2025 Edition

Practice Exam for the NCLEX-RN

Take this free practice exam to get a sample of the types of questions that are on the NCLEX-RN exam.

The actual NCLEX exam includes these categories: Basic Nursing Care, Management and Practice Directives, Preventing Risks and Complications, Caring for Acute and Chronic Conditions, Safety, Mental Health, Pharmacology and Growth and Development.

To prepare for your RN licensure exam, see the complete Practice Exam for the NCLEX-RN with 850 questions and case studies, written by nursing experts and medical writers.

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Management of Care

1.	At the beginning of the shift, a nurse receives a report for her daily assignment. Which of the following situations should the nurse give first priority?
		a. A diabetic client with a blood glucose level of 195 mg/dL
		b. A family member of an elderly client who has questions
		c. A client with COPD with an oxygen saturation of 84%
		d. A client who requires assistance to use the bathroom
When prioritizing needs of clients, the nurse must begin with the unstable client or manage conditions that affect airway, breathing, or circulation first. The client with COPD has a condition that affects breathing and is exhibiting decreased oxygen saturation levels; therefore, this client should be the first priority. Incorrect answer. Please choose another answer.

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2.	A patient is to get an MRI of the abdomen. Which of the following instructions should the nurse give the patient?
		a. Do not wear metal objects during the MRI, including jewelry.
		b. Do not take oral medications up to 12 hours after the MRI.
		c. Do not urinate prior to the MRI.
		d. Do not eat solid foods 12 hours prior to the MRI.
Metal objects should not be used near an MRI. An MRI, or Magnetic Resonance Imaging device, will not function properly when magnetic objects, such as jewelry are nearby, and can cause harm to the patient through the MRI pulling the objects away from the patient. Patients should be assessed for metal materials within the body as well, such as joint replacement or spinal hardware. Unless otherwise instructed, it is safe for a patient to take oral medications, eat solid foods, and urinate as usual prior to getting an MRI or following an MRI. Incorrect answer. Please choose another answer.

3.	Which of the following symptoms would support a diagnosis of Crohn's disease?
		a. Fatigue and headache
		b. Rectal cramping and bleeding
		c. Stomach swelling and gas
		d. All of the above
Rectal cramping and bleeding would be the most consistent in supporting a diagnosis of Crohn's Disease. While it is unclear what causes Crohn's disease, patients almost always present with these symptoms. Fatigue and headaches could result following blood loss in Crohn's disease but would not be used to make a definitive diagnosis. People with Crohn's disease may experience stomach swelling and gas. These are also symptoms of all types of IBD. They would not necessarily be used to make a diagnosis as these symptoms are present in many other intestinal-related diseases. Incorrect answer. Please choose another answer.

4.	A 50-year-old female is one-day post-op from a total abdominal hysterectomy. The RN is busy with another patient and asks the certified nursing assistant for help. Which of the following is inappropriate delegation by the RN?
		a. Asking the certified nursing assistant to ambulate the patient.
		b. Asking the certified nursing assistant to empty the Foley catheter.
		c. Asking the certified nursing assistant to teach the patient how to care for her incision.
		d. Asking the certified nursing assistant to check a blood pressure on the patient.
The certified nursing assistant is not authorized to instruct patients on post-operative care or wound care. This should never be delegated. It is within the certified nursing assistant's scope of practice to perform the other interventions. Incorrect answer. Please choose another answer.

5.	A doctor visits a patient in the morning prior to a scheduled cholecystectomy to get consent for the procedure. He hands the nurse the consent form prior to leaving the unit. When the nurse steps into the room, the patient has multiple questions regarding the surgery, indicating that everything about the procedure was not disclosed. Which is the appropriate response by the nurse?
		a. "You have already signed the consent form, so we need to proceed with the surgery."
		b. "I will answer any questions that you have about the procedure and the risks/benefits."
		c. "I will call the medical director and let him know the physician did not explain your procedure."
		d. "I will call the doctor and have him return to explain everything and answer your questions."
The physician has the responsibility of discussing a procedure, risks/benefits, and alternatives to the procedure; the nurse is unable to do this. Additionally, choice A is incorrect as a patient has the right to withdraw consent at any time, even after signing the consent form. Incorrect answer. Please choose another answer.

6.	Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?
		a. Call the supervisor and file a complaint against the physical therapy department
		b. Contact the physician to notify him that the orders were not carried out
		c. Assess the client's activity level by assisting with ambulation using a gait belt
		d. Contact the physical therapy department again and repeat the order
Nurses must typically work as part of a larger interdisciplinary team that involves collaboration with other professionals. In order to fulfill the client's needs, communication between disciplines should remain respectful, with clear directions about each discipline's responsibilities. Communication between all parties minimizes confusion about the client's care. Incorrect answer. Please choose another answer.

7.	The "B" in the SBAR acronym stands for:
		a. Background
		b. Basic
		c. Beginning
		d. Break
The "B" in the SBAR acronym stands for Background. The SBAR is a communication tool used between providers that regulates the type and amount of information given. When contacting a physician, the nurse provides information about the situation, the client's background, the nurse's assessment, and further recommendations. Incorrect answer. Please choose another answer.

Safety and Infection Control

8.	Which of the following is an example of client handling equipment?
		a. Wheelchair
		b. Height-adjustable bed
		c. Shower chair
		d. Call light
Client handling equipment is designed to reduce the stress and workload on nurses who must assist, turn, or lift clients. This equipment decreases the risk of injuries associated with improper lifting. A height-adjustable bed raises the client up to a proper working height for the nurse who must provide assistance. Incorrect answer. Please choose another answer.

9.	Which practice will help to reduce the risk of a needlestick injury?
		a. Only expose the end of the needle once ready to enter the room for the procedure
		b. Always place the cap back on a needle after it has been used
		c. Keep a sharps container nearby where it can be easily accessed
		d. Pass needles between nurses by using the hand-over technique
When administering an injection or using sharps for a procedure, the nurse can minimize safety risks by keeping a sharps container nearby. This provides easy access for quick disposal to prevent the possibility of a needlestick. Needles should never be recapped after use and nurses should always exchange needles from a central area rather than passing them between workers. Incorrect answer. Please choose another answer.

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10.	Which of the following is an organizational factor that affects workplace violence directed at nurses?
		a. Clients who have short hospital stays
		b. The presence of security guards
		c. Restricted client areas
		d. Understaffing of nursing personnel
Understaffing of nursing personnel may be an organizational risk associated with workplace violence for nurses. Understaffing involves too few nurses on duty, which may not be enough to meet client needs at the time or may result in longer delays for provision of care. Greater amounts of activity and diminished numbers of nurses to provide care may result in aggression, violence, or anger from clients or families directed toward staff. Incorrect answer. Please choose another answer.

11.	Which of the following infectious control methods should be used when caring for a patient with bacterial pneumonia?
		a. Wear a mask when taking vital signs.
		b. Do not allow flowers in the patient's room.
		c. Require the patient to use disposable eating utensils.
		d. Do not allow visitors.
A patient with Bacterial Pneumonia may spread the disease through droplets from coughing or sneezing. Droplet precautions would be appropriate. A mask is required to prevent inhalation of droplets containing bacteria. Flowers are allowed into the patient room as this should not worsen the patient's condition, unless the patient has an allergy. Proper sanitization measures are acceptable when handling utensils used by a patient on Droplet precautions. Visitors can be allowed, provided a mask is worn within the room of a patient who may be coughing. Incorrect answer. Please choose another answer.

12.	The nurse notices a CNA using an alcohol-based hand sanitizer after walking out of a room marked as Enteric Contact Precautions. What should the nurse's response be?
		a. Nothing as the CNA has appropriately washed their hands after leaving the room
		b. Tell the CNA they need to wear a mask in the room
		c. Tell the CNA they should dispose of their gloves outside of the room
		d. Tell the CNA they need to wash their hands with soap and water
A room marked with Enteric Contact Precautions indicates that normal alcohol-based hand sanitizer will not remove the bacteria present in the room. Hands should be washed with soap and water, instead of using hand sanitizer. A mask is not indicated with Enteric Contact Precautions. The CNA should dispose of gloves inside the room to contain the bacteria within the room, then hands should be washed with water and soap. Incorrect answer. Please choose another answer.

13.	A newly diagnosed type 1 diabetic presents with a blood glucose of 700, increased ketones, fruity-smelling breath, and rapid deep breathing. An ABG is performed. As the nurse reviews the labs, she notes the following values: pH of 7.25, HCO3 of 17mEq/L, PaCO2 31 mm Hg. Which acid-base imbalance is present?
		a. Respiratory acidosis
		b. Metabolic acidosis
		c. Metabolic alkalosis
		d. Respiratory alkalosis
First, we look at the pH. The normal pH range is 7.35-7.45. Acidosis is present when the pH is below 7.35. Thus, we can eliminate the alkalosis answers. The HCO3 is also low (normal is 22-26) as is the PaCO2 (normal is 35-45). Both values point to metabolic acidosis. Incorrect answer. Please choose another answer.

14.	A nurse is advising a patient with Chronic Fatigue Syndrome on infection control procedures. Which of the following statements by the patient indicates that the patient understands the advice?
		a. I'm going to a basketball game tonight.
		b. I should avoid anyone with cold symptoms.
		c. I should have a blood test.
		d. I'm not going to attend functions with large crowds.
A patient making this statement understands that one step in infection control is avoiding patients who have cold symptoms. This is important as the person with Chronic Fatigue Syndrome may be more susceptible to a virus or the virus may trigger more disease symptoms. The patient who verbalizes they are not going to the basketball game or are going to avoid functions with large crowds may understand that Chronic Fatigue Syndrome can cause the patient to become tired, but this does not indicate the patient understands infection control. Infection control measures can be implemented at events by following standard precautions, such as handwashing. If the patient stops going to social events, this can also cause the patient to become depressed and isolated. Infection control statements would more accurately be made about prevention of infection. A blood test would only indicate if the patient already has an infection. Incorrect answer. Please choose another answer.

15.	A portion of a building collapses after an earthquake, sending multiple patients to the nearest emergency room. Which of the following patients should be first priority?
		a. A 20-year-old male with a head laceration and substantial bleeding.
		b. A 42-year-old female with dyspnea, oxygen saturation of 88%, and a pulse of 120bpm.
		c. A 50-year-old male with partial amputation of the right foot, with pulse present
		d. A 12-year-old female complaining of pain and has a large bruise on her left shoulder and neck.
This patient is experiencing respiratory distress and needs immediate attention. While the other patients need to be evaluated as well, Option C is the most urgent situation. Incorrect answer. Please choose another answer.

16.	Which of the following patients would not require a mask to be worn while providing care?
		a. A 10-year-old female with varicella
		b. A 67-year-old African male with tuberculosis
		c. A 52-year-old female with shingles
		d. A 40-year-old male with COVID-19
Shingles is caused by the herpes zoster virus and requires contact precautions. Varicella and tuberculosis require airborne precautions which are necessary for diseases where infectious material can remain suspended in the air for extended periods of time. Droplet precautions are required for diseases where pathogens are transmitted by respiratory droplets (droplets greater than 5 microns), which can occur when a patient is coughing, sneezing, or even talking. Incorrect answer. Please choose another answer.

17.	A doctor orders restraints on a confused patient who is constantly pulling her NG tube out and has tried several times to remove her catheter. The nurse understands that appropriate use of restraints includes all of the following except:
		a. It is necessary to check the patient's skin, as well as neurovascular status every 30 minutes.
		b. The restraints should be tied to the side rails, allowing enough slack to allow some movement of restrained body part.
		c. The restraints should be discontinued as soon as the patient is not at risk of harming themselves or others.
		d. The nurse should offer toileting and range-of-motion exercises every 2 hours.
While the restraint should have some slack, they should NOT be tied to the side rails. Instead, a quick-release knot should be used and tied in an area where the patient cannot reach. Incorrect answer. Please choose another answer.

Health Promotion and Maintenance

18.	A patient is not to eat or drink anything 24 hours before a colonoscopy.
		a. True
		b. False
A patient may be instructed to not eat any solid foods up to 24 hours prior to a colonoscopy, however clear liquids are typically allowed until midnight prior to the procedure up to a couple hours prior to the procedure. The nurse will need to verify the orders given by the physician. Incorrect answer. Please choose another answer.

19.	A nurse is putting together an educational seminar on advance directives. What information would be included in the materials?
		a. A patient may change a treatment decision in an advance directive if the patient's health care agent approves the change.
		b. When admitted to the hospital, a patient must appoint a Durable Power of Attorney for health care decisions.
		c. A health care facility must provide a patient informational material advising them of their rights to declare their desires concerning treatment decisions.
		d. A health care facility is required to provide a patient an attorney when the patient is signing a living will.
Under Federal law, all healthcare facilities are required to provide patients with information on how to make medical decisions under Federal and State law, including accepting or refusing treatments and creation of an Advance Directive. The patient has the right to change a treatment decision in an advance directive, regardless of whether the patient's healthcare agent approves or denies the change. It is the patient's right to appoint a Durable Power of Attorney at the time and place of his choosing. It is not required for entry to a hospital. The healthcare facility is not required to provide an attorney to a patient to sign a living will. The patient needs to determine which attorney they want to hire or if they want to hire an attorney. Incorrect answer. Please choose another answer.

20.	Which of the following patients should a nurse recognize as having an increased risk of breast cancer while doing breast cancer screening?
		a. A 44 year old who has had five children
		b. A 28 year old who is breast feeding her first child
		c. A 35 year old who started her menstrual cycle at age 12
		d. A 61 year old who has not had children
The risk for breast cancer is increased in elderly patients who have not had children. Patients who have had children are at less risk for breast cancer than those who have not had children. Breastfeeding decreases the risk for breast cancer. A patient who started her menstrual cycle at age 12 would be a decreased risk for breast cancer. Patients with irregular cycles or who started at an earlier age may be at an increased risk for breast cancer. Incorrect answer. Please choose another answer.

Caring for Acute or Chronic Conditions

21.	A nurse just started a blood transfusion for a patient with a Hemoglobin of 6. The patient says, "I feel hot, my stomach hurts, and I am having difficulty breathing." What should be the nurses first action?
		a. Notify the physician immediately
		b. Stop the infusion
		c. Take vital signs
		d. Call a code
The first action should be to stop the transfusion immediately once the patient complains of any unusual symptoms. The patient is reporting symptoms of a transfusion reaction therefore the transfusion should be stopped to prevent the patient from worsening. The provider should be notified immediately after stopping the transfusion. Vital signs should be taken as quickly as possible or as instructed by the provider after the transfusion has been stopped and the physician has been notified. A code should be called if the patient becomes unresponsive. A rapid response could be called if the patient is at risk of destabilizing. Incorrect answer. Please choose another answer.

22.	Which of the following statements should the nurse give to a Type 2 Diabetic patient?
		a. Eat less fruits and vegetables and more grains.
		b. Try to wear closed toe shoes whenever ambulating.
		c. Minimize physical activity to prevent fatigue.
		d. Check your blood sugar only after meals.
The correct statement by the nurse is that the patient should wear closed toe shoes when ambulating. Patients with Diabetes are at high risk for impaired sensation in their lower extremities and may develop wounds that are difficult to heal. Patients with Diabetes should be encouraged to eat more fruits and vegetables as part of a healthy blood-sugar regulating diet. Increasing physical activity is another way the patient with Diabetes can regulate blood sugar levels. If the Diabetic patient is checking blood sugars, the levels would normally be checked prior to meals, typically to determine a dose of insulin. Incorrect answer. Please choose another answer.

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23.	Which of the following advisements should a patient suffering from GERG receive?
		a. To eat high-protein, low-fat foods
		b. To stay upright two to three hours after a meal
		c. Limit the intake of acid-stimulating food and drink
		d. All of the above
All of the answers are correct. A high-protein, low-fat diet is appropriate for patients with GERD as following this diet helps prevent symptoms of acid reflux. A high-fat diet may delay gastric emptying leading to more acid reflux. Remaining upright will help keep pressure off of the esophageal sphincter and allow the muscle to work appropriately. Limiting the intake of acid-stimulating food and drink will also prevent heartburn by calming the esophageal lining and preventing the esophageal sphincter from weakening. Incorrect answer. Please choose another answer.

24.	Which of the following symptoms would a patient exhibit with hyperthyroidism?
		a. Intolerance to cold
		b. Decreased bowl movements
		c. Slow heart rate
		d. None of the above
A patient with hyperthyroidism will present with the opposites of the listed symptoms. Too much thyroxine is produced, causing the body's metabolism to rise. This leads to an intolerance to heat, a decrease in weight gain, increased bowel movements, a rapid heart rate, and warm, clammy skin. Incorrect answer. Please choose another answer.

25.	A patient has Incentive Spirometry ordered QID x 10 breaths after a cholecystectomy. The patient is asking why they need to perform this action. Which of the following would not be a reason the patient should use the Incentive Spirometer?
		a. To decrease lung capacity
		b. To gently exercise the lungs
		c. To improve recovery time
		d. To prevent pneumonia
Using an Incentive Spirometer will increase lung capacity, opening the bronchioles, and allowing for better oxygenation throughout the body. Using an Incentive Spirometer gently exercises the lungs and will encourage the patient to take long and deep breaths instead of short and shallow breaths which are common following surgery. Maintaining adequately expanded lungs and allow better oxygenation through the blood stream will improve recovery times, allowing for the patient to start ambulating sooner as well as encourage proper healing to the surgical site. Incentive Spirometry use prevents pneumonia by keeping bronchioles open and clear, minimizing the sustainable environment for pneumonia to develop. Incorrect answer. Please choose another answer.

Psychosocial Integrity

26.	While preparing for discharge, a patient makes the statement to the nurse, "I'm not sure I will be able to take care of myself at home." Who is the most appropriate team member to report this statement?
		a. Doctor
		b. Physical Therapist
		c. Case Manager
		d. Director of Nursing
The case manager is the most appropriate healthcare team member to report this kind of statement to, especially around discharge. An assessment may need to take place regarding the living and financial situation of the patient. The doctor and director of nursing would most likely refer the nurse back to the case manager, so it would be appropriate for the nurse to report this statement to the case manager first. Incorrect answer. Please choose another answer.

27.	A patient's spouse died three months ago. The patient says "I would like my friend Tom to have my collection of artwork because I don't need to look at them anymore." Which of the following responses by the nurse would be proper?
		a. Did Tom ask for the artwork?
		b. Are you planning to commit suicide?
		c. Does Tom know you want to give him the artwork?
		d. Why do you want to give the artwork away?
It is appropriate for the nurse to ask this question of the patient as a close-ended question with two responses. The nurse can decide based on the patient's response if further evaluation is needed. As to the other answer options, the focus should remain on the patient as it will be easy for the patient to sidetrack a conversation. In answer option d, it is an open-ended question and gives the patient an opportunity to evade further questions about the patient's plan to commit suicide. Incorrect answer. Please choose another answer.

28.	A patient with a history of schizophrenia says "The medical staff is secretly employed by the CIA to take me out." The nurse should respond as follows:
		a. The CIA protects us and is not out to hurt you.
		b. No other patient thinks that.
		c. I want to help you, not harm you. It must be frightening thinking people want to hurt you.
		d. When did you first start having these thoughts?
The best therapeutic communication with a schizophrenic patient is to acknowledge their fears while also developing rapport with the patient as a nurse. This statement best meets those needs. A patient with schizophrenia will truly believe in the statements they are making, so the nurse should not try to convince the patient they are wrong as this may develop distrust between the nurse and patient. The focus should remain on the patient and their beliefs. The nurse should not bring other patients into the conversation. As to answer option d, this statement does not acknowledge that the patient's thoughts are their reality. The patient may also not know the answer to this question and the nurse will not be able to develop rapport with the patient. Incorrect answer. Please choose another answer.

29.	The spouse of a patient in a long term treatment facility asks a nurse for information about the patient's treatment plan. The nurse should respond as follows:
		a. The nurse should ask the patient for the information.
		b. "I cannot give you information on any patient."
		c. "The doctor will speak to you about the treatment plan."
		d. "Can you give me the patient's Social Security Number?"
Unless the patient has given consent for information to be given to the spouse, the nurse should respond that no PHI, or Protected Health Information, can be given out. Treatment plan information would be considered PHI under HIPAA. It would not be appropriate to direct the spouse to the patient for the information. The nurse should already be aware of the treatment plan information and can ask permission from the patient to speak to the spouse. It is not appropriate for the nurse to pass the buck to the provider. In this scenario, the nurse should tell the spouse that information cannot be given. Even if the spouse knows the patient's Social Security Number, the patient's PHI is protected under HIPAA. Incorrect answer. Please choose another answer.

30.	A patient is brought to the emergency room by her spouse. The patient's injuries are indicative of physical abuse. Which of the following actions should be taken by the nurse?
		a. Question the couple about how their marriage is going.
		b. Inform the spouse that the patient's injuries appear to be the result of abuse.
		c. Inform the patient that she will have to speak to the police.
		d. With the spouse out of the room, question the patient about the possibility of abuse.
Using therapeutic communication, the nurse should question the patient about the possibility of abuse. It is appropriate to talk with the patient when the spouse is out of the room as the patient may be fearful and not answer questions honestly if the spouse is in the room. It is not appropriate to question the patient when spouse is in the same room. It is not appropriate to approach the spouse with suspicion of abuse as this could cause further damage to the patient and make it more difficult for the patient to leave the abuser. The patient is not required to speak to the police. It is up to the patient to determine if they want to speak to the police, though the nurse can encourage the patient. Incorrect answer. Please choose another answer.

31.	A patient is scheduled for surgery to have his appendix out due to acute appendicitis. The patient says "I don't think I need surgery now because I feel better." A nurse should respond as follows:
		a. I will have your spouse explain the procedure to you again.
		b. I will call your doctor to explain the procedure to you.
		c. I will explain the procedure to you and answer any questions you have.
		d. Your appendix may rupture and that could cause serious problems.
It is most appropriate to notify the doctor that the patient is rethinking about receiving the surgery. The doctor will need to discuss their options again and reinforce to the patient that surgery is required or not. It is not appropriate for the spouse to explain the procedure to the patient. This should be done by medical staff. The patient may have questions that can only be answered by the doctor, therefore the doctor should be notified. The nurse may not be able to explain the procedure appropriately and may cause the patient to distrust the medical staff, therefore the doctor should be notified as they may need to receive consent a second time. Incorrect answer. Please choose another answer.

32.	Which method should be the last resort in assisting a patient who is experiencing mild anxiety?
		a. Therapeutic Communication
		b. Deep-Breathing
		c. Progressive Muscle Relaxation
		d. Administration of Haldol
Non-pharmacological methods should be used prior to pharmacological methods. Haldol is normally given to patients experiencing severe anxiety or agitation and should be used as a last resort. A patient may benefit from the nurse sitting with them and providing calm conversation over the anxiety-causing issue. Deep-breathing is well-known calming technique used to calm the nervous system and can help in cases of anxiety or panic attacks. Progressive Muscle Relaxation can be used to encourage the patient into a more relaxed state. The nurse can assist the patient to lay on the bed and provide instructions to the patient in a slow calm voice. Progressive Muscle Relaxation would be helpful for mild anxiety. Incorrect answer. Please choose another answer.

33.	A client has been diagnosed with a form of terminal cancer and has started receiving hospice care. The nurse notes that both the client and his family avoid talking about the diagnosis. All attempts at discussion result in changing the subject. The nurse recognizes that this family is exhibiting:
		a. Closed awareness
		b. Mutual pretense
		c. Open awareness
		d. Powerless assessment
Mutual pretense is a form of awareness as a response to death or dying in which those involved avoid discussing the situation. In a case of terminal illness, a client and his family are aware of the diagnosis; but the client may not want to talk about the situation for various reasons, such as saving his family from feelings of grief, fear of the future, or discomfort with talking about feelings. Incorrect answer. Please choose another answer.

34.	A nurse is caring for a child whose parents live in a home with several other unrelated children and adults. Some of the people who live in the home have visited and the nurse discovers that this group all shares finances and living conditions. What type of family is this most likely an example of?
		a. Blended family
		b. Communal family
		c. Foster family
		d. Extended family
A communal family is a group classified as a non-traditional family. In this situation, adults who are not related may live and work with other adults and their children all together in a household. The communal family may share expenses, food, and childcare in the same way as a traditional family. Incorrect answer. Please choose another answer.

35.	A fellow nursing student receives a poor grade after failing to perform a clinical procedure correctly. He vents to you, stating "My instructor does not like me. She is always singling me out and does not want me to graduate." This is an example of which defense mechanism?
		a. Regression
		b. Dissociation
		c. Rationalization
		d. Substitution
Rationalization occurs when a person tries to avoid taking responsibility for their behavior, choosing instead to blame someone or something else. Regression is defined as going backward to a previous developmental stage, usually because it makes a person feel safe. Dissociation deals with a temporary shift in consciousness (such as disconnecting oneself from one's feelings), usually as a reaction to significant stress or trauma. Substitution is when a person substitutes an easier goal or desire for an original goal or desire which proves unreachable. Incorrect answer. Please choose another answer.

36.	A patient is prescribed lithium for bipolar disorder. Which of the following patient statements is concerning?
		a. "I need to make sure I drink plenty of water and that my salt intake remains about the same every day."
		b. "I will immediately stop this medication if I become pregnant."
		c. "I will check my lithium levels regularly."
		d. "I need to avoid ibuprofen because it can cause high levels of lithium in my body."
While lithium has been associated with increased risk of Ebstein's anomaly in pregnant women, abruptly discontinuing lithium will likely lead to a relapse of symptoms, which can be detrimental to the patient. Incorrect answer. Please choose another answer.

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37.	A nurse is preparing to talk about body changes with a client who just had a bilateral mastectomy. Which of the following actions of the nurse is most appropriate during this discussion?
		a. Provide a room that offers minimal distractions
		b. Ask closed-ended questions to allow the client to think about her situation
		c. Write detailed notes during the conversation to track important information
		d. Ask personal questions about the client's background to determine how the procedure has affected her self-concept
When preparing to talk with a client about a difficult subject, the nurse can provide an environment that is private and that offers minimal distractions. This gives the client an opportunity to open up about personal feelings without being interrupted, and may provide more open communication between the nurse and client. Incorrect answer. Please choose another answer.

38.	A nurse is attempting to speak with a client about his personal feelings of self-esteem and self-concept. Which of the following questions is most appropriate for assessing a client's personal identity?
		a. "What is your educational background?"
		b. "Are your parents still living?"
		c. "What do you like about your life right now?"
		d. "Where do you see yourself in 10 years?"
When assessing a client's personal identity, the nurse should focus on questions that determine how the client feels about himself. This may mean asking questions that help him identify his personal strengths and weaknesses, as well as how he thinks others see him. Incorrect answer. Please choose another answer.

Basic Care and Comfort

39.	In which of the following ways can the nurse promote the sense of taste for an older adult?
		a. Mix foods together on the dinner tray
		b. Avoid cologne, air fresheners, or room deodorizers
		c. Encourage the client to chew food thoroughly
		d. Discourage the use of salt or seasonings with prepared food
As clients age, their sense of taste may diminish, reducing the joy that comes with eating. A nurse can promote the sense of taste for a client by encouraging him to chew his food thoroughly while eating. This results in longer contact of food with the taste buds and a greater chance of tasting the food. Incorrect answer. Please choose another answer.

40.	All but which of the following medications may cause urinary retention?
		a. Benadryl (diphenhydramine)
		b. Xanax (alprazolam)
		c. Lioresal (baclofen)
		d. Hydrodiuril (hydrochlorothiazide)
Hydrochlorothiazide or HCTZ is a diuretic, which generally leads to increased urination. Benadryl is an antihistamine, Xanax a benzodiazepine, and Lioresal an anticholinergic, all of which are drug classes that can cause urinary retention. Incorrect answer. Please choose another answer.

41.	A woman presents to the labor unit, reporting contractions every five minutes which are getting stronger. She rates her pain 7 out of 10 on the pain scale. Upon assessment, she is 5cm dilated. She declines pharmacologic intervention. Which of the following pain therapies would not be appropriate in this situation?
		a. Pudendal nerve block
		b. Guided imagery
		c. Massage
		d. TENS unit
Pudendal nerve blocks use medication, like lidocaine, to numb the area between the vagina and rectum. Additionally, it is usually used in the second stage of labor (once a patient is 10cm dilated and pushing). It is the only option that is considered a pharmacologic intervention. The other options are nonpharmacologic in nature. Per the question, the patient declines pharmacologic intervention. Incorrect answer. Please choose another answer.

42.	Which of the following is a potential complication from prolonged immobility?
		a. Pneumonia
		b. Stiffening of the joints
		c. Deep vein thrombosis
		d. All of the above
A, B, and C are all complications of prolonged mobility. Prolonged mobility also decreases appetite. Incorrect answer. Please choose another answer.

43.	Which of the following is classified as a prerenal condition that affects urinary elimination?
		a. Nephrotoxic medications
		b. Pericardial tamponade
		c. Neurogenic bladder
		d. Polycystic kidney disease
A prerenal condition is that which causes reduced urinary elimination due to a diminished blood flow to the kidneys. A condition such as cardiac tamponade affects the heart's ability to pump adequate amounts of blood, thereby reducing blood flow to vital organs throughout the body, including the kidneys. Incorrect answer. Please choose another answer.

44.	A nurse is assessing an African American client for risks of a pressure ulcer. Which of the following best describes what the nurse might find with an early pressure ulcer in this client?
		a. Skin has a purple/bluish color
		b. Capillary refill is one second
		c. Skin appears blanched at the pressure site
		d. Tenting appears when checking skin turgor
When assessing for signs of developing pressure ulcers in a client with dark skin, decreased circulation may not always be readily apparent. For instance, blanching, the red undertones seen in light-skinned clients, will not always be present. Instead, the skin of an early pressure ulcer may develop a purple or bluish color. Incorrect answer. Please choose another answer.

45.	A nurse is teaching a staff seminar on patient confidentiality. Which of the following statements would be included in the presentation?
		a. Verbal consent is sufficient to allow family members to see a patient's medical records.
		b. If a family member is at the hospital, he or she would be entitled to an update on the patient's status.
		c. All hospital staff may have access to a patient's medical records.
		d. Consent to disclosure is implied when a patient is transferred from one health provider or facility to another.
Consent to disclosure is implied in the transfer from one health provider to another for Continuity of Care under HIPAA laws as long as the facility members receiving the Patient Health Information, or PHI, are directly involved in the care of the patient. Consent must be in writing from the patient to allow the family members to see the patient's medical record or receive information from care providers. Updates on the patient's status should only be given with consent from the patient. This includes all family members, even a spouse. Under HIPAA laws, only staff operating in the direct care of the patient are allowed access to a patient's medical records. Incorrect answer. Please choose another answer.

46.	A patient is suffering from heart failure. Which of the following would be recommended by a nurse as part of the patient's health care plan?
		a. Discouraging a diet of fruit and vegetables
		b. Checking for swelling of the lower limbs
		c. Encourage the daily intake of fluids
		d. Encouraging vigorous exercise
Swelling of the lower limbs, known as edema, is due to a buildup of fluid from an impaired circulatory system and is a common side effect of Congestive Heart Failure. It would not be appropriate to discourage fruits and vegetables, as they are part of a heart healthy diet and should be encouraged. Patients with heart failure are usually put on a water regimen of around 1-2 L of fluid total per day. This is due to the increased pressure on the heart to process fluids and may cause worsening edema. Patients with heart failure need to be careful with the amount of vigorous exercise activities they undertake. Heart rate should be monitored closely to prevent overexertion. Incorrect answer. Please choose another answer.

47.	A patient has had diarrhea for the past 72 hours. Which of the symptoms would support a diagnosis of hypovolemia?
		a. Light colored urine output
		b. Decreased pulse rate
		c. Wet mucous membranes
		d. Dizzy Spells
Hypovolemia indicates low fluid volume within the body. Dizziness spells would be one symptom of hypovolemia due to the decreased pressure in the brain. Urine would be dark colored, not light colored, as the urine contains more byproducts and the kidneys process less fluid. An increased pulse rate would indicate hypovolemia as the heart works harder to spread the limited amount of fluid volume throughout the body. A patient would have dry mucus membranes as fluid is directed towards more vital body organs. Incorrect answer. Please choose another answer.

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48.	A patient is being discharged with a new diagnosis of Congestive Heart Failure. Which of the following statements made by the patient indicate understanding of the diagnosis?
		a. "I can drink as much fluid as I want."
		b. "I should notify my doctor if my feet start to swell."
		c. "Weight gain of 3-5 lbs in one day is to be expected."
		d. "It is normal to have difficulty breathing at night."
The patient should notify the physician if edema starts developing in the lower extremities. This indicates more pressure on the heart and can cause complications. Patients with Congestive Heart Failure need to have a limited fluid intake, typically around 2 L per day to prevent fluid overloading. The patient should be aware this includes all types of fluids, not just water. Weight gain of 3-5 lbs in one day should be reported to the physician as this is a significant weight increase and may indicate fluid retention. The patient's medications may need to be adjusted. The patient complaining of difficulty breathing at night is experiencing pulmonary edema, a condition in which fluid builds up into the lungs. This symptom should be reported to the physician immediately. Incorrect answer. Please choose another answer.

49.	A patient is about to be discharged from the hospital after a diagnosis of congestive heart failure. Which of the following statements from the patient indicates the need for further nutritional teaching?
		a. "I can eat things like grilled chicken and steamed vegetables."
		b. "I will have my wife go to the grocery store to buy blueberries, oatmeal, and yogurt."
		c. "I am looking forward to eating a ham sandwich but will make sure to switch out the white bread to whole grain bread."
		d. "I understand that I need to avoid fried foods, and instead choose baked or grilled foods."
While whole grains are healthy, ham is a processed food and tends to be high in sodium. High-sodium foods should be avoided in patients with CHF. The other options show the patient understands proper dietary nutrition for patients with congestive heart failure. Incorrect answer. Please choose another answer.

Pharmacological and Parenteral Therapies

50.	A patient, who weighs 200 pounds, has a prescription for a Dopamine Drip at 5 mcg/kg/min. There is 400 mg per 500 ml D5W on hand. The nurse should administer __________ milliliters to the patient each hour.
		a. 17
		b. 24
		c. 34
		d. 44
The correct answer is 34. First, 200 lb is 90.7 kg. Multiply the 5 mcg/min by 90.7 kg to get 453.5 mcg/min. Multiply the 453.5 mcg/min x 60 min to get 27210 mcg/hr. Multiply 27210 mcg/hr x 1 mg/1000 mcg to get 27.21 mg/hr. Multiply 27.21 mg/hr x 500 ml/400 mg to get the answer of 34 ml/hr. Incorrect answer. Please choose another answer.

51.	A patient, who weighs 143 pounds, has a prescription for Garamycin at two mg/kg, IV, every eight hours. There is 100 mg in 50 ml solution on hand. The nurse should administer ____ milliliters to the patient with each dose.
		a. 45
		b. 55
		c. 65
		d. 75
The correct answer is c. First convert 143 lbs to 65 kg. Multiple 65 kg x 2 mg/kg to get 130 mg q 8 hours. Multiple 130 mg x 50ml/100mg to get 65 ml q 8 hrs. Incorrect answer. Please choose another answer.

52.	A patient has a prescription for Tylenol at 650mg every 6 hours. A nurse only has 325mg pills of Tylenol available. How many pills would be administered every 6 hours?
		a. 2
		b. 3
		c. 4
		d. 5
325 mg x 2 pills is equal to a total of 650 mg. Therefore, the patient should receive a maximum of 2 pills every 6 hours. It is important to verify the dosage of certain medications, such as Tylenol, to prevent overdosing a patient within a 24-hour period. Incorrect answer. Please choose another answer.

53.	The patient has only one IV site with a continuous infusion of Lactated Ringers solution. The provider has prescribed Ceftriaxone 100 mg in Normal Saline 50 ml to be given IV now. What should be the nurse's first action?
		a. Mix the Ceftriaxone into the Normal Saline and piggy-back into the primary infusion.
		b. Insert a secondary IV so the infusions can run simultaneously.
		c. Stop the Lactated Ringers Solution and start the Ceftriaxone now.
		d. Check the IV compatibility of the two medications.
The nurse's first action after receiving the new IV medication order should be to check the Y-site compatibility of the two IV infusions. Depending upon the response, the nurse may need to start a new IV or run the medications into the same IV. In this case, the IV compatibility will show as incompatible for Lactated Ringers and Ceftriaxone, so these medications should not be run on the same IV line. If possible, the continuous infusion should not be stopped unless an IV access is obtained, or the physician gives the order to pause the continuous infusion while the antibiotic is given. Incorrect answer. Please choose another answer.

54.	Which of the following lab tests would be considered Point of Care testing?
		a. Urinalysis
		b. Sputum Culture
		c. Complete Metabolic Panel
		d. Blood Glucose
A Blood Glucose would be considered a Point of Care test as the test can be completed at the bedside with the result given immediately. A Urinalysis, Sputum Culture, or Complete Metabolic Panel would not be considered Point of Care tests because these tests need to be run in a laboratory setting with specialized equipment not available at the bedside. Incorrect answer. Please choose another answer.

55.	The nurse enters the room of a patient complaining of lower back pain after a left hip replacement surgery. Which non-pharmacological intervention would not be appropriate?
		a. Reposition the patient onto the left side.
		b. Massage the patient's back.
		c. Lower the head of the bed and elevate the patient's legs onto a pillow.
		d. Apply a warm pack to the patient's back.
If possible, the patient should not be repositioned onto the side where the hip surgery took place as this may cause decreased circulation or improper healing to the hip or cause more pain to the patient. The patient can be repositioned from supine to the right side. Massage is an appropriate method for nursing staff to use in decreasing pain for the patient. It is appropriate to lower the head of the bed to elongate the patient's back. The patient's legs may be elevated to prevent swelling and pressure ulcers. The application of heat to a painful area is appropriate. It would be acceptable for the nurse to obtain a doctor's order prior to heat application. Incorrect answer. Please choose another answer.

56.	A nurse working in the telemetry unit receives a call that a patient's EKG rhythm has transitioned into Atrial Fibrillation. Which medication is the patient likely to receive long-term in relation to this diagnosis?
		a. Warfarin
		b. Heparin
		c. Furosemide
		d. Albuterol
Warfarin is a common medication given long-term in the management of Atrial Fibrillation to prevent the development of blood clot, or thromboses, that can cause blockages in the heart or lungs. Heparin, while used to prevent thrombosis in Atrial Fibrillation, is not usually administered long-term as it is an IV or Sub-cutaneous injection. Furosemide is given as a diuretic in decreasing fluid retention. It is normally given to patients with Congestive Heart Failure. Albuterol is typically a drug that is inhaled in the treatment of Chronic Obstructive Pulmonary Medication or Asthma as a rescue medication. It is contraindicated in Atrial Fibrillation. Incorrect answer. Please choose another answer.

57.	A drug form in which medication particles are instilled into a liquid and combined through agitation of the solution is called:
		a. Suspension
		b. Elixir
		c. Syrup
		d. Tincture
A suspension is a type of medicine that combines medication particles with a liquid solution. When not administered, medication particles within the suspension may settle to the bottom, requiring the nurse to shake the solution to mix. Suspensions are typically given as oral solutions. Incorrect answer. Please choose another answer.

58.	A nurse is educating a female client about progesterone. Which of the following information is appropriate to include in this teaching?
		a. Progesterone helps the body to maintain pregnancy
		b. Progesterone stimulates the breasts to secrete milk
		c. Progesterone causes uterine contractions during delivery
		d. Progesterone causes development of masculine characteristics in women
Progesterone is a hormone that is produced by the ovaries in women. Progesterone affects the tissue of the endometrium by developing the lining of the uterus in support of embryo implantation. In pregnant women, progesterone nourishes the uterine lining and limits uterine contractions to prevent miscarriage. Incorrect answer. Please choose another answer.

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59.	A patient is receiving a transfusion of packed red blood cells, which was started just prior to shift change. Approximately 30 minutes after the infusion has started, the patient complains of chest pain, chills and dyspnea. The RN notes that D5W is hanging with the blood and immediately recognizes the symptoms as a hemolytic reaction. Which is the first action the nurse should take?
		a. Fill out an incident report.
		b. Stop the transfusion and call the physician.
		c. Immediately administer corticosteroids and antihistamines.
		d. Start an IV bolus of normal saline.
While the nurse may perform all of these actions after a transfusion reaction, the FIRST action should be to immediately stop the transfusion and notify the physician. Incorrect answer. Please choose another answer.

60.	Which of the following is the antidote to warfarin toxicity?
		a. Calcium gluconate
		b. Insulin
		c. Protamine sulfate
		d. Vitamin K
Vitamin K acts to reverse the blood-thinning effects of warfarin. Calcium gluconate is the antidote to magnesium toxicity, insulin can help reverse hyperkalemia, and protamine sulfate reverses unfractionated heparin overdose. Incorrect answer. Please choose another answer.

61.	A patient is receiving an insulin infusion at 2 units/hour. The most recent blood glucose is 220. The RN reviews the infusion protocol and notes the following: If Glucose 150-200 = infuse at 2 units/hour; Glucose 201-250 = infuse at 4 units/hour; Glucose 251-300 = infuse at 6 units/hour. Based on the most recent glucose reading, the nurse should increase the infusion by how many units/hour?
		a. 1 unit/hour
		b. 2 units/hour
		c. 3 units/hour
		d. 4 units/hour
The glucose is 220, which falls between 201-250, thus the infusion needs to run at 4 units/hour. It is currently at 2 units/hour, so the nurse needs to increase by 2 units in order to reach the ordered rate of 4 units/hour. Incorrect answer. Please choose another answer.

62.	Protonix 20mg IV BID has been ordered for a patient and is scheduled for 0900 and 2100. The pharmacy sends a vial of Protonix that reads 40mg/mL. How many mL will the patient receive for his 0900 dose?
		a. 1mL
		b. 0.25mL
		c. 0.5mL
		d. 2mL
The patient receives 20mg twice a day. The vial contains 40mg of medication per mL, thus, to give 20mg of the medication, you would give half a mL or 0.5mL. Incorrect answer. Please choose another answer.

63.	Following a dose of medication, a client develops inflamed mucous membranes and nasal discharge. What type of minor reaction is this client experiencing?
		a. Urticaria
		b. Pruritis
		c. Hives
		d. Rhinitis
Rhinitis may occur as a mild reaction following some types of medication administration. Rhinitis involves itchy or inflamed mucous membranes, particularly around the eyes, nose and mouth. The client may also develop swelling of the nasal passages or clear discharge. Incorrect answer. Please choose another answer.

64.	Mr. Y is receiving medication through a catheter that has been placed into the subarachnoid space of his spinal column. What route of medication administration is this called?
		a. Intrapleural
		b. Intraosseous
		c. Intrathecal
		d. Intraperitoneal
Medications administered through the intrathecal route are given through a catheter that has been placed into the subarachnoid space of the spinal column. These medications are given into cerebrospinal fluid, often for pain control. Placement of an intrathecal catheter is typically done by a trained physician or advanced-practice nurse. Incorrect answer. Please choose another answer.

Reduction of Risk Potential

65.	Which of the following nursing interventions is appropriate for a client who is suffering from a fever?
		a. Avoid giving the client food
		b. Increase the client's fluid volume
		c. Provide oxygen
		d. All of the above
		e. Both b and c
Interventions for a client who is suffering from a fever include increasing the client's volume of fluid and providing oxygen. A fever increases the body's metabolism, causing the client to breathe at a faster rate and increasing the work of the heart. The client is at risk of fluid loss due to increased respiration and sweating. The increased work of the heart requires more oxygen to maintain perfusion to the tissues. Incorrect answer. Please choose another answer.

66.	Which of the following complications is associated with premature rupture of membranes in the pregnant client?
		a. Vaginal or cervical lacerations
		b. Shoulder dystocia
		c. Uterine rupture
		d. Chorioamnionitis
Premature rupture of membranes occurs when the amniotic sac of a pregnant client has ruptured before the onset of labor. The client may be at increased risk of chorioamnionitis, which occurs as inflammation of the membranes of the placenta. Infection may develop when bacteria ascend into the uterus without the protection of the intact amniotic sac. Incorrect answer. Please choose another answer.

67.	A pregnant woman has just completed her one-hour glucose screening at 26 weeks. The nurse reviews her labs and notes a value of 160. The nurse anticipates that the physician will:
		a. Order a 3-hour oral glucose tolerance test.
		b. Do nothing as this is a normal value.
		c. Ask that the patient avoid sweets for the rest of her pregnancy.
		d. Repeat the test in 3 weeks.
160 is considered an abnormal value for the 1-hour screening glucose. The correct follow-up is to complete the 3-hour test as this test is diagnostic for gestational diabetes. Incorrect answer. Please choose another answer.

68.	A patient on a medical-surgical floor calls out, complaining of chest pain. An EKG is performed. Which of the following is considered abnormal?
		a. A non-elevated ST segment
		b. PR interval of 0.12-0.20 seconds
		c. Smooth P waves
		d. Wide QRS complex
A wide QRS complex is often associated with ventricular arrhythmias, such as supraventricular tachycardia. Incorrect answer. Please choose another answer.

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69.	A nurse is assessing a patient who had a bowel resection. Which of the following is a concern for a surgical complication?
		a. Distended abdomen and absent bowel sounds.
		b. Borborygmi is heard upon auscultation.
		c. The incision edges are pink.
		d. The patient reports pain 4 out of 10.
The distended abdomen and absent bowel sounds indicate an ileus, which is a common complication after bowel surgery. Pink incision edges and borborygmi are normal findings. Pain is expected after a surgery, and while significant pain is of concern, a pain level of 4 out of 10 is expected. Incorrect answer. Please choose another answer.

70.	A client has started sweating profusely due to intense heat. His overall fluid volume is low and he has developed electrolyte imbalance. This client is most likely suffering from:
		a. Malignant hyperthermia
		b. Heat exhaustion
		c. Heat stroke
		d. Heat cramps
Heat exhaustion occurs when a person has enough diaphoresis that he becomes dehydrated. Intense sweating can cause both fluid and electrolyte imbalances. Untreated heat exhaustion can lead to heat stroke, which results in organ damage, loss of consciousness, or death. Incorrect answer. Please choose another answer.

71.	A nurse is attempting to assess a client's pulse in his foot. She palpates the pulse on the anterior aspect of his ankle, below the lower end of the medial malleolus. Which type of pulse is this nurse taking?
		a. Dorsalis pedis
		b. Popliteal
		c. Posterior tibial
		d. Femoral
The nurse can palpate the posterior tibial pulse to assess circulation to the foot and ankle. The posterior tibial pulse is felt by palpating the inner side of the ankle, behind the medial malleolus. Incorrect answer. Please choose another answer.

72.	Mrs. J is in the adult ICU on a ventilator. The nurse caring for her recognizes that her endotracheal tube needs suctioning. Based on the nurse's understanding of this procedure, what level of pressure should the nurse apply while suctioning?
		a. 70-80 mmHg
		b. 100-120 mmHg
		c. 150-170 mmHg
		d. 200 mmHg
When suctioning the endotracheal tube of an adult client, the nurse should set the suction apparatus at a level no higher than 150 mmHg, with a preferable level between 100 and 120 mmHg. Suction pressure that is too high can contribute to the client's hypoxia. Alternatively, too low of suction pressure may not clear adequate amounts of secretions. Incorrect answer. Please choose another answer.

73.	The nurse caring for Mrs. J is prepared to suction her endotracheal tube. Which of the following interventions will reduce hypoxia during this procedure?
		a. Hyperoxygenate Mrs. J for up to 60 seconds prior to starting
		b. Administer 15 cc of sterile fluid into the tube prior to suctioning
		c. Suction for no longer than 30 seconds at a time
		d. Wait 30 seconds after suctioning before attempting again
Before suctioning a client's endotracheal tube, the nurse should provide extra oxygen for approximately 30 to 60 seconds. Hyperoxygenating a client before suctioning increases oxygen delivery to the tissues and reduces hypoxia that may develop during the procedure. Incorrect answer. Please choose another answer.

74.	Which of the following conditions is a contraindication for performing a diagnostic peritoneal lavage?
		a. A client who is 9 weeks' pregnant
		b. A client with a femur fracture
		c. A morbidly obese client
		d. A client with hypertension
Diagnostic peritoneal lavage is contraindicated in clients who are morbidly obese because excess body fat makes finding essential landmarks for this procedure difficult. Additionally, the equipment used for the procedure may not be large enough to accommodate an obese person. Finally, morbid obesity puts excess strain on the cardiovascular and respiratory systems, such that anesthetic agents used during the procedure could cause further complications. Incorrect answer. Please choose another answer.

75.	Which of the following would alert the nurse to respiratory distress in the newborn?
		a. Respiratory rate of 50 breaths per minute
		b. Acrocyanosis
		c. Circumoral cyanosis
		d. Nasal flaring and retractions
Nasal flaring and retractions indicate that the newborn is working hard to breathe. The other choices are normal findings in the newborn; acrocyanosis and circumoral cyanosis are common in the first day of life, and normal respiratory rate in a newborn is 30-60 breaths per minute. Incorrect answer. Please choose another answer.

76.	A nurse is making a Home Health visit at a home of an elderly couple. The wife states regarding her husband, the patient, "He always sits in that chair all day long." Which of the following should the nurse consider the patient at risk for?
		a. Pressure Ulcer
		b. Deep Vein Thrombosis
		c. Constipation
		d. All of the above
The patient is at risk for all the listed conditions related to decreased mobility. Pressure ulcers form as the skin layers break down between the chair or bed surface and bone. This may happen due to the patient remaining in one position too long. This patient may be at risk for pressure ulcers to his sacrum or areas where his leg meets the foot rest. Patients have been shown to be higher risk for Deep Vein Thrombosis with decreased mobility. The patient should ambulate multiple times a day to lower his risk for DVT. Constipation is another common side effect of decreased mobility as the GI system slows. Incorrect answer. Please choose another answer.

77.	A patient is having a tonic-clonic seizure. A nurse should take which of the following steps?
		a. Put a pillow under the patient's head
		b. Put restraints on the patient
		c. Use a tongue blade on the patient
		d. Lay the patient on his back
Putting a pillow under the patient's head is an acceptable way to prevent injury to the patient until the seizure has completed. Putting restraints on the patient may cause further injury to the patient and will not prevent the muscles from moving. Putting a tongue blade in the patient's mouth may cause injury to the oral cavity and may cause the patient to choke. It is more appropriate to put the patient on their side as this may help to prevent aspiration as well as prevent injury to the head. Incorrect answer. Please choose another answer.

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Physiological Adaptation

78.	A nurse is changing the dressing for a post-op Bilateral Knee Amputation patient. The nurse notes the patient refuses to look at the limb while the dressing is being changed but asks the nurse about their personal life instead. Which nursing care plan should the nurse implement for the patient related to this action?
		a. Disturbed Body Image
		b. Altered Sleep Pattern
		c. Impaired Memory
		d. Impaired Social Interaction
A patient with loss of limb may be experiencing Disturbed Body Image. The nurse should be sensitive to the patient's emotional and mental acceptance of the loss and incorporate therapeutic communication as the patient allows. Acceptance may take time and the patient should not be pressured into looking at the limb. The patient may be experiencing Altered Sleep Patterns related to the surgery, however the patient refusing to look at the limb indicates Disturbed Body Image. The patient remembers the limb is there and is refusing to look at it, therefore Impaired Memory does not appear to be the issue. The patient does not appear to have any issues communicating with the nurse, so the patient is more likely experiencing Disturbed Body Image related to the loss of the limb rather than Impaired Social Interaction. Incorrect answer. Please choose another answer.

79.	Which of the following would be an expected finding in an age assessment of a 2 year old?
		a. Has a 300 word vocabulary
		b. Uses one hand to turn the pages of a book
		c. Runs with a wide stance
		d. All of the above
A 2 year old child should have reached certain developmental milestones. The child will be developing their vocabulary and in addition to knowing almost 300 words, will be developing 2-4 sentences. The child may start using one hand to complete tasks and favoring one hand over the other. The child may start running, as well as walking and standing on tiptoes. A child who is lagging in performing these milestones may be at risk for developmental delay and further assessment is indicated. Incorrect answer. Please choose another answer.

80.	A nurse is instructing a patient on the use of a walker. Which of the following would be included in the instructions?
		a. While putting your body weight on your hands, step into the walker.
		b. Hold the upper handgrips.
		c. When seated, push off the chair to come to a standing position.
		d. All of the above.
All responses are appropriate for the nurse to instruct the patient in the use of a walker. It is appropriate for the patient to put the body weight on their hands, or onto the walker, as this will put less pressure on the weakened leg or legs. The upper hand grips are where the patient should hold the walker, not on the front of the walker, which could cause it to tip forward, or on the middle side rails, which are too low. The patient should push off of the chair to come to a standing position, not pull the walker to stand up, as this could cause them to fall as the walker tilts back. Incorrect answer. Please choose another answer.