Safe and Effective Care Environment in the NCLEX-RN exam evaluates a nurse’s ability to ensure a secure and therapeutic environment for clients, staff, and visitors. This includes managing client care by coordinating and delegating tasks effectively, advocating for clients, and ensuring continuity of care through proper communication and documentation. It also encompasses safety and infection control measures, such as preventing and controlling infections, identifying and mitigating potential hazards, and ensuring the safe use of equipment and technology. Overall, this category emphasizes the importance of maintaining a safe, efficient, and effective care environment to promote health and safety.
The NCLEX-RN (National Council Licensure Examination for Registered Nurses) is a standardized exam that determines whether a candidate is prepared for entry-level nursing practice. It is required for obtaining an RN (Registered Nurse) license in the United States, Canada, and Australia.
Exam Format:
- Computerized Adaptive Testing (CAT): The difficulty of questions adjusts based on your responses.
- Question Range: 85 to 150 questions, including 15 unscored pretest questions.
- Time Limit: 5 hours (including breaks).
Question Types:
- Multiple-choice
- Select all that apply (SATA)
- Fill-in-the-blank
- Drag-and-drop
- Hot spot (image-based)
Test Plan & Content Areas:
The NCLEX-RN follows the NCSBN test plan, which covers:
1. Safe and Effective Care Environment
- Management of Care (17-23%)
- Safety and Infection Control (9-15%)
2. Health Promotion and Maintenance (6-12%)
3. Psychosocial Integrity (6-12%)
4. Physiological Integrity
- Basic Care and Comfort (6-12%)
- Pharmacological and Parenteral Therapies (13-19%)
- Reduction of Risk Potential (9-15%)
- Physiological Adaptation (11-17%)
Passing Standard:
- Uses a logit scoring system (a statistical measurement of ability).
- The test ends when the system is 95% confident that your ability is above or below the passing standard.
Eligibility & Registration:
- Apply through your state board of nursing (BON).
- Register with Pearson VUE and pay the exam fee ($200 in the U.S.).
Scoring & Results:
- Results are not immediate but can be accessed via your BON in a few days.
- Some states offer a quick results service (unofficial results in 48 hours).
- If you fail, you receive a Candidate Performance Report (CPR) to guide your next attempt.
Safe and Effective Care Environment
- Question: A nurse is caring for a client who is scheduled for surgery. Which of the following is the primary responsibility of the nurse in the preoperative phase?
- A. Obtain the client’s consent for surgery
- B. Ensure the client is fasting
- C. Administer preoperative medications
- D. Provide emotional support to the client
Answer 1: A. Obtain the client’s consent for surgery Explanation: The primary responsibility of the nurse in the preoperative phase is to ensure that the client has given informed consent for the surgery. This involves confirming that the client understands the procedure, its risks, benefits, and alternatives.
- Question: When implementing standard precautions, the nurse should do which of the following?
- A. Wear gloves when touching blood or body fluids
- B. Wear a mask and eye protection during all client care
- C. Place all clients in private rooms
- D. Use sterile gloves for all client contact
Answer: A. Wear gloves when touching blood or body fluids Explanation: Standard precautions involve wearing gloves to protect against contact with blood, body fluids, non-intact skin, and mucous membranes. Mask and eye protection are used when splashes or sprays are anticipated, but not for all client care.
- Question: A nurse is reviewing the medication orders for a newly admitted client. Which of the following actions demonstrates the nurse’s understanding of safe medication administration?
- A. Administering medications as soon as they are prescribed
- B. Verifying the client’s allergies before administration
- C. Preparing medications in a busy area to save time
- D. Delegating medication administration to unlicensed assistive personnel
Answer: B. Verifying the client’s allergies before administration Explanation: Verifying the client’s allergies is a critical step in safe medication administration to prevent allergic reactions. Medications should be prepared in a quiet, distraction-free area and only licensed personnel should administer them.
- Question: Which of the following is an appropriate method for a nurse to handle sharps?
- A. Recapping needles before disposal
- B. Placing sharps in a puncture-resistant container
- C. Bending needles before disposal
- D. Disposing of sharps in regular trash bins
Answer: B. Placing sharps in a puncture-resistant container Explanation: Sharps should be placed in a designated puncture-resistant container to prevent needle-stick injuries. Needles should never be recapped, bent, or disposed of in regular trash bins.
- Question: In the event of a fire, what is the nurse’s first priority?
- A. Extinguish the fire
- B. Rescue clients in immediate danger
- C. Activate the fire alarm
- D. Close all doors and windows
Answer: B. Rescue clients in immediate danger Explanation: The first priority in the event of a fire is to rescue clients who are in immediate danger. After ensuring their safety, the nurse should activate the fire alarm and follow the institution’s fire protocols.
- Question: A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which of the following tasks can the nurse delegate?
- A. Administering oral medications
- B. Performing a sterile dressing change
- C. Assisting a client with ambulation
- D. Conducting a client assessment
Answer: C. Assisting a client with ambulation Explanation: The nurse can delegate tasks that do not require professional nursing judgment, such as assisting a client with ambulation. Administering medications, performing sterile procedures, and conducting assessments should be done by licensed personnel.
- Question: A nurse is reviewing a client’s lab results. Which lab value requires immediate intervention?
- A. Sodium 138 mEq/L
- B. Hemoglobin 10 g/dL
- C. Potassium 6.0 mEq/L
- D. White blood cell count 8,000/mm³
Answer: C. Potassium 6.0 mEq/L Explanation: A potassium level of 6.0 mEq/L is above the normal range and requires immediate intervention due to the risk of life-threatening cardiac arrhythmias.
- Question: What is the purpose of conducting a “time-out” before a surgical procedure?
- A. To allow the surgical team to take a break
- B. To verify the client’s identity, surgical site, and procedure
- C. To confirm the availability of necessary surgical equipment
- D. To obtain final consent from the client
Answer: B. To verify the client’s identity, surgical site, and procedure Explanation: A “time-out” is a safety protocol performed immediately before the surgical procedure to ensure the correct client, surgical site, and procedure. This helps prevent surgical errors.
- Question: Which of the following actions should a nurse take to prevent falls in hospitalized clients?
- A. Keep the bed in the highest position
- B. Provide non-slip footwear
- C. Place all clients on bed rest
- D. Remove call bells from the bedside
Answer: B. Provide non-slip footwear Explanation: Providing non-slip footwear helps prevent falls by ensuring clients have better traction when walking. The bed should be kept in the lowest position, call bells should be within reach, and not all clients need to be on bed rest.
- Question: A nurse is planning care for a client who has a communicable disease. Which of the following precautions should the nurse implement?
- A. Use personal protective equipment (PPE)
- B. Place the client in an open ward
- C. Restrict visitors and healthcare staff
- D. Encourage the client to share personal items
Answer: A. Use personal protective equipment (PPE) Explanation: Implementing appropriate personal protective equipment (PPE) such as gloves, gowns, masks, and eye protection helps prevent the transmission of communicable diseases. Clients should not share personal items, and isolation measures should be followed as necessary.
- Question: A nurse is preparing to administer a blood transfusion. Which of the following actions is essential to prevent a transfusion reaction?
- A. Checking the client’s vital signs every 30 minutes
- B. Using a 22-gauge IV catheter
- C. Matching the blood type and Rh factor with the client
- D. Administering the transfusion over 1 hour
Answer: C. Matching the blood type and Rh factor with the client Explanation: To prevent a transfusion reaction, it is crucial to ensure that the blood type and Rh factor are compatible with the client’s blood.
- Question: Which of the following tasks can be safely delegated by a nurse to unlicensed assistive personnel (UAP)?
- A. Inserting a Foley catheter
- B. Performing a sterile dressing change
- C. Feeding a client who requires assistance
- D. Administering insulin
Answer: C. Feeding a client who requires assistance Explanation: UAP can assist with feeding clients who require help, but invasive procedures and medication administration should be performed by licensed nurses.
- Question: What is the nurse’s primary role in maintaining client confidentiality?
- A. Sharing client information with all healthcare team members
- B. Disposing of client documents in regular trash bins
- C. Discussing client information only with those directly involved in their care
- D. Storing client records in an unsecured area
Answer: C. Discussing client information only with those directly involved in their care Explanation: Maintaining client confidentiality involves sharing information only with healthcare team members who are directly involved in the client’s care.
- Question: A nurse is assessing a client with a history of falls. Which of the following interventions should be included in the client’s care plan to prevent falls?
- A. Placing a “Do Not Disturb” sign on the door
- B. Keeping the bed in the lowest position
- C. Encouraging the client to use the bathroom independently
- D. Removing mobility aids from the client’s room
Answer: B. Keeping the bed in the lowest position Explanation: Keeping the bed in the lowest position helps reduce the risk of injury if the client falls out of bed.
- Question: Which of the following is a priority nursing action when a client has a seizure?
- A. Restraining the client’s movements
- B. Placing a tongue blade in the client’s mouth
- C. Turning the client to the side
- D. Administering anti-seizure medication
Answer: C. Turning the client to the side Explanation: Turning the client to the side helps maintain an open airway and prevents aspiration during a seizure.
- Question: When should a nurse perform hand hygiene during client care?
- A. Before and after direct contact with the client
- B. Only if the hands are visibly soiled
- C. At the beginning and end of each shift
- D. After administering medications
Answer: A. Before and after direct contact with the client Explanation: Hand hygiene should be performed before and after direct contact with the client to prevent the spread of infection.
- Question: A nurse is providing discharge teaching to a client with a new colostomy. Which instruction should the nurse include?
- A. Change the colostomy bag once a week
- B. Clean the stoma with hydrogen peroxide
- C. Avoid high-fiber foods
- D. Report any changes in stoma color to the healthcare provider
Answer: D. Report any changes in stoma color to the healthcare provider Explanation: Changes in stoma color can indicate compromised blood flow and should be reported to the healthcare provider immediately.
- Question: Which of the following is an essential component of a nurse’s role in preventing pressure ulcers?
- A. Encouraging the client to stay in bed
- B. Repositioning the client every 2 hours
- C. Using heat lamps on pressure points
- D. Applying alcohol-based lotions to the skin
Answer: B. Repositioning the client every 2 hours Explanation: Regular repositioning helps prevent prolonged pressure on any one area, which can reduce the risk of pressure ulcers.
- Question: A nurse is preparing to discharge a client who is at risk for falls. Which of the following should be included in the discharge instructions?
- A. Remove scatter rugs from the home
- B. Limit fluid intake to avoid frequent trips to the bathroom
- C. Use dim lighting at night
- D. Wear loose-fitting slippers
Answer: A. Remove scatter rugs from the home Explanation: Removing scatter rugs helps prevent tripping and falling at home.
- Question: What is the purpose of using a “two-identifier” system when providing client care?
- A. To ensure that the client is alert and oriented
- B. To verify the client’s identity and match the correct care or treatment
- C. To confirm the client’s insurance information
- D. To determine the client’s dietary preferences
Answer: B. To verify the client’s identity and match the correct care or treatment Explanation: The “two-identifier” system helps ensure that the correct client receives the correct care or treatment, reducing the risk of errors.
- Question: Which of the following actions should the nurse take to ensure a safe environment for a client with visual impairment?
- A. Keep the room dimly lit
- B. Arrange furniture to create a clear path
- C. Encourage the client to use touch as a primary sense
- D. Keep the client’s door closed
Answer: B. Arrange furniture to create a clear path Explanation: Arranging furniture to create a clear path helps prevent falls and injuries for clients with visual impairments.
- Question: When administering a continuous intravenous (IV) infusion, which of the following is a priority nursing action?
- A. Checking the IV site for signs of infiltration
- B. Changing the IV tubing daily
- C. Increasing the infusion rate to prevent dehydration
- D. Administering IV medications through the same line
Answer: A. Checking the IV site for signs of infiltration Explanation: Monitoring the IV site for signs of infiltration or complications is essential to prevent injury and ensure the medication or fluids are being administered correctly.
- Question: Which of the following is the nurse’s responsibility when caring for a client in restraints?
- A. Tying the restraints to the bed rails
- B. Checking the client’s circulation every 30 minutes
- C. Releasing the restraints every 4 hours
- D. Using restraints as a first-line intervention
Answer: B. Checking the client’s circulation every 30 minutes Explanation: Regularly checking the client’s circulation helps prevent complications related to the use of restraints.
- Question: A nurse is caring for a client with a central venous catheter (CVC). Which of the following actions should the nurse take to prevent infection?
- A. Change the CVC dressing every 7 days
- B. Flush the CVC with saline every 12 hours
- C. Use sterile technique when accessing the CVC
- D. Apply an antibiotic ointment to the CVC site
Answer: C. Use sterile technique when accessing the CVC Explanation: Using sterile technique helps prevent infection at the CVC site.
- Question: When transporting a client on a stretcher, which of the following is the nurse’s primary responsibility?
- A. Moving as quickly as possible
- B. Ensuring the client’s safety during transport
- C. Positioning the client supine
- D. Providing the client with a call bell
Answer: B. Ensuring the client’s safety during transport Explanation: The nurse’s primary responsibility is to ensure the client’s safety during transport, which may involve securing the client, using side rails, and moving at a safe pace.
- Question: A nurse is providing care for a client with an airborne infection. Which of the following precautions should be implemented?
- A. Wearing a surgical mask when entering the room
- B. Using a negative pressure room
- C. Placing the client in a private room with standard ventilation
- D. Allowing the client to leave the room without a mask
Answer: B. Using a negative pressure room Explanation: A negative pressure room helps contain airborne pathogens and prevent them from spreading to other areas.
- Question: Which of the following actions demonstrates a nurse’s understanding of proper body mechanics?
- A. Bending at the waist to lift heavy objects
- B. Keeping the feet close together when lifting
- C. Using the leg muscles to lift objects
- D. Twisting the body while lifting
Answer: C. Using the leg muscles to lift objects Explanation: Using the leg muscles, rather than the back, helps prevent injury and demonstrates proper body mechanics.
- Question: What is the primary purpose of a nurse conducting an initial assessment upon a client’s admission?
- A. To determine the client’s insurance coverage
- B. To establish a baseline for care planning
- C. To verify the client’s identity
- D. To schedule follow-up appointments
Answer: B. To establish a baseline for care planning Explanation: Conducting an initial assessment helps the nurse establish a baseline for creating an individualized care plan tailored to the client’s needs.
- Question: When caring for a client with a latex allergy, which of the following interventions should the nurse implement?
- A. Using latex gloves for all procedures
- B. Keeping the client’s room well-ventilated
- C. Placing a sign on the door indicating a latex allergy
- D. Administering antihistamines prophylactically
Answer: C. Placing a sign on the door indicating a latex allergy Explanation: Placing a sign on the door alerts all healthcare personnel to the client’s latex allergy, ensuring that latex-free products are used to prevent an allergic reaction.
- Question: A nurse is preparing to transfer a client from the bed to a wheelchair. Which of the following actions should the nurse take to ensure the client’s safety?
- A. Locking the wheels of the wheelchair
- B. Using a draw sheet to move the client
- C. Placing the wheelchair on the opposite side of the bed
- D. Lowering the bed to the lowest position
Answer: A. Locking the wheels of the wheelchair Explanation: Locking the wheels of the wheelchair ensures it remains stationary during the transfer, preventing falls and injuries.
- Question: Which of the following is a critical step in preventing the spread of healthcare-associated infections (HAIs)?
- A. Wearing personal protective equipment (PPE) at all times
- B. Isolating all clients in private rooms
- C. Performing hand hygiene consistently
- D. Using antimicrobial soap for all handwashing
Answer: C. Performing hand hygiene consistently Explanation: Consistent hand hygiene is one of the most effective ways to prevent the spread of healthcare-associated infections.
- Question: A nurse is caring for a client with a documented DNR (Do Not Resuscitate) order. Which of the following actions should the nurse take if the client experiences cardiac arrest?
- A. Begin chest compressions immediately
- B. Administer emergency medications
- C. Respect the DNR order and provide comfort measures
- D. Call for a code blue and notify the healthcare provider
Answer: C. Respect the DNR order and provide comfort measures Explanation: The nurse must respect the client’s DNR order and provide comfort measures rather than initiating resuscitation efforts.
- Question: A nurse is assessing a client’s readiness for discharge. Which of the following criteria indicates that the client is ready for discharge?
- A. The client’s vital signs are unstable
- B. The client’s family is not available to assist at home
- C. The client understands the discharge instructions
- D. The client has unresolved pain
Answer: C. The client understands the discharge instructions Explanation: Understanding discharge instructions is crucial for the client’s continued care and recovery at home.
- Question: In the event of a hazardous material spill, which of the following is the nurse’s priority action?
- A. Evacuate the area
- B. Contain the spill
- C. Notify the hazardous materials team
- D. Clean up the spill immediately
Answer: A. Evacuate the area Explanation: The nurse’s priority is to evacuate the area to ensure the safety of clients and staff before containing the spill or notifying the hazardous materials team.
- Question: Which of the following is a key component of a nurse’s role in promoting medication safety?
- A. Administering medications without checking the MAR (Medication Administration Record)
- B. Educating clients about their medications
- C. Delegating medication administration to UAP
- D. Preparing all medications at the beginning of the shift
Answer: B. Educating clients about their medications Explanation: Educating clients about their medications helps ensure they understand the purpose, dosage, and potential side effects, promoting safe medication use.
- Question: A nurse is preparing to administer an intramuscular (IM) injection. Which of the following actions should the nurse take to ensure safe administration?
- A. Use a needle with a small gauge
- B. Inject into the same site repeatedly
- C. Aspirate for blood before injecting the medication
- D. Massage the injection site immediately after
Answer: C. Aspirate for blood before injecting the medication Explanation: Aspirating for blood ensures that the needle is not in a blood vessel, which is essential for safe intramuscular injection.
- Question: When caring for a client with a respiratory infection, which of the following precautions should the nurse implement?
- A. Wearing a surgical mask
- B. Placing the client in contact isolation
- C. Using sterile technique for all procedures
- D. Wearing gloves only for direct client contact
Answer: A. Wearing a surgical mask Explanation: Wearing a surgical mask helps prevent the spread of respiratory infections through airborne droplets.
- Question: Which of the following actions should a nurse take to prevent medication errors?
- A. Double-checking the medication label and the client’s MAR
- B. Administering medications prepared by another nurse
- C. Preparing medications in a busy, high-traffic area
- D. Relying on memory to determine medication dosages
Answer: A. Double-checking the medication label and the client’s MAR Explanation: Double-checking the medication label and the client’s MAR helps ensure the correct medication is administered to the correct client.
- Question: A nurse is providing education to a client with diabetes about insulin administration. Which of the following instructions should the nurse include?
- A. Rotate injection sites
- B. Store insulin at room temperature
- C. Administer insulin only when hyperglycemia occurs
- D. Use the same needle for multiple injections
Answer: A. Rotate injection sites Explanation: Rotating injection sites helps prevent lipodystrophy and ensures consistent insulin absorption.
- Question: Which of the following is an appropriate method for verifying a client’s identity before administering medication?
- A. Asking the client’s name
- B. Checking the client’s room number
- C. Using the client’s medical record number and date of birth
- D. Verifying the client’s diagnosis
Answer: C. Using the client’s medical record number and date of birth Explanation: Using two identifiers, such as the client’s medical record number and date of birth, helps ensure accurate client identification.
- Question: A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to reduce the risk of catheter-associated urinary tract infections (CAUTIs)?
- A. Irrigate the catheter daily
- B. Keep the drainage bag above the level of the bladder
- C. Perform perineal care regularly
- D. Use clean technique for catheter insertion
Answer: C. Perform perineal care regularly Explanation: Regular perineal care helps reduce the risk of infection by maintaining cleanliness around the catheter insertion site.
- Question: Which of the following interventions should a nurse include in the care plan for a client at risk for aspiration?
- A. Encourage the client to drink fluids quickly
- B. Position the client in a supine position during meals
- C. Monitor the client while eating
- D. Administer thickened liquids only
Answer: C. Monitor the client while eating Explanation: Monitoring the client while eating helps identify and prevent aspiration risks.
- Question: A nurse is caring for a client who requires isolation precautions. Which of the following actions should the nurse take to ensure compliance with isolation protocols?
- A. Remove the isolation sign from the client’s door
- B. Explain the purpose of isolation to the client and family
- C. Wear gloves only when providing direct client care
- D. Allow visitors without protective equipment
Answer: B. Explain the purpose of isolation to the client and family Explanation: Educating the client and family about the purpose of isolation helps ensure understanding and compliance with isolation protocols.
- Question: When providing postoperative care for a client, which of the following is a priority nursing action?
- A. Encouraging the client to ambulate immediately
- B. Monitoring for signs of infection
- C. Administering pain medications every 4 hours
- D. Limiting fluid intake
Answer: B. Monitoring for signs of infection Explanation: Monitoring for signs of infection is a priority in postoperative care to identify and address complications early.
- Question: Which of the following actions should a nurse take when administering medications through a nasogastric (NG) tube?
- A. Mixing all medications together
- B. Flushing the NG tube with water before and after medication administration
- C. Administering medications in large volumes
- D. Using warm water to dissolve medications
Answer: B. Flushing the NG tube with water before and after medication administration Explanation: Flushing the NG tube before and after medication administration helps ensure that the tube remains patent and that all medication is delivered to the stomach.
- Question: When providing care to a client with a chest tube, which of the following actions should the nurse take?
- A. Clamping the chest tube during transport
- B. Keeping the drainage system below the level of the chest
- C. Emptying the drainage collection chamber every 4 hours
- D. Removing the chest tube after 48 hours
Answer: B. Keeping the drainage system below the level of the chest Explanation: Keeping the drainage system below the level of the chest ensures proper drainage and prevents backflow of fluid into the pleural space.
- Question: Which of the following interventions should a nurse implement to prevent ventilator-associated pneumonia (VAP)?
- A. Administering prophylactic antibiotics
- B. Elevating the head of the bed to 30-45 degrees
- C. Using sterile gloves for all client contact
- D. Performing deep suctioning every hour
Answer: B. Elevating the head of the bed to 30-45 degrees Explanation: Elevating the head of the bed helps prevent aspiration and reduces the risk of ventilator-associated pneumonia.
- Question: A nurse is caring for a client with an IV infusion. Which of the following actions should the nurse take to prevent phlebitis?
- A. Applying ice packs to the IV site
- B. Rotating the IV site every 72 hours
- C. Flushing the IV line with heparin
- D. Using a large-gauge needle for infusion
Answer: B. Rotating the IV site every 72 hours Explanation: Rotating the IV site every 72 hours helps reduce the risk of phlebitis by preventing prolonged irritation of the vein at a single site.
- Question: What is the primary purpose of a nurse conducting a home safety assessment for a client?
- A. To evaluate the client’s financial resources
- B. To identify potential hazards in the home environment
- C. To assess the client’s social support network
- D. To determine the client’s ability to perform self-care
Answer: B. To identify potential hazards in the home environment Explanation: Conducting a home safety assessment helps the nurse identify and address potential hazards in the home environment, reducing the risk of injury for the client.
- Question: A nurse is preparing to administer an intravenous (IV) medication. Which of the following is a critical step in ensuring safe administration?
- A. Preparing the medication at the client’s bedside
- B. Verifying the medication order with another nurse
- C. Administering the medication through an infusion pump
- D. Using clean technique for IV insertion
Answer: B. Verifying the medication order with another nurse Explanation: Verifying the medication order with another nurse is a critical step in ensuring that the correct medication, dose, and route are administered to the correct client.
- Question: A nurse is preparing a sterile field for a dressing change. Which of the following actions is essential to maintain sterility?
- A. Opening the sterile package with clean gloves
- B. Keeping the sterile field at waist level
- C. Placing sterile items on the edge of the sterile field
- D. Using sterile technique only for dressing application
Answer: B. Keeping the sterile field at waist level Explanation: Keeping the sterile field at waist level helps maintain sterility by preventing contamination from lower surfaces.
- Question: When caring for a client with a nasogastric (NG) tube, which of the following actions should the nurse take to ensure proper tube placement?
- A. Checking the pH of gastric aspirate
- B. Measuring the length of the tube
- C. Flushing the tube with 20 mL of water
- D. Administering feedings without verification
Answer: A. Checking the pH of gastric aspirate Explanation: Checking the pH of gastric aspirate helps verify that the NG tube is correctly placed in the stomach.
- Question: A nurse is providing education to a client about preventing urinary tract infections (UTIs). Which of the following instructions should the nurse include?
- A. Wipe from back to front after using the toilet
- B. Drink at least 8-10 glasses of water a day
- C. Avoid urinating before and after sexual activity
- D. Use scented hygiene products
Answer: B. Drink at least 8-10 glasses of water a day Explanation: Drinking plenty of water helps flush out bacteria from the urinary tract, reducing the risk of UTIs.
- Question: When documenting in a client’s medical record, which of the following practices ensures accuracy and completeness?
- A. Using correction fluid for errors
- B. Documenting care immediately after providing it
- C. Leaving blank spaces between entries
- D. Using abbreviations not approved by the facility
Answer: B. Documenting care immediately after providing it Explanation: Documenting care immediately after providing it ensures that the information is accurate and up-to-date.
- Question: A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?
- A. Wearing gloves only
- B. Placing the client in a room with negative air pressure
- C. Using a mask and eye protection for all interactions
- D. Donning a gown and gloves before entering the room
Answer: D. Donning a gown and gloves before entering the room Explanation: Wearing a gown and gloves before entering the room helps prevent the spread of infections through contact.
- Question: A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which of the following assessments is a priority?
- A. Monitoring for signs of infection at the IV site
- B. Checking the client’s blood glucose levels
- C. Evaluating the client’s appetite
- D. Measuring the client’s urine output
Answer: B. Checking the client’s blood glucose levels Explanation: Monitoring blood glucose levels is essential because TPN can cause hyperglycemia.
- Question: Which of the following interventions should a nurse implement to promote effective communication with a client who has hearing impairment?
- A. Speaking loudly and slowly
- B. Using gestures and visual aids
- C. Turning away while speaking
- D. Providing written information only
Answer: B. Using gestures and visual aids Explanation: Using gestures and visual aids enhances communication by providing visual cues that can help the client understand the information.
- Question: A nurse is caring for a client with a history of substance abuse. Which of the following actions demonstrates the nurse’s commitment to providing nonjudgmental care?
- A. Avoiding discussions about the client’s substance use
- B. Using therapeutic communication to discuss the client’s substance use
- C. Assigning the client to a different nurse
- D. Documenting the client’s substance use as irrelevant
Answer: B. Using therapeutic communication to discuss the client’s substance use Explanation: Using therapeutic communication helps the nurse address the client’s substance use in a nonjudgmental and supportive manner.
- Question: When providing postoperative care for a client with a surgical wound, which of the following interventions is essential for preventing infection?
- A. Keeping the wound covered with a dry dressing
- B. Changing the dressing using clean technique
- C. Applying heat to the wound site
- D. Administering prophylactic antibiotics
Answer: B. Changing the dressing using clean technique Explanation: Using clean technique helps prevent contamination and infection of the surgical wound.
- Question: A nurse is caring for a client with a tracheostomy. Which of the following actions is essential for maintaining a patent airway?
- A. Administering humidified oxygen
- B. Suctioning the tracheostomy as needed
- C. Changing the tracheostomy ties daily
- D. Applying an occlusive dressing around the tracheostomy
Answer: B. Suctioning the tracheostomy as needed Explanation: Suctioning helps remove secretions and maintain a patent airway for the client with a tracheostomy.
- Question: When preparing to administer a high-alert medication, which of the following actions should the nurse take to ensure client safety?
- A. Administering the medication without verification
- B. Consulting the client about the medication
- C. Verifying the medication with another nurse
- D. Checking the client’s vital signs after administration
Answer: C. Verifying the medication with another nurse Explanation: Verifying high-alert medications with another nurse helps ensure the correct medication, dose, and route, enhancing client safety.
- Question: A nurse is caring for a client with a cerebrospinal fluid (CSF) leak. Which of the following precautions should the nurse implement?
- A. Placing the client in Trendelenburg position
- B. Keeping the head of the bed elevated
- C. Administering diuretics
- D. Restricting fluid intake
Answer: B. Keeping the head of the bed elevated Explanation: Elevating the head of the bed helps reduce intracranial pressure and facilitates the drainage of cerebrospinal fluid.
- Question: Which of the following actions should a nurse take to ensure the safe use of an electronic health record (EHR) system?
- A. Sharing login credentials with colleagues
- B. Logging off the system when not in use
- C. Allowing clients to view their records unsupervised
- D. Printing client records for reference
Answer: B. Logging off the system when not in use Explanation: Logging off the EHR system when not in use helps protect client information and ensure data security.
- Question: A nurse is providing education to a client about advance directives. Which of the following information should the nurse include?
- A. Advance directives are only for clients with terminal illnesses
- B. Advance directives can be changed or revoked at any time
- C. Only family members can create advance directives
- D. Advance directives are optional and not legally binding
Answer: B. Advance directives can be changed or revoked at any time Explanation: Clients can change or revoke advance directives at any time, allowing them to make decisions about their care as circumstances change.
- Question: When implementing a plan of care for a client with mobility issues, which of the following actions should the nurse prioritize?
- A. Encouraging complete bed rest
- B. Promoting regular physical activity
- C. Limiting fluid intake
- D. Using restraints to prevent falls
Answer: B. Promoting regular physical activity Explanation: Encouraging regular physical activity helps maintain mobility, strength, and overall health for clients with mobility issues.
- Question: A nurse is caring for a client who requires restraints. Which of the following actions should the nurse take to ensure the client’s safety?
- A. Tying the restraints to the bed frame
- B. Using restraints as a first-line intervention
- C. Checking the client’s skin integrity every shift
- D. Removing the restraints every 4 hours
Answer: A. Tying the restraints to the bed frame Explanation: Tying the restraints to the bed frame ensures that the restraints are secure and reduces the risk of injury.
- Question: When assessing a client for pain, which of the following methods is most effective for evaluating pain intensity?
- A. Asking the client to rate their pain on a scale of 0 to 10
- B. Observing the client’s body language
- C. Checking the client’s vital signs
- D. Reviewing the client’s medical history
Answer: A. Asking the client to rate their pain on a scale of 0 to 10 Explanation: Asking the client to rate their pain on a scale of 0 to 10 is a subjective method that allows the client to communicate their pain intensity effectively.
- Question: A nurse is assessing a client for pain. Which of the following methods is most effective for evaluating pain intensity?
- A. Asking the client to rate their pain on a scale of 0 to 10
- B. Observing the client’s body language
- C. Checking the client’s vital signs
- D. Reviewing the client’s medical history
Answer: A. Asking the client to rate their pain on a scale of 0 to 10 Explanation: Asking the client to rate their pain on a scale of 0 to 10 is a subjective method that allows the client to communicate their pain intensity effectively.
- Question: When caring for a client with an indwelling urinary catheter, which of the following actions should the nurse take to prevent catheter-associated urinary tract infections (CAUTIs)?
- A. Keeping the drainage bag above the level of the bladder
- B. Emptying the drainage bag when it is half full
- C. Securing the catheter to the client’s leg
- D. Irrigating the catheter daily
Answer: C. Securing the catheter to the client’s leg Explanation: Securing the catheter to the client’s leg helps prevent movement and trauma to the urethra, reducing the risk of infection.
- Question: A nurse is providing education to a client about the use of an incentive spirometer. Which of the following instructions should the nurse include?
- A. Exhale quickly and forcefully into the spirometer
- B. Inhale slowly and deeply through the mouthpiece
- C. Use the spirometer once a day
- D. Hold your breath for 2 seconds after inhaling
Answer: B. Inhale slowly and deeply through the mouthpiece Explanation: Inhaling slowly and deeply through the mouthpiece helps expand the lungs and improve respiratory function.
- Question: When assessing a client with a new onset of confusion, which of the following is a priority nursing action?
- A. Assessing the client’s level of consciousness
- B. Checking the client’s medication list
- C. Evaluating the client’s nutritional status
- D. Reviewing the client’s medical history
Answer: A. Assessing the client’s level of consciousness Explanation: Assessing the client’s level of consciousness helps determine the severity of confusion and guides further evaluation and interventions.
- Question: A nurse is caring for a client who has been identified as a fall risk. Which of the following interventions should the nurse implement to ensure client safety?
- A. Keeping the bed in the highest position
- B. Placing a fall risk sign at the bedside
- C. Encouraging the client to walk without assistance
- D. Removing all assistive devices
Answer: B. Placing a fall risk sign at the bedside Explanation: Placing a fall risk sign at the bedside alerts all staff members to the client’s fall risk, ensuring appropriate precautions are taken.
- Question: When performing a blood transfusion, which of the following is a critical nursing action?
- A. Administering the transfusion over 1 hour
- B. Verifying the client’s identity and blood type with another nurse
- C. Using a 20-gauge IV catheter
- D. Monitoring the client’s temperature every 30 minutes
Answer: B. Verifying the client’s identity and blood type with another nurse Explanation: Verifying the client’s identity and blood type with another nurse is essential to prevent transfusion reactions and ensure the correct blood is administered.
- Question: A nurse is providing discharge instructions to a client with heart failure. Which of the following information should the nurse include?
- A. Limit fluid intake to 2 liters per day
- B. Weigh yourself weekly
- C. Increase sodium intake
- D. Avoid physical activity
Answer: A. Limit fluid intake to 2 liters per day Explanation: Limiting fluid intake helps manage fluid retention and prevent exacerbation of heart failure symptoms.
- Question: When caring for a client with a chest tube, which of the following actions should the nurse take to ensure proper function of the chest drainage system?
- A. Clamping the chest tube during transport
- B. Keeping the drainage system below the level of the chest
- C. Emptying the collection chamber every 8 hours
- D. Removing the chest tube if it becomes dislodged
Answer: B. Keeping the drainage system below the level of the chest Explanation: Keeping the drainage system below the level of the chest ensures proper drainage and prevents backflow of fluid into the pleural space.
- Question: A nurse is caring for a client with a tracheostomy. Which of the following actions is essential for preventing respiratory complications?
- A. Changing the tracheostomy tube daily
- B. Suctioning the tracheostomy as needed
- C. Keeping the tracheostomy cuff deflated
- D. Administering humidified oxygen
Answer: B. Suctioning the tracheostomy as needed Explanation: Suctioning the tracheostomy helps remove secretions and maintain a patent airway, preventing respiratory complications.
- Question: Which of the following is a priority nursing action when a client experiences a medication error?
- A. Reporting the error to the nurse manager
- B. Documenting the error in the client’s medical record
- C. Assessing the client for adverse effects
- D. Contacting the client’s family
Answer: C. Assessing the client for adverse effects Explanation: Assessing the client for adverse effects is the priority action to ensure the client’s safety and provide appropriate interventions.
- Question: A nurse is providing education to a client about wound care. Which of the following instructions should the nurse include to promote wound healing?
- A. Keep the wound dry and exposed to air
- B. Clean the wound with hydrogen peroxide daily
- C. Apply a sterile dressing to the wound
- D. Avoid eating protein-rich foods
Answer: C. Apply a sterile dressing to the wound Explanation: Applying a sterile dressing helps protect the wound from infection and promotes healing.
- Question: When preparing to administer an intramuscular (IM) injection, which of the following actions should the nurse take to ensure safe administration?
- A. Using a small-gauge needle
- B. Injecting into the same site repeatedly
- C. Aspirating for blood before injecting the medication
- D. Massaging the injection site immediately after
Answer: C. Aspirating for blood before injecting the medication Explanation: Aspirating for blood ensures that the needle is not in a blood vessel, which is essential for safe intramuscular injection.
- Question: A nurse is caring for a client who has been placed in seclusion. Which of the following actions should the nurse take to ensure the client’s safety and well-being?
- A. Leaving the client alone in the seclusion room
- B. Monitoring the client’s physical and psychological status regularly
- C. Restricting the client’s access to food and water
- D. Applying restraints in addition to seclusion
Answer: B. Monitoring the client’s physical and psychological status regularly Explanation: Regular monitoring of the client’s physical and psychological status ensures their safety and well-being while in seclusion.
- Question: When caring for a client with a nasogastric (NG) tube, which of the following interventions should the nurse implement to prevent complications?
- A. Checking tube placement before each feeding
- B. Flushing the tube with alcohol
- C. Administering feedings at room temperature
- D. Inserting the tube without lubrication
Answer: A. Checking tube placement before each feeding Explanation: Checking tube placement before each feeding ensures that the NG tube is correctly positioned in the stomach, preventing complications such as aspiration.
- Question: A nurse is providing discharge instructions to a client with a new ostomy. Which of the following should the nurse include to prevent skin irritation around the stoma?
- A. Using hot water to clean the stoma
- B. Applying a skin barrier before attaching the ostomy appliance
- C. Changing the ostomy appliance every day
- D. Avoiding the use of soap and water
Answer: B. Applying a skin barrier before attaching the ostomy appliance Explanation: Applying a skin barrier helps protect the skin around the stoma from irritation caused by the ostomy appliance and its contents.
- Question: When providing care to a client with a peripheral intravenous (IV) line, which of the following actions should the nurse take to prevent phlebitis?
- A. Inserting the IV line in the antecubital fossa
- B. Using a large-gauge catheter
- C. Rotating the IV site every 72 to 96 hours
- D. Administering all medications through the same IV line
Answer: C. Rotating the IV site every 72 to 96 hours Explanation: Rotating the IV site helps prevent phlebitis by minimizing irritation and inflammation at a single site.
- Question: A nurse is assessing a client’s risk for pressure ulcers. Which of the following factors increases the risk for developing pressure ulcers?
- A. High-protein diet
- B. Regular ambulation
- C. Immobility
- D. Adequate hydration
Answer: C. Immobility Explanation: Immobility increases the risk for pressure ulcers as it leads to prolonged pressure on certain areas of the body, impairing blood flow and causing tissue damage.
- Question: When preparing to transfer a client from a bed to a stretcher, which of the following actions should the nurse take to ensure the client’s safety?
- A. Using a draw sheet to move the client
- B. Locking the wheels of the bed and the stretcher
- C. Asking the client to stand and transfer independently
- D. Positioning the client in Trendelenburg position
Answer: B. Locking the wheels of the bed and the stretcher Explanation: Locking the wheels of the bed and the stretcher ensures that they remain stable during the transfer, preventing falls and injuries.
- Question: A nurse is caring for a client who requires airborne precautions. Which of the following actions should the nurse take to prevent the spread of infection?
- A. Wearing a surgical mask
- B. Placing the client in a negative pressure room
- C. Keeping the door open to the client’s room
- D. Administering prophylactic antibiotics
Answer: B. Placing the client in a negative pressure room Explanation: A negative pressure room helps contain airborne pathogens and prevent them from spreading to other areas of the healthcare facility.
- Question: Which of the following actions should a nurse take to ensure the safe administration of blood products?
- A. Administering blood products through a peripheral IV line
- B. Verifying the client’s identity and blood type with another nurse
- C. Storing blood products at room temperature
- D. Administering blood products over a 1-hour period
Answer: B. Verifying the client’s identity and blood type with another nurse Explanation: Verifying the client’s identity and blood type with another nurse is essential to prevent transfusion reactions and ensure the correct blood is administered.
- Question: When caring for a client with a peripherally inserted central catheter (PICC), which of the following actions should the nurse take to prevent complications?
- A. Changing the PICC dressing every 7 days
- B. Administering medications through the PICC without flushing
- C. Using sterile technique when accessing the PICC
- D. Removing the PICC line when not in use
Answer: C. Using sterile technique when accessing the PICC Explanation: Using sterile technique helps prevent infection and other complications when accessing the PICC line.
- Question: A nurse is providing education to a client about preventing pressure ulcers. Which of the following instructions should the nurse include?
- A. Change positions every 2 hours
- B. Use hot water for bathing
- C. Massage bony prominences
- D. Limit fluid intake
Answer: A. Change positions every 2 hours Explanation: Changing positions regularly helps relieve pressure on bony prominences and reduces the risk of developing pressure ulcers.
- Question: When caring for a client with an indwelling urinary catheter, which of the following actions should the nurse take to reduce the risk of catheter-associated urinary tract infections (CAUTIs)?
- A. Using clean technique for catheter insertion
- B. Keeping the drainage bag below the level of the bladder
- C. Clamping the catheter when the client is ambulating
- D. Irrigating the catheter daily
Answer: B. Keeping the drainage bag below the level of the bladder Explanation: Keeping the drainage bag below the level of the bladder ensures proper drainage and reduces the risk of urinary tract infections.
- Question: A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD). Which of the following should the nurse include to help manage the client’s condition?
- A. Increase fluid intake to thin secretions
- B. Avoid using bronchodilators
- C. Limit physical activity
- D. Use a high-sodium diet
Answer: A. Increase fluid intake to thin secretions Explanation: Increasing fluid intake helps thin respiratory secretions, making them easier to clear and improving breathing in clients with COPD.
- Question: When providing care to a client with diabetes, which of the following actions should the nurse take to prevent complications?
- A. Encouraging a high-carbohydrate diet
- B. Monitoring blood glucose levels regularly
- C. Administering insulin only during hypoglycemic episodes
- D. Restricting physical activity
Answer: B. Monitoring blood glucose levels regularly Explanation: Regular monitoring of blood glucose levels helps manage diabetes and prevent complications such as hyperglycemia and hypoglycemia.
- Question: A nurse is caring for a client with a wound infection. Which of the following actions should the nurse take to prevent the spread of infection?
- A. Using alcohol-based hand sanitizer before and after wound care
- B. Changing the wound dressing every 24 hours
- C. Applying antibiotic ointment to the wound
- D. Performing wound care in the client’s bed
Answer: A. Using alcohol-based hand sanitizer before and after wound care Explanation: Using hand sanitizer before and after wound care helps prevent the spread of infection by maintaining hand hygiene.
- Question: When providing education to a client about medication administration, which of the following should the nurse include to promote safe practices?
- A. Take all medications at the same time each day
- B. Use a medication organizer to keep track of doses
- C. Store medications in a high, inaccessible place
- D. Discontinue medications when symptoms improve
Answer: B. Use a medication organizer to keep track of doses Explanation: Using a medication organizer helps ensure that the client takes the correct medications at the correct times, promoting safe medication practices.
- Question: A nurse is preparing to administer an intramuscular (IM) injection to a client. Which of the following actions should the nurse take to ensure safe administration?
- A. Using a small-gauge needle
- B. Injecting into the same site repeatedly
- C. Rotating injection sites
- D. Massaging the injection site immediately after
Answer: C. Rotating injection sites Explanation: Rotating injection sites helps prevent tissue damage and ensures consistent medication absorption.
- Question: When caring for a client with a chest tube, which of the following actions should the nurse take to ensure proper function of the chest drainage system?
- A. Clamping the chest tube during transport
- B. Keeping the drainage system below the level of the chest
- C. Emptying the collection chamber every 8 hours
- D. Removing the chest tube if it becomes dislodged
Answer: B. Keeping the drainage system below the level of the chest Explanation: Keeping the drainage system below the level of the chest ensures proper drainage and prevents backflow of fluid into the pleural space.
- Question: A nurse is providing education to a client about preventing deep vein thrombosis (DVT). Which of the following instructions should the nurse include?
- A. Avoiding physical activity
- B. Increasing fluid intake
- C. Performing leg exercises regularly
- D. Wearing tight clothing
Answer: C. Performing leg exercises regularly Explanation: Regular leg exercises promote circulation and help prevent the formation of blood clots, reducing the risk of deep vein thrombosis (DVT).
- Question: When administering medications to a client, which of the following actions should the nurse take to ensure safe medication administration?
- A. Preparing medications for multiple clients at once
- B. Administering medications without verifying the client’s identity
- C. Double-checking the medication order with the MAR
- D. Delegating medication administration to unlicensed assistive personnel
Answer: C. Double-checking the medication order with the MAR Explanation: Double-checking the medication order with the Medication Administration Record (MAR) helps ensure that the correct medication, dose, and route are administered to the correct client.
- Question: A nurse is providing education to a client about infection prevention. Which of the following instructions should the nurse include to reduce the risk of infection?
- A. Avoiding hand hygiene
- B. Using antimicrobial soap for handwashing
- C. Sharing personal items with family members
- D. Limiting fluid intake
Answer: B. Using antimicrobial soap for handwashing Explanation: Using antimicrobial soap for handwashing helps reduce the presence of pathogens on the hands, thereby reducing the risk of infection.
- Question: When caring for a client with a central venous catheter (CVC), which of the following actions should the nurse take to prevent catheter-related bloodstream infections (CRBSIs)?
- A. Changing the CVC dressing daily
- B. Using clean technique when accessing the CVC
- C. Applying antibiotic ointment to the insertion site
- D. Maintaining a sterile field when accessing the CVC
Answer: D. Maintaining a sterile field when accessing the CVC Explanation: Maintaining a sterile field helps prevent contamination and infection when accessing a central venous catheter (CVC), thereby reducing the risk of catheter-related bloodstream infections (CRBSIs).
2. Health Promotion and Maintenance
Health Promotion and Maintenance in the NCLEX-RN exam focuses on a nurse’s ability to support clients in maintaining optimal health and preventing illness. This category encompasses various aspects such as growth and development, disease prevention, and health screening. It includes teaching clients about healthy lifestyles, promoting regular health screenings, and providing prenatal and postpartum care. The aim is to empower clients with knowledge and resources to make informed decisions about their health, identify risk factors, and implement preventive measures. Nurses play a crucial role in encouraging healthy behaviors and supporting clients throughout different stages of life to ensure their overall well-being.
- Question: A nurse is teaching a client about the importance of regular physical activity. Which of the following is a benefit of regular exercise?
- A. Increased risk of cardiovascular disease
- B. Improved mental health and mood
- C. Reduced bone density
- D. Decreased immune function
Answer: B. Improved mental health and mood Explanation: Regular physical activity can improve mental health and mood by reducing symptoms of depression and anxiety and enhancing overall well-being.
- Question: When educating a client about a healthy diet, which of the following should the nurse recommend as a primary source of protein?
- A. Fruits
- B. Vegetables
- C. Lean meats and legumes
- D. Sugary snacks
Answer: C. Lean meats and legumes Explanation: Lean meats and legumes are excellent sources of protein that contribute to muscle repair and growth.
- Question: A nurse is conducting a smoking cessation program. Which of the following strategies is most effective for helping clients quit smoking?
- A. Reducing the number of cigarettes smoked each day
- B. Using nicotine replacement therapy (NRT)
- C. Switching to e-cigarettes
- D. Ignoring withdrawal symptoms
Answer: B. Using nicotine replacement therapy (NRT) Explanation: Nicotine replacement therapy helps reduce withdrawal symptoms and cravings, making it easier for clients to quit smoking.
- Question: When providing prenatal education, which of the following should the nurse include as a benefit of breastfeeding?
- A. Decreased risk of allergies in the infant
- B. Increased risk of postpartum depression
- C. Higher likelihood of infant obesity
- D. Reduced bonding between mother and baby
Answer: A. Decreased risk of allergies in the infant Explanation: Breastfeeding is associated with a reduced risk of allergies and other health benefits for the infant.
- Question: A nurse is teaching a client about the importance of regular dental check-ups. How often should the client have a dental examination?
- A. Every 6 months
- B. Every 2 years
- C. Once a month
- D. Only when experiencing tooth pain
Answer: A. Every 6 months Explanation: Regular dental check-ups every 6 months help prevent dental issues and maintain oral health.
- Question: When discussing health screening tests with a client, which of the following is an appropriate age to begin colorectal cancer screening for average-risk individuals?
- A. 20 years old
- B. 30 years old
- C. 45 years old
- D. 60 years old
Answer: C. 45 years old Explanation: Current guidelines recommend that average-risk individuals begin colorectal cancer screening at age 45.
- Question: A nurse is educating a client about the importance of hydration. How many glasses of water should an average adult consume daily?
- A. 2-3 glasses
- B. 4-5 glasses
- C. 6-8 glasses
- D. 10-12 glasses
Answer: C. 6-8 glasses Explanation: Consuming 6-8 glasses of water daily helps maintain hydration and supports overall health.
- Question: Which of the following vaccines should be administered annually to adults to prevent influenza?
- A. Hepatitis B
- B. Influenza
- C. Tetanus
- D. Measles
Answer: B. Influenza Explanation: The influenza vaccine should be administered annually to protect against the flu virus.
- Question: A nurse is conducting a community education session on sun safety. Which of the following should be included as a method to prevent skin cancer?
- A. Using sunscreen with at least SPF 30
- B. Tanning in a tanning bed
- C. Wearing dark clothing
- D. Exposing skin to the sun for long periods
Answer: A. Using sunscreen with at least SPF 30 Explanation: Using sunscreen with a high SPF helps protect the skin from harmful UV rays and reduces the risk of skin cancer.
- Question: When educating a client about stress management techniques, which of the following practices should the nurse recommend?
- A. Suppressing emotions
- B. Practicing deep breathing exercises
- C. Consuming alcohol to relax
- D. Ignoring stressful situations
Answer: B. Practicing deep breathing exercises Explanation: Deep breathing exercises help reduce stress and promote relaxation by calming the nervous system.
- Question: A nurse is teaching a client about the importance of a balanced diet. Which of the following is an essential nutrient that should be included in a healthy diet?
- A. Trans fats
- B. Simple sugars
- C. Fiber
- D. Empty calories
Answer: C. Fiber Explanation: Fiber is an essential nutrient that aids in digestion and helps maintain a healthy weight.
- Question: When providing health education to a client, which of the following is a benefit of regular sleep for overall health?
- A. Increased risk of obesity
- B. Improved cognitive function
- C. Higher likelihood of heart disease
- D. Reduced immune response
Answer: B. Improved cognitive function Explanation: Regular sleep is important for cognitive function, memory, and overall mental health.
- Question: A nurse is educating a client about the importance of routine health screenings. Which of the following screenings is recommended for women to detect breast cancer early?
- A. Pap smear
- B. Mammogram
- C. Colonoscopy
- D. Bone density scan
Answer: B. Mammogram Explanation: Mammograms are recommended for women to detect breast cancer at an early, more treatable stage.
- Question: Which of the following is a modifiable risk factor for cardiovascular disease that a nurse should address in health promotion education?
- A. Age
- B. Family history
- C. Smoking
- D. Gender
Answer: C. Smoking Explanation: Smoking is a modifiable risk factor for cardiovascular disease that can be addressed through lifestyle changes and smoking cessation programs.
- Question: A nurse is teaching a client about the benefits of regular physical exams. Which of the following is a reason for regular physical exams?
- A. To monitor changes in health status
- B. To replace emergency room visits
- C. To avoid the need for vaccinations
- D. To diagnose acute illnesses only
Answer: A. To monitor changes in health status Explanation: Regular physical exams help monitor changes in health status, detect potential health issues early, and provide an opportunity for preventive care.
- Question: Which of the following practices should a nurse recommend to a client to promote healthy sleep hygiene?
- A. Using electronic devices in bed
- B. Establishing a regular sleep schedule
- C. Consuming caffeine before bedtime
- D. Keeping the bedroom brightly lit
Answer: B. Establishing a regular sleep schedule Explanation: Establishing a regular sleep schedule helps regulate the body’s internal clock and promotes better sleep quality.
- Question: A nurse is educating a client about the importance of regular vision screenings. How often should adults have their vision checked?
- A. Every 6 months
- B. Annually
- C. Every 2 years
- D. Only when experiencing vision problems
Answer: B. Annually Explanation: Regular annual vision screenings help detect eye problems early and maintain eye health.
- Question: Which of the following is a benefit of regular hand hygiene that a nurse should emphasize during health education?
- A. Increased spread of infections
- B. Improved immune function
- C. Reduced transmission of pathogens
- D. Higher risk of skin irritation
Answer: C. Reduced transmission of pathogens Explanation: Regular hand hygiene helps reduce the transmission of pathogens and prevent infections.
- Question: When educating a client about healthy aging, which of the following should the nurse recommend to maintain cognitive function?
- A. Avoiding social activities
- B. Engaging in mentally stimulating activities
- C. Consuming a high-fat diet
- D. Reducing physical activity
Answer: B. Engaging in mentally stimulating activities Explanation: Mentally stimulating activities help maintain cognitive function and reduce the risk of cognitive decline with aging.
- Question: A nurse is providing education to a client about the importance of folic acid during pregnancy. Which of the following is a benefit of folic acid for the developing fetus?
- A. Increased risk of neural tube defects
- B. Reduced risk of neural tube defects
- C. Higher likelihood of preterm birth
- D. Lower birth weight
Answer: B. Reduced risk of neural tube defects Explanation: Folic acid is important for preventing neural tube defects in the developing fetus during pregnancy.
- Question: When teaching a client about the importance of vaccinations, which of the following should the nurse emphasize?
- A. Vaccinations cause autism
- B. Vaccinations prevent infectious diseases
- C. Vaccinations are unnecessary for healthy individuals
- D. Vaccinations should be avoided during pregnancy
Answer: B. Vaccinations prevent infectious diseases Explanation: Vaccinations are crucial in preventing the spread of infectious diseases and protecting both individual and public health.
- Question: A nurse is educating a client about osteoporosis prevention. Which of the following is a key factor in preventing osteoporosis?
- A. Low calcium intake
- B. Regular weight-bearing exercise
- C. High caffeine consumption
- D. Smoking
Answer: B. Regular weight-bearing exercise Explanation: Regular weight-bearing exercise helps build and maintain strong bones, reducing the risk of osteoporosis.
- Question: When teaching a client about managing hypertension, which of the following dietary recommendations should the nurse include?
- A. Increasing sodium intake
- B. Limiting alcohol consumption
- C. Consuming a high-fat diet
- D. Avoiding fruits and vegetables
Answer: B. Limiting alcohol consumption Explanation: Limiting alcohol consumption helps manage blood pressure and reduce the risk of hypertension-related complications.
- Question: A nurse is providing education to a client about colorectal cancer prevention. Which of the following is a recommended screening method?
- A. Mammogram
- B. Colonoscopy
- C. Bone density scan
- D. Chest X-ray
Answer: B. Colonoscopy Explanation: Colonoscopy is a recommended screening method for colorectal cancer that can detect and remove polyps before they become cancerous.
- Question: Which of the following is a benefit of regular prenatal care that a nurse should emphasize to a pregnant client?
- A. Reduced risk of pregnancy complications
- B. Increased likelihood of preterm labor
- C. Higher risk of gestational diabetes
- D. Lower chance of fetal development
Answer: A. Reduced risk of pregnancy complications Explanation: Regular prenatal care helps monitor the health of both the mother and the developing fetus, reducing the risk of pregnancy complications.
- Question: A nurse is teaching a client about the importance of regular cholesterol screenings. At what age should cholesterol screening begin for average-risk adults?
- A. 18 years old
- B. 20 years old
- C. 35 years old
- D. 50 years old
Answer: B. 20 years old Explanation: Cholesterol screening is recommended to begin at age 20 for average-risk adults to help identify and manage cardiovascular risk factors early.
- Question: When educating a client about dental health, which of the following practices should the nurse recommend to prevent cavities?
- A. Brushing teeth once a day
- B. Avoiding fluoride toothpaste
- C. Flossing daily
- D. Consuming sugary snacks frequently
Answer: C. Flossing daily Explanation: Flossing daily helps remove plaque and food particles between teeth, reducing the risk of cavities and gum disease.
- Question: A nurse is providing education to a client about the benefits of a balanced diet. Which of the following should be included as a key component of a balanced diet?
- A. Trans fats
- B. Empty calories
- C. Vitamins and minerals
- D. High sugar content
Answer: C. Vitamins and minerals Explanation: A balanced diet should include essential vitamins and minerals to support overall health and well-being.
- Question: When teaching a client about the importance of hydration, which of the following is a sign of dehydration that the nurse should mention?
- A. Clear, pale urine
- B. Dark, concentrated urine
- C. Increased energy levels
- D. Regular bowel movements
Answer: B. Dark, concentrated urine Explanation: Dark, concentrated urine is a sign of dehydration, indicating that the body needs more fluids.
- Question: A nurse is educating a client about the benefits of regular physical activity for weight management. Which of the following is a recommended amount of moderate-intensity exercise for adults per week?
- A. 30 minutes
- B. 60 minutes
- C. 150 minutes
- D. 300 minutes
Answer: C. 150 minutes Explanation: Adults should aim for at least 150 minutes of moderate-intensity exercise per week to support weight management and overall health.
- Question: Which of the following is an important aspect of health promotion for older adults that a nurse should address?
- A. Ignoring the risk of falls
- B. Encouraging social engagement
- C. Limiting physical activity
- D. Consuming a high-sodium diet
Answer: B. Encouraging social engagement Explanation: Social engagement is important for mental and emotional well-being in older adults, helping to prevent isolation and depression.
- Question: A nurse is teaching a client about the importance of regular blood pressure monitoring. Which of the following blood pressure readings is considered normal for adults?
- A. 120/80 mmHg
- B. 140/90 mmHg
- C. 160/100 mmHg
- D. 180/120 mmHg
Answer: A. 120/80 mmHg Explanation: A blood pressure reading of 120/80 mmHg is considered normal for adults, indicating healthy blood pressure levels.
- Question: When providing health education to a client about cancer prevention, which of the following is a recommended screening test for cervical cancer?
- A. Colonoscopy
- B. Pap smear
- C. Mammogram
- D. Bone density scan
Answer: B. Pap smear Explanation: A Pap smear is a recommended screening test for cervical cancer that helps detect abnormal cells early.
- Question: A nurse is educating a client about the importance of regular exercise for cardiovascular health. Which of the following types of exercise is most beneficial for improving cardiovascular fitness?
- A. Resistance training
- B. Aerobic exercise
- C. Flexibility exercises
- D. Balance exercises
Answer: B. Aerobic exercise Explanation: Aerobic exercise, such as walking, running, or swimming, is most beneficial for improving cardiovascular fitness.
- Question: When teaching a client about the benefits of a healthy diet, which of the following should the nurse recommend to reduce the risk of chronic diseases?
- A. Consuming a diet high in processed foods
- B. Eating a variety of fruits and vegetables
- C. Limiting water intake
- D. Avoiding whole grains
Answer: B. Eating a variety of fruits and vegetables Explanation: Eating a variety of fruits and vegetables provides essential nutrients that help reduce the risk of chronic diseases.
- Question: A nurse is providing education to a client about stress management. Which of the following techniques is effective for reducing stress levels?
- A. Avoiding physical activity
- B. Engaging in regular exercise
- C. Consuming high-caffeine beverages
- D. Ignoring stressful situations
Answer: B. Engaging in regular exercise Explanation: Regular exercise is an effective stress management technique that helps reduce stress levels and improve overall well-being.
- Question: When educating a client about the importance of prenatal vitamins, which of the following should the nurse emphasize as a key nutrient?
- A. Vitamin D
- B. Iron
- C. Calcium
- D. Folic acid
Answer: D. Folic acid Explanation: Folic acid is a key nutrient in prenatal vitamins that helps prevent neural tube defects in the developing fetus.
- Question: A nurse is teaching a client about the importance of regular mammograms. How often should women aged 50-74 have a mammogram to screen for breast cancer?
- A. Every 6 months
- B. Annually
- C. Every 2 years
- D. Every 5 years
Answer: C. Every 2 years Explanation: Women aged 50-74 should have a mammogram every 2 years to screen for breast cancer.
- Question: When providing education about flu prevention, which of the following is a key recommendation that a nurse should include?
- A. Avoiding hand hygiene
- B. Receiving the annual flu vaccine
- C. Limiting fluid intake
- D. Taking antibiotics
Answer: B. Receiving the annual flu vaccine Explanation: Receiving the annual flu vaccine is a key recommendation for preventing the flu and protecting public health.
- Question: A nurse is educating a client about the importance of regular dental care. Which of the following practices helps maintain oral health?
- A. Brushing teeth twice a day
- B. Avoiding flossing
- C. Using sugary mouthwash
- D. Consuming acidic beverages frequently
Answer: A. Brushing teeth twice a day Explanation: Brushing teeth twice a day helps remove plaque and maintain oral health, preventing dental issues.
- Question: When teaching a client about safe sleep practices for infants, which of the following recommendations should the nurse include to reduce the risk of sudden infant death syndrome (SIDS)?
- A. Place the infant on their stomach to sleep
- B. Use soft bedding and pillows in the crib
- C. Place the infant on their back to sleep
- D. Allow the infant to sleep in the parents’ bed
Answer: C. Place the infant on their back to sleep Explanation: Placing infants on their backs to sleep is recommended to reduce the risk of sudden infant death syndrome (SIDS).
- Question: A nurse is providing education to a client about sun safety. Which of the following practices should the nurse recommend to protect the skin from harmful UV rays?
- A. Applying sunscreen only on cloudy days
- B. Wearing wide-brimmed hats and sunglasses
- C. Using tanning beds instead of sunbathing
- D. Limiting sunscreen use to once a day
Answer: B. Wearing wide-brimmed hats and sunglasses Explanation: Wearing wide-brimmed hats and sunglasses helps protect the skin and eyes from harmful UV rays and reduces the risk of skin cancer.
- Question: When educating a client about the importance of regular physical activity for children, which of the following is a recommended amount of physical activity for school-aged children?
- A. 30 minutes per week
- B. 60 minutes per day
- C. 90 minutes per day
- D. 120 minutes per week
Answer: B. 60 minutes per day Explanation: School-aged children should engage in at least 60 minutes of physical activity per day to support healthy growth and development.
- Question: A nurse is teaching a client about the importance of regular Pap smears. How often should women aged 21-65 have a Pap smear to screen for cervical cancer?
- A. Every 6 months
- B. Annually
- C. Every 3 years
- D. Every 5 years
Answer: C. Every 3 years Explanation: Women aged 21-65 should have a Pap smear every 3 years to screen for cervical cancer and detect abnormal cells early.
- Question: When providing education about the benefits of breastfeeding, which of the following should the nurse include as a benefit for the mother?
- A. Increased risk of breast cancer
- B. Faster postpartum weight loss
- C. Higher likelihood of postpartum depression
- D. Reduced bonding with the baby
Answer: B. Faster postpartum weight loss Explanation: Breastfeeding can help mothers lose weight more quickly after childbirth by burning additional calories.
- Question: A nurse is teaching a client about the importance of regular exercise for diabetes management. Which of the following is a benefit of regular physical activity for individuals with diabetes?
- A. Increased blood glucose levels
- B. Improved insulin sensitivity
- C. Reduced physical endurance
- D. Higher risk of hypoglycemia
Answer: B. Improved insulin sensitivity Explanation: Regular physical activity helps improve insulin sensitivity, making it easier to manage blood glucose levels in individuals with diabetes.
- Question: When educating a client about alcohol consumption, which of the following is a recommended limit for moderate alcohol intake for women?
- A. Up to 1 drink per day
- B. Up to 2 drinks per day
- C. Up to 3 drinks per day
- D. Up to 4 drinks per day
Answer: A. Up to 1 drink per day Explanation: For women, moderate alcohol intake is defined as up to 1 drink per day, which helps reduce the risk of alcohol-related health issues.
- Question: A nurse is providing education to a client about the importance of regular mental health check-ups. Which of the following is a benefit of routine mental health assessments?
- A. Increased stigma around mental health
- B. Early detection of mental health issues
- C. Reduced access to mental health services
- D. Higher likelihood of undiagnosed conditions
Answer: B. Early detection of mental health issues Explanation: Routine mental health assessments help detect mental health issues early, allowing for timely intervention and support.
- Question: When teaching a client about safe medication practices, which of the following should the nurse emphasize to prevent medication errors?
- A. Taking medications prescribed for someone else
- B. Using a medication organizer
- C. Ignoring medication labels
- D. Stopping medications without consulting a healthcare provider
Answer: B. Using a medication organizer Explanation: Using a medication organizer helps ensure that the client takes the correct medications at the correct times, reducing the risk of medication errors.
- Question: A nurse is educating a client about the importance of regular bone density screenings. At what age should women begin routine bone density screenings to detect osteoporosis?
- A. 30 years old
- B. 40 years old
- C. 50 years old
- D. 65 years old
Answer: D. 65 years old Explanation: Women should begin routine bone density screenings at age 65 to detect osteoporosis and prevent fractures.
3. Psychosocial Integrity (6-12%)
Psychosocial Integrity in the NCLEX-RN exam assesses a nurse’s ability to support the emotional, mental, and social well-being of clients. It includes helping clients cope with stress and adapt to changes, providing support during grief and loss, implementing behavioral interventions, and addressing mental health issues. This category focuses on holistic care that ensures clients’ overall psychosocial health by promoting effective coping strategies, therapeutic communication, and emotional support. Nurses must be adept at recognizing and addressing the psychological and social aspects of a client’s health to ensure comprehensive care.
- Question: A nurse is caring for a client who is experiencing grief after the loss of a loved one. Which of the following is an appropriate nursing intervention?
- A. Encouraging the client to avoid talking about the deceased
- B. Providing a supportive and empathetic presence
- C. Discouraging the client from expressing emotions
- D. Suggesting the client suppress their feelings
Answer: B. Providing a supportive and empathetic presence Explanation: Offering a supportive and empathetic presence helps the client process their grief and emotions.
- Question: A client with a history of depression is admitted to the hospital. Which of the following is a priority assessment for the nurse?
- A. Monitoring fluid intake
- B. Assessing for suicidal ideation
- C. Checking blood glucose levels
- D. Evaluating dietary habits
Answer: B. Assessing for suicidal ideation Explanation: Assessing for suicidal ideation is crucial in clients with a history of depression to ensure their safety.
- Question: A nurse is caring for a client who is experiencing anxiety. Which of the following interventions should the nurse implement?
- A. Encouraging the client to avoid stressful situations
- B. Administering anxiolytic medication as prescribed
- C. Providing a quiet and calm environment
- D. Discouraging the client from expressing their feelings
Answer: C. Providing a quiet and calm environment Explanation: Creating a quiet and calm environment helps reduce anxiety and promotes relaxation.
- Question: A client with schizophrenia is exhibiting signs of auditory hallucinations. Which of the following is an appropriate nursing intervention?
- A. Ignoring the client’s hallucinations
- B. Validating the client’s feelings and experiences
- C. Encouraging the client to argue with the voices
- D. Isolating the client from others
Answer: B. Validating the client’s feelings and experiences Explanation: Validating the client’s feelings and experiences helps build trust and rapport, promoting therapeutic communication.
- Question: A nurse is caring for a client who is experiencing acute stress. Which of the following is an appropriate nursing intervention?
- A. Encouraging the client to suppress their emotions
- B. Providing information about stress management techniques
- C. Discouraging the client from seeking support
- D. Ignoring the client’s stress
Answer: B. Providing information about stress management techniques Explanation: Providing information about stress management techniques helps the client develop coping strategies and reduce stress.
- Question: A client with bipolar disorder is experiencing a manic episode. Which of the following interventions should the nurse implement?
- A. Encouraging the client to engage in high-risk behaviors
- B. Providing a structured and consistent environment
- C. Allowing the client to make impulsive decisions
- D. Ignoring the client’s behavior
Answer: B. Providing a structured and consistent environment Explanation: A structured and consistent environment helps manage the client’s behavior and promotes stability.
- Question: A nurse is caring for a client who is experiencing a panic attack. Which of the following interventions should the nurse implement?
- A. Encouraging the client to breathe rapidly
- B. Administering a sedative medication as prescribed
- C. Providing reassurance and a calm environment
- D. Ignoring the client’s symptoms
Answer: C. Providing reassurance and a calm environment Explanation: Providing reassurance and a calm environment helps reduce the client’s anxiety and promotes relaxation.
- Question: A client with a history of substance abuse is admitted to the hospital. Which of the following is a priority assessment for the nurse?
- A. Monitoring fluid intake
- B. Assessing for withdrawal symptoms
- C. Checking blood glucose levels
- D. Evaluating dietary habits
Answer: B. Assessing for withdrawal symptoms Explanation: Assessing for withdrawal symptoms is crucial in clients with a history of substance abuse to ensure their safety and manage symptoms.
- Question: A nurse is caring for a client who is experiencing domestic violence. Which of the following is an appropriate nursing intervention?
- A. Encouraging the client to stay with the abuser
- B. Providing information about local support services
- C. Discouraging the client from seeking help
- D. Ignoring the client’s situation
Answer: B. Providing information about local support services Explanation: Providing information about local support services helps the client access resources and support to address the domestic violence.
- Question: A client with a history of post-traumatic stress disorder (PTSD) is admitted to the hospital. Which of the following is a priority assessment for the nurse?
- A. Monitoring fluid intake
- B. Assessing for flashbacks and nightmares
- C. Checking blood glucose levels
- D. Evaluating dietary habits
Answer: B. Assessing for flashbacks and nightmares Explanation: Assessing for flashbacks and nightmares helps monitor the client’s PTSD symptoms and provides insight into their mental health status.
- Question: A nurse is caring for a client who is experiencing acute stress. Which of the following interventions should the nurse implement?
- A. Encouraging the client to suppress their emotions
- B. Providing information about stress management techniques
- C. Discouraging the client from seeking support
- D. Ignoring the client’s stress
Answer: B. Providing information about stress management techniques Explanation: Providing information about stress management techniques helps the client develop coping strategies and reduce stress.
- Question: A client with schizophrenia is exhibiting signs of auditory hallucinations. Which of the following is an appropriate nursing intervention?
- A. Ignoring the client’s hallucinations
- B. Validating the client’s feelings and experiences
- C. Encouraging the client to argue with the voices
- D. Isolating the client from others
Answer: B. Validating the client’s feelings and experiences Explanation: Validating the client’s feelings and experiences helps build trust and rapport, promoting therapeutic communication.
- Question: A nurse is caring for a client who is experiencing a panic attack. Which of the following interventions should the nurse implement?
- A. Encouraging the client to breathe rapidly
- B. Administering a sedative medication as prescribed
- C. Providing reassurance and a calm environment
- D. Ignoring the client’s symptoms
Answer: C. Providing reassurance and a calm environment Explanation: Providing reassurance and a calm environment helps reduce the client’s anxiety and promotes relaxation.
- Question: A client with a history of substance abuse is admitted to the hospital. Which of the following is a priority assessment for the nurse?
- A. Monitoring fluid intake
- B. Assessing for withdrawal symptoms
- C. Checking blood glucose levels
- D. Evaluating dietary habits
Answer: B. Assessing for withdrawal symptoms Explanation: Assessing for withdrawal symptoms is crucial in clients with a history of substance abuse to ensure their safety and manage symptoms.
- Question: A nurse is caring for a client who is experiencing domestic violence. Which of the following is an appropriate nursing intervention?
- A. Encouraging the client to stay with the abuser
- B. Providing information about local support services
- C. Discouraging the client from seeking help
- D. Ignoring the client’s situation
Answer: B. Providing information about local support services Explanation: Providing information about local support services helps the client access resources and support to address the domestic violence.
- Question: A client with a history of post-traumatic stress disorder (PTSD) is admitted to the hospital. Which of the following is a priority assessment for the nurse?
- A. Monitoring fluid intake
- B. Assessing for flashbacks and nightmares
- C. Checking blood glucose levels
- D. Evaluating dietary habits
Answer: B. Assessing for flashbacks and nightmares Explanation: Assessing for flashbacks and nightmares helps monitor the client’s PTSD symptoms and provides insight into their mental health status.
- Question: A nurse is caring for a client who is experiencing acute stress. Which of the following interventions should the nurse implement?
- A. Encouraging the client to suppress their emotions
- B. Providing information about stress management techniques
- C. Discouraging the client from seeking support
- D. Ignoring the client’s stress
Answer: B. Providing information about stress management techniques Explanation: Providing information about stress management techniques helps the client develop coping strategies and reduce stress.
- Question: A client with schizophrenia is exhibiting signs of auditory hallucinations. Which of the following is an appropriate nursing intervention?
- A. Ignoring the client’s hallucinations
- B. Validating the client’s feelings and experiences
- C. Encouraging the client to argue with the voices
- D. Isolating the client from others
Answer: B. Validating the client’s feelings and experiences Explanation: Validating the client’s feelings and experiences helps build trust and rapport, promoting therapeutic communication.
- Question: A nurse is caring for a client who is experiencing a panic attack. Which of the following interventions should the nurse implement?
- A. Encouraging the client to breathe rapidly
- B. Administering a sedative medication as prescribed
- C. Providing reassurance and a calm environment
- D. Ignoring the client’s symptoms
Answer: C. Providing reassurance and a calm environment Explanation: Providing reassurance and a calm environment helps reduce the client’s anxiety and promotes relaxation.
- Question: A client with a history of substance abuse is admitted to the hospital. Which of the following is a priority assessment for the nurse?
- A. Monitoring fluid intake
- B. Assessing for withdrawal symptoms
- C. Checking blood glucose levels
- D. Evaluating dietary habits
Answer: B. Assessing for withdrawal symptoms Explanation: Assessing for withdrawal symptoms is crucial in clients with a history of substance abuse to ensure their safety and manage symptoms.
- Question: A nurse is caring for a client who is experiencing domestic violence. Which of the following is an appropriate nursing intervention?
- A. Encouraging the client to stay with the abuser
- B. Providing information about local support services
- C. Discouraging the client from seeking help
- D. Ignoring the client’s situation
Answer: B. Providing information about local support services Explanation: Providing information about local support services helps the client access resources and support to address the domestic violence.
- Question: A client with a history of post-traumatic stress disorder (PTSD) is admitted to the hospital. Which of the following is a priority assessment for the nurse?
- A. Monitoring fluid intake
- B. Assessing for flashbacks and nightmares
- C. Checking blood glucose levels
- D. Evaluating dietary habits
Answer: B. Assessing for flashbacks and nightmares Explanation: Assessing for flashbacks and nightmares helps monitor the client’s PTSD symptoms and provides insight into their mental health status.
- Question: A nurse is caring for a client who is experiencing acute stress. Which of the following interventions should the nurse implement?
- A. Encouraging the client to suppress their emotions
- B. Providing information about stress management techniques
- C. Discouraging the client from seeking support
- D. Ignoring the client’s stress
Answer: B. Providing information about stress management techniques Explanation: Providing information about stress management techniques helps the client develop coping strategies and reduce stress.
- Question: A client with an eating disorder is admitted to the hospital. Which of the following is a priority nursing intervention?
- A. Monitoring the client’s weight daily
- B. Encouraging the client to eat in isolation
- C. Allowing the client to choose their meals independently
- D. Providing laxatives as prescribed
Answer: A. Monitoring the client’s weight daily Explanation: Monitoring the client’s weight daily helps assess the severity of the eating disorder and provides data for treatment planning.
- Question: A nurse is providing care for a client with borderline personality disorder (BPD). Which of the following interventions should the nurse implement to establish a therapeutic relationship?
- A. Setting consistent boundaries and limits
- B. Avoiding discussions about the client’s feelings
- C. Allowing the client to make all decisions independently
- D. Ignoring the client’s behavior
Answer: A. Setting consistent boundaries and limits Explanation: Setting consistent boundaries and limits helps establish a therapeutic relationship and provides structure for clients with BPD.
- Question: A client with major depressive disorder is admitted to the hospital. Which of the following is a priority nursing intervention?
- A. Encouraging the client to remain isolated
- B. Monitoring the client for signs of suicidal ideation
- C. Discouraging the client from expressing their feelings
- D. Providing a stimulating environment
Answer: B. Monitoring the client for signs of suicidal ideation Explanation: Monitoring for signs of suicidal ideation is crucial in clients with major depressive disorder to ensure their safety.
- Question: A nurse is caring for a client with obsessive-compulsive disorder (OCD). Which of the following is an appropriate nursing intervention?
- A. Discouraging the client from performing rituals
- B. Allowing the client to perform rituals initially
- C. Encouraging the client to suppress their compulsions
- D. Ignoring the client’s behaviors
Answer: B. Allowing the client to perform rituals initially Explanation: Allowing the client to perform rituals initially helps reduce anxiety while gradually working on alternative coping strategies.
- Question: A client with generalized anxiety disorder (GAD) is receiving treatment. Which of the following interventions should the nurse implement to support the client’s mental health?
- A. Encouraging excessive caffeine intake
- B. Promoting relaxation techniques
- C. Allowing the client to avoid all responsibilities
- D. Ignoring the client’s anxiety
Answer: B. Promoting relaxation techniques Explanation: Promoting relaxation techniques helps the client manage anxiety and develop effective coping strategies.
- Question: A nurse is providing care for a client with schizophrenia who is experiencing delusions. Which of the following interventions should the nurse implement?
- A. Challenging the client’s delusions directly
- B. Reinforcing the delusional beliefs
- C. Providing reality-based statements
- D. Isolating the client from others
Answer: C. Providing reality-based statements Explanation: Providing reality-based statements helps the client differentiate between delusions and reality without reinforcing false beliefs.
- Question: A client with bipolar disorder is experiencing depressive symptoms. Which of the following interventions should the nurse implement to support the client’s mental health?
- A. Encouraging social isolation
- B. Promoting engagement in activities
- C. Discouraging participation in therapy
- D. Ignoring the client’s symptoms
Answer: B. Promoting engagement in activities Explanation: Promoting engagement in activities helps improve mood and provides positive reinforcement for clients with depressive symptoms.
- Question: A client with a history of panic disorder is admitted to the hospital. Which of the following is a priority nursing intervention?
- A. Encouraging the client to avoid all social interactions
- B. Teaching the client deep breathing exercises
- C. Allowing the client to consume large amounts of caffeine
- D. Ignoring the client’s symptoms
Answer: B. Teaching the client deep breathing exercises Explanation: Teaching the client deep breathing exercises helps manage panic attacks and reduce anxiety.
- Question: A nurse is providing care for a client with postpartum depression. Which of the following interventions should the nurse implement?
- A. Encouraging the client to care for the baby without assistance
- B. Providing support and resources for new mothers
- C. Discouraging the client from discussing their feelings
- D. Ignoring the client’s symptoms
Answer: B. Providing support and resources for new mothers Explanation: Providing support and resources helps the client manage postpartum depression and access the help they need.
- Question: A client with obsessive-compulsive disorder (OCD) is admitted to the hospital. Which of the following interventions should the nurse implement?
- A. Encouraging the client to avoid their compulsions
- B. Allowing the client to perform rituals initially
- C. Discouraging the client from expressing their feelings
- D. Isolating the client from others
Answer: B. Allowing the client to perform rituals initially Explanation: Allowing the client to perform rituals initially helps reduce anxiety while gradually working on alternative coping strategies.
- Question: A nurse is caring for a client with dementia who is experiencing agitation. Which of the following interventions should the nurse implement?
- A. Providing a structured and predictable routine
- B. Encouraging the client to remain isolated
- C. Using physical restraints to manage agitation
- D. Ignoring the client’s behavior
Answer: A. Providing a structured and predictable routine Explanation: A structured and predictable routine helps reduce agitation and promotes a sense of security for clients with dementia.
- Question: A client with borderline personality disorder (BPD) is exhibiting self-harm behaviors. Which of the following is a priority nursing intervention?
- A. Ignoring the client’s behavior
- B. Providing a safe environment
- C. Allowing the client to self-harm
- D. Discouraging the client from seeking help
Answer: B. Providing a safe environment Explanation: Providing a safe environment helps prevent self-harm and ensures the client’s safety.
- Question: A nurse is providing care for a client with generalized anxiety disorder (GAD). Which of the following interventions should the nurse implement?
- A. Encouraging the client to suppress their anxiety
- B. Promoting relaxation techniques
- C. Discouraging the client from expressing their feelings
- D. Ignoring the client’s anxiety
Answer: B. Promoting relaxation techniques Explanation: Promoting relaxation techniques helps the client manage anxiety and develop effective coping strategies.
- Question: A client with major depressive disorder is experiencing feelings of hopelessness. Which of the following interventions should the nurse implement?
- A. Encouraging the client to remain isolated
- B. Providing support and active listening
- C. Discouraging the client from discussing their feelings
- D. Ignoring the client’s symptoms
Answer: B. Providing support and active listening Explanation: Providing support and active listening helps the client feel heard and understood, promoting emotional healing.
- Question: A nurse is caring for a client with bipolar disorder who is experiencing a depressive episode. Which of the following interventions should the nurse implement?
- A. Encouraging the client to stay in bed all day
- B. Promoting engagement in therapeutic activities
- C. Discouraging the client from participating in therapy
- D. Ignoring the client’s symptoms
Answer: B. Promoting engagement in therapeutic activities Explanation: Engaging in therapeutic activities helps improve mood and provides positive reinforcement for clients with depressive symptoms.
- Question: A client with schizophrenia is exhibiting signs of paranoia. Which of the following interventions should the nurse implement?
- A. Challenging the client’s paranoid beliefs directly
- B. Reinforcing reality and providing reassurance
- C. Encouraging the client to trust their delusions
- D. Ignoring the client’s behavior
Answer: B. Reinforcing reality and providing reassurance Explanation: Reinforcing reality and providing reassurance helps the client feel safe and supported, reducing paranoia.
- Question: A nurse is providing care for a client with post-traumatic stress disorder (PTSD) who is experiencing flashbacks. Which of the following interventions should the nurse implement?
- A. Encouraging the client to avoid discussing their trauma
- B. Providing a safe and calming environment
- C. Discouraging the client from seeking therapy
- D. Ignoring the client’s symptoms
Answer: B. Providing a safe and calming environment Explanation: A safe and calming environment helps reduce the intensity of flashbacks and provides a sense of security for the client.
- Question: A client with a history of substance abuse is seeking treatment. Which of the following is a priority nursing intervention?
- A. Encouraging the client to continue using substances
- B. Providing information about detoxification programs
- C. Discouraging the client from seeking help
- D. Ignoring the client’s situation
Answer: B. Providing information about detoxification programs Explanation: Providing information about detoxification programs helps the client access the resources they need for recovery.
- Question: A nurse is caring for a client who is experiencing bereavement after the loss of a spouse. Which of the following interventions should the nurse implement?
- A. Encouraging the client to suppress their emotions
- B. Providing a supportive and empathetic presence
- C. Discouraging the client from expressing their grief
- D. Ignoring the client’s feelings
Answer: B. Providing a supportive and empathetic presence Explanation: Offering a supportive and empathetic presence helps the client process their grief and emotions.
- Question: A client with an anxiety disorder is experiencing difficulty sleeping. Which of the following interventions should the nurse implement?
- A. Encouraging the client to consume caffeine before bedtime
- B. Promoting good sleep hygiene practices
- C. Allowing the client to stay up all night
- D. Ignoring the client’s sleep difficulties
Answer: B. Promoting good sleep hygiene practices Explanation: Promoting good sleep hygiene practices helps improve the client’s sleep quality and reduce anxiety.
- Question: A nurse is caring for a client with anorexia nervosa. Which of the following is a priority nursing intervention?
- A. Monitoring the client’s food intake and weight
- B. Allowing the client to choose not to eat
- C. Discouraging the client from expressing their feelings
- D. Ignoring the client’s behavior
Answer: A. Monitoring the client’s food intake and weight Explanation: Monitoring the client’s food intake and weight helps assess the severity of the eating disorder and provides data for treatment planning.
- Question: A client with a history of depression is being discharged from the hospital. Which of the following discharge instructions should the nurse include?
- A. Avoiding all social interactions
- B. Continuing prescribed medications and follow-up appointments
- C. Discontinuing medications when feeling better
- D. Ignoring any changes in mood
Answer: B. Continuing prescribed medications and follow-up appointments Explanation: Continuing prescribed medications and follow-up appointments ensures ongoing treatment and support for the client’s mental health.
- Question: A nurse is providing care for a client with a history of self-harm behaviors. Which of the following interventions should the nurse implement?
- A. Ignoring the client’s behavior
- B. Providing a safe environment and close supervision
- C. Allowing the client to self-harm
- D. Discouraging the client from seeking help
Answer: B. Providing a safe environment and close supervision Explanation: Providing a safe environment and close supervision helps prevent self-harm and ensures the client’s safety.
- Question: A client with schizophrenia is experiencing negative symptoms such as social withdrawal. Which of the following interventions should the nurse implement?
- A. Encouraging social interaction and engagement in activities
- B. Allowing the client to remain isolated
- C. Discouraging participation in group therapy
- D. Ignoring the client’s symptoms
Answer: A. Encouraging social interaction and engagement in activities Explanation: Encouraging social interaction and engagement in activities helps reduce negative symptoms and improve the client’s social functioning.
- Question: A nurse is caring for a client with bipolar disorder who is experiencing a manic episode. Which of the following interventions should the nurse implement?
- A. Encouraging the client to engage in high-risk behaviors
- B. Providing a structured and calm environment
- C. Allowing the client to make impulsive decisions
- D. Ignoring the client’s behavior
Answer: B. Providing a structured and calm environment Explanation: A structured and calm environment helps manage the client’s behavior and promotes stability during a manic episode.
- Question: A client with a history of substance abuse is seeking treatment. Which of the following is a priority nursing intervention?
- A. Encouraging the client to continue using substances
- B. Providing information about detoxification programs
- C. Discouraging the client from seeking help
- D. Ignoring the client’s situation
Answer: B. Providing information about detoxification programs Explanation: Providing information about detoxification programs helps the client access the resources they need for recovery.
- Question: A nurse is caring for a client with major depressive disorder who is experiencing suicidal ideation. Which of the following is a priority nursing intervention?
- A. Leaving the client alone in their room
- B. Providing constant supervision and a safe environment
- C. Discouraging the client from discussing their feelings
- D. Ignoring the client’s symptoms
Answer: B. Providing constant supervision and a safe environment Explanation: Providing constant supervision and a safe environment is crucial to ensure the client’s safety and prevent self-harm.
4. Physiological Integrity
Physiological Integrity is one of the four major categories of client needs tested on the NCLEX-RN exam. This category encompasses the nurse’s ability to promote physical health and wellness by providing care and comfort, reducing risk potential, and managing health alterations..
This section includes questions from Basic Care and Comfort (6-12%), Pharmacological and Parenteral Therapies (13-19%), Reduction of Risk Potential (9-15%) and Physiological Adaptation (11-17%)
- Question: A nurse is providing care for a client who is bedridden. Which of the following interventions should the nurse implement to prevent skin breakdown?
- A. Massaging bony prominences
- B. Keeping the client in one position for extended periods
- C. Using moisture barriers on the skin
- D. Limiting fluid intake
Answer: C. Using moisture barriers on the skin Explanation: Moisture barriers help protect the skin from breakdown due to incontinence and excessive moisture.
- Question: When providing perineal care to a female client, the nurse should wipe:
- A. From back to front
- B. From front to back
- C. In a circular motion
- D. Only when necessary
Answer: B. From front to back Explanation: Wiping from front to back helps prevent the spread of bacteria from the anal area to the urinary tract.
- Question: A client who is postoperative following abdominal surgery is experiencing pain. Which of the following non-pharmacological interventions should the nurse implement to help manage the client’s pain?
- A. Encouraging deep breathing and relaxation techniques
- B. Applying a cold compress to the surgical site
- C. Encouraging the client to remain immobile
- D. Administering an analgesic as prescribed
Answer: A. Encouraging deep breathing and relaxation techniques Explanation: Deep breathing and relaxation techniques can help alleviate pain by promoting relaxation and reducing muscle tension.
- Question: Which of the following interventions should a nurse implement to promote sleep for a client in the hospital?
- A. Keeping the room brightly lit at night
- B. Administering a sleep aid medication
- C. Encouraging a bedtime routine
- D. Allowing frequent visitors
Answer: C. Encouraging a bedtime routine Explanation: Establishing a bedtime routine helps signal the body that it is time to sleep, promoting better sleep hygiene.
- Question: A nurse is caring for a client with limited mobility. Which of the following interventions should the nurse implement to prevent the formation of contractures?
- A. Keeping the client in a semi-Fowler’s position
- B. Encouraging the client to perform range-of-motion exercises
- C. Applying cold packs to the joints
- D. Limiting the client’s physical activity
Answer: B. Encouraging the client to perform range-of-motion exercises Explanation: Range-of-motion exercises help maintain joint flexibility and prevent contractures.
- Question: Which of the following actions should a nurse take to promote adequate nutrition for an older adult client with dysphagia?
- A. Offering thin liquids
- B. Providing small, frequent meals
- C. Encouraging the client to eat quickly
- D. Avoiding the use of thickening agents
Answer: B. Providing small, frequent meals Explanation: Small, frequent meals can be easier to manage and help ensure adequate nutrition intake for clients with dysphagia.
Pharmacological and Parenteral Therapies
- Question: A nurse is administering a medication to a client and observes swelling and redness at the IV site. Which of the following actions should the nurse take first?
- A. Increase the IV flow rate
- B. Apply a warm compress to the site
- C. Stop the IV infusion
- D. Elevate the affected limb
Answer: C. Stop the IV infusion Explanation: The nurse should stop the IV infusion immediately to prevent further complications and assess the site for signs of infiltration or phlebitis.
- Question: A client is prescribed digoxin for heart failure. Which of the following should the nurse monitor to assess for digoxin toxicity?
- A. Blood pressure
- B. Respiratory rate
- C. Heart rate
- D. Blood glucose levels
Answer: C. Heart rate Explanation: The nurse should monitor the heart rate, as bradycardia can be a sign of digoxin toxicity.
- Question: When administering insulin to a client, which of the following is the correct technique?
- A. Injecting at a 90-degree angle
- B. Massaging the injection site after administration
- C. Injecting into the same site each time
- D. Administering insulin at room temperature
Answer: A. Injecting at a 90-degree angle Explanation: Insulin should be injected at a 90-degree angle to ensure proper absorption.
- Question: A nurse is preparing to administer an intramuscular (IM) injection of a medication. Which of the following sites is appropriate for an IM injection?
- A. Deltoid muscle
- B. Abdomen
- C. Inner forearm
- D. Dorsogluteal muscle
Answer: A. Deltoid muscle Explanation: The deltoid muscle is a commonly used site for IM injections, especially for smaller volumes of medication.
- Question: A client is prescribed a diuretic medication. Which of the following laboratory values should the nurse monitor to assess for potential side effects?
- A. Hemoglobin
- B. Potassium
- C. White blood cell count
- D. Creatinine
Answer: B. Potassium Explanation: Diuretics can cause electrolyte imbalances, including hypokalemia, so potassium levels should be monitored.
- Question: A nurse is providing education to a client about the use of a metered-dose inhaler (MDI). Which of the following instructions should the nurse include?
- A. Shake the inhaler before each use
- B. Exhale immediately after inhaling the medication
- C. Use the inhaler only once a day
- D. Store the inhaler in a humid environment
Answer: A. Shake the inhaler before each use Explanation: Shaking the inhaler helps ensure the medication is properly mixed and delivered effectively.
Reduction of Risk Potential
- Question: A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse report to the healthcare provider immediately?
- A. Bubbling in the water seal chamber
- B. Continuous bubbling in the suction control chamber
- C. Drainage of 100 mL per hour
- D. Dislodgment of the chest tube
Answer: D. Dislodgment of the chest tube Explanation: Dislodgment of the chest tube is a medical emergency that requires immediate intervention.
- Question: A client is at risk for deep vein thrombosis (DVT). Which of the following interventions should the nurse implement to reduce this risk?
- A. Encouraging bed rest
- B. Applying compression stockings
- C. Restricting fluid intake
- D. Elevating the client’s legs
Answer: B. Applying compression stockings Explanation: Compression stockings help promote venous return and reduce the risk of DVT.
- Question: When monitoring a client who is receiving enteral nutrition, which of the following is a priority assessment?
- A. Blood pressure
- B. Blood glucose levels
- C. Residual gastric volume
- D. Urine output
Answer: C. Residual gastric volume Explanation: Monitoring residual gastric volume helps assess tolerance to enteral feeding and reduces the risk of aspiration.
- Question: A nurse is caring for a client who is receiving chemotherapy. Which of the following is an important intervention to reduce the risk of infection?
- A. Placing the client in a private room
- B. Restricting the client’s intake of fluids
- C. Allowing visitors without restrictions
- D. Administering antibiotics prophylactically
Answer: A. Placing the client in a private room Explanation: Placing the client in a private room helps reduce the risk of infection by minimizing exposure to potential pathogens.
- Question: When caring for a client with a urinary catheter, which of the following interventions helps reduce the risk of catheter-associated urinary tract infections (CAUTIs)?
- A. Clamping the catheter intermittently
- B. Keeping the drainage bag above the level of the bladder
- C. Ensuring the catheter is secured to the client’s leg
- D. Irrigating the catheter daily
Answer: C. Ensuring the catheter is secured to the client’s leg Explanation: Securing the catheter to the client’s leg helps prevent movement and trauma to the urethra, reducing the risk of infection.
- Question: A nurse is assessing a client for signs of hypoglycemia. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Diaphoresis
- C. Hypertension
- D. Flushed skin
Answer: B. Diaphoresis Explanation: Diaphoresis (sweating) is a common sign of hypoglycemia.
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Physiological Adaptation
- Question: A client with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath. Which of the following positions should the nurse encourage the client to use to improve ventilation?
- A. Supine position
- B. High Fowler’s position
- C. Prone position
- D. Trendelenburg position
Answer: B. High Fowler’s position Explanation: High Fowler’s position helps improve lung expansion and ventilation for clients experiencing shortness of breath.
- Question: A nurse is caring for a client with acute renal failure. Which of the following laboratory values should the nurse monitor to assess the client’s renal function?
- A. Hemoglobin
- B. Blood urea nitrogen (BUN) and creatinine
- C. White blood cell count
- D. Serum glucose
Answer: B. Blood urea nitrogen (BUN) and creatinine Explanation: BUN and creatinine levels are key indicators of renal function and should be monitored in clients with acute renal failure.
- Question: When providing care for a client with liver cirrhosis, which of the following is a priority assessment for the nurse?
- A. Monitoring for signs of jaundice
- B. Assessing for peripheral edema
- C. Evaluating for signs of ascites
- D. Monitoring for changes in mental status
Answer: D. Monitoring for changes in mental status Explanation: Changes in mental status can indicate hepatic encephalopathy, a serious complication of liver cirrhosis that requires immediate attention.
- Question: A nurse is caring for a client with hypothyroidism. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Weight loss
- C. Cold intolerance
- D. Diarrhea
Answer: C. Cold intolerance Explanation: Cold intolerance is a common symptom of hypothyroidism due to the decreased metabolic rate.
- Question: When providing care for a client with heart failure, which of the following interventions should the nurse implement to reduce fluid volume overload?
- A. Encouraging high sodium intake
- B. Monitoring daily weight
- C. Restricting fluid intake to 2 liters per day
- D. Administering bronchodilators
Answer: B. Monitoring daily weight Explanation: Monitoring daily weight helps assess fluid balance and detect early signs of fluid volume overload in clients with heart failure.
- Question: A nurse is caring for a client with diabetes mellitus who is experiencing hyperglycemia. Which of the following interventions should the nurse implement?
- A. Administering an oral hypoglycemic agent
- B. Providing a high-sugar snack
- C. Administering insulin as prescribed
- D. Encouraging increased physical activity
Answer: C. Administering insulin as prescribed Explanation: Administering insulin helps lower blood glucose levels and is essential in managing hyperglycemia in clients with diabetes mellitus.
- Question: When assessing a client with a head injury, which of the following is a priority assessment?
- A. Monitoring blood pressure
- B. Assessing level of consciousness
- C. Evaluating peripheral pulses
- D. Checking bowel sounds
Answer: B. Assessing level of consciousness Explanation: Assessing the level of consciousness is crucial in clients with head injuries to detect changes in neurological status and possible complications.
- Question: A nurse is providing care for a client with an acute asthma exacerbation. Which of the following interventions should the nurse implement to improve the client’s oxygenation?
- A. Administering a bronchodilator
- B. Encouraging the client to lie flat
- C. Restricting fluid intake
- D. Providing a high-carbohydrate diet
Answer: A. Administering a bronchodilator Explanation: Administering a bronchodilator helps open the airways and improve oxygenation in clients with asthma exacerbations.
- Question: A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which of the following should the nurse monitor during the procedure?
- A. Blood pressure
- B. Blood glucose levels
- C. White blood cell count
- D. Hemoglobin levels
Answer: A. Blood pressure Explanation: Monitoring blood pressure during hemodialysis is important to detect and manage potential complications such as hypotension.
- Question: When providing care for a client with anemia, which of the following dietary recommendations should the nurse include?
- A. High-fiber foods
- B. Foods rich in iron
- C. Low-protein foods
- D. Low-calorie foods
Answer: B. Foods rich in iron Explanation: Foods rich in iron help improve hemoglobin levels and manage anemia.
- Question: A nurse is caring for a client with pancreatitis. Which of the following is a priority nursing intervention?
- A. Administering oral fluids
- B. Providing a high-fat diet
- C. Administering pain medication
- D. Encouraging ambulation
Answer: C. Administering pain medication Explanation: Managing pain is a priority in clients with pancreatitis to improve comfort and support recovery.
- Question: When caring for a client with hyperthyroidism, which of the following findings should the nurse expect?
- A. Weight gain
- B. Bradycardia
- C. Heat intolerance
- D. Constipation
Answer: C. Heat intolerance Explanation: Heat intolerance is a common symptom of hyperthyroidism due to the increased metabolic rate.
- Question: A nurse is assessing a client with peripheral artery disease (PAD). Which of the following findings should the nurse expect?
- A. Warm, reddened skin
- B. Increased hair growth on legs
- C. Intermittent claudication
- D. Edema
Answer: C. Intermittent claudication Explanation: Intermittent claudication, or pain in the legs during exercise, is a common symptom of peripheral artery disease.
- Question: When providing care for a client with liver cirrhosis and ascites, which of the following interventions should the nurse implement?
- A. Encouraging high-protein intake
- B. Administering diuretics as prescribed
- C. Restricting fluid intake to 1 liter per day
- D. Providing a low-calorie diet
Answer: B. Administering diuretics as prescribed Explanation: Administering diuretics helps manage fluid retention and reduce ascites in clients with liver cirrhosis.
- Question: A nurse is providing care for a client with a spinal cord injury. Which of the following is a priority assessment?
- A. Monitoring respiratory function
- B. Assessing skin integrity
- C. Evaluating bowel sounds
- D. Checking peripheral pulses
Answer: A. Monitoring respiratory function Explanation: Monitoring respiratory function is crucial in clients with spinal cord injuries due to the risk of respiratory compromise.
- Question: When caring for a client with chronic heart failure, which of the following dietary recommendations should the nurse include?
- A. High-sodium diet
- B. Low-potassium diet
- C. Fluid restriction
- D. High-fat diet
Answer: C. Fluid restriction Explanation: Fluid restriction helps manage fluid balance and reduce the risk of fluid volume overload in clients with chronic heart failure.
- Question: A nurse is assessing a client with acute pancreatitis. Which of the following laboratory values should the nurse monitor to assess the severity of the condition?
- A. Serum amylase and lipase
- B. Hemoglobin and hematocrit
- C. Blood urea nitrogen (BUN)
- D. Serum potassium
Answer: A. Serum amylase and lipase Explanation: Elevated serum amylase and lipase levels are indicators of pancreatitis and help assess the severity of the condition.
- Question: When providing care for a client with peptic ulcer disease, which of the following interventions should the nurse implement?
- A. Administering proton pump inhibitors as prescribed
- B. Encouraging a high-fiber diet
- C. Administering antacids before meals
- D. Restricting fluid intake
Answer: A. Administering proton pump inhibitors as prescribed Explanation: Proton pump inhibitors help reduce gastric acid production and promote healing of peptic ulcers.
- Question: A nurse is caring for a client with chronic liver disease. Which of the following dietary recommendations should the nurse include to manage the client’s condition?
- A. High-protein diet
- B. High-sodium diet
- C. Low-fat diet
- D. Low-sodium diet
Answer: D. Low-sodium diet Explanation: A low-sodium diet helps manage fluid retention and reduce ascites in clients with chronic liver disease.
- Question: A client with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath. Which of the following positions should the nurse encourage the client to use to improve ventilation?
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