NCLEX-PN Practice Test

1. A client is recovering from a chest tube placement for a pneumothorax. The nurse notices continuous vigorous bubbling in the water seal chamber. What does this finding most likely indicate?

• A. The chest tube system is functioning normally.
• B. The client's lung has fully re-expanded.
• C. The suction level is set too low.
• D. There is an air leak in the chest tube system that requires further assessment.

2. A nurse is caring for a client with heart failure. Which finding best indicates fluid retention is worsening?

• A. A weight gain of 3 pounds over two days
• B. A blood pressure reading of 122/78
• C. A reported appetite decrease
• D. A heart rate of 78 beats per minute

3. A client with type 1 diabetes is diaphoretic, tremulous, tachycardic and confused. What should the nurse suspect and do first?

• A. Hypoglycemia; check the blood glucose and provide a fast-acting carbohydrate if the client can swallow safely
• B. Hyperglycemia; administer additional rapid-acting insulin
• C. Dehydration; increase intravenous fluids without checking glucose
• D. Anxiety; provide reassurance and reassess in one hour

4. A client with chronic obstructive pulmonary disease is receiving oxygen. Which nursing consideration is most important?

• A. Titrate oxygen to the prescribed target saturation, avoiding unnecessarily high flow
• B. Administer the highest flow rate available to maximize oxygenation
• C. Withhold oxygen entirely to preserve respiratory drive
• D. Use oxygen only during ambulation

5. A client suddenly develops facial droop, slurred speech and unilateral arm weakness. What is the nurse's priority action?

• A. Note the time of symptom onset and activate the facility's stroke response immediately
• B. Give the client aspirin and reassess in 30 minutes
• C. Offer oral fluids to assess swallowing ability
• D. Place the client in Trendelenburg position

6. A client is admitted with severe dehydration. Which assessment finding is most consistent with this diagnosis?

• A. Elevated heart rate, decreased urine output and dry mucous membranes
• B. Bounding pulses and jugular vein distention
• C. Crackles throughout both lung fields
• D. Rapid weight gain over 24 hours

7. A nurse is caring for a client with a new colostomy. Which stoma assessment finding requires immediate provider notification?

• A. A stoma that appears dusky purple or black
• B. A stoma that appears pink to red and moist
• C. A small amount of bleeding when the stoma is cleaned
• D. Mild swelling of the stoma in the first days after surgery

8. A nurse is caring for a client whose vital signs are temperature 38.9 C, heart rate 118, respiratory rate 26 and blood pressure 88/50. Which condition should the nurse suspect?

• A. Possible sepsis, requiring prompt provider notification
• B. Expected postoperative variation requiring no action
• C. Hypothyroidism
• D. Fluid volume overload

9. A client who is postoperative day two reports sudden shortness of breath and pleuritic chest pain, with a heart rate of 122. What should the nurse suspect?

• A. Possible pulmonary embolism, requiring immediate escalation
• B. Normal postoperative discomfort
• C. Constipation from opioid analgesia
• D. Mild dehydration

10. A client with acute kidney injury has a urine output of 15 mL over the past hour and rising serum creatinine. Which finding should the nurse also monitor closely as a priority complication?

• A. Hypoglycemia
• B. Hypocalcemia
• C. Hyponatremia
• D. Hyperkalemia

11. A client with a history of asthma develops audible wheezing, use of accessory muscles, and a respiratory rate of 32 breaths per minute. Which nursing action is the priority?

• A. Have the client lie flat to reduce work of breathing.
• B. Encourage the client to drink cold fluids to soothe the airway.
• C. Administer the prescribed short-acting bronchodilator and reassess respiratory status.
• D. Wait 30 minutes to see if symptoms resolve independently before intervening.

12. A nurse is reinforcing teaching for a client newly prescribed phenytoin for seizure control. Which instruction should the nurse include regarding oral care?

• A. Phenytoin has no effect on oral tissue and no special oral care is needed.
• B. Maintain consistent oral hygiene and report any gum swelling or bleeding, as phenytoin can cause gingival hyperplasia.
• C. Avoid brushing teeth entirely while taking this medication.
• D. Use only very hot water when rinsing the mouth to reduce medication residue.

13. A client is prescribed a beta-blocker for hypertension. Which assessment finding should prompt the nurse to hold the medication and notify the provider?

• A. Blood pressure of 128/78 mm Hg.
• B. Heart rate of 72 beats per minute.
• C. Heart rate of 48 beats per minute with dizziness.
• D. Respiratory rate of 16 breaths per minute.

14. Before administering digoxin to an adult client, the nurse should take which action?

• A. Count the apical pulse for one full minute and withhold the dose if it is below 60 beats per minute
• B. Check the radial pulse for 15 seconds and multiply by four
• C. Withhold the dose if the blood pressure is above 140/90
• D. Administer the dose regardless of heart rate and document the rate afterward

15. A client is prescribed intravenous potassium chloride. Which nursing action is essential?

• A. Administer only diluted and by infusion pump; never give potassium by IV push
• B. Administer undiluted by rapid IV push for faster correction
• C. Add the potassium to the intravenous bag at the bedside without inversion
• D. Give intramuscularly if intravenous access is unavailable

16. A client receiving warfarin asks about diet. Which instruction is correct?

• A. Maintain a consistent intake of vitamin K-containing foods rather than eliminating them
• B. Eliminate all green leafy vegetables permanently
• C. Increase green leafy vegetables to enhance the medication's effect
• D. Diet has no effect on warfarin therapy

17. A nurse is preparing to mix regular insulin and NPH insulin in the same syringe. What is the correct technique?

• A. Inject air into both vials, then withdraw the regular (clear) insulin before the NPH (cloudy)
• B. Withdraw the NPH insulin first, then the regular insulin
• C. Withdraw each insulin into a separate syringe and combine them afterward
• D. Shake both vials vigorously before withdrawing

18. A nurse is administering an oral medication that is enteric coated. Which action is appropriate?

• A. Administer the tablet whole without crushing or splitting it
• B. Crush the tablet and mix it with applesauce for easier swallowing
• C. Dissolve the tablet in warm water before administration
• D. Split the tablet in half to reduce gastric irritation

19. A provider prescribes 500 mg of a medication. The available supply is 250 mg per tablet. How many tablets should the nurse administer?

• A. 2 tablets
• B. 1 tablet
• C. 0.5 tablet
• D. 4 tablets

20. A client is to receive 1,000 mL of intravenous fluid over 8 hours using tubing with a drop factor of 15 drops per mL. What is the flow rate in drops per minute?

• A. 31 drops per minute
• B. 21 drops per minute
• C. 42 drops per minute
• D. 125 drops per minute

21. A nurse notes that a client's intravenous site is cool, pale and swollen, and the infusion has slowed. What is the nurse's first action?

• A. Stop the infusion and remove the catheter, then elevate the extremity
• B. Increase the flow rate to clear the obstruction
• C. Apply a warm compress and continue the infusion
• D. Flush the line vigorously with saline

22. A nurse is giving a change-of-shift report on an assigned client. Which information is most important to include?

• A. The client's complete medical history from previous admissions
• B. Recent changes in the client's condition and any assessments or treatments still pending
• C. The nurse's personal opinion of the client's family dynamics
• D. Routine tasks that were completed exactly as scheduled

23. A client asks the nurse, "Is my tumor cancer? I want the truth." The biopsy result, which the provider has already discussed with the client's family but not the client, confirms malignancy. The nurse encourages the provider to speak honestly with the client. Which ethical principle is the nurse supporting?

• A. Veracity
• B. Nonmaleficence
• C. Justice
• D. Fidelity

24. A licensed practical nurse is caring for four clients. Which client should the nurse assess first?

• A. A client with an oxygen saturation of 86 percent on room air and increased work of breathing
• B. A client reporting incisional pain rated 7 out of 10
• C. A client requesting assistance to the bathroom
• D. A client whose family is asking about discharge planning

25. A registered nurse delegates tasks on a medical-surgical unit. Which task is appropriate to assign to a licensed practical nurse?

• A. Reinforcing teaching about a prescribed diet that the RN has already taught
• B. Performing the initial admission assessment on a newly admitted client
• C. Developing the nursing care plan for a complex client
• D. Evaluating the client's response to the overall plan of care

26. A nurse is preparing to delegate to unlicensed assistive personnel. Which task may appropriately be delegated?

• A. Measuring and recording a stable client's intake and output
• B. Administering an oral medication
• C. Inserting an indwelling urinary catheter
• D. Interpreting a change in the client's wound appearance

27. A nurse discovers that a client's signed surgical consent form does not list the correct surgical site. What is the nurse's best action?

• A. Notify the surgeon and hold the client from transport until the consent is corrected
• B. Correct the site on the form and have the client initial the change
• C. Send the client to surgery and report the discrepancy to the operating room nurse
• D. Ask a family member to confirm the correct site and proceed

28. A nurse is caring for a client who has a do-not-resuscitate order and who then stops breathing and has no pulse. What is the nurse's appropriate action?

• A. Provide comfort measures and notify the provider and family; do not initiate CPR
• B. Begin chest compressions until the family arrives
• C. Call a code and initiate full resuscitation
• D. Administer emergency medications but withhold compressions

29. A nurse observes a coworker accessing the electronic health record of a neighbor who is not assigned to that coworker. What should the nurse do?

• A. Report the incident through the facility's chain of command, as this is a privacy violation
• B. Say nothing, since no information appears to have been shared outside the facility
• C. Ask the coworker to delete the access log entry
• D. Discuss the neighbor's condition with the coworker to assess intent

30. A nurse discovers a medication error after administering the wrong dose. What is the nurse's first responsibility?

• A. Assess the client, then notify the provider and complete an incident report
• B. Complete the incident report before assessing the client
• C. Document the error only in the incident report, not in the medical record
• D. Wait to see whether the client develops symptoms before reporting

31. A nurse receives a verbal order from a provider during an emergency. What is the correct process?

• A. Write the order down, read it back to the provider for verification, and have it authenticated within the required timeframe
• B. Carry out the order and document it at the end of the shift
• C. Ask another nurse to listen and rely on shared memory
• D. Refuse all verbal orders under any circumstance

32. A nurse is documenting in a client's paper medical record and makes an error in an entry. What is the correct correction technique?

• A. Draw a single line through the entry, write the word error or per policy, and initial and date it
• B. Use correction fluid and write over the entry
• C. Erase the entry completely and rewrite it
• D. Black out the entry so it cannot be read

33. A licensed practical nurse is assigned to complete the initial comprehensive admission assessment for a newly admitted client. Which action by the LPN is most appropriate?

• A. Complete the admission assessment and document the findings
• B. Inform the registered nurse that the initial admission assessment must be performed by the RN, and offer to collect supporting data
• C. Ask unlicensed assistive personnel to obtain the admission history
• D. Delay the assessment until the provider arrives to examine the client

34. A client slides from a chair to the floor and is uninjured. After completing an incident report, which documentation by the nurse in the medical record is correct?

• A. "Incident report completed and forwarded to risk management."
• B. "Client fell because the aide left the room; incident report filed."
• C. An objective description of the event, the client's condition, and the care provided, without mentioning the incident report
• D. No entry, because the incident report replaces charting for the event

35. A client refuses the prescribed evening dose of an oral antihypertensive medication. Which action should the nurse take first?

• A. Ask the client to describe the reason for refusing the medication
• B. Document the refusal and move on to the next client
• C. Crush the medication and mix it into the client's dessert
• D. Tell the client the medication is required by the provider's order

36. A hospitalized client has a living will declining resuscitation, but the client's adult child demands that "everything be done" if the client's heart stops. What is the licensed practical nurse's best action?

• A. Follow the family's wishes because they are present at the bedside
• B. Remove the living will from the chart until the conflict is settled
• C. Promise the family that resuscitation will be attempted
• D. Report the conflict to the supervising registered nurse so the care team can address it with the family and provider

37. A caller who identifies himself as a client's cousin telephones the unit and asks whether the client has been admitted and how she is doing. The client has not authorized release of information. How should the nurse respond?

• A. Explain that no information can be shared, without confirming whether the client is on the unit
• B. Confirm the admission but decline to give clinical details
• C. Provide a brief update since the caller is a family member
• D. Ask the caller to state the client's diagnosis to verify the relationship

38. A licensed practical nurse who normally works on a medical unit is floated to a busy orthopedic unit for the shift. Which action by the nurse is most appropriate?

• A. Refuse the float assignment and go home for the shift
• B. Accept the assignment and perform all tasks, including unfamiliar ones, without comment
• C. Accept the assignment and ask the charge nurse for tasks that match the nurse's demonstrated competencies, with orientation to unfamiliar equipment
• D. Ask another LPN on the orthopedic unit to trade assignments after report

39. A nurse witnesses a client sign the consent form for a scheduled procedure. What does the nurse's signature as a witness legally verify?

• A. That the nurse explained the procedure and its risks
• B. That the procedure is medically necessary
• C. That the client will not experience complications
• D. That the client is the person who signed and did so voluntarily and without apparent coercion

40. The laboratory telephones the unit with a critical potassium result for an assigned client. Which action by the nurse reflects correct handling of the call?

• A. File the value with routine results for the provider's next visit
• B. Ask the laboratory to call back when the provider is on the unit
• C. Write down the value, read it back to the caller for confirmation, and report it promptly to the appropriate provider
• D. Memorize the value and chart it at the end of the shift

41. At the start of a shift, a nurse notices that a coworker smells of alcohol and has slurred speech while preparing to give medications. What should the nurse do?

• A. Wait and discuss the concern with the coworker after the shift ends
• B. Privately suggest the coworker drink coffee and take a break
• C. Watch the coworker closely during the shift and intervene only if an error occurs
• D. Report the observation to the nursing supervisor immediately so the coworker is relieved of client care

42. A client with pneumonia announces he is leaving the hospital against medical advice. The provider has been notified and the client remains determined to leave. Which statement about this situation is accurate?

• A. Security may hold the client until discharge paperwork is complete
• B. The client forfeits the right to return to the hospital for future care
• C. The nurse should remove the client's IV access only after the client signs a promise to follow up
• D. The client with decision-making capacity may not be physically prevented from leaving, and the risks of leaving should be explained and documented

43. A licensed practical nurse is working with unlicensed assistive personnel to care for a group of stable clients. Which task must the nurse perform rather than delegate?

• A. Repositioning a client who is on a turning schedule
• B. Recording the oral fluid intake of a client on intake and output monitoring
• C. Determining how a client's skin has responded to a new pressure-relief mattress
• D. Assisting a client with a bed bath and hygiene care

44. A nurse is reinforcing discharge instructions for a client who speaks very limited English. The client's teenage son offers to translate. What is the nurse's best action?

• A. Accept the son's offer because he knows the client best
• B. Arrange for a qualified medical interpreter before continuing the teaching
• C. Speak slowly and loudly in English while using gestures
• D. Give the client written instructions in English to read at home

45. During a mass-casualty event, the unit must free beds for incoming victims. Which current client is most appropriate for the nurse to recommend for early discharge?

• A. A client admitted this morning with chest pain awaiting cardiac workup
• B. A client receiving continuous intravenous antibiotics for sepsis
• C. A client two hours post upper endoscopy still recovering from sedation
• D. A client three days after an uncomplicated hernia repair who is ambulating and tolerating a regular diet

46. The spouse of an assigned client asks the licensed practical nurse to explain the results of the client's biopsy, which the provider has not yet discussed with the client. Which response is most appropriate?

• A. Summarize the results in simple terms so the spouse is not left waiting
• B. State that nurses are never told test results
• C. Suggest the spouse look up the result in the client's online portal
• D. Explain that the provider will review the results with the client and offer to let the provider know the family has questions

47. A licensed practical nurse is caring for a client newly admitted with a diagnosis of major depressive disorder. The client states, "I don't see the point in any of this anymore." Which is the nurse's PRIORITY action?

• A. Reassure the client that things will improve with treatment
• B. Directly ask the client whether they are thinking about harming themselves
• C. Document the statement and continue with the admission assessment
• D. Notify the client's family of the statement

48. A client experiencing an acute panic attack is hyperventilating and states they feel they are "going to die." Which nursing intervention is MOST appropriate initially?

• A. Leave the client alone to reduce external stimulation
• B. Provide detailed teaching about the physiology of anxiety
• C. Stay with the client and use a calm, reassuring voice with short directions
• D. Encourage the client to discuss the underlying cause of the anxiety

49. A nurse is caring for a client who recently lost a spouse and says, "I keep setting the table for two out of habit." Which response by the nurse is MOST therapeutic?

• A. "You should try to stay busy so you don't dwell on it."
• B. "It sounds like adjusting to this loss has been very difficult for you."
• C. "At least you had many good years together."
• D. "You'll feel better once you get back to your normal routine."

50. A client with alcohol use disorder is admitted for withdrawal. Approximately 12 hours after the last drink, the nurse should monitor MOST closely for which early manifestation?

• A. Tremors, diaphoresis, and elevated vital signs
• B. Complete absence of any symptoms
• C. Profound bradycardia and hypothermia
• D. Sudden euphoria and increased appetite

51. A nurse is reinforcing teaching for the family of a client diagnosed with Alzheimer disease who becomes agitated in the late afternoon. Which strategy should the nurse recommend for this sundowning behavior?

• A. Schedule stimulating activities and visitors in the evening
• B. Keep the environment calm and well-lit as evening approaches
• C. Withhold all daytime naps and increase caffeine intake
• D. Frequently move the client to unfamiliar rooms to provide variety

52. A nurse observes that a client repeatedly checks and rechecks that the door is locked, causing distress and delaying meals. During the acute phase, which nursing approach is MOST appropriate?

• A. Prevent the client from performing the ritual entirely
• B. Allow time for the ritual while gradually setting reasonable limits and reducing anxiety
• C. Ridicule the behavior so the client recognizes it is irrational
• D. Ignore the client until the ritual stops on its own

53. A client on an inpatient unit becomes increasingly loud, paces rapidly, and clenches their fists. Which nursing action BEST demonstrates early de-escalation?

• A. Approach quickly and place a hand on the client's shoulder
• B. Maintain a calm demeanor, ensure personal space, and speak in a low, even tone
• C. Order the client to sit down immediately
• D. Gather several staff members to surround the client

54. A client tells the nurse, "The voices are telling me that no one here can be trusted." Which response by the nurse is MOST therapeutic?

• A. "There are no voices; you are safe in the hospital."
• B. "What exactly are the voices saying to you right now?" asked with alarm
• C. "I understand the voices are real to you, but I do not hear them. You are safe here."
• D. "You should just ignore the voices and they will go away."

55. A nurse is providing culturally sensitive care to a client whose cultural practices differ from the nurse's own. Which action BEST reflects culturally competent psychosocial care?

• A. Assume the client shares the beliefs typical of their cultural group
• B. Ask the client about their preferences and incorporate them into the plan of care when safe
• C. Encourage the client to adopt the practices of the majority culture
• D. Avoid discussing cultural topics to prevent discomfort

56. A nurse suspects that an older adult client is experiencing abuse by a caregiver. Which is the nurse's MOST appropriate initial action?

• A. Confront the caregiver directly about the suspected abuse
• B. Interview the client privately and document objective findings
• C. Wait for additional incidents before taking any action
• D. Advise the client to move out of the caregiver's home immediately

57. A nurse is caring for a client experiencing alcohol withdrawal 24 hours after the last drink. Which finding requires immediate provider notification?

• A. A new onset seizure
• B. Mild hand tremor
• C. Reported difficulty sleeping
• D. Mild anxiety and irritability

58. A client with major depressive disorder suddenly appears calm and energized after weeks of profound withdrawal. What is the nurse's priority concern?

• A. The client may now have the energy to act on suicidal thoughts and requires close assessment
• B. The client has recovered and can be prepared for discharge
• C. The medication dose should be reduced immediately
• D. The change indicates the development of mania

59. A client states, "I have nothing left to live for." Which is the nurse's most appropriate initial response?

• A. "Are you thinking about killing yourself?"
• B. "You have so much to live for; think of your family."
• C. "Things will look better in the morning."
• D. "Why would you feel that way?"

60. A nurse is caring for a client who is experiencing auditory hallucinations. Which response is therapeutic?

• A. "I do not hear the voices, but I understand they feel real to you. What are they saying?"
• B. "There are no voices; you are imagining things."
• C. "I hear them too, but we can ignore them together."
• D. "Stop listening to the voices and focus on me."

61. During the NCLEX-PN, the number of items a candidate answers can vary from one test-taker to another. Which range represents the possible number of questions?

• A. 75 to 145 questions
• B. 85 to 150 questions
• C. 100 to 200 questions
• D. A fixed 120 questions for everyone

62. A test-taker answers the minimum number of NCLEX-PN questions and finishes with time to spare. What is the maximum amount of time still theoretically available for a session under the exam's rules, regardless of how many questions were answered?

• A. Up to 300 minutes
• B. Up to 240 minutes
• C. Up to 360 minutes
• D. Exactly 85 minutes

63. Before administering a scheduled oral medication, the nurse checks the client's identity. Which combination of identifiers is acceptable?

• A. The client's room number and bed position
• B. The client's first name and the diagnosis on the whiteboard
• C. A visitor's confirmation of who the client is
• D. The client's full name and date of birth compared against the identification band and medication record

64. A client is placed on contact precautions for Clostridioides difficile infection. Which hand hygiene method is required?

• A. Washing with soap and water, because alcohol-based rubs do not kill spores
• B. Alcohol-based hand rub only, as it is faster and more effective
• C. Either method, as both are equally effective against C. difficile
• D. Antiseptic wipes applied to gloved hands

65. A client is admitted with suspected pulmonary tuberculosis. Which precautions should the nurse implement?

• A. Airborne precautions with a negative pressure room and an N95 respirator
• B. Droplet precautions with a surgical mask within three feet
• C. Contact precautions with gown and gloves only
• D. Standard precautions alone

66. A nurse is donning personal protective equipment before entering an isolation room. What is the correct sequence?

• A. Gown, mask or respirator, goggles or face shield, then gloves
• B. Gloves, gown, mask, then goggles
• C. Mask, gloves, gown, then goggles
• D. Goggles, gloves, gown, then mask

67. A client begins to have a generalized tonic-clonic seizure while sitting in a chair. What is the nurse's priority action?

• A. Ease the client to the floor, protect the head, and turn the client to the side
• B. Insert a padded tongue blade into the client's mouth
• C. Restrain the client's extremities to prevent injury
• D. Leave to obtain suction equipment immediately

68. A nurse is caring for a confused older adult who is attempting to climb out of bed. Which intervention should the nurse implement first?

• A. Use the least restrictive measures, such as a bed alarm, frequent checks and moving the client near the nurses' station
• B. Apply wrist restraints to prevent the client from getting up
• C. Raise all four side rails on the bed
• D. Administer a sedative before attempting other measures

69. A nurse is preparing to transfer a client from bed to chair. Which action promotes safe body mechanics for the nurse?

• A. Keep the back straight, bend at the knees and hips, and keep the client close to the body
• B. Bend at the waist and lift with the back muscles
• C. Keep the feet together to maintain a narrow base of support
• D. Twist at the waist while moving the client toward the chair

70. A nurse is caring for a client in restraints. How frequently must the client generally be monitored, and what must be assessed?

• A. At regular short intervals per policy, assessing circulation, skin integrity, elimination, nutrition and the continued need for restraint
• B. Once per shift, assessing only whether the restraint remains secure
• C. Only when the client complains of discomfort
• D. Once every 24 hours when the order is renewed

71. A client with a history of latex allergy is scheduled for a procedure. What is the nurse's most important action?

• A. Ensure the allergy is documented and communicated, and that latex-free supplies are used throughout
• B. Administer an antihistamine before the procedure and use standard supplies
• C. Use latex gloves but change them frequently
• D. Rely on the client to identify latex products during the procedure

72. A nurse is preparing the room of a client who is neutropenic following chemotherapy. Which item should the nurse remove from the room?

• A. A vase of fresh-cut flowers delivered by a florist
• B. A framed family photograph on the bedside table
• C. A sealed bottle of drinking water
• D. The client's own clean bathrobe from home

73. A client is admitted with suspected bacterial meningitis. In addition to standard precautions, which transmission-based precaution should the nurse implement?

• A. Contact precautions with a gown for all room entry
• B. Airborne precautions with a negative-pressure room
• C. Droplet precautions, wearing a surgical mask when working close to the client
• D. Protective isolation with sterile linens

74. A nurse has finished providing wound care for a client on contact precautions and is preparing to leave the room wearing a gown and gloves. Which item of personal protective equipment should be removed first?

• A. The gown, by breaking the neck ties
• B. The gloves, using a glove-to-glove then skin-to-skin technique
• C. The mask, by touching only the elastic bands
• D. Whichever item feels most contaminated

75. A nurse discovers a small fire in a trash can in an occupied client room. What is the nurse's first action?

• A. Activate the nearest fire alarm pull station
• B. Close all doors along the corridor
• C. Locate a fire extinguisher and attempt to put out the fire
• D. Move the client out of the room to a safe area

76. While setting up an infusion pump, the nurse notices that its power cord is frayed with exposed wire. Which action should the nurse take?

• A. Use the pump but plug it into an outlet farther from the bed
• B. Wrap the frayed section in tape and continue the infusion
• C. Remove the pump from use, tag it as defective, and report it for biomedical inspection
• D. Run the pump on battery power for the rest of the shift

77. A nurse has just administered a subcutaneous injection using a needle equipped with a safety device. Which action should the nurse take next?

• A. Recap the needle carefully using both hands before disposal
• B. Activate the safety device and place the entire unit in a puncture-resistant sharps container
• C. Set the syringe on the medication tray to dispose of after leaving the room
• D. Bend the needle so it cannot be reused before discarding it in the trash

78. A nurse is reinforcing safety teaching for a client who will use home oxygen via nasal cannula. Which client statement indicates a need for further teaching?

• A. "I will post no-smoking signs where visitors can see them."
• B. "I will keep the oxygen concentrator away from the fireplace."
• C. "I can cook at my gas stove while wearing my cannula as long as I am careful."
• D. "I will use water-based lotion instead of petroleum jelly on my nose."

79. A nurse is assisting with a sterile dressing change and has set up a sterile field. Which action contaminates the field?

• A. Reaching over the center of the sterile field to reposition supplies on the far side
• B. Placing sterile gauze well inside the edges of the drape
• C. Keeping gloved hands above waist level throughout the procedure
• D. Facing the sterile field at all times while working

80. A nurse is reinforcing teaching with a client in the second trimester of pregnancy about warning signs. Which symptom should the client report to the provider immediately?

• A. Mild ankle swelling at the end of the day
• B. Occasional heartburn after large meals
• C. Whitish vaginal discharge without odor
• D. Bright red vaginal bleeding

81. A nurse is teaching an adult client about recommended health screening. Which statement reflects appropriate general guidance?

• A. Screening recommendations depend on age, sex, personal and family history, and should be individualized with the provider
• B. All adults require identical screening tests on the same schedule
• C. Screening is unnecessary for anyone without symptoms
• D. Family history has no bearing on screening timing

82. A nurse is reinforcing teaching with a pregnant client in the first trimester about nutrition. Which supplement is most important for preventing neural tube defects?

• A. Folic acid
• B. Vitamin E
• C. Vitamin K
• D. Magnesium

83. A nurse is assessing an infant at a well-child visit. Which finding requires further evaluation?

• A. An anterior fontanel that is bulging and tense while the infant is calm and upright
• B. An anterior fontanel that is soft and flat
• C. A posterior fontanel that has closed by two months of age
• D. An infant who tracks a face across the midline

84. A nurse is reinforcing discharge teaching for an older adult client at risk for falls at home. Which instruction is most appropriate?

• A. Remove loose throw rugs, improve lighting, and install grab bars in the bathroom
• B. Wear loose backless slippers for comfort when walking
• C. Keep the home dimly lit at night to promote sleep
• D. Rise quickly from bed to avoid dizziness

85. A nurse is reinforcing teaching about a low-sodium diet for a client with hypertension. Which food choice indicates the teaching was effective?

• A. Fresh baked chicken breast with herbs
• B. Canned soup with crackers
• C. Processed deli turkey sandwich
• D. Cured ham with pickles

86. A nurse is providing perineal care for a female client with an indwelling urinary catheter. Which technique is correct?

• A. Cleanse from the front toward the back, using a clean area of the cloth for each stroke
• B. Cleanse from the rectal area upward to ensure thorough coverage
• C. Scrub the catheter tubing vigorously toward the meatus
• D. Use the same section of washcloth throughout to conserve linens

87. A nurse is repositioning a client who is at risk for pressure injury. How often should a bedbound client generally be repositioned?

• A. At least every two hours, with the schedule individualized to skin assessment findings
• B. Once per shift
• C. Every eight hours
• D. Only when the client requests a change

88. A nurse is assessing a pressure injury and finds partial-thickness skin loss with exposed dermis presenting as a shallow open ulcer with a red-pink wound bed and no slough. How is this staged?

• A. Stage 2
• B. Stage 1
• C. Stage 3
• D. Unstageable

89. A client with dysphagia following a stroke is being assisted with a meal. Which nursing action promotes safe swallowing?

• A. Position the client upright at 90 degrees and instruct a chin-tuck while swallowing
• B. Have the client recline to 30 degrees to slow the passage of food
• C. Offer thin liquids through a straw to ease intake
• D. Encourage the client to tilt the head back when swallowing

90. A client reports constipation. Which nursing recommendation is most appropriate as an initial measure?

• A. Increase dietary fiber and fluid intake and encourage regular physical activity
• B. Begin daily enemas to establish a routine
• C. Restrict fluids to firm the stool
• D. Encourage prolonged bed rest

91. A client is receiving chemotherapy and the nurse notes an absolute neutrophil count indicating neutropenia. Which instruction is most important for the nurse to reinforce?

• A. Increase intake of fresh, unwashed fruits and vegetables for nutrition.
• B. Avoid hand hygiene since neutropenic clients are already protected.
• C. Discontinue all visitors' use of masks since the client is not contagious.
• D. Avoid crowds and people who are ill, and report fever immediately.

92. A client receiving intravenous heparin has a partial thromboplastin time (PTT) reported as significantly elevated above the therapeutic range. Which nursing action is the priority?

• A. Increase the heparin infusion rate to reach therapeutic effect faster.
• B. Administer an extra dose of heparin to compensate.
• C. Notify the provider and prepare to hold or adjust the infusion per protocol while monitoring for bleeding.
• D. Continue the current rate without any change since PTT naturally fluctuates.

93. A nurse is monitoring a client after a cardiac catheterization via the femoral artery. Which finding requires immediate action?

• A. Absent pedal pulse in the affected extremity
• B. Client reports mild discomfort at the insertion site
• C. Blood pressure of 118/74
• D. Client requests to change position slightly in bed

94. A client's serum potassium level is reported as 6.2 mEq/L. Which assessment is the nurse's priority?

• A. Cardiac rhythm, because hyperkalemia can cause life-threatening dysrhythmias
• B. Skin turgor and mucous membranes
• C. Bowel sounds in all four quadrants
• D. Pupillary response to light

95. A nurse is verifying nasogastric tube placement before administering a feeding. Which method is most reliable?

• A. Radiographic confirmation, which is the standard for initial placement verification
• B. Auscultating over the epigastrium while injecting air
• C. Asking the client whether they feel the tube in the stomach
• D. Observing for the absence of coughing

96. A client is scheduled for surgery and reports taking a daily aspirin. What is the significance of this information?

• A. It increases bleeding risk and must be communicated to the surgical team
• B. It has no bearing on surgical risk
• C. It reduces the need for postoperative pain medication
• D. It eliminates the need for deep vein thrombosis prophylaxis

97. A postoperative client is reluctant to move because of incisional pain. Which intervention best reduces the risk of postoperative pneumonia?

• A. Medicate for pain, then encourage deep breathing, coughing and use of an incentive spirometer
• B. Maintain strict bed rest until the incision is fully healed
• C. Restrict fluids to reduce pulmonary secretions
• D. Administer oxygen continuously in place of breathing exercises

98. A nurse is performing tracheostomy suctioning. Which technique is correct?

• A. Apply suction only while withdrawing the catheter, limiting each pass to about 10 to 15 seconds
• B. Apply continuous suction during both insertion and withdrawal
• C. Suction for at least 30 seconds per pass to clear all secretions
• D. Instill saline routinely before each suction pass

99. A nurse is completing a preoperative assessment for a client scheduled for surgery under general anesthesia. Which finding is most important to report to the anesthesia provider before the procedure?

• A. The client reports a loose tooth and wears a partial denture.
• B. The client's stated preference for a warm blanket in the operating room.
• C. The client's shoe size for postoperative footwear.
• D. The client's preferred visiting hours for family after surgery.

100. A client undergoing a paracentesis for ascites has 2 liters of fluid removed. Which finding after the procedure requires the nurse to notify the provider immediately?

• A. Mild soreness at the puncture site.
• B. Blood pressure dropping significantly with reported dizziness and tachycardia.
• C. Blood pressure within the client's baseline range.
• D. A small amount of serous drainage on the dressing.