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Rhenis Nursing

NCLEX PN-Practice Exam-1

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Exam Details

Title NCLEX PN-Practice Exam-1

Type Special

Category NCLEX PN

Subcategory NCLEX-PN Practice Exams

Domain NCLEX-PN (Practice Exams)

Fragment N/A

Module N/A

Status active

Rating 95.00%

Attempts 50

Year 2025

Duration 180 min

Questions 130

Pass Score 90%

Difficulty Advanced

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1 :
A nurse is collecting data on a client who is admitted to the inpatient mental health unit. The client is complaining of sleep disturbances, feelings of helplessness, and a loss of appetite. The nurse recognizes these symptoms to be indicative of

anxiety.

bipolar disorder.

delusional disorder.

depression.

Hint : 😕Low mood with changes in sleep and appetite.

Correct Answers:

No Correct Answers Available !

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2 :
Mr. Anderson is a 50-year-old male client who presented to the emergency department (ED) at 0615 with intermittent cramping abdominal pain, abdominal bloating, and nausea and vomiting for the past 3 days. He denies constipation or diarrhea. He completed his second cycle of chemotherapy infusion last week for a newly diagnosed stage III gastric cancer. Mr. Anderson's maintenance intravenous fluid was started at 0930. The practical nurse checks the fluid level at 1100. How much IV fluid did Mr. Anderson receive during that time?

200 mL

225 mL

250 mL

275 mL

Hint : 🔍Multiply 150 mL/hr by 1.5 hours.

Correct Answers:

No Correct Answers Available !

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3 :
Mr. Anderson is a 50-year-old male client who presented to the emergency department (ED) at 0615 with intermittent cramping abdominal pain, abdominal bloating, and nausea and vomiting for the past 3 days. He denies constipation or diarrhea. He completed his second cycle of chemotherapy infusion last week for a newly diagnosed stage III gastric cancer. Which of the following interventions does the nurse anticipate performing? Select all that apply.

Irrigate the client's NG tube.

Perform a bladder scan

Administer furosemide.

Increase IV fluid rate.

Change the wall suction setting to high.

Hint : 👀Evaluate urinary output and correct dehydration.

Correct Answers:

No Correct Answers Available !

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4 :
Mr. Anderson is a 50-year-old male client who presented to the emergency department (ED) at 0615 with intermittent cramping abdominal pain, abdominal bloating, and nausea and vomiting for the past 3 days. He denies constipation or diarrhea. He completed his second cycle of chemotherapy infusion last week for a newly diagnosed stage III gastric cancer. The nurse notifies the physician of Mr. Anderson's oliguria, and new orders are placed. At 1530, Mr. Anderson still has no further urine output. A bladder scan shows approximately 50 mL of urine in the bladder. Based on Mr. Anderson's updated profile, which medications does the nurse anticipate administering? Select all that apply.

Magnesium sulfate

Potassium chloride

Spironolactone

Calcium gluconate

Ibuprofen

Hint : 💡Protect the heart and correct the electrolyte losses.

Correct Answers:

No Correct Answers Available !

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5 :
Mr. Anderson is a 50-year-old male client who presented to the emergency department (ED) at 0615 with intermittent cramping abdominal pain, abdominal bloating, and nausea and vomiting for the past 3 days. He denies constipation or diarrhea. He completed his second cycle of chemotherapy infusion last week for a newly diagnosed stage III gastric cancer. Due to Mr. Anderson's acute kidney injury (AKI), he received an additional bolus of 1 liter intravenous 0.9% sodium chloride over 1 hour. Upon completion of the infusion, he complains of shortness of breath and an intermittent productive cough. Based on Mr. Anderson's recent vital signs, which of the following interventions does the nurse expect to see in his care plan? Select all that apply.

Apply oxygen via nasal cannula.

Obtain a chest x-ray.

Reduce furosemide dose.

Prepare the client for a renal biopsy.

Arrange a thoracentesis

Hint : 🌬️Look for pulmonary edema and support oxygenation.

Correct Answers:

No Correct Answers Available !

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6 :
Mr. Anderson is a 50-year-old male client who presented to the emergency department (ED) at 0615 with intermittent cramping abdominal pain, abdominal bloating, and nausea and vomiting for the past 3 days. He denies constipation or diarrhea. He completed his second cycle of chemotherapy infusion last week for a newly diagnosed stage III gastric cancer.

Indicate whether each item listed is a contributing factor for Mr. Anderson's acute kidney injury or pleural effusion.

Factor	Acute Kidney Injury (AKI)	Pleural Effusion
IV contrast dye injection
IV 0.9% sodium chloride bolus
NPO status
Chemotherapy
Vomiting

Hint : 🌟Match nephrotoxins and fluid shifts to the appropriate organ system injury.

Correct Answers

IV contrast dye injection [ Acute Kidney Injury (AKI) ]
IV 0.9% sodium chloride bolus [ Pleural Effusion ]
NPO status [ Acute Kidney Injury (AKI) ]
Chemotherapy [ Acute Kidney Injury (AKI) ; Pleural Effusion ]
Vomiting [ Acute Kidney Injury (AKI) ]

Rationale :

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7 :
A client delivered an infant with Dandy- Walker syndrome. The nurse overhears the client tell a friend that the infant is "perfectly fine." The nurse knows that this statement indicates that the client is in which stage of grief?

Acceptance

Anger

Bargaining

Denial

Hint : 🛑The client is rejecting the reality of her infant’s condition.

Correct Answers:

No Correct Answers Available !

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8 :
The nurse on a medical-surgical unit has received a report on a group of clients. Which client should the nurse see first?

A 62-year-old client with lymphoma who has a hemoglobin of 8.6 gm/dL

An 84-year-old client with bilateral pneumonia and a pulse oximetry reading of 91%

A 38-year-old client who had abdominal surgery yesterday and a temperature of 100.2°F

A 20-year-old client admitted last night with a fractured tibia/fibula and a heart rate of 114 bpm

Hint : 👀Assess the client with the most significant impaired oxygenation first.

Correct Answers:

No Correct Answers Available !

Rationale :

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9 :
The nurse is participating in the care of a client who is diagnosed with post- traumatic stress disorder (PTSD). Which of the following is the most therapeutic and beneficial intervention for a client diagnosed with PTSD?

Administering anti-anxiety medications per order

Encouraging the client to express his feelings openly

Monitoring the client's physical symptoms

Observing the client's interactions with family and friends

Hint : 🗣️Facilitating emotional expression supports healing from trauma.

Correct Answers:

No Correct Answers Available !

Rationale :

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10 :
The nurse is assisting in the plan of care for a client with dissociative amnesia disorder. The nurse plans care for a client with

alternating periods of euphoria and depression.

gradual loss of mental abilities.

loss of personal memories.

loss of personal reality.

Hint : 📚Think about forgetting who you are, not simply feeling sad or confused.

Correct Answers:

No Correct Answers Available !

Rationale :

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11 :
Mrs. Rodriguez, a 65-year-old patient with multiple chronic conditions, is admitted to the hospital for an exacerbation of her illnesses. The practical nurse is responsible for discussing advance directives with Mrs. Rodriguez. Select all appropriate actions for the practical nurse regarding advance directives.

Initiating a conversation with Mrs. Rodriguez about her preferences for end-of-life care

Contacting Mrs. Rodriguez's family without her consent to discuss advance directives

Documenting Mrs. Rodriguez's advance directives in her medical record

Explaining the purpose and significance of advance directives to Mrs. Rodriguez

Collaborating with the healthcare team to ensure Mrs. Rodriguez's advance directives are honored

Hint : 🔑Focus on informed choices, documentation, and team coordination.

Correct Answers:

No Correct Answers Available !

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12 :
The nurse is participating in the care of a client who is terminally ill. The client states, "I know I'm going to die today." Which of the following is the best response by the nurse?

"Don't worry, you aren't going to die."

"Oh no, you're doing quite well considering your condition."

"We have equipment to monitor you and your problems."

"Why do you think you're going to die today?"

Hint : 🔎Encourage the client to explain what they’re feeling or experiencing.

Correct Answers:

No Correct Answers Available !

Rationale :

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13 :
The nurse is assisting in the care of a client with a diabetic leg ulcer. The physician has planned to debride the wound in the morning, but the client, who is alert and oriented, tells the nurse that she changed her mind and does not want to have the debridement. The nurse should tell the client,

"Everything will be OK."

"I will let your physician know."

"The debridement will be tomorrow."

"This is a common procedure."

Hint : 📝Notify the provider about her choice.

Correct Answers:

No Correct Answers Available !

Rationale :

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14 :
The nurse is entering the room of a client on droplet precautions to take the client's blood pressure. The nurse should put on which of the following protective equipment?
1. Gloves
2. Goggles
3. Gown
4. Mask

1, 2, 3

2, 3, 4

1, 2, 4

1, 3, 4

Hint : 😷Protect against droplets with barrier coverage for your clothing and hands.

Correct Answers:

No Correct Answers Available !

Rationale :

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15 :
The nurse is assisting in the delivery of a staff educational program on organ donation. The nurse recognizes additional teaching is needed when a staff member states that which of the following is a contraindication to organ donation?

Age greater than 65

Trauma

Malignancy

Communicable disease

Hint : 📝Only conditions that risk infecting the recipient are absolute contraindications.

Correct Answers:

No Correct Answers Available !

Rationale :

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16 :
Ms. Morse, a 45-year-old woman, presents with persistent fatigue, discomfort in the upper right abdomen, and occasional mild jaundice noticed in the eyes. She has a history of obesity, type 2 diabetes, insulin resistance, and metabolic syndrome. Consider the following interventions related to promoting self-care in Ms. Morse.

Lab Results

Laboratory Test	Reference Range (U/L)	Result (U/L)
Alanine aminotransferase (ALT)	7 – 56	60
Aspartate aminotransferase (AST)	13 – 39	45

Click to indicate whether the intervention can help to improve Ms. Morse's condition.

Intervention	Indicated	Not Indicated
Encouraging regular physical exercise
Advising adequate sleep hygiene practices
Promoting a diet high in saturated fats
Recommending mindfulness meditation
Encouraging moderate alcohol consumption

Hint : 🕵️‍♂️Choose interventions that directly reduce liver fat and improve metabolic control.

Correct Answers

Encouraging regular physical exercise [ Indicated ]
Advising adequate sleep hygiene practices [ Not Indicated ]
Promoting a diet high in saturated fats [ Not Indicated ]
Recommending mindfulness meditation [ Not Indicated ]
Encouraging moderate alcohol consumption [ Indicated ]

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17 :
The nurse is working on a medical unit caring for a 72-year-old client whose son is a nurse in the same facility. The nurse observes the client's son reading the client's chart at the nurse's computer work station. Which of the following actions should the nurse take to protect the client's confidentiality in this situation?

Since the son is a nurse in the same facility, it is okay to let him view the client's record.

The nurse should log off the workstation and immediately report the situation to the supervisor.

Stay with the client's son while he views the client's medical record as the son is allowed to read the chart with the nurse present

Log off the computer and inform the client's son that he is not allowed to review the medical record without specific client consent.

Hint : 💡Stop unauthorized access and explain that consent is required.

Correct Answers:

No Correct Answers Available !

Rationale :

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18 :
A practical nurse is getting ready to administer morning medications to Mrs. Wong. The doctor's orders indicate that 10 units of lispro should be administered subcutaneously before each meal three times per day, 25 mg of metoprolol should be administered orally once daily, and 10 mg of atorvastatin should be administered orally once daily. The nurse is also provided the medications list in the electronic medication administration record (eMAR) system, as shown below.
Lispro 10 units subcutaneously three times per day before each meal
Lispro 10 units subcutaneously three times per day before each meal
Metoprolol 25 mg orally once daily
Atorvastatin 10 mg orally once daily
Which actions should the Practical Nurse take? Select all that apply.

Document the duplicate medication entry.

Contact the IT support team about the duplicate medication entry.

Retract the duplicate medication entry.

Administer 10 units of insulin.

Administer the medications as shown.

Hint : 🔍Report and correct the system error, then give the single prescribed dose.

Correct Answers:

No Correct Answers Available !

Rationale :

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19 :
The nurse is caring for a client diagnosed with allergic asthma. The client is prescribed an Intal (cromolyn sodium) inhaler. The nurse understands that which of the following is a common side- effect of this medication?

Bronchospasms

Constipation

Diarrhea

Insomnia

Hint : 🤧Watch for sudden tightening of chest or wheezing after inhalation.

Correct Answers:

No Correct Answers Available !

Rationale :

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20 :
The nurse is participating in the care of a client who is retaining carbon dioxide (CO2) related to respiratory disease. The nurse anticipates that as the client's CO2 level rises, the client's pH level will

decrease.

double.

increase.

remain unchanged.

Hint : 📊Higher carbon dioxide means lower blood pH.

Correct Answers:

No Correct Answers Available !

Rationale :

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21 :
The nurse is caring for a client on the evening following abdominal surgery. The client is ordered "diet as tolerated." The nurse recognizes that which of the following is the most appropriate diet for the client?

clear liquid diet

low-sodium diet

regular diet

soft diet

Hint : 🚦Start with fluids that require minimal digestion after surgery.

Correct Answers:

No Correct Answers Available !

Rationale :

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22 :
The nurse is reinforcing teaching with the parents of a child diagnosed with phenylketonuria (PKU) about the prevention of central nervous system damage from toxic levels of phenylalanine. The nurse realizes additional teaching is needed when the parents state that the child will need to avoid

aspartame.

fish.

ice cream.

jelly.

Hint : 🔎Choose the item that does not contain phenylalanine.

Correct Answers:

No Correct Answers Available !

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23 :
The nurse is participating in the care of a male client with a chest tube. While assisting the client to the bathroom, the chest tube becomes dislodged. The most appropriate initial nursing action when a chest tube is dislodged from the insertion site is

auscultating the client's breath sounds.

instructing the client to hold his breath.

covering the opening to keep air out.

reinserting the dislodged chest tube.

Hint : 🕵️Prevent air from entering the pleural space.

Correct Answers:

No Correct Answers Available !

Rationale :

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24 :
The nurse is caring for a client with heart failure who is on diuretic therapy. Which client finding should the nurse report to the healthcare provider?

A BUN level of 15 mg/dL this morning

780 mL of urine output over the past 24 hours

A serum glucose level of 120 gm/dL this morning

Orthostatic blood pressures of 130/80 supine to 104/72 standing

Hint : 👀Watch for signs of volume depletion after diuretic therapy.

Correct Answers:

No Correct Answers Available !

Rationale :

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25 :
The nurse is caring for a client receiving bexatolol hydrochloride (Betoptic) eye drops for glaucoma. The nurse understands that which of the following is a common side effect of this medication?

Decreased blood glucose levels

Decreased blood pressure

Elevated heart rate

Elevated temperature

Hint : 🌐Anticipate beta-blocker effects beyond the eye.

Correct Answers:

No Correct Answers Available !

Rationale :

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26 :
The nurse is participating in the care of a client diagnosed with a lower urinary tract infection who is being discharged from a medical-surgical unit. The client is prescribed Pyridium (phenazopyridine hydrochloride) for pain relief. The nurse should reinforce which of the following?

Discontinue the medication if a headache develops.

Expect a reddish-orange discoloration of the urine.

Take the medication at bedtime.

Take the medication prior to meals.

Hint : 👁️Urine will change to a bright orange hue.

Correct Answers:

No Correct Answers Available !

Rationale :

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27 :
The nurse is participating in the care of a client who has just completed an alcohol rehabilitation program. Which of the following statements, if made by the client, indicates an understanding of discharge care?

"I am really going to try to not drink."

"I can have a couple of beers but no vodka."

"I can't wait to see all my old friends and hang out."

"I found two different places that have AA meetings."

Hint : 🔍Identify an active support strategy for sobriety.

Correct Answers:

No Correct Answers Available !

Rationale :

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28 :
Ms. Mambwe, a 58-year-old receptionist at Green Valley Rehabilitation Center, has been experiencing back pain that radiates down her left arm for the past three days. She sits at her office desk for 8 to 10 hours a day, six days a week, with a 30-minute lunch break. She also babysits her 10-year-old granddaughter on weekday evenings. What recommendations should the practical nurse make to help Ms. Mambwe? Select all that apply.

Take breaks throughout the day to stand and stretch.

Use a standing desk to minimize bending.

Perform lightweight lifting exercises to increase strength.

Use a specialized chair that is adjustable.

Wear a back brace to reduce movement of the spine.

Hint : 🕵️‍♂️Focus on ergonomic adjustments to reduce strain from prolonged sitting.

Correct Answers:

No Correct Answers Available !

Rationale :

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29 :
The nurse is administering medications on a telemetry unit. A client is ordered 5 mg of oral sustained-release nitroglycerin (Nitro-Time). The medication is supplied in 2.5-mg tablets. How many tablets will the nurse administer?

Hint : 🕵️Divide the ordered dose by the tablet strength.

Correct Answers:

No Correct Answers Available !

Rationale :

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30 :
The nurse is assisting the RN with a client admission to the medical unit. The client has several pieces of jewelry, $90 in cash, and an electronic tablet. What is the nurse's responsibility to safeguard the client's valuables?

Give the jewelry to the client's spouse and allow the client to keep the cash.

Collect the items according to hospital policy and contact security to secure the items.

Allow the client to keep the jewelry and cash as long as the items are in the client's pocketbook.

Safeguard the items by storing the items in the closet and reassure the client the items are nearby.

Hint : 🔑Secure valuables per facility protocol and involve security.

Correct Answers:

No Correct Answers Available !

Rationale :

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31 :
The nurse is caring for a client who is ordered to undergo a lumbar puncture to rule out meningitis. The nurse is helping the physician position the client for the procedure. Which of the following indicates that the nurse has placed the client in the correct position?

The client is in the prone position with his head turned to the side.

The client is in the recumbent position with his feet elevated.

The client is in the side-lying position with his knees drawn to the chest.

The client is in the supine position with the head of the bed elevated.

Hint : 📐Flex the spine by drawing knees to chest in a side‐lying posture.

Correct Answers:

No Correct Answers Available !

Rationale :

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32 :
The nurse is observing an LPN providing care for a male client diagnosed with leukemia. Which of the LPN's actions indicates the need for additional teaching when caring for this client?

maintaining protective isolation precautions

taking the client's temperature orally

using a cotton-tipped swab to clean the client's teeth

utilizing a standard razor and warm towel when shaving the client

Hint : 🛑Avoid any shaving method that can cause skin cuts in thrombocytopenic clients.

Correct Answers:

No Correct Answers Available !

Rationale :

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33 :
The nurse is caring for a widowed client with lung cancer who has been through several chemotherapy and radiation treatments. The client tells the nurse that she wants to discontinue treatments, but the client's adult children want the client to continue with treatments. Which statement made by the nurse would demonstrate client advocacy?

"I will ask your healthcare provider for a hospice/palliative care consult."

"It sounds like you have some difficult decisions to make regarding your treatment."

"I can help you identify your treatment options and am willing to discuss them with you."

"I can help to set up a meeting with your healthcare provider, you, and your family to identify your needs."

Hint : 💡Offer to explore her own preferences without imposing family views.

Correct Answers:

No Correct Answers Available !

Rationale :

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34 :
Mrs. Vale, a 78-year-old patient who lives alone and has a history of falls, has recently been discharged and is now receiving home care services. During a home visit, the nurse conducted a safety assessment and found the following:
In the living room, there are small, loose rugs used to reduce cold from the hardwood floor.
The bathroom lacks grab bars and has only one shower seat.
A lamp uses an electrical cord that crosses the floor and is plugged in on the other side of the entryway.
The kitchen floor is slippery, especially near the sink and refrigerator.
The bedroom furniture includes a bed, a nightstand, a lamp, and a set of drawers with a chair in the corner.
Which interventions are appropriate to enhance Mrs. Vale's safety at home? Select all that apply.

Replace loose rugs in the living room with a secured area rug.

Install grab bars in the bathroom.

Leave electrical cords as they are for convenience.

Place non-slip mats on the kitchen floor.

Remove bedroom furniture to create more space.

Recommend a second shower chair.

Hint : 💡Eliminate tripping hazards and add supportive features where needed.

Correct Answers:

No Correct Answers Available !

Rationale :

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35 :
The nurse is participating in the care of a seven-month-old male child who is being prepared for discharge following a urinary stent procedure to repair a hypospadias. The nurse will reinforce which of the following teaching points to the child's parents?

Clean the tip of the penis three times daily with soap and water.

Measure the child's urinary output from the drainage bag.

Avoid letting the child drink fruit juices.

Do not bathe the child until the stent is removed.

Hint : 👀Ensure you record how much urine drains each time.

Correct Answers:

No Correct Answers Available !

Rationale :

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36 :
The nurse is participating in the care of an elderly nursing home client with escalating dementia. The client has been wandering the nursing unit at night and has an unsteady gait. As a result, the client has fallen three times, with no resultant injuries. Which of the following is the most appropriate action for the nurse to take?

Help the client to and from bed and assure that all four side bedrails are raised.

Inquire if the client's family members can stay with the client at night

Place the client in a room closer to the nurse's station and apply a bed alarm.

Place the client in a reclining chair across from the nurse's station at night

Hint : 💡Use proximity and alarms to monitor wandering and prevent falls.

Correct Answers:

No Correct Answers Available !

Rationale :

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37 :
The nurse is participating in client care-planning for a client with chronic and acute pain. The nurse knows that there are several theories on pain control. Which non-invasive, pain management therapies are associated with the gate control pain theory? Select all that apply.

Massage therapy

Biofeedback therapy

Acupuncture therapy

Distraction and imagery

Hot and cold applications

Transcutaneous electrical nerve stimulation (TENS)

Hint : 🔍Choose therapies that use sensory stimulation to block pain impulses.

Correct Answers:

No Correct Answers Available !

Rationale :

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38 :
The nurse is working in a nursing home. The facility has instituted a falls prevention program. Which of the following nursing actions will most likely assure the highest level of fall prevention?

Assuring "Fall Risk" signs are posted outside of the clients' rooms

Having clients wear colored armbands that indicate a fall risk

Making frequent rounds of the unit and the clients' rooms

Positioning the clients' beds in the lowest position

Hint : 💡Increase direct monitoring to catch fall risks early.

Correct Answers:

No Correct Answers Available !

Rationale :

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39 :
The nurse is reinforcing teaching about sleep habits for a client with insomnia. Which statement would indicate that further teaching is required?

"I will practice breathing exercises before bedtime to help fall asleep."

"I will try progressive muscle relaxation in a sequential pattern to help fall asleep."

"I will ask my doctor for sleeping medication; that is the only way I will get to sleep."

"I will practice using guided imagery and recall comforting and relaxing images to sleep."

Hint : ✨Nonpharmacologic strategies can be effective before considering medication.

Correct Answers:

No Correct Answers Available !

Rationale :

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40 :
The nurse has just been trained on how to use and care for a blood glucose monitor (glucometer). Which of the following nursing interventions demonstrates the proper use of a glucometer?

The nurse recalibrates the monitor after new batteries are inserted.

The nurse removes her gloves after removing the test strip from the monitor.

The nurse smears the blood sample on the test strip.

The nurse obtains the blood sample directly after cleansing the digit with alcohol.

Hint : 🔍Ensure accurate readings by recalibrating after power changes.

Correct Answers:

No Correct Answers Available !

Rationale :

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41 :
The LPN and an RN are conducting a program for high school students on sexually transmitted infections (STIs). After the program has concluded, a 15-year-old girl tells the nurse that she is pregnant and that she has not received prenatal care. The girl admits to smoking and drinking but denies illicit drug use. The nurse's priority is to help the girl

find prenatal care.

quit drinking.

quit smoking.

tell her parents.

Hint : 💡Connect her with healthcare services for pregnancy.

Correct Answers:

No Correct Answers Available !

Rationale :

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42 :
The charge nurse is planning the nursing assignments for the upcoming weekly shifts based on the following roster of available practical nurses (PNs).

Case

PN	Expertise
Practical Nurse Adair	Pediatrics, Critical Care
Practical Nurse Brett	Medical/Surgical, Pediatrics
Practical Nurse Chris	Critical Care, Medical/Surgical
Practical Nurse Drew	Behavioral Health, Critical Care

According to the concepts of management and supervision, what is the most appropriate action for the charge nurse to take when scheduling the nurses?

Answer Options

Assign Practical Nurse Adair exclusively to medical/surgical patients to help them gain confidence.

Rotate the assignments, allowing Practical Nurse Brett to care for critical care patients occasionally.

Allow Practical Nurse Chris to trade behavioral health assignments with another nurse when desired.

Transfer Practical Nurse Drew to another unit with minimal pediatric patient exposure.

Hint : 🔍Rotate assignments to promote skill development under supervision.

Correct Answers:

No Correct Answers Available !

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43 :
The nurse working in a pediatric clinic is helping the RN conduct a developmental assessment on a five-month-old child. The nurse determines that the infant may need additional evaluation upon noting that the infant demonstrates which of the following behaviors?

Inability to build a four-block tower

Voluntary object grasp

Strong palmar grasp reflex

Well-developed pincer grasp

Hint : 🕵️‍♂️Primitive reflexes should appear absent by 5 months.

Correct Answers:

No Correct Answers Available !

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44 :
The nurse has just received the client report for her nursing shift. Which of the clients should the nurse see first?

A client requiring a dressing change

A client requiring oral suctioning

A client who is incontinent and needs cleansing

A client who needs medication for incisional pain

Hint : 🔍Prioritize interventions that secure the airway first.

Correct Answers:

No Correct Answers Available !

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45 :
The nurse is assisting a newborn infant and recognizes which of the following should be reported to the physician?

bulging posterior fontanel

cephalohematoma

molding of infant's head

open posterior fontanel

Hint : 🕵️‍♀️Look for signs of increased intracranial pressure.

Correct Answers:

No Correct Answers Available !

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46 :
Emma, an autistic 15-month-old toddler, presents to the clinic for a routine well child checkup. During the visit, Emma is banging her head with her hands in the exam room. Mrs. Tores, Emma's mother, says Emma has been self-soothing at home by banging her head. Emma has started to walk, and Mrs. Torres is concerned about ensuring a safe environment for Emma at home. Which recommendations should the practical nurse make to ensure a safe environment for the toddler? Select all that apply.

Place an orthotic helmet on Emma when she is awake to prevent injuries.

Designate a quiet space where Emma can retreat when overwhelmed.

Establish a consistent daily routine to provide a sense of predictability.

Place soft bumpers in the crib to prevent Emma from banging her head against the bars.

Install safety gates at the top and bottom of stairs to prevent falls.

Use soft lighting and provide sensory-friendly textures throughout the house.

Hint : 🕵️‍♂️Adapt the environment to reduce sensory triggers and protect against injury.

Correct Answers:

No Correct Answers Available !

Rationale :

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47 :
The nurse is caring for a child with an arm board in place to secure IV access. The arm board is taped in position. To provide care for the child, the nurse should do which of the following?

Leave the arm board in place while providing care

Remove the arm board and clean the child's arm

Remove one piece of tape at time while bathing the child's arm

Remove the arm board and perform range of motion exercises

Hint : 🎯Maintain external support to keep the IV line stable during care.

Correct Answers:

No Correct Answers Available !

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48 :
A child with tetralogy of Fallot begins to cry and becomes cyanotic while the nurse is in the room. The nurse should place the child in which position?

Knee-chest

Right lateral

Standing

Trendelenburg

Hint : 🛑Position to increase pulmonary circulation and reduce shunting.

Correct Answers:

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49 :
The nurse is caring for a client with a diabetic foot ulcer in the acute care setting. The nurse would expect which of the following to be involved in this client's care?

Nutritionist

Occupational therapist

Recreational therapist

Risk management

Hint : 🍎Consult a specialist for diet planning to support healing.

Correct Answers:

No Correct Answers Available !

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50 :
A client who was diagnosed with obstructive sleep apnea is discharged home with a continuous positive airway pressure (CPAP) machine and mask. The nurse will reinforce which information in the discharge teaching about the CPAP device?

How to place the nasal prongs on the face properly

Information on how to replace the oxygen supply source

An understanding that two fingers should fit under the face mask

The necessity of the bed at a 30-degree bed angle when using CPAP

Hint : 💡Focus on ensuring no air leaks around the mask.

Correct Answers:

No Correct Answers Available !

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51 :
Mrs. Chan, a 45-year-old woman, presents to the clinic with complaints of increased thirst, frequent urination, and unexplained weight loss over the past few weeks. She mentions feeling fatigued and occasionally dizzy. Mrs. Chan also reports blurred vision and increased hunger.

Case

Laboratory Test	Reference Range	Result
Hemoglobin A1c	< 5.7%	9.5%
Fasting Blood Glucose	70–100 mg/dL	180 mg/dL
Urinalysis	—	Positive for glucose and ketones

Which lifestyle choices will the practical nurse tell Mrs. Chan are contributing to her current condition? Select all that apply.

Answer Options

Reduced physical activity

Consistent healthy body weight

Consuming refined carbohydrates

Consuming monounsaturated fats

Consuming spicy foods

Hint : 💡Focus on choices that cause blood sugar spikes and reduce glucose utilization.

Correct Answers:

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52 :
The nurse is participating in the care of a male client suspected of having colon cancer. A diagnostic study of the colon is ordered that requires the administration. of an enema prior to the testing. The client tells the nurse he'd like to administer the enema himself. Which of the following statement by the client indicates the client has a correct understanding of the procedure?

"I'll administer the enema while lying on my right side with my left knee flexed."

"I'll lie on my back with both knees flexed while administering the enema."

"I will sit on the bathroom toilet while administering the enema."

"I will lie on my left side with my right knee flexed while administering the enema."

Hint : 📐Choose the position that uses gravity to direct fluid into the colon.

Correct Answers:

No Correct Answers Available !

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53 :
The nurse is reviewing the laboratory results of her assigned clients. Which of the following client data should have the highest priority?

Hemoglobin level, 15 g/dL

Pulse oximetry reading, 84%

Urine output, 245 mL/8 hours

Serum potassium level, 4.0 mEq/L

Hint : 🕵️Focus on the most critical sign of respiratory distress first.

Correct Answers:

No Correct Answers Available !

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54 :
The nurse is caring for a client who experienced a stroke, is unresponsive, and does not have advance directives. Just prior to the stroke, the client told the nurse that he would "not want all the tubes and stuff to keep him alive should something happen to him. Currently, the client's adult children are all present and they are undecided as to the next steps in the management of the client's care. What is the nurse's first action in this situation?

Explain the advantages of a feeding tube and breathing tube.

Notify the nursing supervisor or charge nurse of the current situation.

Ask the family members if they would like a chaplain or spiritual advisor.

Suggest that the situation be presented to the hospital ethics committee.

Hint : 💡Escalate the client’s wishes to the appropriate leadership immediately.

Correct Answers:

No Correct Answers Available !

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55 :
Ms. Spencer, a 72-year-old woman, has been diagnosed with end-stage chronic obstructive pulmonary disease (COPD). She resides in a rural area with limited access to healthcare facilities. Ms. Spencer values her independence and has expressed a wish to receive palliative care at home. She lives with her two adult sons, who take an active role in her care. Given Ms. Spencer's case, what nursing interventions are appropriate for the practical nurse to perform? Select all that apply.

Collaborate with local community resources to arrange home visits by healthcare professionals for regular assessments.

Educate Ms. Spencer and her sons about managing respiratory symptoms and optimizing her comfort at home.

Explore the feasibility of telehealth services for remote consultations with healthcare providers.

Discuss the option of transferring Ms. Spencer to a hospice facility to ensure specialized end-of-life care.

Assess Ms. Spencer's spiritual and cultural preferences and involve local spiritual leaders as needed.

Provide a detailed plan for aggressive medical interventions to prolong Ms. Spencer's life.

Encourage Ms. Spencer to participate in community based support groups for individuals with COPD.

Hint : 🕵️‍♀️Focus on home-based support, education, and resources that respect her preferences.

Correct Answers:

No Correct Answers Available !

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56 :
The LPN is participating in the care of a client with a low hemoglobin/hematocrit. The client is ordered the administration of 2 units of packed red blood cells. The RN asks the LPN to begin the transfusion because she is too busy with other clients. The LPN's best response is which of the following?

Have the RN double check the order for the transfusion, and then hang the blood.

Obtain the client's initial VS and then begin the transfusion as ordered.

Refuse to initiate the client's blood transfusion, and consult with another RN

Verify the client's identity, and check the client's VS prior to administering the blood.

Hint : 💡Seek clarification when a task exceeds your scope of practice.

Correct Answers:

No Correct Answers Available !

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57 :
The nurse is caring for a client diagnosed with pneumonia. During nursing rounds, the nurse notes the client has a productive cough, chills, and is diaphoretic with a temperature of 102.5°F. Which of the following actions should the nurse include in the care for this client?

Changing the client's linens frequently

Completing oral suctioning

Providing the client with a bedpan

Repositioning the client every four hours

Hint : 🕵️Keep the client dry and comfortable during high fevers.

Correct Answers:

No Correct Answers Available !

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58 :
The nurse has contributed to a staff development program in advance directives and legal issues. Which statement, made by a staff member, indicates correct understanding of a health-care proxy?

"It protects health-care providers from lawsuits and liability from potential malpractice."

"It is a set of instructions that directs a client's care when the client becomes incapacitated."

"It directs providers not to attempt resuscitation in the event of a cardiac or respiratory arrest."

"It serves as a durable power of attorney for a client when he or she is unable to make health-care decisions."

Hint : 💡Identify the document that grants someone authority to make healthcare decisions.

Correct Answers:

No Correct Answers Available !

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59 :
The nurse is caring for a client with hypertension who is ordered the application of a Clonidine (Catapres) transdermal patch. Which of the following actions are contraindicated when applying a transdermal patch?

Applying a bioclussive seal over the patch after application

Applying the patch to a dry, hairless area of subcutaneous tissue

Performing hand hygiene after the application of the patch

Removing any previously applied transdermal patch

Hint : 🔍Avoid covering the patch with occlusive materials that alter absorption.

Correct Answers:

No Correct Answers Available !

Rationale :

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60 :
The LPN is assigned to care for numerous clients on a mental health unit. Which of the following clients requires the nurse's immediate attention?

A female client crying and rocking back and forth in a chair

An unclothed female client sitting in the corner of the room facing the wall

A male client walking in circles continuously while spitting in the air

A male client walking through the nursing unit yelling

Hint : 👀Prioritize the client exhibiting the most aggressive, unpredictable behavior.

Correct Answers:

No Correct Answers Available !

Rationale :

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61 :
Mr. Ahmed, a 45-year-old patient, is admitted to the hospital for a surgical procedure. He follows the Islamic faith and observes dietary restrictions. Mr. Ahmed is known to prioritize his religious practices and beliefs as integral to his overall well-being. In providing culturally sensitive care for Mr. Ahmed, what nursing interventions should the practical nurse perform? Select all that apply.

Arrange for a communal dining experience with diverse cultural dishes.

Schedule necessary medical procedures or treatments considering Mr. Ahmed's prayer times.

Provide a private space for Mr. Ahmed to perform his daily prayers.

Offer a menu that includes a variety of halal food options.

Respect Mr. Ahmed's request for privacy during religious practices.

Hint : 💡Integrate religious practices and dietary needs into care planning.

Correct Answers:

No Correct Answers Available !

Rationale :

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62 :
The nurse is serving on a quality improvement committee that is reviewing the number of code blue events in the hospital for the previous six months with the goal of reducing the number of code blues. What data would the nurse collect to assist with this goal?

Review charts for all client outcomes after code blue events.

Check charts to review how many code blue events were called.

Check charts to review how many rapid response events were called.

Review charts to see what medications were used in rapid response events.

Hint : 🔎Look at how often full code blue calls occur to gauge the magnitude of the problem.

Correct Answers:

No Correct Answers Available !

Rationale :

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63 :
The LPN is assisting the RN in the development of a plan of care for a client that had an emergency colostomy. The LPN notices a history of drinking a six pack daily. The plan of care should include assessment for all of the following except

agitation.

bradycardia.

seizures.

sweating.

Hint : 💡Anticipate signs that reflect increased sympathetic activity.

Correct Answers:

No Correct Answers Available !

Rationale :

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64 :
A newly licensed LPN is orienting to a new position in the nursing home setting and asks his preceptor how to decide whether he can perform certain nursing procedures. Which answer by the preceptor is the best response to the LPN's question on legal scope of practice?

"We can check with the state Nurse Practice Act and see if you are allowed to perform a certain procedure."

"We will refer to the policies and procedures to see whether you can perform a specific procedure."

"If you receive sufficient training and education and gain significant experience, then it is acceptable to perform a procedure."

"Just watch and see how we do things here; if you are shown how to do a procedure and you do it correctly, then you should be okay."

Hint : 💡Learn through direct observation and replicate exactly as demonstrated.

Correct Answers:

No Correct Answers Available !

Rationale :

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65 :
The nurse is caring for a client who has suffered a cerebral vascular accident (CVA). The nurse is reinforcing the principles of using a cane. The nurse understands the reason the client should hold the cane on the unaffected side is which of the following?

Distribution of weight to the unaffected side

Prevent edema formation on the affected side

Prevent the client from leaning while ambulating

Promotion of stride and endurance while ambulating

Hint : 💡Support more weight on the stronger side during ambulation.

Correct Answers:

No Correct Answers Available !

Rationale :

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66 :
The nurse observes a health-care provider pick up a client's medical chart and start to review the client's record. The nurse knows that the provider is not a consulting physician on the client's case. What is the nurse's best action in this situation?

Immediately document the incident as a variance report and notify the charge nurse.

Confront the provider and gently remove the client's record from the staff member.

Immediately inform the nursing supervisor or charge nurse about the breach of the client's record.

Inform the provider that he or she may not review the client's record without a need to know.

Hint : 💡Escalate any unauthorized access to leadership immediately.

Correct Answers:

No Correct Answers Available !

Rationale :

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67 :
Mrs. de Los Reyes, an 80-year-old resident in the long-term care facility, has recently been diagnosed with macular degeneration. She also experiences difficulty hearing and has been provided with hearing aids. Mrs. de Los Reyes is prone to disorientation and anxiety, especially during nighttime hours. Which of the following interventions by the practical nurse (PN) working the night shift is most appropriate to address Mrs. de Los Reyes's situation? Select all that apply.

Allow increased hallway noise during the night to create a livelier atmosphere.

Group all care activities for Mrs. de Los Reyes in the middle of the night to minimize disruptions.

Use dim, ambient lighting in Mrs. de Los Reyes's room to create a calming atmosphere during the night.

Tell Mrs. de Los Reyes to wear her hearing aids while she sleeps so that she can hear during the night.

Create a consistent routine for Mrs. de Los Reyes's nighttime care activities to establish predictability.

Hint : 💡Use minimal light and consistent patterns to reduce disorientation.

Correct Answers:

No Correct Answers Available !

Rationale :

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68 :
The nurse is caring for a client with amyotrophic lateral sclerosis (ALS) whose wife expresses being tired and "run-down" because of the constant care she provides to her husband. What resources could the nurse suggest for the client's wife for the immediate concern?

Respite care services

Financial service referral

Chaplain or spiritual care

Community support group

Hint : 💡Identify a service that offers temporary relief for caregivers.

Correct Answers:

No Correct Answers Available !

Rationale :

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69 :
The nurse is caring for a client who is diagnosed with Parkinson's disease. The client is receiving 500 mg of oral L-Dopa (levodopa) b.i.d. The desired effect of this medication includes which of the following?

Decreased muscle tremors

Improved mental capacity

Increased appetite

Increased urinary output

Hint : 💡Focus on motor symptoms controlled by dopamine.

Correct Answers:

No Correct Answers Available !

Rationale :

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70 :
Ms. Rosenberg is a 62-year-old female who presents to the emergency department (ED) with severe upper abdominal pain that radiates to her back. She also is experiencing nausea but denies vomiting. She has a history of type 2 diabetes mellitus and hyperlipidemia. After initiating pain management intervention for Ms. Rosenberg, the practical nurse takes the client's vital signs. Based on the client's updated vital signs, which of the following interventions should the nurse perform? Select all that apply.

Apply oxygen via nasal cannula to the client.

Obtain blood cultures.

Instruct the client to perform pursed-lip breathing.

Administer oral acetaminophen.

Notify the physician.

Hint : 💡Address respiratory changes immediately and inform the provider of any deterioration.

Correct Answers:

No Correct Answers Available !

Rationale :

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71 :
Ms. Rosenberg is a 62-year-old female who presents to the emergency department (ED) with severe upper abdominal pain that radiates to her back. She also is experiencing nausea but denies vomiting. She has a history of type 2 diabetes mellitus and hyperlipidemia.

Click whether or not each of the diagnostic tests listed is indicated for Ms. Rosenberg based on her profile.

Medications	Indicated	Not Indicated
Lactate level
Thyroid function tests
Abdominal computed tomography (CT) scan
Brain magnetic resonance imaging (MRI)

Hint : 💡Choose tests that directly assess for pancreatic inflammation and exclude acute intra-abdominal complications.

Correct Answers

Lactate level [ Indicated ]
Thyroid function tests [ Not Indicated ]
Abdominal computed tomography (CT) scan [ Indicated ]
Brain magnetic resonance imaging (MRI) [ Not Indicated ]

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72 :
Ms. Rosenberg is a 62-year-old female who presents to the emergency department (ED) with severe upper abdominal pain that radiates to her back. She also is experiencing nausea but denies vomiting. She has a history of type 2 diabetes mellitus and hyperlipidemia. Which of the following interventions should the nurse perform? Select all that apply.

Stop injecting the contrast dye.

Administer diphenhydramine.

Initiate cardiopulmonary resuscitation (CPR).

Notify the physician.

Hint : 💡Halt exposure and seek medical orders immediately.

Correct Answers:

No Correct Answers Available !

Rationale :

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73 :
Ms. Rosenberg is a 62-year-old female who presents to the emergency department (ED) with severe upper abdominal pain that radiates to her back. She also is experiencing nausea but denies vomiting. She has a history of type 2 diabetes mellitus and hyperlipidemia. Ms. Rosenberg returns to the ED. She is now receiving an intravenous infusion of 10 mEq of potassium chloride over 1 hour through a peripheral intravenous (IV) catheter in her right hand for electrolyte repletion. Which of the following interventions should the nurse take after reviewing Ms. Rosenberg's peripheral IV status? Select all that apply.

Apply a cold compress to the IV site.

Prepare to administer an antidote.

Apply a cold compress to the IV site.

Prepare to administer an antidote.

Elevate the right hand.

Stop the infusion.

Notify the physician.

Hint : 💡Act quickly to stop the infusion, elevate the limb, and arrange for protective measures to limit damage.

Correct Answers:

No Correct Answers Available !

Rationale :

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74 :
The nurse is caring for an elderly client who is receiving chemotherapy for the treatment of colon cancer. Which of the following findings predisposes the client to the greatest risk for infection?

Decreased client appetite

Oral temperature reading of 99.0°F

Stage II pressure ulcer on the right buttocks

White blood cell count of 8,500 cells/mm³

Hint : 💡Identify the existing skin breakdown as the highest infection risk.

Correct Answers:

No Correct Answers Available !

Rationale :

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75 :
The nurse is caring for a client who had a recent cerebral vascular incident and exhibits expressive aphasia. For suggestions on ways to facilitate communication with the client, the nurse should read the notes from which of the following disciplines?

Occupational therapy

Physical therapy

Recreational therapy

Speech therapy

Hint : 💡Refer to the discipline that evaluates and treats language deficits.

Correct Answers:

No Correct Answers Available !

Rationale :

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76 :
Mr. Williams, a 72-year-old patient, has been admitted to the hospital for the management of a chronic illness. He lives alone, and the practical nurse is responsible for assessing and addressing his support system needs. What are appropriate interventions by the practical nurse to ensure a supportive environment for Mr. Williams? Select all that apply.

Assess the current network of family and friends around Mr. Williams.

Discuss advance directives and end-of-life care preferences with Mr. Williams.

Encourage Mr. Williams to manage all aspects of his care independently.

Provide Mr. Williams with information on local support groups for people with his illness.

Limit communication with Mr. Williams to minimize emotional stress.

Explore potential community resources for Mr. Williams.

Hint : 💡Evaluate his social network, ensure his wishes are recorded, and connect him to supportive services.

Correct Answers:

No Correct Answers Available !

Rationale :

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77 :
The nurse is assessing the reflexes of a neonate. Which of the findings should the nurse document as abnormal? .

Extension of right arm and curling of left

Extension of arms when startled

Head turns toward cheek when stroked

Plantar flexion of toes when heel stroked

Hint : 💡Recognize that a Babinski response should cause toe fanning, not curling.

Correct Answers:

No Correct Answers Available !

Rationale :

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78 :
A client who is admitted to the labor and delivery unit has screened positive for group B strep (GBS). The LPN should reinforce with the client the RN's teaching concerning which of the following plans for the client's care?

Artificial rupturing of the amniotic membrane

Administration of IV antibiotics during labor

Placement on respiratory isolation precautions

Emergency cesarean delivery

Hint : 💡Prevent neonatal GBS transmission by giving IV antibiotics in labor.

Correct Answers:

No Correct Answers Available !

Rationale :

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79 :
Mr. Harris, a 55-year-old who is the CEO of a Fortune 500 company, has a history of rheumatoid arthritis (RA). He takes methotrexate to help reduce inflammation and alleviate symptoms of his RA. He typically works 10 hours a day and most weekends. During the assessment, Mr. Harris complains of frequent headaches, heartburn, diarrhea, sleep loss, and a rash on his hands. A review of his medical history shows that he has missed several wellness checkups and never received his second measles, mumps, and rubella (MMR) vaccine.

Vital Signs

Vital Sign	Value
Blood Pressure	140/90 mmHg
Heart Rate	110 bpm
Respiratory Rate	22 breaths/min
Temperature	98.6°F (37.0°C)
SpO₂	98% on room air

Which lifestyle changes should the practical nurse suggest to help Mr. Harris manage his condition? Select all that apply.

Answer Options

Engage in high-intensity, low-impact exercises for 15 minutes a day.

Consume grapefruit instead of fast food for breakfast.

Swap brown rice for white rice to support gut bacteria.

Practice mindfulness and meditation techniques.

Establish realistic goals and prioritizing tasks.

Give him the measles, mumps, and rubella (MMR) vaccine to prevent illness.

Engage in progressive muscle relaxation (PMR) exercises.

Hint : 💡Think about brief joint-friendly workouts, stress-reduction practices, balanced workloads, and techniques that ease muscle tension.

Correct Answers:

No Correct Answers Available !

Rationale :

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80 :
The nurse is administering to a client whose medications need to be crushed prior to administration. The nurse recognizes that which of the client's medications should not be crushed?

Lanoxin

Lasix

Metformin

Singular

Hint : 💡Identify which medication uses an extended-release formulation that must remain intact.

Correct Answers:

No Correct Answers Available !

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81 :
The nurse is reviewing the chart for al client who is scheduled for surgery but has not yet signed a consent form. Which of the following elements must be met for a client to provide informed consent? Select all that apply.

Disclosure

Willingness

Competence

Voluntariness.

Comprehension

Comprehensiveness

Hint : 🎯Focus on the core components that ensure a client’s decision is knowledgeable, independent, and understood.

Correct Answers:

No Correct Answers Available !

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82 :
A client with a history of congestive heart failure is admitted with weakness and diarrhea. The client's medication list includes Lasix and Lanoxin. Which lab result would be important for the nurse to monitor?

A1c

Hemoglobin

Sodium

Potassium

Hint : ⚡Watch electrolytes that influence digoxin levels, especially when diuretics are used.

Correct Answers:

No Correct Answers Available !

Rationale :

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83 :
The LPN is assisting in the RN conducting a community education class on Type II diabetes. The LPN realizes that additional education is needed when a participant identifies which of the following as a risk factor for Type II diabetes?

Age 35-45

BMI>25

Polycystic ovary syndrome

Sleep apnea

Hint : 💡Consider which group is truly most associated with onset of Type II diabetes.

Correct Answers:

No Correct Answers Available !

Rationale :

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84 :
A client is diagnosed with depression and states that he is "such a failure." The best therapeutic response by the nurse is,

"I feel like a failure sometimes."

"What did you do wrong?"

"You are not a failure."

"You feel like a failure?"

Hint : 🙂‍↔️Use reflective statements to show you understand his emotion.

Correct Answers:

No Correct Answers Available !

Rationale :

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85 :
The nurse is participating in the care of a client who had an emergency splenectomy performed. Nursing care for this client will include which of the following?

Administration of oral diuretics

Increasing fluid intake

Pneumococcal vaccination

Chest physiotherapy

Hint : 🦠Protect against encapsulated bacteria for post-splenectomy clients.

Correct Answers:

No Correct Answers Available !

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86 :
Ms. Wong, a 55-year-old patient, has undergone abdominal surgery and is experiencing postoperative pain as 7 out of 10. She has a history of peptic ulcers, gastrointestinal bleeding, and stage IV chronic kidney disease. Select the three appropriate nursing interventions related to pharmacological pain management for Ms. Wong.

Administer an opioid analgesic.

Educate Ms. Wong about non-pharmacological pain management techniques.

Withhold pain medication to assess Ms. Wong's pain tolerance.

Monitor Ms. Wong's response to analgesic administration.

Administer a nonsteroidal anti-inflammatory drug.

Discontinue pain medication if Ms. Wong reports feeling better.

Hint : 💡Select interventions that avoid GI irritation and protect renal health while ensuring safe, effective pain relief.

Correct Answers:

No Correct Answers Available !

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87 :
The LPN is caring for a 16-year-old client requiring the surgical repair of a fractured wrist. The nurse has been asked to have the client's mother sign the operative permit. The nurse's best action is which of the following?

Ask an RN to have the mother sign the permit.

Have the client's mother sign the permit.

Have the client sign the permit.

Refuse to ask the mother to sign the permit.

Hint : 👶Minors require a parent or guardian to consent for surgery.

Correct Answers:

No Correct Answers Available !

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88 :
Mrs. Johnson, a 75-year-old patient, is admitted to a long-term care facility. She expresses concern about the nursing staff entering her room without permission and wishes to maintain her privacy. Which action by the nurse best demonstrates adherence to the client's right to privacy?

Knock on Mrs. Johnson's door before entering and asking to come in.

Explain to Mrs. Johnson that the nursing staff needs access to her room for routine check-ups.

Assure Mrs. Johnson that her room is equipped with surveillance cameras for security purposes.

Ignore Mrs. Johnson's concerns as routine check-ups are essential for her well-being.

Hint : 💡Always seek permission before entering a client’s private space.

Correct Answers:

No Correct Answers Available !

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89 :
Which tasks should the LPN assign to the nursing assistant in the nursing home setting? Select all that apply.

Change a sacral wound dressing that has been soiled by fecal matter.

Obtain a wound sample from a client's leg for culture and sensitivity.

Check the client's fingerstick blood glucose prior to the morning meal.

Give the client the oral medications that the nurse left on the meal tray.

Take a set of vital signs on a post-operative client who was just readmitted.

Hint : 💡Assign only routine, non-sterile tasks that do not require clinical judgment to the assistant.

Correct Answers:

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90 :
Mr. Smith, a 56-year-old male managing Crohn's disease, has recently received diagnoses of celiac disease, diabetes, high BMI, and prostate cancer. Despite these challenges, he is determined to enhance his well-being. Mr. Smith seeks guidance from the practical nurse, inquiring about lifestyle choices he can implement to improve his health.

Click to indicate whether or not the lifestyle choice can help improve Mr. Smith's health.

Lifestyle Choice	Indicated	Not Indicated
Eating a heart-healthy cereal every morning
Eating foods high in fiber
Consuming a diet rich in saturated fats
Maintaining a healthy body weight

Hint : 🍏Consider how gluten, fiber, and fats affect his health.

Correct Answers

Eating a heart-healthy cereal every morning [ Not Indicated ]
Eating foods high in fiber [ Not Indicated ]
Consuming a diet rich in saturated fats [ Not Indicated ]
Maintaining a healthy body weight [ Indicated ]

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91 :
The practical nurse is caring for a patient with multiple chronic conditions, transitioning from the hospital to home care. During the discharge planning process, the nurse discovers that the patient has limited transportation. Which action by the nurse demonstrates continuity of care for this patient?

Provide the patient with a detailed written discharge plan.

Explore community resources with the patient.

Discharge the patient immediately to avoid additional hospital costs.

Recommend the patient rely on family members for all transportation.

Hint : 🗺️Think about how to bridge the gap between hospital care and the patient’s community needs.

Correct Answers:

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92 :
The LPN is assisting the RN completing discharge teaching for a client prescribed a tricyclic antidepressant. The client should be instructed to contact his or her physician prior to taking
Allergy medication
Cold medications.
Fiber additives
Stool softeners

1 and 2

2 and 3

2 and 4

1 and 4

Hint : ⚠️Avoid combining TCAs with other anticholinergic or sympathomimetic agents.

Correct Answers:

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93 :
A practical nurse is assigned to care for a patient who is a Jehovah's Witness. The patient has refused a blood transfusion. However, the healthcare team believes that a blood transfusion is medically necessary to save the patient's life. In the context of ethical practice, what should the practical nurse prioritize?

Advocate for alternative medical interventions.

Give a medically necessary blood transfusion.

Seek guidance from the hospital's ethics committee.

Ask the patient's family about their preferences for blood transfusion.

Hint : 🔄Focus on respecting patient values by finding acceptable treatment options.

Correct Answers:

No Correct Answers Available !

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94 :
Use the following to answer questions 106. As a practical nurse working in a busy emergency department (ED), you encounter a surge in patient volume. The ED is receiving patients with varying medical conditions and acuity levels. Your role involves triaging patients to ensure effective resource management and timely care delivery.

Patient Triage

Patient	Mr. Alvarez	Mr. Balik	Mr. Cooper
Check In Time	1102	1107	1115
Chief Complaint	Oozing rash on the left arm and face	Deep laceration on the forearm, bleeding	9/10 abdominal pain
Respiratory Rate	18 bpm	16 bpm	22 bpm
Heart Rate	62 bpm	95 bpm	115 bpm
Oxygen Saturation(room air)	95 %	97 %	98 %
Patient Appearance	Alert and conscious, reporting having an irritating rash for the past three days	Alert and conscious, reporting pain at the site	In pain, describing the pain as constant and sharp in the right lower abdomen

As the PN triaging patients in the ED, which patient should you prioritize for immediate attention?

Answer Options

Mr. Alvarez

Mr. Balik

Ms. Cooper

Ms. Domingo

Hint : 🚑Identify which patient’s condition threatens life or major function first.

Correct Answers:

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95 :
A practical nurse is preparing to administer medications to multiple patients. While organizing the medication cart, the nurse notices a vial containing a hazardous medication has a cracked seal. What should the nurse do according to standard handling procedures?

Use the medication from the vial.

Discard the vial in the trash bin.

Seal the vial with tape before administering the medication.

Place the unopened vial in the hazardous waste container.

Hint : ♻️Think about how to dispose of a hazardous drug safely without risking exposure.

Correct Answers:

No Correct Answers Available !

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96 :
The practical nurse is caring for Mrs. Micelli, a patient who has been transferred to the hospital from a dementia care facility after breaking her hip during a fall. The facility let the PN know that Mrs. Micelli is prone to wandering at night. Which action should the PN perform to help ensure the patient's safety in their new environment?

Implement a bed alarm that alerts the staff when the patient attempts to get out of bed.

Place a locking tray on the patient's wheelchair to limit mobility.

Apply soft wrist restraints to prevent the patient from. wandering.

Lock the room door to confine the patient during unsupervised periods.

Hint : 🔔Choose a strategy that alerts staff without confining the patient.

Correct Answers:

No Correct Answers Available !

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97 :
The nurse is caring for a male client diagnosed with gout. The client requires assistance in completing his lunch menu. When completing the lunch menu, the nurse is correct in telling the client to avoid which of the following food items? Select all that apply.
Beef stew
Spinach
Salmon
Tofu
Vegetable soup

1, 3, 4

2, 4, 5

1,3

2, 4

Hint : ⚠️Think about which foods are highest in purines.

Correct Answers:

No Correct Answers Available !

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98 :
The practical nurse is taking care of Ms. Jones, an 80-year-old patient in a long-term care facility. Ms. Jones fell in her room while attempting to get out of bed independently. The incident occurred at approximately 0830 during morning care rounds. The patient was conscious but complained of pain in her left hip. There were no signs of external injuries.

Vital Signs

Time	0845
Blood Pressure (BP)	130/80 mmHg
Heart Rate (HR)	82 bpm
Respiratory Rate (RR)	18 bpm
Temperature (T)	98.6°F (37.0°C)
SpO₂ (room air)	90%

What is the most appropriate action for the practical nurse following Ms. Jones's fall?

Answer Options

Complete the incident report and document the details in the medical record.

Inform the healthcare provider about the incident and wait for further instructions.

Provide oxygen until 95% or above oxygen saturation is achieved.

Discuss the incident with the nursing supervisor during the next shift change.

Hint : 🫁Address any evidence of hypoxia before other actions.

Correct Answers:

No Correct Answers Available !

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99 :
During a routine shift in a healthcare facility, a practical nurse observes a broken access control device near a sensitive patient area. What is the nurse's most appropriate course of action?

Document the issue in the shift report and continue with assigned tasks.

Use alternative routes to access the area without using the broken device.

Immediately report the broken access control device to the facility's maintenance department.

Inform colleagues about the broken device during the next team meeting.

Hint : 🛠️Report malfunctioning security equipment right away to prevent unauthorized access.

Correct Answers:

No Correct Answers Available !

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100 :
The practical nurse is administering medications to Ms. Morgan, who has a history of Addison's disease and hypertension. The doctor's orders indicate 20 mg of lisinopril should be taken orally once daily in the morning, 10 mg of hydrocortisone should be taken orally twice a day, and 50 mg of dehydroepiandrosterone (DHEA) should be taken orally once daily in the evening. Ms. Morgan is administered her medications as ordered at 0830, and then her vitals are taken. A short while later, she complains of feeling dizzy and lightheaded when attempting to sit up in the hospital bed but denies any chest pain, shortness of breath, or other acute symptoms. She appears pale and diaphoretic.

Vital Signs

Time	0830
Blood Pressure (BP)	100/60 mmHg
Heart Rate (HR)	12 bpm
Respiratory Rate (RR)	16 bpm
Temperature (T)	98.6°F (37.0°C)
SpO₂ (room air)	99%

What should the practical nurse do first?

Answer Options

Document the symptoms in the patient's chart.

Update the patient's family about her condition.

Report to the charge nurse or supervisor.

Notify the doctor of the situation.

Hint : 🚨Inform the physician immediately when a patient develops post-medication hypotensive symptoms.

Correct Answers:

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101 :
The practical nurse is providing care to an elderly resident in a long-term care facility. During the morning assessment, the PN noted significant bruising on the resident's upper arms and left side of the face, displaying a purplish hue and tenderness. Additionally, the PN observed bilateral forearm abrasions at varying stages of healing, with associated discomfort. What is the appropriate nursing action?

Note the observations mentally, as the resident has a history of falls.

Document the findings in the resident's medical record without reporting them.

Ask the resident privately if they are being mistreated.

Report the observations to the appropriate authorities as per facility policy.

Hint : 👀Unexplained bruises in different healing stages often warrant mandatory reporting.

Correct Answers:

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102 :
The nurse is performing a sterile dressing on a surgical wound to a client' abdomen. Place the steps for opening a sterile package in the correct sequence.

Lay the drape across a clean, dry surface without reaching over it.
Pinch the remaining side flaps to reveal the inner package.
Sterile supplies may now be placed into the sterile field.
Pull the fourth flap toward you, grasping the down corner.
Lay the package on a clean and dry surface on the center of the workspace.
Pluck the back of the drape and allow it to open freely without touching anything—sterile field established.
Reaching around (not over), pinch the first flap on the outer wrapper.

Hint : 🔍Think about how each motion keeps the sterile package from contacting nonsterile surfaces.

Correct Order:

No correct order available !

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103 :
Mr. Fuller, a 40-year-old patient with a history of alcohol use disorder, is admitted to the rehabilitation unit for detoxification. He exhibits signs of alcohol withdrawal, including restlessness, irritability, and elevated blood pressure. The nursing team is implementing behavioral management strategies to support Mr. Fuller during this critical period. Given Mr. Fuller's case, what is the priority nursing intervention for the practical nurse?

Monitor Mr. Fuller's blood pressure every hour and implement a structured schedule.

Administer a high dose of sedative medication to induce sleep and minimize agitation.

Assign a peer support specialist with a history of alcohol use disorder and give Mr. Fuller the schedule for group sessions.

Isolate Mr. Fuller in a quiet room to prevent overstimulation and agitation.

Hint : 🩹Prioritize frequent vital sign checks to detect and prevent serious withdrawal complications.

Correct Answers:

No Correct Answers Available !

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104 :
Mrs. Patel, a 50-year-old patient, is admitted to the hospital for a surgical procedure. She follows Hinduism, and it's essential for her to maintain personal cleanliness and hygiene as part of her religious beliefs. Mrs. Patel expresses discomfort with the hospital's bathroom. facilities and requests a solution that aligns with her cultural practices. What nursing action demonstrates cultural awareness in providing care for Mrs. Patel?

Explain to Mrs. Patel that the hospital's bathroom facilities. are standard and cannot be altered.

Provide Mrs. Patel with culturally appropriate cleansing wipes or materials for her personal hygiene.

Request Mrs. Patel's family to bring in materials from home for her personal hygiene.

Suggest Mrs. Patel adapt her cultural practices temporarily to accommodate the hospital environment.

Hint : 🚿Provide hygiene options that honor her cultural practices and ensure comfort.

Correct Answers:

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105 :
Mr. Castello, a 72-year-old woman, was admitted to the medical-surgical unit after a fall at home during which she sustained a hip fracture. She is postoperative 1 day following a surgical repair (ORIF). She reports pain at the incision site of 5/10. The surgical site is intact, with no signs of infection or excessive bleeding. Ms. Castello reports minimal mobility due to pain and surgical site discomfort. The nurse notices fine crackles auscultated at the bases of both lungs. Ms. Castello has a weak and non-productive cough.

Vital Signs

Parameter	Value
BP	130/80 mmHg
HR	110 bpm
RR	22 bpm
Temperature (T)	100.4 °F (38.0 °C)
SpO₂ (room air)	98 %

Considering the provided data, which action should the nurse prioritize for Ms. Castello?

Answer Options

Administer a prescribed analgesic to address the pain.

Encourage deep breathing exercises to improve lung function.

Request a chest x-ray to assess for possible pneumonia.

Monitor oxygen saturation continuously for respiratory status.

Hint : 🔎Look for signs of infection before focusing solely on symptomatic relief.

Correct Answers:

No Correct Answers Available !

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106 :
A client has a C-diff infection. When caring for the client, which should the nurse do?
Cleanse hands with soap and water.
Cleanse hands with hand sanitizer.
Follow contact precautions.
Follow airborne precautions.

1 and 3

1 and 4

2 and 3

2 and 4

Hint : 🔍Which hand hygiene method removes spores?

Correct Answers:

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107 :
Ms. Turner, a 65-year-old woman, recently underwent below-the-knee amputation of her right leg due to complications from peripheral artery disease. She is admitted to the hospital for post-operative care and rehabilitation. Ms. Turner expresses concerns about her mobility, adjusting to the amputation, and returning home. She reports 6/10 pain at the surgical site. Which immediate nursing interventions are the most crucial to promote her care and mobility as she transitions to home care?

Ensure her home has a ramp for wheelchair accessibility.

Provide her with pain management techniques.

Teach her the proper use of a prosthetic limb.

Provide her with details about community support groups.

Hint : 🦶Focus on facilitating her ability to walk safely.

Correct Answers:

No Correct Answers Available !

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108 :
The nurse works in a rehabilitation unit where there has been an increased number of client falls over the past six months. The quality improvement committee is studying this trend and is collecting data to develop a fall prevention program. What data would the nurse expect to collect regarding client falls in the facility? Select all that apply.

Review client-specific patterns.

Review times of the day when falls occur.

Review medication trends and polypharmacy.

Identify precipitating factors and risks for falls.

Examine staffing patterns and nurse-specific occurrences.

Hint : 🤔Consider when, who, and why falls happen.

Correct Answers:

No Correct Answers Available !

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109 :
While providing care in a long-term care facility, the practical nurse encounters the death of a resident. What is the priority action for the nurse in postmortem care?

Begin postmortem care and maintain dignity for the deceased.

Notify the funeral home to start the transfer of the deceased resident.

Remove the patient from the EHR system.

Conduct a brief prayer for the deceased resident's soul

Hint : 📞Arrange for the body’s transfer without delay.

Correct Answers:

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110 :
The practical nurse is preparing to administer insulin to a patient with diabetes. The healthcare provider orders the patient to receive 10 units of regular insulin subcutaneously. The insulin vial available is labeled 100 units/mL. How many milliliters (mL) of insulin should the nurse administer for this dose?

0.05 mL

0.1 mL

0.5 mL

1.0 mL

Hint : 📏How do you convert units into mL with 100 units/mL?

Correct Answers:

No Correct Answers Available !

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111 :
Use the following to answer questions 126. Mr. Davies, a 55-year-old male, was admitted to the medical-surgical unit following a motor vehicle accident. He sustained multiple fractures and is experiencing severe pain. The healthcare provider has prescribed opioid analgesics for pain management. At 1100, an initial dose of oxycodone (5 mg every 4 hours as needed) is administered; Mr. Davies reports a pain level of 8/10 with sharp, constant pain. At 1500 he is unresponsive to verbal stimuli and requires a sternal rub for arousal. His eyes remain closed, and his breathing is shallow. Additionally, cyanosis is noted in the nail beds and lips.

Vital Signs

Parameter	Value
Blood Pressure	85/60 mmHg
Heart Rate	50 bpm
Respiratory Rate	9 bpm
Temperature	97.7°F (36.5°C)
SpO₂ (room air)	90%

Which action should the practical nurse prioritize?

Answer Options

Administer another dose of oxycodone.

Encourage Mr. Davies to continue with deep breathing exercises.

Administer naloxone to Mr. Davies.

Monitor the vital signs more frequently to assess for changes.

Hint : 🛑Reverse life-threatening opioid-induced respiratory depression promptly.

Correct Answers:

No Correct Answers Available !

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112 :
The practical nurse is preparing to administer a dose of 3 mcg/kg of digoxin to a 150-lb. patient. How many micrograms of digoxin should the nurse administer?

104 mcg

150 mcg

200 mcg

204 mcg

Hint : 📏Convert pounds to kilograms before multiplying by the mcg/kg dosage.

Correct Answers:

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113 :
Use the following to answer questions 128. Mrs. Lee was admitted to the medical-surgical unit with complaints of weakness and lethargy. She has a history of hypertension and diabetes mellitus. Mrs. Lee reports nausea and a poor appetite.

Laboratory Results

Laboratory Test (Reference Range)	Result
Blood urea nitrogen (BUN) (7–22 mg/dL)	26 mg/dL
Creatinine, serum (0.60–1.30 mg/dL)	1.5 mg/dL
Fasting blood glucose (70–100 mg/dL)	126 mg/dL
Sodium (135–145 mEq/L)	150 mEq/L

What intervention is most important for immediately addressing Mrs. Lee's condition?

Answer Options

Administer a loop diuretic to increase urine output.

Encourage increased fluid intake to promote hydration.

Encourage restricting salt in the diet.

Administer insulin to address hyperglycemia.

Hint : 💡Prioritize correcting hypernatremia and volume depletion first.

Correct Answers:

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114 :
The nurse is caring for a client with MRSA in his wound. Prior to entering the room to perform the dressing change, the nurse should do which of the following?
Wash hands
Put on a gown
Put on gloves
Put on a mask

1, 2, 3

2, 3, 4

1, 2, 4

1, 3, 4

Hint : 🔐Use only the PPE required for contact precautions.

Correct Answers:

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115 :
Ms. Vasquez is a 45-year-old female client with a past medical history of type 1 diabetes mellitus, hypertension, and hyperlipidemia. She presents to the outpatient clinic for a follow-up appointment after 1 week of taking oral chemotherapy for her newly diagnosed stage 2 breast cancer. Which of the following interventions should the practical nurse take? Select all that apply.

Notify the physician.

Instruct the client to bear down.

Place the client in a supine position.

Apply oxygen via nasal cannula.

Administer intramuscular epinephrine.

Hint : 🚨Prioritize perfusion and emergency medication for severe reactions.

Correct Answers:

No Correct Answers Available !

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116 :
The nurse is caring for a client with hypertension. On the illustration below, identify the area where the nurse will place the stethoscope to best auscultate the pulmonic valve.

Hint : 🫀Think “second space” on the left side of the sternum.

Correct Answers:

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117 :
The nurse needs to assess and palpate a client's dorsalis pedis pulse. Identify the area where the nurse places her fingers to palpate the pedal pulse.

Site 3

Site 1

Site 2

Site 4

Hint : 🦵Feel for the strongest beat next to the big toe tendon on the top of the foot.

Correct Answers:

No Correct Answers Available !

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118 :
The nurse is caring for a client with a cystostomy for urine drainage. Identify the area on the following image where the nurse should check for cystostomy placement.

Site 3

Site 4

Site 1

Site 2

Hint : 🩹Check just above the pubic symphysis in the lower midline of the abdomen.

Correct Answers:

No Correct Answers Available !

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119 :
The nurse is assisting in a teen pregnancy prevention program. The nurse is discussing conception and the female reproductive system and determines that the clients have understood the teaching when they identify the location where the egg and sperm unite. Indicate this location by clicking on the appropriate letter below.

Hint : 🧭Think of the widened middle section of the fallopian tube between the ovary and uterus.

Correct Answers:

No Correct Answers Available !

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120 :
A nurse is assisting with the care of a client in an orthopedic unit.

Progress Report

Day 1

Admission 0800

Client hospitalized following a motor vehicle crash. Open fracture to right femur. Reduction of fracture and internal fixation device used to stabilize. Splint applied.

Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developingand

Hint : 🦵Fractures and immobility create risks from both internal pressure and blood stasis.

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121 :
A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. How many should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Hint : 📐Use ratio-proportion formula to match dose with volume.

Correct Answers:

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122 :
Following a left nephrectomy, which concern should be Nurse Liza’s primary focus when monitoring the client back on the unit?

Hourly urine output

Temperature

Able to turn side to side

Able to sips clear liquid

Hint : 🧪Focus on a measurement that directly reflects kidney function post-surgery.

Correct Answers:

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123 :
In preparing a 64-year-old man with hypertension and angina for a cardiac catheterization, what key purpose should Nurse Cherry emphasize during teaching?

To determine the existence of CHD.

To visualize the disease process in the coronary arteries.

To obtain the heart chambers pressure.

To measure oxygen content of different heart chambers.

Hint : 📷Focus on what the dye and camera allow providers to see inside the heart.

Correct Answers:

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124 :
During the initial hours after a client’s cardiac catheterization, which nursing intervention should take the highest priority?

Elevate the client's bed at 45°.

Instruct the client to cough and deep breathe every 2 hours.

Frequently monitor the client's apical pulse and blood pressure.

Monitor client's temperature every hour.

Hint : 🩺Think of what changes would indicate internal bleeding or hemodynamic shifts.

Correct Answers:

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125 :
After mitral valve replacement, if a client starts to bleed persistently from the surgical site, which medication should Nurse Aiza get ready to administer?

Protamine Sulfate

Quinidine Sulfate

Vitamin C

Coumadin

Hint : 🩸Consider the antidote commonly used for heparin-related bleeding.

Correct Answers:

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126 :
In a teaching plan for a client with endocarditis, which dental tool should be discouraged to prevent risk of infection?

Dental floss

Electric toothbrush

Manual toothbrush

Irrigation device

Hint : 🦷Think of what device could unintentionally cause small gum injuries during use.

Correct Answers:

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127 :
After the removal of a long leg cast, what care advice should be given to the male client?

Cleanse the leg by scrubbing with a brisk motion

Put leg through full range of motion twice daily

Report any discomfort or stiffness to the physician

Elevate the leg when sitting for long periods of time

Hint : 🪑Consider positioning that reduces swelling while the leg adjusts post-immobilization.

Correct Answers:

No Correct Answers Available !

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128 :
For a client with gout affecting the big toe, which additional area should Nurse Vivian check for urate crystal deposits?

Buttocks

Ears

Face

Abdomen

Hint : 👀Look for crystal buildup in areas where circulation and temperature are relatively lower.

Correct Answers:

No Correct Answers Available !

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129 :
While teaching a client the tripod gait technique with crutches, what indicates correct understanding of weight distribution?

Palms of the hands and axillary regions

Palms of the hand

Axillary regions

Feet, which are set apart

Hint : 💪Focus on a technique that avoids pressure on nerves in the underarm region.

Correct Answers:

No Correct Answers Available !

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130 :
When Mang Jose, who has rheumatoid arthritis, finds relief only when lying still, what nursing intervention during recovery is best encouraged?

Active joint flexion and extension

Continued immobility until pain subsides

Range of motion exercises twice daily

Flexion exercises three times daily

Hint : 🤸Choose an option that preserves movement without causing excessive strain or fatigue.

Correct Answers:

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Ans

1 : A nurse is collecting data on a client who is admitted to the inpatient mental health unit. The client is complaining of sleep disturbances, feelings of helplessness, and a loss of appetite. The nurse recognizes these symptoms to be indicative of

Correct Answers

7 : A client delivered an infant with Dandy- Walker syndrome. The nurse overhears the client tell a friend that the infant is "perfectly fine." The nurse knows that this statement indicates that the client is in which stage of grief?

8 : The nurse on a medical-surgical unit has received a report on a group of clients. Which client should the nurse see first?

9 : The nurse is participating in the care of a client who is diagnosed with post- traumatic stress disorder (PTSD). Which of the following is the most therapeutic and beneficial intervention for a client diagnosed with PTSD?

10 : The nurse is assisting in the plan of care for a client with dissociative amnesia disorder. The nurse plans care for a client with

12 : The nurse is participating in the care of a client who is terminally ill. The client states, "I know I'm going to die today." Which of the following is the best response by the nurse?

14 : The nurse is entering the room of a client on droplet precautions to take the client's blood pressure. The nurse should put on which of the following protective equipment? 1. Gloves 2. Goggles 3. Gown 4. Mask

15 : The nurse is assisting in the delivery of a staff educational program on organ donation. The nurse recognizes additional teaching is needed when a staff member states that which of the following is a contraindication to organ donation?

Correct Answers

19 : The nurse is caring for a client diagnosed with allergic asthma. The client is prescribed an Intal (cromolyn sodium) inhaler. The nurse understands that which of the following is a common side- effect of this medication?

20 : The nurse is participating in the care of a client who is retaining carbon dioxide (CO2) related to respiratory disease. The nurse anticipates that as the client's CO2 level rises, the client's pH level will

21 : The nurse is caring for a client on the evening following abdominal surgery. The client is ordered "diet as tolerated." The nurse recognizes that which of the following is the most appropriate diet for the client?

22 : The nurse is reinforcing teaching with the parents of a child diagnosed with phenylketonuria (PKU) about the prevention of central nervous system damage from toxic levels of phenylalanine. The nurse realizes additional teaching is needed when the parents state that the child will need to avoid

23 : The nurse is participating in the care of a male client with a chest tube. While assisting the client to the bathroom, the chest tube becomes dislodged. The most appropriate initial nursing action when a chest tube is dislodged from the insertion site is

24 : The nurse is caring for a client with heart failure who is on diuretic therapy. Which client finding should the nurse report to the healthcare provider?

25 : The nurse is caring for a client receiving bexatolol hydrochloride (Betoptic) eye drops for glaucoma. The nurse understands that which of the following is a common side effect of this medication?

26 : The nurse is participating in the care of a client diagnosed with a lower urinary tract infection who is being discharged from a medical-surgical unit. The client is prescribed Pyridium (phenazopyridine hydrochloride) for pain relief. The nurse should reinforce which of the following?

27 : The nurse is participating in the care of a client who has just completed an alcohol rehabilitation program. Which of the following statements, if made by the client, indicates an understanding of discharge care?

29 : The nurse is administering medications on a telemetry unit. A client is ordered 5 mg of oral sustained-release nitroglycerin (Nitro-Time). The medication is supplied in 2.5-mg tablets. How many tablets will the nurse administer?

30 : The nurse is assisting the RN with a client admission to the medical unit. The client has several pieces of jewelry, $90 in cash, and an electronic tablet. What is the nurse's responsibility to safeguard the client's valuables?

31 : The nurse is caring for a client who is ordered to undergo a lumbar puncture to rule out meningitis. The nurse is helping the physician position the client for the procedure. Which of the following indicates that the nurse has placed the client in the correct position?

32 : The nurse is observing an LPN providing care for a male client diagnosed with leukemia. Which of the LPN's actions indicates the need for additional teaching when caring for this client?

35 : The nurse is participating in the care of a seven-month-old male child who is being prepared for discharge following a urinary stent procedure to repair a hypospadias. The nurse will reinforce which of the following teaching points to the child's parents?

37 : The nurse is participating in client care-planning for a client with chronic and acute pain. The nurse knows that there are several theories on pain control. Which non-invasive, pain management therapies are associated with the gate control pain theory? Select all that apply.

38 : The nurse is working in a nursing home. The facility has instituted a falls prevention program. Which of the following nursing actions will most likely assure the highest level of fall prevention?

39 : The nurse is reinforcing teaching about sleep habits for a client with insomnia. Which statement would indicate that further teaching is required?

40 : The nurse has just been trained on how to use and care for a blood glucose monitor (glucometer). Which of the following nursing interventions demonstrates the proper use of a glucometer?

42 : The charge nurse is planning the nursing assignments for the upcoming weekly shifts based on the following roster of available practical nurses (PNs).

Answer Options

43 : The nurse working in a pediatric clinic is helping the RN conduct a developmental assessment on a five-month-old child. The nurse determines that the infant may need additional evaluation upon noting that the infant demonstrates which of the following behaviors?

44 : The nurse has just received the client report for her nursing shift. Which of the clients should the nurse see first?

45 : The nurse is assisting a newborn infant and recognizes which of the following should be reported to the physician?

47 : The nurse is caring for a child with an arm board in place to secure IV access. The arm board is taped in position. To provide care for the child, the nurse should do which of the following?

48 : A child with tetralogy of Fallot begins to cry and becomes cyanotic while the nurse is in the room. The nurse should place the child in which position?

49 : The nurse is caring for a client with a diabetic foot ulcer in the acute care setting. The nurse would expect which of the following to be involved in this client's care?

50 : A client who was diagnosed with obstructive sleep apnea is discharged home with a continuous positive airway pressure (CPAP) machine and mask. The nurse will reinforce which information in the discharge teaching about the CPAP device?

51 : Mrs. Chan, a 45-year-old woman, presents to the clinic with complaints of increased thirst, frequent urination, and unexplained weight loss over the past few weeks. She mentions feeling fatigued and occasionally dizzy. Mrs. Chan also reports blurred vision and increased hunger.

Answer Options

53 : The nurse is reviewing the laboratory results of her assigned clients. Which of the following client data should have the highest priority?

57 : The nurse is caring for a client diagnosed with pneumonia. During nursing rounds, the nurse notes the client has a productive cough, chills, and is diaphoretic with a temperature of 102.5°F. Which of the following actions should the nurse include in the care for this client?

58 : The nurse has contributed to a staff development program in advance directives and legal issues. Which statement, made by a staff member, indicates correct understanding of a health-care proxy?

59 : The nurse is caring for a client with hypertension who is ordered the application of a Clonidine (Catapres) transdermal patch. Which of the following actions are contraindicated when applying a transdermal patch?

60 : The LPN is assigned to care for numerous clients on a mental health unit. Which of the following clients requires the nurse's immediate attention?

62 : The nurse is serving on a quality improvement committee that is reviewing the number of code blue events in the hospital for the previous six months with the goal of reducing the number of code blues. What data would the nurse collect to assist with this goal?

63 : The LPN is assisting the RN in the development of a plan of care for a client that had an emergency colostomy. The LPN notices a history of drinking a six pack daily. The plan of care should include assessment for all of the following except

64 : A newly licensed LPN is orienting to a new position in the nursing home setting and asks his preceptor how to decide whether he can perform certain nursing procedures. Which answer by the preceptor is the best response to the LPN's question on legal scope of practice?

65 : The nurse is caring for a client who has suffered a cerebral vascular accident (CVA). The nurse is reinforcing the principles of using a cane. The nurse understands the reason the client should hold the cane on the unaffected side is which of the following?

66 : The nurse observes a health-care provider pick up a client's medical chart and start to review the client's record. The nurse knows that the provider is not a consulting physician on the client's case. What is the nurse's best action in this situation?

68 : The nurse is caring for a client with amyotrophic lateral sclerosis (ALS) whose wife expresses being tired and "run-down" because of the constant care she provides to her husband. What resources could the nurse suggest for the client's wife for the immediate concern?

69 : The nurse is caring for a client who is diagnosed with Parkinson's disease. The client is receiving 500 mg of oral L-Dopa (levodopa) b.i.d. The desired effect of this medication includes which of the following?

71 : Ms. Rosenberg is a 62-year-old female who presents to the emergency department (ED) with severe upper abdominal pain that radiates to her back. She also is experiencing nausea but denies vomiting. She has a history of type 2 diabetes mellitus and hyperlipidemia.

Correct Answers

74 : The nurse is caring for an elderly client who is receiving chemotherapy for the treatment of colon cancer. Which of the following findings predisposes the client to the greatest risk for infection?

75 : The nurse is caring for a client who had a recent cerebral vascular incident and exhibits expressive aphasia. For suggestions on ways to facilitate communication with the client, the nurse should read the notes from which of the following disciplines?

77 : The nurse is assessing the reflexes of a neonate. Which of the findings should the nurse document as abnormal? .

78 : A client who is admitted to the labor and delivery unit has screened positive for group B strep (GBS). The LPN should reinforce with the client the RN's teaching concerning which of the following plans for the client's care?

Answer Options

80 : The nurse is administering to a client whose medications need to be crushed prior to administration. The nurse recognizes that which of the client's medications should not be crushed?

81 : The nurse is reviewing the chart for al client who is scheduled for surgery but has not yet signed a consent form. Which of the following elements must be met for a client to provide informed consent? Select all that apply.

82 : A client with a history of congestive heart failure is admitted with weakness and diarrhea. The client's medication list includes Lasix and Lanoxin. Which lab result would be important for the nurse to monitor?

83 : The LPN is assisting in the RN conducting a community education class on Type II diabetes. The LPN realizes that additional education is needed when a participant identifies which of the following as a risk factor for Type II diabetes?

84 : A client is diagnosed with depression and states that he is "such a failure." The best therapeutic response by the nurse is,

85 : The nurse is participating in the care of a client who had an emergency splenectomy performed. Nursing care for this client will include which of the following?

87 : The LPN is caring for a 16-year-old client requiring the surgical repair of a fractured wrist. The nurse has been asked to have the client's mother sign the operative permit. The nurse's best action is which of the following?

88 : Mrs. Johnson, a 75-year-old patient, is admitted to a long-term care facility. She expresses concern about the nursing staff entering her room without permission and wishes to maintain her privacy. Which action by the nurse best demonstrates adherence to the client's right to privacy?

89 : Which tasks should the LPN assign to the nursing assistant in the nursing home setting? Select all that apply.

Correct Answers

92 : The LPN is assisting the RN completing discharge teaching for a client prescribed a tricyclic antidepressant. The client should be instructed to contact his or her physician prior to taking Allergy medication Cold medications. Fiber additives Stool softeners

Answer Options

95 : A practical nurse is preparing to administer medications to multiple patients. While organizing the medication cart, the nurse notices a vial containing a hazardous medication has a cracked seal. What should the nurse do according to standard handling procedures?

Answer Options

99 : During a routine shift in a healthcare facility, a practical nurse observes a broken access control device near a sensitive patient area. What is the nurse's most appropriate course of action?

Answer Options

102 : The nurse is performing a sterile dressing on a surgical wound to a client' abdomen. Place the steps for opening a sterile package in the correct sequence.

Answer Options

106 : A client has a C-diff infection. When caring for the client, which should the nurse do? Cleanse hands with soap and water. Cleanse hands with hand sanitizer. Follow contact precautions. Follow airborne precautions.

109 : While providing care in a long-term care facility, the practical nurse encounters the death of a resident. What is the priority action for the nurse in postmortem care?

Answer Options

112 : The practical nurse is preparing to administer a dose of 3 mcg/kg of digoxin to a 150-lb. patient. How many micrograms of digoxin should the nurse administer?

1 :
A nurse is collecting data on a client who is admitted to the inpatient mental health unit. The client is complaining of sleep disturbances, feelings of helplessness, and a loss of appetite. The nurse recognizes these symptoms to be indicative of

7 :
A client delivered an infant with Dandy- Walker syndrome. The nurse overhears the client tell a friend that the infant is "perfectly fine." The nurse knows that this statement indicates that the client is in which stage of grief?

8 :
The nurse on a medical-surgical unit has received a report on a group of clients. Which client should the nurse see first?

9 :
The nurse is participating in the care of a client who is diagnosed with post- traumatic stress disorder (PTSD). Which of the following is the most therapeutic and beneficial intervention for a client diagnosed with PTSD?

10 :
The nurse is assisting in the plan of care for a client with dissociative amnesia disorder. The nurse plans care for a client with

12 :
The nurse is participating in the care of a client who is terminally ill. The client states, "I know I'm going to die today." Which of the following is the best response by the nurse?

14 :
The nurse is entering the room of a client on droplet precautions to take the client's blood pressure. The nurse should put on which of the following protective equipment?
1. Gloves
2. Goggles
3. Gown
4. Mask

15 :
The nurse is assisting in the delivery of a staff educational program on organ donation. The nurse recognizes additional teaching is needed when a staff member states that which of the following is a contraindication to organ donation?

19 :
The nurse is caring for a client diagnosed with allergic asthma. The client is prescribed an Intal (cromolyn sodium) inhaler. The nurse understands that which of the following is a common side- effect of this medication?

20 :
The nurse is participating in the care of a client who is retaining carbon dioxide (CO2) related to respiratory disease. The nurse anticipates that as the client's CO2 level rises, the client's pH level will

21 :
The nurse is caring for a client on the evening following abdominal surgery. The client is ordered "diet as tolerated." The nurse recognizes that which of the following is the most appropriate diet for the client?

22 :
The nurse is reinforcing teaching with the parents of a child diagnosed with phenylketonuria (PKU) about the prevention of central nervous system damage from toxic levels of phenylalanine. The nurse realizes additional teaching is needed when the parents state that the child will need to avoid

23 :
The nurse is participating in the care of a male client with a chest tube. While assisting the client to the bathroom, the chest tube becomes dislodged. The most appropriate initial nursing action when a chest tube is dislodged from the insertion site is

24 :
The nurse is caring for a client with heart failure who is on diuretic therapy. Which client finding should the nurse report to the healthcare provider?

25 :
The nurse is caring for a client receiving bexatolol hydrochloride (Betoptic) eye drops for glaucoma. The nurse understands that which of the following is a common side effect of this medication?

26 :
The nurse is participating in the care of a client diagnosed with a lower urinary tract infection who is being discharged from a medical-surgical unit. The client is prescribed Pyridium (phenazopyridine hydrochloride) for pain relief. The nurse should reinforce which of the following?

27 :
The nurse is participating in the care of a client who has just completed an alcohol rehabilitation program. Which of the following statements, if made by the client, indicates an understanding of discharge care?

29 :
The nurse is administering medications on a telemetry unit. A client is ordered 5 mg of oral sustained-release nitroglycerin (Nitro-Time). The medication is supplied in 2.5-mg tablets. How many tablets will the nurse administer?

30 :
The nurse is assisting the RN with a client admission to the medical unit. The client has several pieces of jewelry, $90 in cash, and an electronic tablet. What is the nurse's responsibility to safeguard the client's valuables?

31 :
The nurse is caring for a client who is ordered to undergo a lumbar puncture to rule out meningitis. The nurse is helping the physician position the client for the procedure. Which of the following indicates that the nurse has placed the client in the correct position?

32 :
The nurse is observing an LPN providing care for a male client diagnosed with leukemia. Which of the LPN's actions indicates the need for additional teaching when caring for this client?

35 :
The nurse is participating in the care of a seven-month-old male child who is being prepared for discharge following a urinary stent procedure to repair a hypospadias. The nurse will reinforce which of the following teaching points to the child's parents?

37 :
The nurse is participating in client care-planning for a client with chronic and acute pain. The nurse knows that there are several theories on pain control. Which non-invasive, pain management therapies are associated with the gate control pain theory? Select all that apply.

38 :
The nurse is working in a nursing home. The facility has instituted a falls prevention program. Which of the following nursing actions will most likely assure the highest level of fall prevention?

39 :
The nurse is reinforcing teaching about sleep habits for a client with insomnia. Which statement would indicate that further teaching is required?

40 :
The nurse has just been trained on how to use and care for a blood glucose monitor (glucometer). Which of the following nursing interventions demonstrates the proper use of a glucometer?

42 :
The charge nurse is planning the nursing assignments for the upcoming weekly shifts based on the following roster of available practical nurses (PNs).

43 :
The nurse working in a pediatric clinic is helping the RN conduct a developmental assessment on a five-month-old child. The nurse determines that the infant may need additional evaluation upon noting that the infant demonstrates which of the following behaviors?

44 :
The nurse has just received the client report for her nursing shift. Which of the clients should the nurse see first?

45 :
The nurse is assisting a newborn infant and recognizes which of the following should be reported to the physician?

47 :
The nurse is caring for a child with an arm board in place to secure IV access. The arm board is taped in position. To provide care for the child, the nurse should do which of the following?

48 :
A child with tetralogy of Fallot begins to cry and becomes cyanotic while the nurse is in the room. The nurse should place the child in which position?

49 :
The nurse is caring for a client with a diabetic foot ulcer in the acute care setting. The nurse would expect which of the following to be involved in this client's care?

50 :
A client who was diagnosed with obstructive sleep apnea is discharged home with a continuous positive airway pressure (CPAP) machine and mask. The nurse will reinforce which information in the discharge teaching about the CPAP device?

51 :
Mrs. Chan, a 45-year-old woman, presents to the clinic with complaints of increased thirst, frequent urination, and unexplained weight loss over the past few weeks. She mentions feeling fatigued and occasionally dizzy. Mrs. Chan also reports blurred vision and increased hunger.

53 :
The nurse is reviewing the laboratory results of her assigned clients. Which of the following client data should have the highest priority?

57 :
The nurse is caring for a client diagnosed with pneumonia. During nursing rounds, the nurse notes the client has a productive cough, chills, and is diaphoretic with a temperature of 102.5°F. Which of the following actions should the nurse include in the care for this client?

58 :
The nurse has contributed to a staff development program in advance directives and legal issues. Which statement, made by a staff member, indicates correct understanding of a health-care proxy?

59 :
The nurse is caring for a client with hypertension who is ordered the application of a Clonidine (Catapres) transdermal patch. Which of the following actions are contraindicated when applying a transdermal patch?

60 :
The LPN is assigned to care for numerous clients on a mental health unit. Which of the following clients requires the nurse's immediate attention?

62 :
The nurse is serving on a quality improvement committee that is reviewing the number of code blue events in the hospital for the previous six months with the goal of reducing the number of code blues. What data would the nurse collect to assist with this goal?

63 :
The LPN is assisting the RN in the development of a plan of care for a client that had an emergency colostomy. The LPN notices a history of drinking a six pack daily. The plan of care should include assessment for all of the following except

64 :
A newly licensed LPN is orienting to a new position in the nursing home setting and asks his preceptor how to decide whether he can perform certain nursing procedures. Which answer by the preceptor is the best response to the LPN's question on legal scope of practice?

65 :
The nurse is caring for a client who has suffered a cerebral vascular accident (CVA). The nurse is reinforcing the principles of using a cane. The nurse understands the reason the client should hold the cane on the unaffected side is which of the following?

66 :
The nurse observes a health-care provider pick up a client's medical chart and start to review the client's record. The nurse knows that the provider is not a consulting physician on the client's case. What is the nurse's best action in this situation?

68 :
The nurse is caring for a client with amyotrophic lateral sclerosis (ALS) whose wife expresses being tired and "run-down" because of the constant care she provides to her husband. What resources could the nurse suggest for the client's wife for the immediate concern?

69 :
The nurse is caring for a client who is diagnosed with Parkinson's disease. The client is receiving 500 mg of oral L-Dopa (levodopa) b.i.d. The desired effect of this medication includes which of the following?

71 :
Ms. Rosenberg is a 62-year-old female who presents to the emergency department (ED) with severe upper abdominal pain that radiates to her back. She also is experiencing nausea but denies vomiting. She has a history of type 2 diabetes mellitus and hyperlipidemia.

74 :
The nurse is caring for an elderly client who is receiving chemotherapy for the treatment of colon cancer. Which of the following findings predisposes the client to the greatest risk for infection?

75 :
The nurse is caring for a client who had a recent cerebral vascular incident and exhibits expressive aphasia. For suggestions on ways to facilitate communication with the client, the nurse should read the notes from which of the following disciplines?

77 :
The nurse is assessing the reflexes of a neonate. Which of the findings should the nurse document as abnormal? .

78 :
A client who is admitted to the labor and delivery unit has screened positive for group B strep (GBS). The LPN should reinforce with the client the RN's teaching concerning which of the following plans for the client's care?

80 :
The nurse is administering to a client whose medications need to be crushed prior to administration. The nurse recognizes that which of the client's medications should not be crushed?

81 :
The nurse is reviewing the chart for al client who is scheduled for surgery but has not yet signed a consent form. Which of the following elements must be met for a client to provide informed consent? Select all that apply.

82 :
A client with a history of congestive heart failure is admitted with weakness and diarrhea. The client's medication list includes Lasix and Lanoxin. Which lab result would be important for the nurse to monitor?

83 :
The LPN is assisting in the RN conducting a community education class on Type II diabetes. The LPN realizes that additional education is needed when a participant identifies which of the following as a risk factor for Type II diabetes?

84 :
A client is diagnosed with depression and states that he is "such a failure." The best therapeutic response by the nurse is,

85 :
The nurse is participating in the care of a client who had an emergency splenectomy performed. Nursing care for this client will include which of the following?

87 :
The LPN is caring for a 16-year-old client requiring the surgical repair of a fractured wrist. The nurse has been asked to have the client's mother sign the operative permit. The nurse's best action is which of the following?

88 :
Mrs. Johnson, a 75-year-old patient, is admitted to a long-term care facility. She expresses concern about the nursing staff entering her room without permission and wishes to maintain her privacy. Which action by the nurse best demonstrates adherence to the client's right to privacy?

89 :
Which tasks should the LPN assign to the nursing assistant in the nursing home setting? Select all that apply.

92 :
The LPN is assisting the RN completing discharge teaching for a client prescribed a tricyclic antidepressant. The client should be instructed to contact his or her physician prior to taking
Allergy medication
Cold medications.
Fiber additives
Stool softeners

95 :
A practical nurse is preparing to administer medications to multiple patients. While organizing the medication cart, the nurse notices a vial containing a hazardous medication has a cracked seal. What should the nurse do according to standard handling procedures?

99 :
During a routine shift in a healthcare facility, a practical nurse observes a broken access control device near a sensitive patient area. What is the nurse's most appropriate course of action?

102 :
The nurse is performing a sterile dressing on a surgical wound to a client' abdomen. Place the steps for opening a sterile package in the correct sequence.

106 :
A client has a C-diff infection. When caring for the client, which should the nurse do?
Cleanse hands with soap and water.
Cleanse hands with hand sanitizer.
Follow contact precautions.
Follow airborne precautions.

109 :
While providing care in a long-term care facility, the practical nurse encounters the death of a resident. What is the priority action for the nurse in postmortem care?

112 :
The practical nurse is preparing to administer a dose of 3 mcg/kg of digoxin to a 150-lb. patient. How many micrograms of digoxin should the nurse administer?

113 :
Use the following to answer questions 128. Mrs. Lee was admitted to the medical-surgical unit with complaints of weakness and lethargy. She has a history of hypertension and diabetes mellitus. Mrs. Lee reports nausea and a poor appetite.

114 :
The nurse is caring for a client with MRSA in his wound. Prior to entering the room to perform the dressing change, the nurse should do which of the following?
Wash hands
Put on a gown
Put on gloves
Put on a mask

116 :
The nurse is caring for a client with hypertension. On the illustration below, identify the area where the nurse will place the stethoscope to best auscultate the pulmonic valve.

117 :
The nurse needs to assess and palpate a client's dorsalis pedis pulse. Identify the area where the nurse places her fingers to palpate the pedal pulse.

118 :
The nurse is caring for a client with a cystostomy for urine drainage. Identify the area on the following image where the nurse should check for cystostomy placement.

120 :
A nurse is assisting with the care of a client in an orthopedic unit.

121 :
A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7-month-old infant who is febrile. Available is ibuprofen 50 mg/1.25 mL. How many should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

122 :
Following a left nephrectomy, which concern should be Nurse Liza’s primary focus when monitoring the client back on the unit?

123 :
In preparing a 64-year-old man with hypertension and angina for a cardiac catheterization, what key purpose should Nurse Cherry emphasize during teaching?

124 :
During the initial hours after a client’s cardiac catheterization, which nursing intervention should take the highest priority?

125 :
After mitral valve replacement, if a client starts to bleed persistently from the surgical site, which medication should Nurse Aiza get ready to administer?

126 :
In a teaching plan for a client with endocarditis, which dental tool should be discouraged to prevent risk of infection?