Fowler’s position elevates the head of the bed 30–45°, which decreases pressure on the diaphragm, promotes lung expansion, and improves ventilation.
KoiYour patient receives bad news this morning and has been lashing out at the nursing staff. You understand he is likely displaying THIS type of ego defense mechanism.
A. Sublimation
B. Repression
C. Displacement
D. Rationalization
What is C. displacement?
Which nursing intervention is most appropriate to prevent constipation in a hospitalized patient?
A. Restricting oral fluids
B. Encouraging early ambulation
C. Administering enemas daily
D. Offering a low‑fiber diet
Correct Answer: B. Encouraging early ambulation
Rationale:
Movement stimulates peristalsis, helping prevent constipation.
Enemas and low-fiber diets are not first-line preventive measures.
Which factor increases the risk for urinary tract infection (UTI)?
A. Increased fluid intake
B. Frequent voiding
C. Urinary catheter use
D. Acidic urine
Correct Answer: C. Urinary catheter use
Rationale:
Indwelling catheters provide a pathway for bacteria to enter the urinary tract and are the leading cause of healthcare‑associated UTIs
Which factor most commonly interferes with sleep in hospitalized patients?
A. Diurnal hormone release
B. Vital sign monitoring
C. REM sleep cycles
D. Sleep debt recovery
Correct Answer: B. Vital sign monitoring
Rationale:
Frequent assessments, medications, and alarms are major contributors to sleep disruption in acute care settings.
The nurse palpates the carotid pulse primarily to assess which of the following?
A. Peripheral circulation
B. Capillary refill
C. Central circulation during emergencies
D. Blood pressure accuracy
Correct Answer: C. Central circulation during emergencies
Rationale:
The carotid pulse reflects central circulation and is the recommended pulse site during cardiac arrest or shock in adults.
Mr. Smith is pacing, shouting, breathing rapidly, and you are unable to reason with him. The nurse underdtands he is likely at ______ level of anxiety, so she ______. SATA
A. Panic; administers anti-anxiety medications.
B. Panic; recommends he relax and talk to a counselor
C. Panic; attempts to assist him with deep breathing exercises.
D. Delusion; places him in restraints
What is A and C?
A patient reports hard, dry stools and straining during defecation. These findings are most consistent with which condition?
A. Diarrhea
B. Fecal incontinence
C. Constipation
D. Bowel obstruction
Correct Answer: C. Constipation
Rationale:
Constipation is characterized by:
Which nursing intervention helps prevent urinary retention in postoperative patients?
A. Restricting fluids
B. Encouraging voiding every 2–3 hours
C. Providing bedpan only
D. Delaying ambulation
Correct Answer: B. Encouraging voiding every 2–3 hours
Rationale:
Scheduled voiding helps maintain bladder tone and prevents overstretching of the bladder, which can lead to urinary retention.
A patient reports difficulty falling asleep. Which nursing assessment question is most appropriate?
A. “Do you take any sleep medications?”
B. “How many hours do you sleep each night?”
C. “What do you usually do before going to bed?”
D. “Have you ever been diagnosed with insomnia?”
Correct Answer: C. “What do you usually do before going to bed?”
Rationale:
This assesses sleep hygiene, such as caffeine intake, screen use, or exercise, which commonly affects sleep onset.
A patient with decreased peripheral circulation is most likely to exhibit which assessment finding?
A. Warm, flushed skin
B. Bounding peripheral pulses
C. Cool, pale extremities
D. Capillary refill under 2 seconds
Correct Answer: C. Cool, pale extremities
Rationale:
Poor circulation leads to vasoconstriction, reducing blood flow to the skin, causing it to be cool and pale.
The Joint Commission requires that THESE patients receive evaluation of spiritual beliefs, needs, preferences.
Who are patients receiving psychosocial services to treat substance use disorders and those receiving end of life care?
A patient receiving opioid analgesics is at risk for constipation primarily because opioids:
A. Increase intestinal secretions
B. Stimulate the gastrocolic reflex
C. Decrease bowel motility
D. Increase smooth muscle contractions
Correct Answer: C. Decrease bowel motility
Rationale:
Opioids slow peristalsis, increase water absorption from stool, and reduce the urge to defecate, leading to constipation.
A postoperative patient has not voided for 8 hours and reports suprapubic discomfort. The nurse’s priority action is to:
A. Encourage increased oral fluids
B. Perform a bladder scan
C. Insert a urinary catheter
D. Document normal postoperative findings
Correct Answer: B. Perform a bladder scan
Rationale:
A bladder scan noninvasively assesses urinary retention and guides further intervention. Catheterization is not the first step unless retention is confirmed.
During which sleep stage does the body experience the greatest physical restoration, including tissue repair and growth hormone release?
A. Stage N1
B. Stage N2
C. Stage N3 (deep sleep)
D. REM sleep
Correct Answer: C. Stage N3 (deep sleep)
Rationale:
Stage N3, also called deep sleep or slow‑wave sleep, is the most physically restorative stage of the sleep cycle. During this stage:
Stages N1 and N2 are lighter stages of sleep and serve primarily as transition and maintenance stages.
REM sleep is important for mental restoration, memory consolidation, and dreaming, not physical repair.
A patient with severe anemia presents with fatigue and confusion. Assessment findings include:
Which statement best explains this patient’s condition?
A. The patient is experiencing hypoxemia related to impaired oxygen diffusion.
B. The patient is experiencing hypoxia due to decreased oxygen-carrying capacity.
C. The patient is not experiencing oxygenation problems because SpO₂ is normal.
D. The patient has hypoxemia caused by ventilation–perfusion mismatch.
Correct Answer: B. The patient is experiencing hypoxia due to decreased oxygen-carrying capacity.
Rationale
This question tests a critical distinction:
Hypoxemia
Hypoxia
Why B is correct:
Why the other options are incorrect:
A. Hypoxemia due to impaired diffusion
❌ Incorrect — SpO₂ is normal, ruling out hypoxemia.
C. No oxygenation problem because SpO₂ is normal
❌ Dangerous misconception — SpO₂ does not reflect oxygen delivery, only saturation.
D. Hypoxemia from V/Q mismatch
❌ Would present with low SpO₂ or PaO₂, which is not seen here.
Clinical Pearl (NCLEX Favorite)
“Hypoxemia is about oxygen in the blood.
Hypoxia is about oxygen in the tissues.”
You can have hypoxia without hypoxemia, especially in:
This is the primary difference between hospice and palliative care.
What is hospice includes life expectancy of 6 months or less
Which finding most strongly suggests fecal impaction?
A. Liquid stool leakage
B. Abdominal cramping
C. Hyperactive bowel sounds
D. Sudden weight loss
Correct Answer: A. Liquid stool leakage
Rationale:
With fecal impaction, liquid stool may leak around hardened stool, often mistaken for diarrhea. This is a common NCLEX trap.
An older adult patient experiences involuntary urine loss when coughing or sneezing. This is best described as:
A. Urge incontinence
B. Functional incontinence
C. Overflow incontinence
D. Stress incontinence
Correct Answer: D. Stress incontinence
Rationale:
Stress incontinence occurs when increased intra‑abdominal pressure (coughing, sneezing, laughing) causes urine leakage, often due to weakened pelvic floor muscles.
A nurse notes that a patient is restless, irritable, and has impaired concentration after several nights of poor sleep. These findings are best explained by which concept?
A. Sleep latency
B. Sleep apnea
C. Sleep deprivation
D. Circadian rhythm entrainment
Correct Answer: C. Sleep deprivation
Rationale:
Sleep deprivation leads to cognitive impairment, mood changes, and reduced coping ability. These symptoms worsen cumulatively over time.