Question 1: Maternity

A nurse is assessing a 32-year-old pregnant client at 30 weeks of gestation. The client reports
swelling in her feet and legs, which increases throughout the day. Which of the following actions
should the nurse take first?

 A) Educate the client about resting with her legs elevated.

 B) Measure the client’s blood pressure.
 C) Assess the client’s urine output.
 D) Check for protein in the urine.

Correct Answer: B
Rationale: The first action the nurse should take is to measure the client’s blood pressure.
Swelling in the feet and legs can be a normal finding in pregnancy, but it can also indicate
complications like gestational hypertension or preeclampsia. Blood pressure assessment will help
determine if further evaluation is necessary.

Question 2: Pharmacology

A nurse is teaching a patient who has been prescribed warfarin about the medication. Which
statement by the patient indicates a need for further teaching?

 A) “I will need to have my INR checked regularly.”

 B) “I can eat as much spinach as I want.”
 C) “I should take this medication at the same time every day.”
 D) “I need to report any unusual bleeding to my doctor.”

Correct Answer: B
Rationale: This statement indicates a need for further teaching. While spinach and other leafy
greens are healthy, they are high in vitamin K, which can affect the effectiveness of warfarin.
Patients on warfarin should maintain a consistent intake of vitamin K, not consume it freely.

Question 3: Adult Health

A nurse is caring for a patient with a diagnosis of heart failure. The patient complains of
shortness of breath and is exhibiting signs of edema. Which assessment finding would be most
concerning?

 A) Increased heart rate.

 B) Crackles upon auscultation.
 C) Decreased urine output.
 D) Elevated blood pressure.
Correct Answer: B
Rationale: Crackles upon auscultation indicate fluid in the lungs, which is a sign of worsening
heart failure and potential pulmonary edema. This finding is the most concerning and requires
immediate attention.

Question 4: Pediatric Nursing

A nurse is assessing a 6-year-old child who has been diagnosed with asthma. Which of the
following symptoms would indicate that the child's asthma is poorly controlled?

 A) Occasional cough.
 B) Frequent nighttime awakenings due to coughing.
 C) Normal activity levels during the day.
 D) Use of a rescue inhaler less than once a week.

Correct Answer: B
Rationale: Frequent nighttime awakenings due to coughing are a sign that asthma is poorly
controlled. The goal of asthma management is to minimize nighttime symptoms and ensure
normal activity levels during the day.

Question 5: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia who is experiencing auditory
hallucinations. Which nursing intervention is most appropriate?

 A) Tell the patient to ignore the voices.

 B) Provide distraction with activities.
 C) Validate the patient’s experience of hallucinations.
 D) Ask the patient to describe the hallucinations in detail.

Correct Answer: C
Rationale: Validating the patient’s experience of hallucinations helps the nurse to establish
rapport and trust. It allows the nurse to engage in therapeutic communication while not endorsing
the hallucinations.

Question 6: Surgical Nursing

A nurse is preparing a patient for surgery. Which of the following is the priority assessment
before administering preoperative medications?
  A) Assess the patient’s pain level.
 B) Verify the patient's allergies.
 C) Review the surgical consent form.
 D) Obtain the patient’s vital signs.

Correct Answer: B
Rationale: Verifying the patient’s allergies is the priority assessment to prevent any adverse
reactions to medications that may be administered before surgery.

Question 7: Infection Control

A nurse is caring for a patient in a private room who is on contact precautions due to a
methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following actions
should the nurse take?

 A) Wear gloves when entering the room.

 B) Remove the gown and gloves before leaving the room.
 C) Wash hands with soap and water after leaving the room.
 D) Place a surgical mask on the patient when providing care.

Correct Answer: A
Rationale: The nurse should wear gloves when entering the room to prevent the spread of
MRSA. Hand hygiene should always be performed after leaving the room, and a gown should be
worn if there is a risk of contact with the patient or their environment.

Question 8: Nutrition

A nurse is teaching a patient with diabetes mellitus about dietary choices. Which food choice
would the nurse recommend as a source of complex carbohydrates?

 A) White rice.
 B) Whole grain bread.
 C) Table sugar.
 D) Honey.

Correct Answer: B
Rationale: Whole grain bread is a source of complex carbohydrates, which are digested more
slowly and help to maintain stable blood glucose levels, making it a better choice for someone
with diabetes.
Question 10: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
receiving oxygen therapy. Which of the following should the nurse monitor closely?

 A) Respiratory rate
 B) Oxygen saturation
 C) Heart rate
 D) Blood pressure

Correct Answer: B
Rationale: Monitoring oxygen saturation is critical in patients with COPD to ensure they are
receiving adequate oxygen without causing carbon dioxide retention.

Question 11: Gastrointestinal

A nurse is caring for a patient who is scheduled for a colonoscopy. Which pre-procedure
instruction should the nurse provide?

 A) “You can eat solid foods until midnight.”

 B) “You will need to drink a bowel prep solution.”
 C) “You must stop all medications 24 hours prior.”
 D) “You will be required to stay NPO for 8 hours before.”

Correct Answer: B
Rationale: Patients must drink a bowel preparation solution to cleanse the intestines before a
colonoscopy, allowing for a clear view during the procedure.

Question 12: Endocrine

A patient with diabetes is being discharged after starting insulin therapy. Which statement by the
patient indicates a need for further teaching?

 A) “I will inject my insulin into the same area each time.”

 B) “I need to monitor my blood sugar regularly.”
 C) “I should carry a source of glucose with me at all times.”
 D) “I will rotate my injection sites to avoid tissue damage.”
Correct Answer: A
Rationale: Injecting insulin into the same area repeatedly can cause lipodystrophy and affect
absorption. Patients should rotate injection sites.

Question 13: Neurological

A nurse is assessing a patient who has experienced a stroke. Which finding would indicate that
the patient is at risk for aspiration?

 A) Difficulty speaking
 B) Increased muscle tone
 C) Weak gag reflex
 D) Facial drooping

Correct Answer: C
Rationale: A weak gag reflex indicates that the patient may not be able to adequately protect
their airway, putting them at risk for aspiration.

Question 14: Pharmacology

A nurse is administering digoxin (Lanoxin) to a patient. Before administering the medication,

which assessment is most important?

 A) Assess the patient’s heart rate.

 B) Measure the patient’s blood pressure.
 C) Check the patient’s weight.
 D) Evaluate the patient’s potassium level.

Correct Answer: A
Rationale: Digoxin can cause bradycardia; thus, assessing the heart rate is essential before
administration. The nurse should withhold the medication if the heart rate is below the prescribed
threshold.

Question 15: Mental Health

A nurse is caring for a patient diagnosed with major depressive disorder who expresses feelings
of hopelessness. Which nursing diagnosis is the priority?

 A) Risk for self-directed violence

 B) Ineffective coping
  C) Impaired social interaction
 D) Low self-esteem

Correct Answer: A
Rationale: Given the patient’s expressed feelings of hopelessness, the priority nursing diagnosis
is the risk for self-directed violence, which requires immediate attention.

Question 16: Infection Control

A nurse is providing care to a patient with tuberculosis (TB). Which precaution should the nurse
take?

 A) Wear gloves only.

 B) Wear a standard surgical mask.
 C) Use an N95 respirator.
 D) Use a face shield.

Correct Answer: C
Rationale: An N95 respirator is necessary when caring for a patient with TB to protect against
airborne transmission of the bacteria.

Question 17: Pediatric Nursing

A nurse is assessing a 2-year-old child who is admitted with a high fever and rash. Which finding
would be most concerning?

 A) Child is irritable and fussy.

 B) Rash is maculopapular and blanching.
 C) Child has a decreased level of consciousness.
 D) Child is drinking fluids.

Correct Answer: C
Rationale: A decreased level of consciousness is a concerning finding that could indicate severe
illness or complications and requires immediate assessment and intervention.

Question 18: Nutrition

A nurse is providing dietary education to a patient with chronic kidney disease. Which food
should the nurse encourage the patient to limit?
  A) Apples
 B) Potatoes
 C) Chicken
 D) Brown rice

Correct Answer: B
Rationale: Potatoes are high in potassium, which should be limited in patients with chronic
kidney disease to prevent hyperkalemia.

Question 19: Cardiovascular

A nurse is teaching a patient about lifestyle modifications to manage hypertension. Which

statement indicates that the patient needs further education?

 A) “I will reduce my salt intake.”

 B) “I can continue to drink alcohol in moderation.”
 C) “I will start exercising regularly.”
 D) “I can stop taking my medication once my blood pressure is normal.”

Correct Answer: D
Rationale: This statement indicates a lack of understanding. Patients should not stop taking
antihypertensive medication without consulting their healthcare provider, even if their blood
pressure normalizes.

Question 20: Surgical Nursing

A nurse is preparing a patient for surgery. Which assessment finding should be reported to the
surgeon immediately?

 A) Patient has a history of hypertension.

 B) Patient has a slight cough.
 C) Patient has a new onset of chest pain.
 D) Patient has not voided for 6 hours.

Correct Answer: C
Rationale: New onset of chest pain is concerning and should be reported immediately, as it may
indicate a serious cardiac issue that could complicate the surgical procedure.

Question 21: Respiratory

A nurse is caring for a patient with asthma who is using a peak flow meter. Which reading
indicates that the patient should take their rescue inhaler?

 A) 80% of personal best

 B) 50% of personal best
 C) 60% of personal best
 D) 90% of personal best

Correct Answer: B
Rationale: A peak flow reading of 50% of the personal best indicates the patient is in a severe
zone and should use their rescue inhaler immediately.

Question 22: Endocrine

A nurse is providing discharge instructions for a patient with newly diagnosed type 2 diabetes.
Which statement by the patient indicates an understanding of the teaching?

 A) “I can eat whatever I want, as long as I take my medication.”

 B) “I need to monitor my blood sugar regularly.”
 C) “I should avoid all carbohydrates in my diet.”
 D) “I will need to inject insulin daily.”

Correct Answer: B
Rationale: Monitoring blood sugar regularly is essential for managing diabetes effectively. The
other statements indicate a misunderstanding of diabetes management.

Question 23: Geriatric Nursing

A nurse is assessing an elderly patient who lives alone. The nurse notices the patient has
difficulty preparing meals. Which intervention should the nurse recommend?

 A) Suggest the patient eat pre-packaged meals.

 B) Refer the patient to a home health aide.
 C) Encourage the patient to join a meal delivery service.
 D) Advise the patient to ask friends for help.

Correct Answer: B
Rationale: Referring the patient to a home health aide provides direct assistance with meal
preparation and other daily activities, ensuring their nutritional needs are met.
Question 24: Oncology

A nurse is caring for a patient receiving chemotherapy who reports nausea. Which intervention
should the nurse implement first?

 A) Administer antiemetic medication as prescribed.

 B) Assess the patient’s abdomen.
 C) Encourage the patient to eat bland foods.
 D) Offer ginger ale or clear liquids.

Correct Answer: A
Rationale: Administering antiemetic medication as prescribed is the priority intervention to
manage nausea and prevent further discomfort.

Question 25: Fluid and Electrolytes

A nurse is monitoring a patient receiving intravenous fluids. Which finding would indicate
potential fluid overload?

 A) Increased urine output

 B) Weight loss
 C) Edema
 D) Decreased blood pressure

Correct Answer: C
Rationale: Edema is a sign of fluid overload, indicating that the patient may be retaining excess
fluid, which can lead to complications such as heart failure.

Question 26: Pharmacology

A nurse is caring for a patient who has been prescribed morphine sulfate for pain management.
Which of the following is the priority assessment for this patient?

 A) Monitor the patient's pain level.

 B) Assess the patient's respiratory rate.
 C) Check for signs of constipation.
 D) Monitor the patient's blood pressure.

Correct Answer: B
Rationale: The priority assessment for a patient receiving morphine is monitoring the respiratory
rate. Morphine is an opioid that can depress the central nervous system, leading to respiratory
depression. Therefore, ensuring the patient's breathing is adequate is critical.
Question 27: Obstetrics

A nurse is caring for a patient in labor who is receiving oxytocin to stimulate contractions.
Which assessment finding should prompt the nurse to discontinue the oxytocin infusion?

 A) Contractions occurring every 5 minutes

 B) A fetal heart rate of 150 beats per minute
 C) Uterine contractions lasting 90 seconds
 D) Maternal blood pressure of 120/80 mmHg

Correct Answer: C
Rationale: Uterine contractions lasting longer than 90 seconds may indicate uterine
hyperstimulation, which can compromise fetal oxygenation. The nurse should discontinue the
oxytocin to prevent complications.

Question 28: Neurological

A nurse is assessing a patient with a history of seizures who is receiving phenytoin. Which
finding would indicate a potential side effect of the medication?

 A) Elevated blood glucose

 B) Gingival hyperplasia
 C) Tinnitus
 D) Weight gain

Correct Answer: B
Rationale: Gingival hyperplasia, or the overgrowth of gum tissue, is a common side effect of
phenytoin. Regular dental care and oral hygiene are essential for patients taking this medication.

Question 29: Renal

A patient with acute kidney injury has a urine output of 200 mL in the last 24 hours. Which term
describes this finding?

 A) Anuria
 B) Oliguria
 C) Polyuria
 D) Nocturia
Correct Answer: B
Rationale: Oliguria is defined as a urine output of less than 400 mL in 24 hours. Anuria would
be urine output less than 100 mL in 24 hours, and polyuria is excessive urine output.

Question 30: Pediatric Nursing

A nurse is caring for a 7-year-old child with dehydration due to gastroenteritis. Which
assessment finding would indicate that the child’s condition is improving?

 A) Sunken eyes
 B) Decreased urine output
 C) Moist mucous membranes
 D) Increased heart rate

Correct Answer: C
Rationale: Moist mucous membranes indicate adequate hydration status and are a sign that the
child’s condition is improving.

Question 31: Gastrointestinal

A nurse is caring for a patient who had a gastric bypass surgery 3 days ago. The patient reports
nausea and abdominal pain. Which intervention should the nurse perform first?

 A) Administer antiemetic medication as prescribed.

 B) Notify the surgeon immediately.
 C) Assess the patient’s abdomen for bowel sounds.
 D) Encourage the patient to ambulate.

Correct Answer: C
Rationale: Assessing for bowel sounds helps determine if the gastrointestinal tract is functioning
normally. Post-surgical complications such as paralytic ileus may cause abdominal pain and
nausea.

Question 32: Musculoskeletal

A nurse is assessing a patient who has a cast on the right leg. The patient reports increased pain
in the leg that is not relieved by medication. Which of the following should the nurse do first?

 A) Apply ice to the affected leg.

 B) Elevate the leg above heart level.
  C) Assess for signs of compartment syndrome.
 D) Administer additional pain medication.

Correct Answer: C
Rationale: Pain that is not relieved by medication can indicate compartment syndrome, a
medical emergency. Immediate assessment and intervention are required to prevent permanent
damage.

Question 33: Endocrine

A nurse is caring for a patient with hyperthyroidism. Which of the following symptoms would
the nurse expect to find during the assessment?

 A) Bradycardia
 B) Weight gain
 C) Heat intolerance
 D) Constipation

Correct Answer: C
Rationale: Patients with hyperthyroidism often experience heat intolerance due to the increased
metabolic rate. Other symptoms include tachycardia, weight loss, and diarrhea.

Question 34: Infection Control

A patient has a Clostridium difficile infection. Which intervention should the nurse include in the
care plan?

 A) Use of alcohol-based hand sanitizers

 B) Administering antibiotics as prescribed
 C) Wearing a surgical mask when entering the room
 D) Using soap and water for hand hygiene

Correct Answer: D
Rationale: Soap and water should be used for hand hygiene when caring for patients with C.
difficile, as alcohol-based hand sanitizers are not effective in killing the spores.

Question 35: Pharmacology

A nurse is preparing to administer metoprolol to a patient. Which assessment finding would

prompt the nurse to hold the medication and notify the healthcare provider?
  A) Heart rate of 55 beats per minute
 B) Blood pressure of 130/80 mmHg
 C) Respiratory rate of 18 breaths per minute
 D) Temperature of 98.6°F (37°C)

Correct Answer: A
Rationale: Metoprolol is a beta-blocker that can lower the heart rate. A heart rate below 60 beats
per minute is a contraindication for administering the medication without further evaluation.

Question 36: Obstetrics

A nurse is caring for a patient in the postpartum unit who is experiencing heavy vaginal
bleeding. Which intervention should the nurse implement first?

 A) Increase the intravenous fluid rate.

 B) Administer oxytocin as prescribed.
 C) Massage the uterine fundus.
 D) Place the patient in Trendelenburg position.

Correct Answer: C
Rationale: Massaging the uterine fundus stimulates contractions, which can help reduce
bleeding caused by uterine atony, a common cause of postpartum hemorrhage.

Question 37: Respiratory

A nurse is assessing a patient with chronic bronchitis who is experiencing shortness of breath.
Which intervention should the nurse implement first?

 A) Administer a bronchodilator as prescribed.

 B) Encourage the patient to drink fluids.
 C) Place the patient in a high-Fowler’s position.
 D) Perform chest physiotherapy.

Correct Answer: C
Rationale: Placing the patient in a high-Fowler’s position helps to maximize lung expansion and
improve breathing.

Question 38: Adult Health

A nurse is caring for a patient with cirrhosis who is at risk for bleeding. Which laboratory result
should the nurse monitor closely?

 A) Serum creatinine
 B) White blood cell count
 C) Prothrombin time (PT)
 D) Serum albumin

Correct Answer: C
Rationale: Prothrombin time (PT) measures the blood’s ability to clot. Patients with cirrhosis
often have prolonged PT, indicating a higher risk of bleeding.

Question 39: Neurological

A nurse is caring for a patient who is post-stroke and has right-sided hemiplegia. Which nursing
intervention is most appropriate to prevent skin breakdown?

 A) Place the patient on a high-protein diet.

 B) Encourage the patient to use the right side for mobility.
 C) Turn the patient every 2 hours.
 D) Apply lotion to dry skin areas.

Correct Answer: C
Rationale: Regularly turning the patient helps prevent pressure ulcers by redistributing pressure
and promoting circulation.

Question 40: Pediatric Nursing

A nurse is caring for a 5-month-old infant who is admitted for failure to thrive. Which
assessment finding would support this diagnosis?

 A) Weight below the 5th percentile

 B) Height at the 25th percentile
 C) Normal growth milestones
 D) Poor feeding habits

Correct Answer: A
Rationale: Weight below the 5th percentile indicates that the infant is not growing at an
expected rate, which is a sign of failure to thrive.
Question 41: Mental Health

A nurse is caring for a patient with generalized anxiety disorder who is experiencing a panic
attack. Which intervention is most appropriate?

 A) Encourage the patient to verbalize their feelings.

 B) Instruct the patient to take deep, slow breaths.
 C) Administer an anti-anxiety medication.
 D) Leave the patient alone to calm down.

Correct Answer: B
Rationale: Deep, slow breathing helps reduce hyperventilation and calm the patient during a
panic attack.

Question 42: Geriatrics

A nurse is assessing an elderly patient for signs of dehydration. Which symptom is most
commonly associated with dehydration in older adults?

 A) Dry skin
 B) Confusion
 C) Increased blood pressure
 D) Bradycardia

Correct Answer: B
Rationale: Confusion is a common symptom of dehydration in older adults due to decreased
total body water and physiological changes in the aging brain.

Question 43: Pharmacology

A patient is prescribed gentamicin for a bacterial infection. Which assessment finding would
indicate a possible adverse effect of the medication?

 A) Tinnitus
 B) Constipation
 C) Elevated blood sugar
 D) Dry mouth

Correct Answer: A
Rationale: Tinnitus can indicate ototoxicity, a potential adverse effect of gentamicin.
Monitoring for hearing changes is important during treatment.
Question 44: Oncology

A nurse is providing care for a patient with neutropenia following chemotherapy. Which of the
following precautions should the nurse implement?

 A) Avoid fresh flowers in the patient’s room.

 B) Wear a mask when entering the room.
 C) Place the patient in isolation.
 D) Use contact precautions.

Correct Answer: A
Rationale: Fresh flowers may harbor bacteria that can pose a risk to immunocompromised
patients, such as those with neutropenia.

Question 45: Endocrine

A nurse is caring for a patient with Addison’s disease. Which clinical manifestation should the
nurse expect to observe?

 A) Moon face
 B) Hyperpigmentation of the skin
 C) Hypertension
 D) Weight gain

Correct Answer: B
Rationale: Hyperpigmentation of the skin, especially in areas exposed to sunlight, is a
characteristic sign of Addison’s disease due to increased levels of ACTH.

Question 46: Cardiovascular

A nurse is monitoring a patient who is receiving warfarin therapy. Which laboratory test should
the nurse review to assess the effectiveness of this medication?

 A) Platelet count
 B) Prothrombin time (PT) and INR
 C) Activated partial thromboplastin time (aPTT)
 D) Fibrinogen level

Correct Answer: B
Rationale: Prothrombin time (PT) and International Normalized Ratio (INR) are used to monitor
the effectiveness of warfarin therapy and ensure that the patient’s blood coagulation is within the
therapeutic range.

Question 47: Infection Control

A nurse is caring for a patient with a suspected viral infection. Which of the following
precautions should the nurse implement?

 A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions

Correct Answer: D
Rationale: Standard precautions should be used for all patients, regardless of infection status,
and include hand hygiene and the use of personal protective equipment (PPE) as needed.

Question 48: Geriatrics

A nurse is assessing an older adult patient for signs of depression. Which of the following
findings would most likely indicate depression in this population?

 A) Increased appetite
 B) Social withdrawal
 C) Excessive energy
 D) Improved sleep patterns

Correct Answer: B
Rationale: Social withdrawal is a common sign of depression in older adults, who may isolate
themselves from family and friends.

Question 49: Gastrointestinal

A nurse is caring for a patient who has just undergone an esophagectomy. Which of the
following should the nurse prioritize in the immediate postoperative care?

 A) Assessing the patient's pain level

 B) Monitoring for signs of infection
 C) Assessing the airway and breathing
 D) Encouraging early ambulation
Correct Answer: C
Rationale: The priority in immediate postoperative care is to assess the airway and breathing,
especially after thoracic surgery, to ensure the patient is stable.

Question 50: Pediatric Nursing

A nurse is assessing a toddler during a well-child visit. Which of the following developmental
milestones should the nurse expect the child to achieve by this age?

 A) Ability to ride a tricycle

 B) Ability to dress independently
 C) Ability to speak in full sentences
 D) Ability to build a tower of six blocks

Correct Answer: D
Rationale: By age 2, a toddler typically can build a tower of 6 blocks, demonstrating fine motor
skills and coordination.

Question 51: Mental Health

A nurse is caring for a patient diagnosed with obsessive-compulsive disorder (OCD). Which
nursing intervention is most appropriate?

 A) Encourage the patient to stop compulsive behaviors immediately.

 B) Allow the patient to verbalize feelings about their obsessions and compulsions.
 C) Redirect the patient’s attention to other activities.
 D) Limit the patient’s time spent on rituals.

Correct Answer: B
Rationale: Allowing the patient to verbalize feelings provides an opportunity for therapeutic
communication and helps the nurse understand the patient's experience with their condition.

Question 52: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
intervention is essential for managing this patient’s care?

 A) Administering high-flow oxygen

 B) Encouraging coughing and deep breathing
 C) Teaching the patient to use an inhaler with a spacer
  D) Placing the patient in a supine position

Correct Answer: C
Rationale: Teaching the patient to use an inhaler with a spacer improves medication delivery to
the lungs and is essential for managing COPD effectively.

Question 53: Pharmacology

A patient is prescribed levothyroxine for hypothyroidism. Which statement by the patient

indicates a need for further teaching?

 A) “I should take this medication on an empty stomach.”

 B) “I can stop taking this medication if I feel better.”
 C) “I need to have my thyroid levels checked regularly.”
 D) “I should report any chest pain or palpitations.”

Correct Answer: B
Rationale: Patients should not stop taking levothyroxine without consulting their healthcare
provider, even if they feel better, as it is a lifelong treatment.

Question 54: Neurological

A nurse is assessing a patient with a spinal cord injury. Which of the following findings would
indicate an emergency?

 A) Hypotension and bradycardia

 B) Loss of reflexes below the injury level
 C) Inability to move limbs
 D) Bladder distension

Correct Answer: A
Rationale: Hypotension and bradycardia can indicate neurogenic shock, which is a medical
emergency requiring immediate intervention.

Question 55: Adult Health

A patient with heart failure is experiencing shortness of breath while lying flat. Which condition
does this symptom most likely indicate?

 A) Orthopnea
  B) Paroxysmal nocturnal dyspnea
 C) Pulmonary edema
 D) Hypoxia

Correct Answer: A
Rationale: Orthopnea is difficulty breathing when lying flat, often seen in patients with heart
failure due to fluid accumulation in the lungs.

Question 56: Obstetrics

A nurse is monitoring a laboring patient receiving epidural anesthesia. Which assessment finding
should the nurse report immediately?

 A) Maternal blood pressure of 90/60 mmHg

 B) Increased fetal heart rate
 C) Urinary retention
 D) Mild headache

Correct Answer: A
Rationale: A maternal blood pressure of 90/60 mmHg may indicate hypotension due to epidural
anesthesia, which can affect fetal heart rate and requires immediate attention.

Question 57: Endocrine

A patient with type 1 diabetes is experiencing hypoglycemia. Which symptom should the nurse
expect to find?

 A) Sweating
 B) Nausea
 C) Bradycardia
 D) Dry skin

Correct Answer: A
Rationale: Sweating is a common symptom of hypoglycemia due to the release of adrenaline in
response to low blood sugar levels.

Question 58: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). What
type of precautions should the nurse implement?
  A) Standard precautions
 B) Contact precautions
 C) Droplet precautions
 D) Airborne precautions

Correct Answer: B
Rationale: Contact precautions are necessary for patients with MRSA to prevent the spread of
infection through direct or indirect contact.

Question 59: Nutrition

A nurse is teaching a patient about dietary sources of iron. Which of the following foods should
the nurse recommend?

 A) Apples
 B) Whole grains
 C) Spinach
 D) Dairy products

Correct Answer: C
Rationale: Spinach is a good source of non-heme iron, and educating patients about iron-rich
foods is important for preventing or treating iron deficiency anemia.

Question 60: Pediatric Nursing

A nurse is caring for a child with asthma who is prescribed a corticosteroid inhaler. Which
statement by the child’s parent indicates an understanding of the medication?

 A) “I should give this medication only during an asthma attack.”

 B) “I will rinse my child’s mouth after using the inhaler.”
 C) “This inhaler will help my child’s asthma, but it doesn’t have any side effects.”
 D) “My child should take this medication once a day at bedtime.”

Correct Answer: B
Rationale: Rinsing the mouth after using a corticosteroid inhaler helps prevent thrush, a
common side effect. The other statements indicate a misunderstanding of the medication.

Question 61: Cardiovascular

A nurse is educating a patient about lifestyle modifications to manage hypertension. Which
statement indicates a need for further teaching?

 A) “I will reduce my sodium intake.”

 B) “I can continue to eat processed foods occasionally.”
 C) “I will exercise for at least 30 minutes most days of the week.”
 D) “I will limit my alcohol intake.”

Correct Answer: B
Rationale: Processed foods are often high in sodium and can exacerbate hypertension.
Educating the patient on avoiding these foods is crucial.

Question 62: Mental Health

A nurse is developing a care plan for a patient diagnosed with schizophrenia. Which of the
following interventions is most appropriate?

 A) Encourage the patient to isolate from others.

 B) Use firm, direct communication.
 C) Allow the patient to express delusional thoughts.
 D) Avoid setting limits on the patient’s behavior.

Correct Answer: B
Rationale: Using firm, direct communication helps provide structure and clarity for patients
with schizophrenia, who may struggle with perception and understanding.

Question 63: Gastrointestinal

A nurse is caring for a patient with acute pancreatitis. Which of the following findings should the
nurse expect to assess?

 A) Jaundice
 B) Abdominal pain in the left upper quadrant
 C) Hypoactive bowel sounds
 D) Hyperglycemia

Correct Answer: D
Rationale: Hyperglycemia can occur in acute pancreatitis due to the pancreas's impaired ability
to produce insulin.
Question 64: Pharmacology

A nurse is preparing to administer insulin to a patient with diabetes. Which of the following
should the nurse do first?

 A) Check the patient's blood glucose level.

 B) Verify the insulin dosage with another nurse.
 C) Teach the patient about insulin action.
 D) Review the patient's medication history.

Correct Answer: A
Rationale: The nurse should always check the patient's blood glucose level before administering
insulin to ensure safe and appropriate dosing.

Question 65: Neurological

A nurse is caring for a patient diagnosed with multiple sclerosis (MS). Which symptom should
the nurse expect to see?

 A) Sudden onset of weakness in one arm

 B) Unilateral facial drooping
 C) Difficulty with coordination and balance
 D) Intense headache

Correct Answer: C
Rationale: Difficulty with coordination and balance is a common symptom of MS due to the
demyelination of nerves in the central nervous system.

Question 66: Pediatric Nursing

A nurse is assessing a 3-year-old child. Which developmental milestone should the nurse expect
the child to have achieved?

 A) Can hop on one foot

 B) Can speak in short sentences
 C) Can dress independently
 D) Can understand abstract concepts

Correct Answer: B
Rationale: By age 3, children typically can speak in short sentences, demonstrating language
development appropriate for their age.
Question 67: Obstetrics

A nurse is monitoring a patient in the second stage of labor. Which of the following findings
would indicate that the patient is ready to deliver?

 A) Complete dilation of the cervix

 B) Fetal heart rate of 120 bpm
 C) Maternal blood pressure of 110/70 mmHg
 D) Increased urge to push

Correct Answer: A
Rationale: Complete dilation of the cervix indicates that the patient is ready to deliver, as this
stage involves pushing and delivery.

Question 68: Endocrine

A nurse is teaching a patient about signs and symptoms of hyperglycemia. Which of the
following symptoms should the nurse include?

 A) Sweating
 B) Tremors
 C) Increased thirst
 D) Palpitations

Correct Answer: C
Rationale: Increased thirst (polydipsia) is a common symptom of hyperglycemia due to osmotic
diuresis.

Question 69: Infection Control

A nurse is caring for a patient with tuberculosis (TB). Which type of room should the nurse place
the patient in?

 A) Private room with negative pressure

 B) Shared room with other patients
 C) Room with high humidity
 D) Isolation room with a surgical mask
Correct Answer: A
Rationale: A private room with negative pressure is required for patients with TB to prevent the
spread of airborne droplets.

Question 70: Renal

A nurse is assessing a patient with chronic kidney disease (CKD). Which finding would the
nurse expect to see in this patient?

 A) Hypercalcemia
 B) Decreased phosphorus levels
 C) Anemia
 D) Increased urine output

Correct Answer: C
Rationale: Anemia is common in CKD due to decreased erythropoietin production by the
kidneys.

Question 71: Mental Health

A nurse is working with a patient diagnosed with post-traumatic stress disorder (PTSD). Which
of the following interventions is most appropriate?

 A) Encourage avoidance of reminders of the trauma.

 B) Teach relaxation techniques.
 C) Use confrontation techniques to address trauma.
 D) Limit the patient’s time spent discussing the trauma.

Correct Answer: B
Rationale: Teaching relaxation techniques can help the patient manage anxiety and stress related
to PTSD.

Question 72: Adult Health

A nurse is caring for a patient with liver cirrhosis. Which laboratory value would the nurse
expect to be altered?

 A) Elevated hemoglobin
 B) Elevated bilirubin
 C) Decreased INR
  D) Normal albumin levels

Correct Answer: B
Rationale: Elevated bilirubin levels are common in liver cirrhosis due to impaired liver function
and bile production.

Question 73: Cardiovascular

A patient is being discharged after an acute myocardial infarction (AMI). Which discharge
instruction should the nurse emphasize?

 A) Engage in strenuous exercise immediately.

 B) Monitor blood pressure and heart rate daily.
 C) Maintain a low-fiber diet.
 D) Stop taking medications if feeling better.

Correct Answer: B
Rationale: Monitoring blood pressure and heart rate is crucial for patients recovering from an
AMI to assess cardiovascular stability and medication effectiveness.

Question 74: Pediatric Nursing

A nurse is assessing a newborn. Which of the following findings would indicate a potential
problem with the infant’s development?

 A) Unable to track objects visually

 B) Startles to loud noises
 C) Cries when hungry
 D) Can lift head briefly while lying on stomach

Correct Answer: A
Rationale: Newborns should be able to visually track objects by 2-3 months. Inability to do so
may indicate a vision problem or developmental delay.

Question 75: Obstetrics

A nurse is caring for a patient who is 6 weeks postpartum and reports experiencing mood swings
and irritability. Which of the following should the nurse assess for?

 A) Postpartum depression
  B) Maternal bonding issues
 C) Adjustments to parenthood
 D) Hormonal changes

Correct Answer: A
Rationale: While mood swings can be normal in the postpartum period due to hormonal
changes, the nurse should assess for postpartum depression, which can occur within the first few
weeks after delivery.

Question 76: Pharmacology

A nurse is preparing to administer digoxin to a patient. Before giving the medication, which of
the following assessments is the priority?

 A) Assessing blood pressure

 B) Checking apical pulse
 C) Monitoring serum potassium levels
 D) Reviewing the patient's weight

Correct Answer: B
Rationale: Checking the apical pulse is essential before administering digoxin, as the medication
can cause bradycardia. If the pulse is below 60 bpm, the nurse should hold the medication and
notify the healthcare provider.

Question 77: Infection Control

A nurse is caring for a patient with a C. difficile infection. Which precaution should the nurse
implement?

 A) Standard precautions only

 B) Droplet precautions
 C) Airborne precautions
 D) Contact precautions

Correct Answer: D
Rationale: Contact precautions are necessary for C. difficile infections to prevent the spread of
spores through direct contact with contaminated surfaces or materials.

Question 78: Pediatric Nursing

A nurse is assessing a 2-year-old child. Which of the following findings is developmentally
appropriate for this age?

 A) Can count to ten

 B) Can speak in complete sentences
 C) Can follow simple commands
 D) Can dress independently

Correct Answer: C
Rationale: At 2 years old, children can typically follow simple commands, while counting and
complete sentences are typically seen at an older age.

Question 79: Endocrine

A nurse is caring for a patient with hyperthyroidism. Which symptom should the nurse expect to
assess?

 A) Weight gain
 B) Cold intolerance
 C) Fatigue
 D) Increased appetite

Correct Answer: D
Rationale: Increased appetite is a common symptom of hyperthyroidism, as the metabolism is
elevated. Other symptoms include weight loss and heat intolerance.

Question 80: Neurological

A nurse is caring for a patient who has experienced a stroke. Which of the following assessments
is most important for the nurse to perform?

 A) Assessing cranial nerve function

 B) Monitoring blood pressure
 C) Evaluating level of consciousness
 D) Checking for sensory deficits

Correct Answer: C
Rationale: Evaluating the level of consciousness is critical for stroke patients to assess
neurological status and potential complications.
Question 81: Cardiovascular

A nurse is teaching a patient with hypertension about dietary changes. Which statement indicates
a need for further teaching?

 A) “I will limit my sodium intake.”

 B) “I can eat as much red meat as I want.”
 C) “I should include more fruits and vegetables in my diet.”
 D) “I will choose whole grains over refined grains.”

Correct Answer: B
Rationale: Limiting red meat intake is essential for managing hypertension, as it can be high in
saturated fats and sodium.

Question 82: Oncology

A nurse is caring for a patient undergoing chemotherapy. Which of the following interventions is
most important for the nurse to implement?

 A) Encourage a high-fiber diet

 B) Monitor for signs of infection
 C) Provide a low-calorie diet
 D) Encourage strict bed rest

Correct Answer: B
Rationale: Patients undergoing chemotherapy are at an increased risk for infection due to
immunosuppression, so monitoring for signs of infection is critical.

Question 83: Gastrointestinal

A nurse is caring for a patient with a diagnosis of peptic ulcer disease. Which medication class
should the nurse anticipate the provider to prescribe?

 A) Antacids
 B) Proton pump inhibitors
 C) Antibiotics
 D) Laxatives

Correct Answer: B
Rationale: Proton pump inhibitors (PPIs) are commonly prescribed to reduce gastric acid
secretion and promote healing of peptic ulcers.
Question 84: Respiratory

A patient with asthma is prescribed a rescue inhaler. Which medication is typically found in a
rescue inhaler?

 A) Budesonide
 B) Salmeterol
 C) Albuterol
 D) Fluticasone

Correct Answer: C
Rationale: Albuterol is a short-acting beta-agonist (SABA) used in rescue inhalers to provide
rapid relief of asthma symptoms.

Question 85: Mental Health

A nurse is caring for a patient diagnosed with depression. Which of the following symptoms
should the nurse assess for?

 A) Increased energy
 B) Euphoric mood
 C) Changes in appetite
 D) Improved concentration

Correct Answer: C
Rationale: Changes in appetite (either increased or decreased) are common symptoms of
depression, while increased energy and euphoric mood are not typical.

Question 86: Geriatrics

A nurse is assessing an older adult for signs of dehydration. Which of the following findings
should the nurse expect?

 A) Decreased skin turgor

 B) Increased urinary output
 C) Moist mucous membranes
 D) Weight gain
Correct Answer: A
Rationale: Decreased skin turgor is a classic sign of dehydration, while increased urinary output
and weight gain would not typically be present in dehydrated patients.

Question 87: Obstetrics

A nurse is monitoring a laboring patient who received an epidural. Which assessment finding is
most concerning?

 A) Maternal blood pressure of 100/60 mmHg

 B) Fetal heart rate of 140 bpm
 C) Maternal reports of pain relief
 D) Urinary retention

Correct Answer: A
Rationale: A maternal blood pressure of 100/60 mmHg could indicate hypotension, which can
affect fetal heart rate and may require intervention.

Question 88: Renal

A nurse is caring for a patient with chronic kidney disease. Which dietary modification is most
appropriate for this patient?

 A) High-protein diet
 B) Low-sodium diet
 C) High-potassium diet
 D) Low-calcium diet

Correct Answer: B
Rationale: A low-sodium diet is essential for managing chronic kidney disease to help control
blood pressure and reduce fluid retention.

Question 89: Infection Control

A nurse is caring for a patient with a respiratory infection. Which intervention should the nurse
prioritize to prevent the spread of infection?

 A) Use of antibiotics
 B) Implementing droplet precautions
 C) Encouraging fluid intake
  D) Administering antipyretics

Correct Answer: B
Rationale: Implementing droplet precautions is essential for preventing the spread of respiratory
infections to others.

Question 90: Adult Health

A nurse is teaching a patient about the signs of heart failure. Which statement indicates that the
patient understands the teaching?

 A) “I will watch for sudden weight loss.”

 B) “I should report any swelling in my legs or ankles.”
 C) “I can continue my regular exercise routine without changes.”
 D) “I should increase my sodium intake to prevent dehydration.”

Correct Answer: B
Rationale: Reporting swelling in the legs or ankles is essential, as it can indicate fluid retention
associated with heart failure.

Question 91: Pharmacology

A nurse is administering a dose of a medication that is known to cause photosensitivity. Which

instruction should the nurse give to the patient?

 A) “You can go outside as long as it’s cloudy.”

 B) “Avoid direct sunlight and use sunscreen.”
 C) “There are no restrictions on sun exposure.”
 D) “You should increase your fluid intake while on this medication.”

Correct Answer: B
Rationale: Patients should avoid direct sunlight and use sunscreen to protect their skin when
taking medications that cause photosensitivity.

Question 92: Oncology

A nurse is caring for a patient with cancer who is experiencing severe pain. Which of the
following interventions should the nurse implement first?

 A) Assess the patient’s pain level using a pain scale.

  B) Administer prescribed analgesics.
 C) Consult the healthcare provider for additional pain management options.
 D) Encourage the patient to use relaxation techniques.

Correct Answer: A
Rationale: Assessing the patient’s pain level is essential to determine the effectiveness of
current pain management strategies and guide further interventions.

Question 93: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is experiencing increased

shortness of breath. Which assessment finding would indicate worsening respiratory status?

 A) Increased wheezing on auscultation

 B) Decreased respiratory rate
 C) Improved oxygen saturation
 D) Decreased work of breathing

Correct Answer: A
Rationale: Increased wheezing on auscultation indicates bronchoconstriction and worsening
respiratory status in patients with COPD.

Question 94: Geriatrics

A nurse is assessing an older adult patient for signs of depression. Which of the following
findings should the nurse expect?

 A) Increased interest in hobbies

 B) Unexplained weight loss
 C) Improved sleep patterns
 D) Enhanced social interactions

Correct Answer: B
Rationale: Unexplained weight loss can be a sign of depression in older adults, who may lose
interest in eating and activities.

Question 95: Neurological

A nurse is caring for a patient with a head injury. Which assessment finding would indicate
increased intracranial pressure (ICP)?
  A) Pupils that are equal and reactive
 B) Decreased level of consciousness
 C) Slurred speech
 D) Stable vital signs

Correct Answer: B
Rationale: A decreased level of consciousness is a key indicator of increased intracranial
pressure and requires immediate attention.

Question 96: Obstetrics

A nurse is monitoring a patient who received oxytocin for labor induction. Which finding
indicates a potential complication?

 A) Regular uterine contractions

 B) Maternal heart rate of 85 bpm
 C) Fetal heart rate of 180 bpm
 D) Cervical dilation of 4 cm

Correct Answer: C
Rationale: A fetal heart rate of 180 bpm can indicate fetal distress and may require further
evaluation and intervention.

Question 97: Endocrine

A patient with diabetes is being discharged with a new insulin regimen. Which statement by the
patient indicates a need for further teaching?

 A) “I will rotate my injection sites.”

 B) “I can skip a dose if my blood sugar is low.”
 C) “I need to monitor my blood glucose regularly.”
 D) “I will notify my healthcare provider if I experience signs of hypoglycemia.”

Correct Answer: B
Rationale: Patients should not skip doses of insulin, even if their blood sugar is low, without
consulting their healthcare provider.

Question 98: Adult Health

A nurse is caring for a patient with a history of deep vein thrombosis (DVT). Which intervention
should the nurse prioritize?

 A) Administer anticoagulants as prescribed.

 B) Encourage ambulation as tolerated.
 C) Apply compression stockings.
 D) Educate the patient on dietary restrictions.

Correct Answer: A
Rationale: Administering anticoagulants as prescribed is a priority intervention to prevent the
formation of new clots and manage the existing DVT.

Question 99: Pediatric Nursing

A nurse is assessing a school-aged child with asthma. Which statement by the child indicates a
good understanding of asthma management?

 A) “I can run as much as I want during gym class.”

 B) “I will use my inhaler only when I have an attack.”
 C) “I should avoid my asthma triggers.”
 D) “I don’t need to tell anyone about my asthma.”

Correct Answer: C
Rationale: Avoiding asthma triggers is a crucial aspect of managing the condition effectively.

Question 100: Infection Control

A nurse is caring for a patient with a viral infection. Which type of isolation precaution should
the nurse implement?

 A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions

Correct Answer: B
Rationale: Droplet precautions are required for viral infections that are transmitted through
respiratory droplets, such as influenza.

Question 101: Pharmacology

A nurse is preparing to administer a medication via a nasogastric tube. Which of the following
actions should the nurse take first?

 A) Crush the medication into a fine powder.

 B) Verify the tube placement.
 C) Flush the tube with water.
 D) Administer the medication quickly.

Correct Answer: B
Rationale: Verifying tube placement is the priority action to ensure that the medication is
delivered into the stomach and not the lungs.

Question 102: Neurological

A nurse is assessing a patient with a spinal cord injury. Which of the following findings would
indicate spinal shock?

 A) Hyperreflexia
 B) Flaccid paralysis
 C) Increased muscle tone
 D) Intact deep tendon reflexes

Correct Answer: B
Rationale: Flaccid paralysis is a key indicator of spinal shock, where there is a loss of reflexes
and muscle tone below the level of injury.

Question 103: Cardiovascular

A nurse is monitoring a patient who is on digoxin therapy. Which finding would require the
nurse to hold the medication and notify the provider?

 A) Heart rate of 70 bpm

 B) Blood pressure of 110/70 mmHg
 C) Serum potassium level of 3.2 mEq/L
 D) Digoxin level of 1.0 ng/mL

Correct Answer: C
Rationale: A low serum potassium level can increase the risk of digoxin toxicity; therefore, the
nurse should hold the medication and notify the provider.
Question 104: Mental Health

A nurse is caring for a patient diagnosed with generalized anxiety disorder. Which of the
following interventions is most appropriate?

 A) Encourage the patient to avoid discussing anxiety triggers.

 B) Teach the patient deep breathing exercises.
 C) Suggest the patient engage in high-energy activities.
 D) Discourage the use of relaxation techniques.

Correct Answer: B
Rationale: Teaching deep breathing exercises can help the patient manage anxiety and promote
relaxation.

Question 105: Pediatric Nursing

A nurse is caring for a 5-year-old child with chickenpox. Which nursing intervention is
appropriate?

 A) Administer aspirin for fever.

 B) Encourage the child to scratch the lesions.
 C) Apply calamine lotion to relieve itching.
 D) Isolate the child for 48 hours after the rash appears.

Correct Answer: C
Rationale: Applying calamine lotion can help relieve itching associated with chickenpox, while
aspirin should be avoided due to the risk of Reye’s syndrome.

Question 106: Endocrine

A patient with type 1 diabetes is experiencing hypoglycemia. Which of the following symptoms
should the nurse expect to assess?

 A) Dry mouth
 B) Confusion
 C) Increased thirst
 D) Weight gain

Correct Answer: B
Rationale: Confusion is a common symptom of hypoglycemia due to insufficient glucose
reaching the brain.
Question 107: Respiratory

A patient is experiencing acute respiratory distress. Which of the following findings would
indicate that the patient is in respiratory failure?

 A) Oxygen saturation of 95%

 B) Respiratory rate of 12 breaths per minute
 C) Arterial blood gas (ABG) results showing PaCO2 of 50 mmHg
 D) Use of accessory muscles for breathing

Correct Answer: C
Rationale: An elevated PaCO2 level indicates hypoventilation and can signify respiratory
failure.

Question 108: Gastrointestinal

A nurse is caring for a patient who has undergone a laparoscopic cholecystectomy. Which
assessment finding would be a priority for the nurse to monitor?

 A) Abdominal pain
 B) Nausea and vomiting
 C) Return of bowel sounds
 D) Signs of infection at the incision site

Correct Answer: D
Rationale: Monitoring for signs of infection at the incision site is a priority after surgery to
prevent complications.

Question 109: Infection Control

A nurse is caring for a patient with an active methicillin-resistant Staphylococcus aureus

(MRSA) infection. Which type of precautions should the nurse implement?

 A) Standard precautions
 B) Contact precautions
 C) Airborne precautions
 D) Droplet precautions
Correct Answer: B
Rationale: Contact precautions are necessary for MRSA to prevent transmission through direct
contact with the patient or contaminated surfaces.

Question 110: Adult Health

A nurse is assessing a patient with heart failure. Which symptom should the nurse prioritize
during the assessment?

 A) Chest pain
 B) Shortness of breath
 C) Nausea
 D) Fatigue

Correct Answer: B
Rationale: Shortness of breath is a common and concerning symptom in patients with heart
failure, indicating worsening respiratory status or fluid overload.

Question 111: Pharmacology

A nurse is preparing to administer an anticoagulant. Which of the following laboratory values is

most important for the nurse to review before administration?

 A) Hemoglobin level
 B) Prothrombin time (PT)
 C) Serum potassium level
 D) Blood glucose level

Correct Answer: B
Rationale: Prothrombin time (PT) is essential to determine the appropriate dosage of
anticoagulants and assess bleeding risk.

Question 112: Obstetrics

A nurse is caring for a woman in labor who is experiencing intense pain. Which of the following
interventions should the nurse implement first?

 A) Administer analgesics as ordered.

 B) Assist the patient with breathing techniques.
 C) Assess the fetal heart rate.
  D) Offer support and reassurance.

Correct Answer: C
Rationale: Assessing the fetal heart rate is critical to ensure the fetus is not in distress before
addressing the mother’s pain.

Question 113: Renal

A nurse is educating a patient with end-stage renal disease about dietary modifications. Which
statement indicates a need for further teaching?

 A) “I will eat foods high in potassium.”

 B) “I need to limit my protein intake.”
 C) “I should avoid high-sodium foods.”
 D) “I will monitor my fluid intake closely.”

Correct Answer: A
Rationale: Patients with end-stage renal disease should limit foods high in potassium to prevent
hyperkalemia.

Question 114: Pediatric Nursing

A nurse is caring for an 8-month-old infant who is receiving formula. Which of the following
interventions should the nurse include in the plan of care?

 A) Introduce cow’s milk as the primary drink.

 B) Ensure the infant is receiving adequate iron supplementation.
 C) Encourage the infant to eat whole fruits instead of purees.
 D) Provide water to the infant during feedings.

Correct Answer: B
Rationale: Ensuring adequate iron supplementation is important for infants on formula to
prevent iron deficiency anemia.

Question 115: Mental Health

A nurse is working with a patient diagnosed with bipolar disorder. Which behavior might
indicate a manic episode?

 A) Withdrawal from social interactions

  B) Excessive sleeping
 C) Decreased self-esteem
 D) Rapid speech and racing thoughts

Correct Answer: D
Rationale: Rapid speech and racing thoughts are common symptoms of a manic episode in
bipolar disorder.

Question 116: Cardiovascular

A nurse is caring for a patient with hypertension who is prescribed a diuretic. Which assessment
finding would indicate that the medication is effective?

 A) Decreased heart rate

 B) Increased blood pressure
 C) Decreased edema
 D) Increased potassium level

Correct Answer: C
Rationale: Decreased edema is an indicator that the diuretic is effectively reducing fluid
retention.

Question 117: Gastrointestinal

A nurse is teaching a patient about dietary modifications for managing gastroesophageal reflux
disease (GERD). Which statement indicates understanding of the teaching?

 A) “I can eat large meals before bedtime.”

 B) “I should avoid spicy foods.”
 C) “I will drink citrus juices regularly.”
 D) “I can eat tomato-based products.”

Correct Answer: B
Rationale: Avoiding spicy foods can help manage GERD symptoms, while large meals, citrus
juices, and tomato-based products may exacerbate symptoms.

Question 118: Infection Control

A nurse is preparing to care for a patient with an infectious disease requiring airborne
precautions. Which of the following actions should the nurse take?
  A) Wear a surgical mask.
 B) Place the patient in a private room with negative pressure.
 C) Use gloves and gowns when entering the room.
 D) Limit the patient’s visitors to one person.

Correct Answer: B
Rationale: Placing the patient in a private room with negative pressure is essential for airborne
precautions to prevent the spread of infectious agents.

Question 119: Adult Health

A nurse is caring for a patient who is post-operative from an abdominal surgery. Which finding
is most concerning and requires immediate intervention?

 A) Absent bowel sounds

 B) Moderate abdominal distention
 C) Temperature of 101°F
 D) Dark red urine output

Correct Answer: D
Rationale: Dark red urine output may indicate bleeding or hematuria, which requires immediate
assessment and intervention.

Question 120: Pediatric Nursing

A nurse is assessing a child with suspected pneumonia. Which assessment finding would be most
indicative of this condition?

 A) Productive cough with green sputum

 B) Wheezing on auscultation
 C) Decreased breath sounds
 D) Fever of 100°F

Correct Answer: A
Rationale: A productive cough with green sputum is indicative of an infection such as
pneumonia.

Question 121: Pharmacology

A nurse is administering furosemide (Lasix) to a patient. Which laboratory value should the
nurse monitor to assess for potential complications?

 A) Calcium level
 B) Sodium level
 C) Potassium level
 D) Glucose level

Correct Answer: C
Rationale: Furosemide is a loop diuretic that can cause hypokalemia, so monitoring potassium
levels is essential.

Question 122: Neurological

A nurse is caring for a patient who has experienced a stroke. Which assessment finding would
indicate that the patient is having a left-sided stroke?

 A) Difficulty with speech

 B) Impaired judgment
 C) Hemiparesis on the right side
 D) Vision changes

Correct Answer: C
Rationale: A left-sided stroke typically affects the right side of the body due to contralateral
brain control.

Question 123: Cardiovascular

A patient with heart failure is prescribed a beta-blocker. Which of the following actions should
the nurse take prior to administering the medication?

 A) Assess the patient's respiratory rate.

 B) Monitor the patient's blood pressure and heart rate.
 C) Obtain a blood sample for liver function tests.
 D) Instruct the patient to limit sodium intake.

Correct Answer: B
Rationale: Monitoring blood pressure and heart rate is critical before administering beta-
blockers, as they can lower heart rate and blood pressure.
Question 124: Infection Control

A patient diagnosed with tuberculosis is being discharged. Which instruction should the nurse
provide regarding home care?

 A) “You can return to work as soon as you feel better.”

 B) “You should sleep in the same room as family members.”
 C) “Wear a mask when around other people until you are no longer infectious.”
 D) “Take your medication only when you feel symptoms.”

Correct Answer: C
Rationale: Wearing a mask when around others is important to prevent the spread of
tuberculosis until the patient is no longer infectious.

Question 125: Mental Health

A nurse is caring for a patient who is experiencing hallucinations. Which intervention is most
appropriate?

 A) Encourage the patient to act on the hallucinations.

 B) Validate the patient’s experiences.
 C) Distract the patient with activities.
 D) Provide a quiet environment.

Correct Answer: C
Rationale: Distracting the patient with activities can help redirect their focus away from the
hallucinations and provide support.

Question 126: Pediatric Nursing

A nurse is caring for a child with croup. Which of the following symptoms is characteristic of
this condition?

 A) High fever
 B) Barking cough
 C) Wheezing
 D) Cyanosis

Correct Answer: B
Rationale: A barking cough is a classic symptom of croup, often associated with stridor.
Question 127: Endocrine

A nurse is caring for a patient with diabetes who reports increased thirst and frequent urination.
Which of the following actions should the nurse take first?

 A) Administer insulin as prescribed.

 B) Assess the patient’s blood glucose level.
 C) Educate the patient about dietary modifications.
 D) Obtain a urine specimen for analysis.

Correct Answer: B
Rationale: Assessing the blood glucose level is essential to determine the cause of the symptoms
and guide further interventions.

Question 128: Gastrointestinal

A nurse is caring for a patient with a history of pancreatitis. Which dietary instruction should the
nurse provide?

 A) Increase saturated fat intake.

 B) Avoid alcohol consumption.
 C) Limit carbohydrate intake.
 D) Eat small, frequent high-protein meals.

Correct Answer: B
Rationale: Avoiding alcohol is crucial for preventing exacerbations of pancreatitis.

Question 129: Adult Health

A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which
finding would indicate the need for further assessment?

 A) Use of accessory muscles for breathing

 B) Oxygen saturation of 92%
 C) Productive cough with clear sputum
 D) Respiratory rate of 18 breaths per minute

Correct Answer: C
Rationale: A productive cough with clear sputum may indicate effective clearance; however,
any sudden change in sputum color or consistency should prompt further assessment.
Question 130: Obstetrics

A nurse is caring for a postpartum patient who is experiencing heavy vaginal bleeding. Which
assessment finding would require immediate intervention?

 A) Fundus is firm and midline.

 B) Saturation of a pad in 1 hour.
 C) Blood pressure of 90/60 mmHg.
 D) Heart rate of 110 bpm.

Correct Answer: C
Rationale: A blood pressure of 90/60 mmHg indicates possible hypovolemic shock, requiring
immediate intervention.

Question 131: Renal

A nurse is teaching a patient with chronic kidney disease about dietary restrictions. Which
statement by the patient indicates a need for further teaching?

 A) “I need to limit my protein intake.”

 B) “I can eat as many fruits as I want.”
 C) “I should avoid foods high in potassium.”
 D) “I need to restrict my sodium intake.”

Correct Answer: B
Rationale: Patients with chronic kidney disease should be mindful of fruit intake, particularly
potassium-rich fruits, to manage electrolyte levels.

Question 132: Infection Control

A nurse is caring for a patient with Clostridium difficile (C. diff) infection. Which precaution
should the nurse implement?

 A) Droplet precautions
 B) Airborne precautions
 C) Contact precautions
 D) Standard precautions

Correct Answer: C
Rationale: Contact precautions are essential for preventing the spread of C. difficile through
direct contact.
Question 133: Cardiovascular

A nurse is monitoring a patient who received a dose of anticoagulant medication. Which finding
would require immediate intervention?

 A) Platelet count of 150,000/mm³

 B) Blood pressure of 120/80 mmHg
 C) Patient reports a headache and blurred vision
 D) INR of 2.5

Correct Answer: C
Rationale: A headache and blurred vision could indicate possible bleeding or elevated
intracranial pressure and require immediate evaluation.

Question 134: Neurological

A nurse is assessing a patient after a head injury. Which of the following findings is the most
concerning?

 A) Dizziness
 B) Nausea
 C) Unresponsive to verbal stimuli
 D) Mild headache

Correct Answer: C
Rationale: Unresponsiveness to verbal stimuli indicates a severe change in neurological status
and requires immediate intervention.

Question 135: Pediatric Nursing

A nurse is providing education to the parents of a child with asthma. Which statement by the
parents indicates a need for further teaching?

 A) “We will keep a rescue inhaler with us at all times.”

 B) “We should avoid known triggers for my child’s asthma.”
 C) “My child can take the inhaler whenever they feel like it.”
 D) “We need to watch for signs of worsening asthma.”
Correct Answer: C
Rationale: The inhaler should only be used as prescribed and not whenever the child feels like
it, indicating the need for further teaching.

Question 136: Mental Health

A nurse is caring for a patient diagnosed with depression. Which behavior should the nurse be
most concerned about?

 A) Withdrawal from social activities

 B) Increased sleep
 C) Talking about feeling hopeless
 D) Changes in appetite

Correct Answer: C
Rationale: Talking about feeling hopeless can indicate suicidal ideation, which is a priority
concern.

Question 137: Gastrointestinal

A patient is diagnosed with peptic ulcer disease. Which medication should the nurse anticipate
being prescribed?

 A) Antacids
 B) Proton pump inhibitors (PPIs)
 C) Laxatives
 D) Corticosteroids

Correct Answer: B
Rationale: Proton pump inhibitors (PPIs) reduce gastric acid secretion and promote healing of
peptic ulcers.

Question 138: Adult Health

A nurse is assessing a patient with a suspected myocardial infarction. Which finding would the
nurse expect?

 A) Sudden weight loss

 B) Intermittent claudication
 C) Chest pain radiating to the left arm
  D) Lower back pain

Correct Answer: C
Rationale: Chest pain radiating to the left arm is a classic symptom of myocardial infarction.

Question 139: Obstetrics

A nurse is assessing a pregnant woman at 28 weeks gestation. Which finding would be a cause
for concern?

 A) Fundal height of 28 cm
 B) Fetal heart rate of 140 bpm
 C) Presence of edema in the legs
 D) Positive glucose tolerance test

Correct Answer: D
Rationale: A positive glucose tolerance test indicates gestational diabetes, which requires further
evaluation and management.

Question 140: Endocrine

A nurse is caring for a patient with Addison's disease. Which symptom would the nurse expect to
find?

 A) Hyperglycemia
 B) Hypotension
 C) Increased energy levels
 D) Weight gain

Correct Answer: B
Rationale: Hypotension is a common symptom of Addison's disease due to insufficient adrenal
hormone production.

Question 141: Pharmacology

A nurse is administering an opioid analgesic to a patient. Which of the following assessments

should the nurse perform before administering the medication?

 A) Assess the patient’s pain level.

 B) Monitor the patient’s blood glucose level.
  C) Check the patient’s respiratory rate.
 D) Evaluate the patient’s temperature.

Correct Answer: C
Rationale: Opioids can cause respiratory depression; therefore, monitoring the respiratory rate is
essential before administration.

Question 142: Neurological

A nurse is caring for a patient with a seizure disorder. Which of the following actions should the
nurse take during a seizure?

 A) Restrain the patient’s arms and legs.

 B) Place a padded tongue blade in the patient’s mouth.
 C) Position the patient on their side.
 D) Hold the patient still until the seizure is over.

Correct Answer: C
Rationale: Positioning the patient on their side helps maintain an open airway and prevent
aspiration during a seizure.

Question 143: Cardiovascular

A patient with heart failure is prescribed a potassium-sparing diuretic. Which of the following
laboratory values should the nurse monitor?

 A) Serum sodium level

 B) Serum calcium level
 C) Serum potassium level
 D) Serum creatinine level

Correct Answer: C
Rationale: Monitoring serum potassium levels is crucial because potassium-sparing diuretics
can lead to hyperkalemia.

Question 144: Infection Control

A nurse is caring for a patient with a draining abscess. Which type of dressing should the nurse
use?
  A) Sterile dressing
 B) Dry gauze dressing
 C) Moist-to-dry dressing
 D) Hydrocolloid dressing

Correct Answer: C
Rationale: A moist-to-dry dressing helps to absorb drainage and promotes healing of the wound.

Question 145: Mental Health

A nurse is providing discharge instructions to a patient with schizophrenia. Which statement

indicates the patient understands the teaching?

 A) “I will stop taking my medication when I feel better.”

 B) “I will attend all of my follow-up appointments.”
 C) “I can skip my therapy sessions if I’m busy.”
 D) “I should avoid social interactions to reduce stress.”

Correct Answer: B
Rationale: Attending follow-up appointments is vital for monitoring and managing
schizophrenia.

Question 146: Pediatric Nursing

A nurse is caring for a child with asthma who is experiencing an acute asthma attack. Which
medication should the nurse anticipate administering first?

 A) Corticosteroids
 B) Long-acting beta agonist (LABA)
 C) Short-acting beta agonist (SABA)
 D) Leukotriene receptor antagonist

Correct Answer: C
Rationale: A short-acting beta agonist (SABA) is the first-line treatment for acute asthma
attacks to quickly relieve bronchospasm.

Question 147: Endocrine

A patient with hyperthyroidism is being treated with radioactive iodine. Which of the following
statements by the patient indicates a need for further education?
  A) “I need to avoid close contact with pregnant women.”
 B) “I should drink plenty of fluids after treatment.”
 C) “I can take my thyroid medication after the treatment.”
 D) “I will increase my caloric intake to gain weight.”

Correct Answer: D
Rationale: Patients with hyperthyroidism typically require a balanced caloric intake; gaining
weight is not usually a goal of treatment.

Question 148: Gastrointestinal

A nurse is assessing a patient with a history of liver cirrhosis. Which symptom would indicate
the development of hepatic encephalopathy?

 A) Jaundice
 B) Confusion and altered mental status
 C) Abdominal pain
 D) Fatigue

Correct Answer: B
Rationale: Confusion and altered mental status are key indicators of hepatic encephalopathy due
to the accumulation of toxins.

Question 149: Obstetrics

A nurse is caring for a woman in labor who is requesting pain relief. Which of the following
interventions should the nurse prioritize?

 A) Provide comfort measures such as breathing techniques.

 B) Administer intravenous fluids.
 C) Assess the fetal heart rate.
 D) Discuss options for epidural anesthesia.

Correct Answer: C
Rationale: Assessing the fetal heart rate is crucial to ensure the fetus is not in distress before
proceeding with pain relief interventions.

Question 150: Renal

A nurse is caring for a patient with chronic kidney disease who is on a low-protein diet. Which
food choice is appropriate for this patient?

 A) Chicken breast
 B) Lentils
 C) White rice
 D) Eggs

Correct Answer: C
Rationale: White rice is low in protein, making it a suitable choice for patients on a low-protein
diet due to chronic kidney disease.

Question 151: Infection Control

A nurse is caring for a patient with a respiratory infection. Which of the following actions should
the nurse take to prevent the spread of infection?

 A) Place the patient in a private room.

 B) Wear gloves when entering the room.
 C) Use alcohol-based hand sanitizer before and after patient contact.
 D) Encourage the patient to cough into their hands.

Correct Answer: C
Rationale: Using alcohol-based hand sanitizer is effective in preventing the spread of infection
before and after patient contact.

Question 152: Cardiovascular

A patient who had a myocardial infarction is being discharged on aspirin therapy. Which
statement by the patient indicates a need for further teaching?

 A) “I can take aspirin with my other medications.”

 B) “I need to watch for signs of bleeding.”
 C) “I can stop taking aspirin once I feel better.”
 D) “I should notify my doctor if I have a rash.”

Correct Answer: C
Rationale: The patient should not stop taking aspirin without consulting their healthcare
provider, as it is essential for preventing future cardiovascular events.
Question 153: Neurological

A nurse is assessing a patient who has just undergone a craniotomy. Which finding should the
nurse report immediately?

 A) Clear drainage from the nose

 B) Increased intracranial pressure
 C) Alert and oriented to person, place, and time
 D) Mild headache

Correct Answer: B
Rationale: Increased intracranial pressure is a critical finding that requires immediate
intervention.

Question 154: Pediatric Nursing

A nurse is caring for an infant with a suspected congenital heart defect. Which of the following
assessment findings would support this diagnosis?

 A) Normal growth and development

 B) Cyanosis with crying
 C) Unusual fussiness
 D) Excessive sleepiness

Correct Answer: B
Rationale: Cyanosis with crying can indicate a congenital heart defect, as it suggests poor
oxygenation during stress.

Question 155: Mental Health

A nurse is providing care for a patient diagnosed with obsessive-compulsive disorder (OCD).
Which statement should the nurse include in the plan of care?

 A) “You should try to suppress your compulsions.”

 B) “Gradual exposure to anxiety-provoking situations can help.”
 C) “Avoid discussing your obsessions with others.”
 D) “You need to stop your compulsive behaviors immediately.”

Correct Answer: B
Rationale: Gradual exposure to anxiety-provoking situations can help the patient manage OCD
symptoms.
Question 156: Gastrointestinal

A patient is experiencing symptoms of gastroesophageal reflux disease (GERD). Which of the

following dietary modifications should the nurse recommend?

 A) Increase consumption of high-fat foods.

 B) Eat smaller, more frequent meals.
 C) Drink caffeinated beverages.
 D) Avoid eating before bedtime.

Correct Answer: B
Rationale: Eating smaller, more frequent meals can help reduce GERD symptoms.

Question 157: Adult Health

A nurse is caring for a patient who has just received a blood transfusion. Which of the following
findings should the nurse monitor for as a sign of a transfusion reaction?

 A) Fever
 B) Low blood pressure
 C) Increased heart rate
 D) All of the above

Correct Answer: D
Rationale: All of the listed findings (fever, low blood pressure, increased heart rate) can indicate
a transfusion reaction and should be closely monitored.

Question 158: Obstetrics

A nurse is assessing a postpartum patient who is 24 hours post-delivery. Which finding should
the nurse report to the provider?

 A) Moderate uterine tenderness

 B) Saturation of a pad in 1 hour
 C) Elevated temperature of 100.4°F
 D) Presence of foul-smelling lochia

Correct Answer: D
Rationale: Foul-smelling lochia can indicate infection and should be reported to the provider
immediately.
Question 159: Endocrine

A patient with type 2 diabetes is prescribed metformin. Which of the following statements by the
patient indicates a need for further teaching?

 A) “I can take this medication with my meals.”

 B) “I need to monitor my blood sugar regularly.”
 C) “I can stop taking this medication if my blood sugar is normal.”
 D) “I should avoid excessive alcohol intake.”

Correct Answer: C
Rationale: The patient should not stop taking metformin without consulting their healthcare
provider, even if blood sugar levels are normal.

Question 160: Renal

A nurse is caring for a patient on hemodialysis. Which complication should the nurse monitor for
during the treatment?

 A) Hypertension
 B) Hyperkalemia
 C) Hypotension
 D) Hypercalcemia

Correct Answer: C
Rationale: Hypotension is a common complication during hemodialysis due to rapid fluid shifts.

Question 161: Pharmacology

A nurse is teaching a patient about the use of warfarin (Coumadin). Which of the following
statements indicates that the patient understands the instructions?

 A) “I can take aspirin if I have a headache.”

 B) “I should eat a consistent amount of green leafy vegetables.”
 C) “I will stop taking warfarin if I have a nosebleed.”
 D) “I can take over-the-counter medications without consulting my doctor.”

Correct Answer: B
Rationale: Consistent intake of vitamin K-rich foods is important to maintain stable INR levels
while on warfarin.
Question 162: Neurological

A nurse is assessing a patient with a spinal cord injury. Which of the following findings would
indicate a risk for autonomic dysreflexia?

 A) Bladder distension
 B) Hypotension
 C) Increased heart rate
 D) Cold, clammy skin

Correct Answer: A
Rationale: Bladder distension is a common trigger for autonomic dysreflexia, which can cause
severe hypertension and bradycardia.

Question 163: Cardiovascular

A nurse is caring for a patient with congestive heart failure (CHF) who is experiencing shortness
of breath. Which position is best for this patient?

 A) Supine
 B) Prone
 C) High Fowler's
 D) Trendelenburg

Correct Answer: C
Rationale: High Fowler's position helps facilitate breathing by reducing pressure on the
diaphragm.

Question 164: Infection Control

A nurse is providing care to a patient with a methicillin-resistant Staphylococcus aureus (MRSA)

infection. Which type of precautions should the nurse implement?

 A) Droplet precautions
 B) Contact precautions
 C) Airborne precautions
 D) Standard precautions
Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of MRSA through direct
contact.

Question 165: Mental Health

A nurse is developing a care plan for a patient diagnosed with generalized anxiety disorder.
Which intervention should be included to help the patient manage anxiety?

 A) Encourage avoidance of stressors.

 B) Teach relaxation techniques.
 C) Recommend complete bed rest.
 D) Limit social interactions.

Correct Answer: B
Rationale: Teaching relaxation techniques can help the patient effectively manage anxiety
symptoms.

Question 166: Pediatric Nursing

A nurse is assessing a child with suspected appendicitis. Which finding would be most indicative
of this condition?

 A) Right lower quadrant pain

 B) Nausea and vomiting
 C) Fever
 D) Diarrhea

Correct Answer: A
Rationale: Right lower quadrant pain is a classic symptom of appendicitis.

Question 167: Endocrine

A patient with type 1 diabetes is experiencing symptoms of hypoglycemia. Which of the

following actions should the nurse take first?

 A) Administer glucagon.
 B) Give the patient a glass of orange juice.
 C) Monitor the patient's blood glucose level.
 D) Call the healthcare provider.
Correct Answer: B
Rationale: Administering a quick source of glucose, such as orange juice, is the first priority in
treating hypoglycemia.

Question 168: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which medication should the nurse anticipate
being prescribed for this condition?

 A) Antacids
 B) Proton pump inhibitors (PPIs)
 C) Laxatives
 D) Opioids

Correct Answer: B
Rationale: Proton pump inhibitors (PPIs) reduce gastric acid secretion, promoting healing of
peptic ulcers.

Question 169: Obstetrics

A nurse is assessing a pregnant patient who is in the second trimester. Which finding would be
considered normal during this stage of pregnancy?

 A) Decreased energy levels

 B) Nausea and vomiting
 C) Fetal movement
 D) Severe abdominal cramping

Correct Answer: C
Rationale: Fetal movement is expected in the second trimester as the fetus develops.

Question 170: Renal

A nurse is teaching a patient with chronic kidney disease about dietary restrictions. Which
statement by the patient indicates a need for further teaching?

 A) “I should limit my sodium intake.”

 B) “I can eat as many fruits as I want.”
 C) “I need to watch my protein intake.”
 D) “I should avoid foods high in potassium.”
Correct Answer: B
Rationale: Patients with chronic kidney disease should monitor their fruit intake, particularly
potassium-rich fruits.

Question 171: Infection Control

A nurse is caring for a patient who is immunocompromised. Which intervention should the nurse
implement to reduce the risk of infection?

 A) Encourage the patient to stay in bed.

 B) Administer prophylactic antibiotics as prescribed.
 C) Isolate the patient from all visitors.
 D) Avoid hand hygiene before patient contact.

Correct Answer: B
Rationale: Administering prophylactic antibiotics can help prevent infections in
immunocompromised patients.

Question 172: Cardiovascular

A patient with atrial fibrillation is prescribed warfarin. Which laboratory test should the nurse
monitor to assess the effectiveness of the medication?

 A) Complete blood count (CBC)

 B) Prothrombin time (PT) and International Normalized Ratio (INR)
 C) Electrolytes
 D) Liver function tests

Correct Answer: B
Rationale: The effectiveness of warfarin is monitored by PT and INR levels.

Question 173: Neurological

A nurse is assessing a patient for signs of increased intracranial pressure (ICP). Which of the
following findings would be concerning?

 A) Decreased level of consciousness

 B) Clear drainage from the nose
 C) Elevated blood pressure
 D) Pupillary constriction
Correct Answer: A
Rationale: Decreased level of consciousness is a critical sign of increased ICP and should be
reported immediately.

Question 174: Pediatric Nursing

A nurse is caring for a child diagnosed with rheumatic fever. Which of the following should the
nurse monitor for in this patient?

 A) Decreased appetite
 B) Joint pain and swelling
 C) Skin rash
 D) Elevated blood pressure

Correct Answer: B
Rationale: Joint pain and swelling are common manifestations of rheumatic fever.

Question 175: Mental Health

A nurse is assessing a patient with major depressive disorder. Which of the following findings
would indicate a need for immediate intervention?

 A) Loss of interest in activities

 B) Feelings of worthlessness
 C) Expressing suicidal thoughts
 D) Difficulty concentrating

Correct Answer: C
Rationale: Expressing suicidal thoughts is a critical finding that requires immediate intervention
and assessment for safety.

Question 176: Gastrointestinal

A nurse is caring for a patient with gastroesophageal reflux disease (GERD). Which lifestyle
modification should the nurse recommend?

 A) Eat large meals before bedtime.

 B) Elevate the head of the bed while sleeping.
 C) Wear tight-fitting clothing.
 D) Consume spicy foods.
Correct Answer: B
Rationale: Elevating the head of the bed can help prevent reflux during sleep.

Question 177: Adult Health

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
experiencing increased shortness of breath. Which action should the nurse take first?

 A) Administer prescribed bronchodilator.

 B) Assess the patient’s lung sounds.
 C) Position the patient in high Fowler's position.
 D) Obtain a pulse oximetry reading.

Correct Answer: A
Rationale: Administering the prescribed bronchodilator is the priority action to relieve acute
shortness of breath.

Question 178: Obstetrics

A nurse is providing education to a pregnant woman about signs of preterm labor. Which
statement indicates the woman needs further teaching?

 A) “I should call my doctor if I have regular contractions.”

 B) “I should report any vaginal bleeding.”
 C) “It’s normal to have occasional back pain.”
 D) “I need to be concerned about increased pelvic pressure.”

Correct Answer: C
Rationale: While some back pain may be normal, increased or persistent back pain should be
reported, as it can indicate preterm labor.

Question 179: Endocrine

A nurse is caring for a patient with diabetic ketoacidosis (DKA). Which assessment finding is
characteristic of DKA?

 A) Low blood glucose level

 B) Fruity-smelling breath
 C) Bradycardia
 D) Hypotension
Correct Answer: B
Rationale: Fruity-smelling breath is a classic sign of diabetic ketoacidosis due to the presence of
ketones.

Question 180: Renal

A nurse is teaching a patient with chronic kidney disease about managing their condition. Which
statement by the patient indicates an understanding of the teaching?

 A) “I need to drink as much fluid as I want.”

 B) “I should avoid high-protein foods.”
 C) “I can eat salt freely since my blood pressure is normal.”
 D) “I will not need to monitor my weight regularly.”

Correct Answer: B
Rationale: Patients with chronic kidney disease should avoid high-protein foods to reduce the
workload on their kidneys.

Question 181: Pharmacology

A nurse is preparing to administer digoxin to a patient. Which assessment is a priority before

administration?

 A) Assess the patient's heart rate.

 B) Monitor the patient's blood pressure.
 C) Check the patient's potassium level.
 D) Evaluate the patient's renal function.

Correct Answer: A
Rationale: Digoxin can cause bradycardia; therefore, assessing the heart rate is crucial before
administration.

Question 182: Neurological

A nurse is caring for a patient who is recovering from a stroke. Which assessment finding would
indicate the need for further evaluation?

 A) Increased ability to follow commands

 B) Sudden weakness on one side of the body
 C) Improved speech clarity
  D) Consistent improvement in motor function

Correct Answer: B
Rationale: Sudden weakness on one side of the body could indicate a possible stroke recurrence
or another neurological issue.

Question 183: Cardiovascular

A patient with heart failure is being treated with furosemide (Lasix). Which laboratory value
should the nurse monitor regularly?

 A) Calcium levels
 B) Potassium levels
 C) Magnesium levels
 D) Sodium levels

Correct Answer: B
Rationale: Furosemide is a loop diuretic that can cause hypokalemia; thus, potassium levels
should be monitored.

Question 184: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis (TB). Which type of isolation
precaution should the nurse implement?

 A) Airborne precautions
 B) Contact precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: A
Rationale: Airborne precautions are necessary for tuberculosis to prevent the spread of
infectious droplets.

Question 185: Mental Health

A nurse is assessing a patient with post-traumatic stress disorder (PTSD). Which symptom is
most characteristic of this condition?

 A) Mood swings
  B) Flashbacks
 C) Insomnia
 D) Excessive energy

Correct Answer: B
Rationale: Flashbacks are a hallmark symptom of PTSD, where the patient relives the traumatic
event.

Question 186: Pediatric Nursing

A nurse is caring for a 3-year-old child diagnosed with asthma. Which of the following is the
priority intervention?

 A) Teach the child to use a peak flow meter.

 B) Assess the child’s respiratory status.
 C) Administer a bronchodilator as prescribed.
 D) Encourage the child to drink fluids.

Correct Answer: B
Rationale: Assessing respiratory status is the priority to determine the severity of the asthma
episode.

Question 187: Endocrine

A patient with hyperthyroidism is prescribed a thioamide medication. Which medication is

classified as a thioamide?

 A) Levothyroxine
 B) Methimazole
 C) Propylthiouracil (PTU)
 D) Radioactive iodine

Correct Answer: B
Rationale: Methimazole is a thioamide medication used to treat hyperthyroidism by inhibiting
thyroid hormone synthesis.

Question 188: Gastrointestinal

A nurse is caring for a patient with a diagnosis of cholecystitis. Which dietary recommendation
should the nurse provide?
  A) High-fat diet
 B) Low-fiber diet
 C) Low-fat diet
 D) High-carbohydrate diet

Correct Answer: C
Rationale: A low-fat diet is recommended to minimize gallbladder stimulation and reduce
symptoms.

Question 189: Obstetrics

A nurse is monitoring a laboring woman who is receiving epidural anesthesia. Which of the
following findings should the nurse monitor for?

 A) Increased fetal heart rate

 B) Hypotension
 C) Elevated blood glucose levels
 D) Increased respiratory rate

Correct Answer: B
Rationale: Hypotension is a potential side effect of epidural anesthesia due to vasodilation.

Question 190: Renal

A nurse is caring for a patient with end-stage renal disease (ESRD) who is receiving
hemodialysis. Which laboratory value is most important to monitor?

 A) Blood urea nitrogen (BUN)

 B) Glucose
 C) Calcium
 D) Phosphorus

Correct Answer: A
Rationale: Monitoring BUN levels is crucial in patients with ESRD as it reflects kidney function
and waste elimination.

Question 191: Infection Control

A nurse is educating a group of nursing students about hand hygiene. Which statement reflects
the correct practice?
  A) Hand sanitizer is effective for all types of infections.
 B) Hands should be washed for at least 10 seconds.
 C) Hand hygiene is important before and after patient contact.
 D) Gloves eliminate the need for hand hygiene.

Correct Answer: C
Rationale: Hand hygiene is crucial before and after any patient contact to prevent the spread of
infection.

Question 192: Cardiovascular

A patient is diagnosed with hypertension and prescribed a calcium channel blocker. Which of the
following medications is classified as a calcium channel blocker?

 A) Lisinopril
 B) Amlodipine
 C) Metoprolol
 D) Hydrochlorothiazide

Correct Answer: B
Rationale: Amlodipine is a calcium channel blocker used to treat hypertension by relaxing blood
vessels.

Question 193: Neurological

A nurse is caring for a patient with Parkinson’s disease. Which of the following symptoms
should the nurse expect?

 A) Increased energy levels

 B) Bradykinesia
 C) Weight gain
 D) Hyperactivity

Correct Answer: B
Rationale: Bradykinesia (slowness of movement) is a common symptom of Parkinson's disease.

Question 194: Pediatric Nursing

A nurse is assessing a child with cystic fibrosis. Which of the following findings is most
indicative of this condition?
  A) Frequent respiratory infections
 B) High fever
 C) Low blood sugar
 D) Jaundice

Correct Answer: A
Rationale: Frequent respiratory infections are a hallmark of cystic fibrosis due to thick, sticky
mucus obstructing airways.

Question 195: Mental Health

A nurse is working with a patient diagnosed with a mood disorder. Which intervention is
appropriate to include in the care plan?

 A) Encourage isolation during depressive episodes.

 B) Promote regular exercise and activity.
 C) Discourage discussing feelings and thoughts.
 D) Limit the patient’s social interactions.

Correct Answer: B
Rationale: Regular exercise and activity can help improve mood and reduce symptoms of
depression.

Question 196: Gastrointestinal

A nurse is caring for a patient with peptic ulcer disease. Which of the following statements by
the patient indicates a need for further education?

 A) “I will avoid caffeine and spicy foods.”

 B) “I can take NSAIDs to relieve my pain.”
 C) “I should eat small, frequent meals.”
 D) “I will take my medications as prescribed.”

Correct Answer: B
Rationale: NSAIDs can exacerbate peptic ulcer disease and should generally be avoided.

Question 197: Adult Health

A nurse is caring for a patient with a deep vein thrombosis (DVT) who is prescribed
anticoagulation therapy. Which laboratory test should the nurse monitor?
  A) Activated partial thromboplastin time (aPTT)
 B) Prothrombin time (PT)
 C) International normalized ratio (INR)
 D) Complete blood count (CBC)

Correct Answer: A
Rationale: The aPTT test is used to monitor anticoagulation therapy, particularly with heparin.

Question 198: Obstetrics

A nurse is assessing a postpartum woman. Which finding would be a cause for concern?

 A) Uterine involution
 B) Lochia rubra that is moderate
 C) Temperature of 100.6°F (38.1°C)
 D) Fundus above the umbilicus

Correct Answer: D
Rationale: The fundus should descend after delivery; if it is above the umbilicus, it may indicate
uterine atony or retained placenta.

Question 199: Endocrine

A patient with Addison's disease is experiencing an adrenal crisis. Which of the following
symptoms should the nurse monitor for?

 A) Hyperglycemia
 B) Hypertension
 C) Severe hypotension
 D) Weight gain

Correct Answer: C
Rationale: Severe hypotension is a critical sign of an adrenal crisis, requiring immediate medical
intervention.

Question 200: Renal

A nurse is teaching a patient with chronic kidney disease about potassium restrictions. Which
food should the nurse advise the patient to avoid?
  A) Apples
 B) Spinach
 C) Bread
 D) Rice

Correct Answer: B
Rationale: Spinach is high in potassium and should be avoided in a potassium-restricted diet for
patients with chronic kidney disease.

Question 201: Pharmacology

A nurse is educating a patient about the use of albuterol. Which statement indicates the patient
understands the medication's purpose?

 A) “This medication will decrease my heart rate.”

 B) “I should use this medication only when I feel short of breath.”
 C) “This medication will help to open my airways.”
 D) “I can stop taking this medication once I feel better.”

Correct Answer: C
Rationale: Albuterol is a bronchodilator that helps open the airways, improving breathing.

Question 202: Neurological

A nurse is assessing a patient with a seizure disorder. Which intervention is most important for
the nurse to implement during a seizure?

 A) Place a padded tongue blade in the patient's mouth.

 B) Hold the patient's arms to prevent movement.
 C) Turn the patient onto their side.
 D) Restrain the patient to prevent injury.

Correct Answer: C
Rationale: Turning the patient onto their side helps prevent aspiration and facilitates drainage of
secretions during a seizure.

Question 203: Cardiovascular

A patient is diagnosed with heart failure and prescribed a thiazide diuretic. Which electrolyte
imbalance should the nurse monitor for?
  A) Hyperkalemia
 B) Hypomagnesemia
 C) Hypokalemia
 D) Hypernatremia

Correct Answer: C
Rationale: Thiazide diuretics can cause hypokalemia, so potassium levels should be closely
monitored.

Question 204: Infection Control

A nurse is caring for a patient with a Clostridium difficile (C. diff) infection. Which precaution
should the nurse implement?

 A) Standard precautions only

 B) Airborne precautions
 C) Contact precautions
 D) Droplet precautions

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of C. diff, which is
transmitted through contaminated surfaces and direct contact.

Question 205: Mental Health

A nurse is caring for a patient with bipolar disorder who is in a manic episode. Which
intervention is most appropriate?

 A) Encourage the patient to socialize with others.

 B) Provide a structured environment with clear limits.
 C) Allow the patient to make their own decisions.
 D) Administer sedatives to control the manic behavior.

Correct Answer: B
Rationale: A structured environment with clear limits helps provide safety and reduce stimuli
for the patient experiencing mania.

Question 206: Pediatric Nursing

A nurse is caring for a child with asthma who is using a peak flow meter. Which reading
indicates that the child's asthma is well-controlled?

 A) 50% of personal best

 B) 80-100% of personal best
 C) 60-75% of personal best
 D) 40% of personal best

Correct Answer: B
Rationale: A reading of 80-100% of the personal best indicates that the child's asthma is well-
controlled.

Question 207: Endocrine

A patient with diabetes mellitus is experiencing signs of hyperglycemia. Which symptom should
the nurse expect?

 A) Shakiness
 B) Sweating
 C) Frequent urination
 D) Confusion

Correct Answer: C
Rationale: Frequent urination is a common symptom of hyperglycemia due to osmotic diuresis.

Question 208: Gastrointestinal

A nurse is caring for a patient with diverticulitis. Which dietary modification should the nurse
recommend during the acute phase?

 A) High-fiber diet
 B) Low-fiber diet
 C) Full liquid diet
 D) Gluten-free diet

Correct Answer: B
Rationale: A low-fiber diet is recommended during the acute phase of diverticulitis to reduce
bowel irritation.

Question 209: Obstetrics

A nurse is assessing a pregnant patient who reports severe headaches and visual changes. Which
condition should the nurse suspect?

 A) Gestational diabetes
 B) Eclampsia
 C) Preterm labor
 D) Hyperemesis gravidarum

Correct Answer: B
Rationale: Severe headaches and visual changes can indicate eclampsia, a serious condition
associated with hypertension during pregnancy.

Question 210: Renal

A patient with chronic kidney disease is prescribed erythropoietin. Which outcome should the
nurse monitor for to evaluate the effectiveness of this medication?

 A) Increased blood pressure

 B) Increased hemoglobin level
 C) Decreased serum creatinine
 D) Decreased potassium level

Correct Answer: B
Rationale: Erythropoietin stimulates red blood cell production, so an increase in hemoglobin
level indicates effectiveness.

Question 211: Infection Control

A nurse is providing education about preventing the spread of respiratory infections. Which
statement by the patient indicates understanding?

 A) “I can share my drinks with family members.”

 B) “I will wash my hands frequently and use hand sanitizer.”
 C) “I should avoid close contact with others only when I feel sick.”
 D) “It’s okay to cough without covering my mouth.”

Correct Answer: B
Rationale: Frequent handwashing and use of hand sanitizer are effective methods to prevent the
spread of respiratory infections.
Question 212: Cardiovascular

A patient is prescribed atorvastatin. Which laboratory test should the nurse monitor?

 A) Blood glucose
 B) Liver function tests
 C) Complete blood count (CBC)
 D) Serum electrolytes

Correct Answer: B
Rationale: Atorvastatin can affect liver function, so liver function tests should be monitored
regularly.

Question 213: Neurological

A nurse is assessing a patient who has had a head injury. Which of the following findings would
indicate increased intracranial pressure (ICP)?

 A) Decreased blood pressure

 B) Bradycardia
 C) Decreased level of consciousness
 D) Warm extremities

Correct Answer: C
Rationale: A decreased level of consciousness is a significant indicator of increased ICP.

Question 214: Pediatric Nursing

A nurse is assessing an infant for signs of dehydration. Which finding is most indicative of
dehydration in infants?

 A) Decreased urinary output

 B) Increased appetite
 C) Soft fontanelle
 D) Warm skin

Correct Answer: A
Rationale: Decreased urinary output is a critical sign of dehydration in infants.

Question 215: Mental Health

A nurse is working with a patient diagnosed with obsessive-compulsive disorder (OCD). Which
intervention is most appropriate?

 A) Encourage the patient to avoid their compulsions.

 B) Provide a safe environment to express feelings.
 C) Suggest medications only as a last resort.
 D) Encourage exposure to feared situations gradually.

Correct Answer: D
Rationale: Gradual exposure to feared situations can help reduce anxiety and compulsive
behaviors associated with OCD.

Question 216: Gastrointestinal

A nurse is caring for a patient with cirrhosis. Which dietary restriction should the nurse
emphasize?

 A) Low carbohydrate
 B) High protein
 C) Low sodium
 D) High fat

Correct Answer: C
Rationale: A low-sodium diet helps prevent fluid retention and complications associated with
cirrhosis.

Question 217: Adult Health

A nurse is teaching a patient about self-management of hypertension. Which statement indicates

the need for further education?

 A) “I will monitor my blood pressure regularly.”

 B) “I can continue to eat as much salt as I want.”
 C) “I will engage in regular physical activity.”
 D) “I should take my medications as prescribed.”

Correct Answer: B
Rationale: Patients with hypertension should limit their salt intake to help manage blood
pressure.
Question 218: Obstetrics

A nurse is monitoring a patient who is 30 weeks pregnant and reports swelling in her legs and
feet. What is the nurse’s best response?

 A) “This is normal at this stage of pregnancy.”

 B) “You should elevate your legs and rest more.”
 C) “You may need to see a specialist about this.”
 D) “This could indicate a serious problem; let’s check your blood pressure.”

Correct Answer: D
Rationale: Swelling can indicate gestational hypertension or preeclampsia, which require
assessment of blood pressure.

Question 219: Endocrine

A patient with type 2 diabetes is being started on metformin. Which of the following should the
nurse include in patient education?

 A) Take metformin with food to minimize gastrointestinal side effects.

 B) Avoid all carbohydrates while taking this medication.
 C) This medication will cure your diabetes.
 D) You should stop taking this medication if you feel better.

Correct Answer: A
Rationale: Taking metformin with food helps reduce gastrointestinal side effects.

Question 220: Renal

A nurse is educating a patient with kidney stones about dietary changes. Which statement
indicates the patient understands the teaching?

 A) “I should increase my intake of calcium-rich foods.”

 B) “I will drink plenty of fluids to stay hydrated.”
 C) “I can eat as much salt as I want.”
 D) “I should avoid all protein foods.”

Correct Answer: B
Rationale: Increasing fluid intake helps prevent the formation of kidney stones by diluting the
urine.
Question 221: Pharmacology

A nurse is preparing to administer morphine to a patient in severe pain. Which assessment should
the nurse perform first?

 A) Assess the patient's respiratory rate.

 B) Check the patient's blood pressure.
 C) Evaluate the patient's pain level.
 D) Monitor the patient's heart rate.

Correct Answer: A
Rationale: Morphine can cause respiratory depression, so it is crucial to assess the respiratory
rate before administration.

Question 222: Neurological

A patient with a spinal cord injury is at risk for autonomic dysreflexia. Which assessment finding
would indicate this condition?

 A) Hypotension
 B) Severe headache
 C) Bradycardia
 D) Fever

Correct Answer: B
Rationale: Severe headache is a common symptom of autonomic dysreflexia, often
accompanied by hypertension.

Question 223: Cardiovascular

A nurse is caring for a patient with a myocardial infarction. Which assessment finding would
indicate the need for immediate intervention?

 A) Chest pain rated 6/10

 B) Sweating and cool, clammy skin
 C) Blood pressure of 90/60 mmHg
 D) Heart rate of 80 beats per minute

Correct Answer: C
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, which is a critical finding in
a patient with a myocardial infarction.
Question 224: Infection Control

A nurse is caring for a patient with a methicillin-resistant Staphylococcus aureus (MRSA)

infection. Which precaution should the nurse implement?

 A) Standard precautions only

 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions

Correct Answer: D
Rationale: Contact precautions are necessary to prevent the spread of MRSA through direct
contact with the infected patient or contaminated surfaces.

Question 225: Mental Health

A nurse is assessing a patient with depression. Which statement by the patient would indicate a
risk for suicide?

 A) “I have been feeling a little down lately.”

 B) “I don’t see a point in living anymore.”
 C) “I plan to start a new hobby.”
 D) “I feel better when I talk to friends.”

Correct Answer: B
Rationale: Expressing a lack of hope or a desire to end one’s life is a significant risk factor for
suicide.

Question 226: Pediatric Nursing

A nurse is caring for a child with croup. Which symptom is most characteristic of this condition?

 A) High fever
 B) Barking cough
 C) Difficulty breathing
 D) Sudden onset of wheezing

Correct Answer: B
Rationale: A barking cough is a hallmark symptom of croup, which is often caused by viral
infections.
Question 227: Endocrine

A patient with hypothyroidism is being treated with levothyroxine. Which laboratory test should
the nurse monitor to evaluate the effectiveness of the treatment?

 A) Thyroid-stimulating hormone (TSH) levels

 B) Serum glucose levels
 C) Serum calcium levels
 D) Complete blood count (CBC)

Correct Answer: A
Rationale: TSH levels are monitored to assess the effectiveness of levothyroxine therapy in
managing hypothyroidism.

Question 228: Gastrointestinal

A nurse is caring for a patient with a diagnosis of pancreatitis. Which dietary recommendation
should the nurse provide?

 A) High-fat diet
 B) Low-carbohydrate diet
 C) Low-fat diet
 D) High-protein diet

Correct Answer: C
Rationale: A low-fat diet is recommended for patients with pancreatitis to reduce pancreatic
stimulation.

Question 229: Obstetrics

A nurse is assessing a pregnant woman at 20 weeks of gestation. Which finding should the nurse
report immediately?

 A) Fundal height of 20 cm
 B) Fetal heart rate of 150 bpm
 C) Severe abdominal pain
 D) Weight gain of 4 lbs since the last visit
Correct Answer: C
Rationale: Severe abdominal pain can indicate a complication in pregnancy and should be
reported immediately.

Question 230: Renal

A patient with chronic kidney disease is receiving dialysis. Which laboratory value should the
nurse monitor closely?

 A) Blood urea nitrogen (BUN)

 B) Blood glucose
 C) Serum calcium
 D) Hemoglobin

Correct Answer: A
Rationale: BUN levels indicate the effectiveness of dialysis and overall kidney function.

Question 231: Infection Control

A nurse is providing education to a patient being discharged after a hospitalization for

pneumonia. Which statement indicates a need for further teaching?

 A) “I will take my antibiotics until they are all gone.”

 B) “I can stop using my inhaler once I feel better.”
 C) “I should rest and drink plenty of fluids.”
 D) “I need to follow up with my doctor if my symptoms worsen.”

Correct Answer: B
Rationale: Patients should continue using prescribed inhalers as directed, even if they start
feeling better.

Question 232: Cardiovascular

A patient with congestive heart failure is experiencing dyspnea and edema. Which intervention
should the nurse prioritize?

 A) Administer diuretics as ordered.

 B) Increase the patient’s fluid intake.
 C) Encourage ambulation.
 D) Provide a low-sodium diet.
Correct Answer: A
Rationale: Administering diuretics will help reduce fluid overload, alleviating dyspnea and
edema.

Question 233: Neurological

A nurse is caring for a patient with a stroke. Which assessment finding would indicate the need
for a swallow study?

 A) Patient is able to speak clearly.

 B) Patient has difficulty holding utensils.
 C) Patient demonstrates facial droop.
 D) Patient is coughing during meals.

Correct Answer: D
Rationale: Coughing during meals may indicate dysphagia, which necessitates a swallow study
to evaluate swallowing safety.

Question 234: Pediatric Nursing

A nurse is monitoring a child with an anaphylactic reaction after a bee sting. Which intervention
is the priority?

 A) Administer antihistamines.
 B) Assess airway patency.
 C) Administer oxygen.
 D) Apply a cold compress to the sting site.

Correct Answer: B
Rationale: Assessing airway patency is the priority intervention to ensure the child can breathe,
as anaphylaxis can lead to airway obstruction.

Question 235: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia. Which symptom is characteristic of
this condition?

 A) Obsessions
 B) Hallucinations
 C) Compulsions
  D) Mood swings

Correct Answer: B
Rationale: Hallucinations, particularly auditory hallucinations, are a key symptom of
schizophrenia.

Question 236: Gastrointestinal

A nurse is teaching a patient with irritable bowel syndrome (IBS) about dietary management.
Which food should the nurse advise the patient to avoid?

 A) Whole grains
 B) Fatty foods
 C) Lean meats
 D) Fruits and vegetables

Correct Answer: B
Rationale: Fatty foods can exacerbate symptoms of IBS and should generally be avoided.

Question 237: Obstetrics

A nurse is assessing a postpartum patient. Which finding would indicate a normal recovery
process?

 A) Bright red lochia rubra on day 5 postpartum

 B) Fundus firm and at the level of the umbilicus on day 3
 C) Temperature of 100.4°F (38°C) on day 2
 D) Mild perineal discomfort

Correct Answer: D
Rationale: Mild perineal discomfort is expected during the postpartum period; the other findings
require further evaluation.

Question 238: Endocrine

A patient with diabetes mellitus is experiencing symptoms of hypoglycemia. Which intervention

should the nurse perform first?

 A) Administer insulin.
 B) Provide a high-protein snack.
  C) Give 15 grams of fast-acting carbohydrates.
 D) Call the physician.

Correct Answer: C
Rationale: Administering fast-acting carbohydrates is the immediate treatment for
hypoglycemia.

Question 239: Renal

A nurse is teaching a patient about the signs and symptoms of kidney stones. Which symptom
should the nurse include?

 A) Fever
 B) Nausea and vomiting
 C) Hematuria
 D) All of the above

Correct Answer: D
Rationale: Fever, nausea, vomiting, and hematuria are all potential symptoms associated with
kidney stones.

Question 240: Infection Control

A nurse is caring for a patient with a respiratory infection. Which intervention is essential to
prevent the spread of infection?

 A) Wear gloves when entering the room.

 B) Limit visitors to immediate family only.
 C) Provide tissues and hand sanitizer for the patient.
 D) Encourage the patient to cough into their hand.

Correct Answer: C
Rationale: Providing tissues and hand sanitizer encourages proper hygiene and helps prevent the
spread of infection.

Question 241: Pharmacology

A patient is prescribed digoxin. Which of the following signs and symptoms should the nurse
monitor for that could indicate digoxin toxicity?
  A) Nausea and vomiting
 B) Bradycardia
 C) Yellow-green vision
 D) All of the above

Correct Answer: D
Rationale: All of these symptoms can indicate digoxin toxicity and require prompt assessment
and intervention.

Question 242: Neurological

A nurse is assessing a patient for signs of increased intracranial pressure (ICP). Which finding
would the nurse expect?

 A) Elevated blood pressure

 B) Hypotension
 C) Bradycardia
 D) All of the above

Correct Answer: A
Rationale: Increased ICP typically presents with hypertension, as the body attempts to maintain
cerebral perfusion.

Question 243: Cardiovascular

A patient is being discharged after a coronary artery bypass graft (CABG). Which statement by
the patient indicates the need for further teaching?

 A) “I will start a walking program as soon as I can.”

 B) “I can lift heavy objects after two weeks.”
 C) “I need to monitor my incision for signs of infection.”
 D) “I should take my medications as prescribed.”

Correct Answer: B
Rationale: Patients should avoid lifting heavy objects for several weeks post-surgery to prevent
strain on the surgical site.

Question 244: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis (TB). Which precaution should the
nurse implement?

 A) Droplet precautions
 B) Airborne precautions
 C) Contact precautions
 D) Standard precautions

Correct Answer: B
Rationale: Airborne precautions are necessary for TB due to the risk of transmission through
airborne particles.

Question 245: Mental Health

A nurse is developing a care plan for a patient diagnosed with major depressive disorder. Which
nursing diagnosis would be a priority?

 A) Social isolation
 B) Ineffective coping
 C) Risk for self-directed violence
 D) Powerlessness

Correct Answer: C
Rationale: The risk for self-directed violence is a priority due to the potential for harm
associated with depression.

Question 246: Pediatric Nursing

A nurse is caring for a child with pneumonia. Which of the following findings is most
concerning?

 A) Mild cough
 B) Temperature of 100.6°F (38.1°C)
 C) Rapid breathing and grunting
 D) Decreased appetite

Correct Answer: C
Rationale: Rapid breathing and grunting are concerning signs that may indicate respiratory
distress.
Question 247: Endocrine

A patient with hyperthyroidism is being treated with radioactive iodine. Which education point
should the nurse include?

 A) Avoid close contact with pregnant women and young children.

 B) Continue taking thyroid medications as prescribed.
 C) No dietary changes are necessary.
 D) Report any weight gain immediately.

Correct Answer: A
Rationale: Patients receiving radioactive iodine should avoid close contact with vulnerable
populations to prevent exposure.

Question 248: Gastrointestinal

A patient is experiencing severe abdominal pain and has a history of gallstones. Which condition
should the nurse suspect?

 A) Pancreatitis
 B) Appendicitis
 C) Diverticulitis
 D) Cholecystitis

Correct Answer: D
Rationale: Cholecystitis, inflammation of the gallbladder, is commonly associated with
gallstones and presents with severe abdominal pain.

Question 249: Obstetrics

A nurse is teaching a pregnant patient about the importance of folic acid. Which statement by the
patient indicates an understanding of the teaching?

 A) “I will stop taking folic acid after the first trimester.”

 B) “Folic acid will prevent neural tube defects in my baby.”
 C) “I can get enough folic acid from my diet alone.”
 D) “I should take folic acid only if I am planning to conceive.”

Correct Answer: B
Rationale: Folic acid is essential in preventing neural tube defects and should be continued
throughout pregnancy.
Question 250: Renal

A patient with end-stage renal disease (ESRD) is undergoing hemodialysis. Which electrolyte
imbalance should the nurse monitor closely?

 A) Hypokalemia
 B) Hyperkalemia
 C) Hyponatremia
 D) Hypercalcemia

Correct Answer: B
Rationale: Patients with ESRD are at risk for hyperkalemia due to the kidneys' inability to
excrete potassium.

Question 251: Infection Control

A nurse is caring for a patient with a central line. Which action is critical to prevent central line-
associated bloodstream infections (CLABSIs)?

 A) Change the dressing every week.

 B) Use sterile technique during insertion and maintenance.
 C) Keep the line capped when not in use.
 D) Change the infusion tubing every 48 hours.

Correct Answer: B
Rationale: Using sterile technique is critical in preventing infections associated with central
lines.

Question 252: Cardiovascular

A nurse is assessing a patient who has just had a pacemaker inserted. Which finding would
require immediate intervention?

 A) Heart rate of 70 bpm

 B) Decreased blood pressure
 C) Swelling at the insertion site
 D) Bruising around the incision
Correct Answer: B
Rationale: A decreased blood pressure may indicate complications such as lead displacement or
other cardiac issues.

Question 253: Neurological

A nurse is caring for a patient with a traumatic brain injury. Which assessment finding would
suggest the development of diabetes insipidus?

 A) Weight gain
 B) Polyuria
 C) Bradycardia
 D) Hypotension

Correct Answer: B
Rationale: Polyuria is a classic sign of diabetes insipidus, often resulting from a disruption in the
hypothalamic-pituitary axis after a head injury.

Question 254: Pediatric Nursing

A nurse is assessing a 2-year-old child. Which finding is considered normal for this age?

 A) Speaking in full sentences

 B) Ability to jump with both feet
 C) Understanding abstract concepts
 D) Ability to dress independently

Correct Answer: B
Rationale: By age 2, children typically develop gross motor skills, including the ability to jump
with both feet.

Question 255: Endocrine

A patient is being discharged after treatment for diabetic ketoacidosis (DKA). Which statement
by the patient indicates a need for further teaching?

 A) “I will check my blood glucose levels regularly.”

 B) “I can stop taking my insulin once I feel better.”
 C) “I need to drink plenty of fluids to stay hydrated.”
 D) “I should follow up with my healthcare provider.”
Correct Answer: B
Rationale: Patients should continue insulin therapy as prescribed and not stop once they feel
better.

Question 256: Gastrointestinal

A patient is diagnosed with peptic ulcer disease. Which lifestyle modification should the nurse
encourage?

 A) Increase caffeine intake.

 B) Stop smoking.
 C) Eat large meals before bedtime.
 D) Take nonsteroidal anti-inflammatory drugs (NSAIDs).

Correct Answer: B
Rationale: Smoking cessation is critical, as smoking can delay healing and increase ulcer
recurrence.

Question 257: Obstetrics

A nurse is assessing a postpartum patient who is 2 days post-delivery. Which finding is normal
during this period?

 A) Lochia serosa is present.

 B) Fundus is above the umbilicus.
 C) Moderate perineal pain.
 D) High fever.

Correct Answer: A
Rationale: Lochia serosa, a pinkish-brown discharge, is expected 2-4 days postpartum.

Question 258: Renal

A nurse is teaching a patient with nephrotic syndrome about dietary changes. Which statement
indicates that the patient understands the dietary restrictions?

 A) “I will increase my protein intake.”

 B) “I need to limit my sodium intake.”
 C) “I can eat as much potassium as I want.”
 D) “I should drink less fluid.”
Correct Answer: B
Rationale: Limiting sodium intake is essential to reduce edema in patients with nephrotic
syndrome.

Question 259: Infection Control

A nurse is caring for a patient with a vancomycin-resistant enterococcus (VRE) infection. What
precautions should the nurse implement?

 A) Droplet precautions
 B) Contact precautions
 C) Airborne precautions
 D) Standard precautions only

Correct Answer: B
Rationale: Contact precautions are required to prevent the spread of VRE through direct or
indirect contact.

Question 260: Cardiovascular

A nurse is monitoring a patient who has just been started on a new antihypertensive medication.
Which side effect should the nurse be particularly vigilant for?

 A) Dizziness
 B) Hypertension
 C) Tachycardia
 D) Weight gain

Correct Answer: A
Rationale: Dizziness is a common side effect of antihypertensive medications, especially when
starting treatment or increasing the dose.

Question 261: Pharmacology

A patient with asthma is prescribed a short-acting beta-agonist (SABA). Which statement by the
patient indicates a need for further teaching?

 A) “I can use this medication before exercise.”

 B) “This medication will help prevent my asthma attacks.”
 C) “I should carry this medication with me at all times.”
  D) “I need to shake the inhaler before using it.”

Correct Answer: B
Rationale: A SABA is used for quick relief of asthma symptoms, not for long-term prevention.

Question 262: Neurological

A nurse is caring for a patient with a recent stroke who exhibits right-sided weakness. Which
intervention should the nurse prioritize?

 A) Encourage the patient to use the affected side.

 B) Assist the patient with activities of daily living.
 C) Teach the patient to speak slowly and clearly.
 D) Provide emotional support to the patient.

Correct Answer: A
Rationale: Encouraging the use of the affected side can help promote recovery and
rehabilitation.

Question 263: Cardiovascular

A patient presents to the emergency department with chest pain and a history of coronary artery
disease. Which diagnostic test should the nurse anticipate?

 A) Electrocardiogram (ECG)
 B) Chest X-ray
 C) Complete blood count (CBC)
 D) Arterial blood gas (ABG)

Correct Answer: A
Rationale: An ECG is the first-line diagnostic test for evaluating chest pain, especially in
patients with a history of coronary artery disease.

Question 264: Infection Control

A nurse is providing care for a patient diagnosed with Clostridium difficile infection (CDI).
Which precaution should the nurse implement?

 A) Standard precautions only

 B) Airborne precautions
  C) Contact precautions
 D) Droplet precautions

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of CDI, which can be
transmitted via contaminated surfaces.

Question 265: Mental Health

A nurse is assessing a patient diagnosed with generalized anxiety disorder. Which symptom
would the nurse expect to observe?

 A) High energy levels

 B) Excessive worry
 C) Lack of motivation
 D) Grandiosity

Correct Answer: B
Rationale: Excessive worry is a hallmark symptom of generalized anxiety disorder.

Question 266: Pediatric Nursing

A nurse is caring for a 5-year-old child with asthma. Which of the following actions should the
nurse take to promote the child’s adherence to the asthma management plan?

 A) Teach the child about the disease using medical jargon.

 B) Involve the child in setting their treatment goals.
 C) Explain the importance of medications only to the parents.
 D) Restrict the child's activities to prevent asthma attacks.

Correct Answer: B
Rationale: Involving the child in setting treatment goals can enhance their understanding and
adherence to the asthma management plan.

Question 267: Endocrine

A patient with type 1 diabetes is hospitalized for diabetic ketoacidosis (DKA). Which assessment
finding would indicate that the treatment is effective?

 A) Elevated blood glucose levels

  B) Decreased ketone levels in urine
 C) Kussmaul respirations
 D) Abdominal pain

Correct Answer: B
Rationale: A decrease in ketone levels in urine indicates that the metabolic derangement of
DKA is being resolved.

Question 268: Gastrointestinal

A nurse is providing discharge teaching for a patient recovering from a gastric bypass surgery.
Which statement indicates the need for further teaching?

 A) “I will eat small, frequent meals.”

 B) “I can drink fluids while I eat.”
 C) “I will avoid high-sugar foods.”
 D) “I will take vitamin supplements as prescribed.”

Correct Answer: B
Rationale: Patients should avoid drinking fluids while eating to prevent dumping syndrome.

Question 269: Obstetrics

A nurse is caring for a postpartum patient who is breastfeeding. Which recommendation should
the nurse provide regarding nutrition?

 A) Increase caloric intake by 500 calories per day.

 B) Limit fluid intake to prevent excessive weight gain.
 C) Avoid all caffeine products.
 D) Reduce protein intake to decrease milk production.

Correct Answer: A
Rationale: Breastfeeding mothers are encouraged to increase their caloric intake to support milk
production.

Question 270: Renal

A nurse is assessing a patient with chronic kidney disease (CKD). Which laboratory value would
indicate worsening kidney function?
  A) Decreased serum creatinine
 B) Decreased blood urea nitrogen (BUN)
 C) Increased serum potassium
 D) Increased hemoglobin

Correct Answer: C
Rationale: An increase in serum potassium indicates impaired renal function, as the kidneys are
unable to excrete potassium effectively.

Question 271: Infection Control

A nurse is caring for a patient with influenza. What precaution should the nurse implement to
prevent the spread of infection?

 A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions

Correct Answer: B
Rationale: Droplet precautions are necessary for patients with influenza to prevent transmission
via respiratory droplets.

Question 272: Cardiovascular

A nurse is monitoring a patient who has just started taking a new antihypertensive medication.
Which assessment finding is a common side effect of this medication?

 A) Weight loss
 B) Dizziness
 C) Increased appetite
 D) Bradycardia

Correct Answer: B
Rationale: Dizziness is a common side effect of many antihypertensive medications, especially
upon initiation.

Question 273: Neurological

A nurse is assessing a patient with a seizure disorder. Which statement by the patient indicates a
need for further teaching?

 A) “I will take my medications as prescribed.”

 B) “I can skip my medication if I’m feeling well.”
 C) “I will avoid triggers that can lead to seizures.”
 D) “I should keep a record of my seizures.”

Correct Answer: B
Rationale: Skipping medication can lead to increased seizure frequency and should not be done.

Question 274: Pediatric Nursing

A nurse is teaching a parent about the immunization schedule for a 12-month-old child. Which
vaccine should the nurse ensure is administered at this age?

 A) MMR (measles, mumps, rubella)

 B) Varicella
 C) DTaP
 D) IPV (inactivated poliovirus)

Correct Answer: A
Rationale: The MMR vaccine is typically administered between 12 and 15 months of age.

Question 275: Endocrine

A patient diagnosed with Cushing's syndrome is being prepared for discharge. Which dietary
recommendation should the nurse provide?

 A) High-sodium diet
 B) Low-potassium diet
 C) High-protein diet
 D) Low-carbohydrate diet

Correct Answer: C
Rationale: A high-protein diet is often recommended to counteract protein loss associated with
Cushing's syndrome.

Question 276: Gastrointestinal

A patient with diverticulitis is being discharged. Which dietary recommendation should the nurse
provide?

 A) Avoid all fiber

 B) Consume a high-fiber diet
 C) Eat small, frequent meals high in fat
 D) Limit fluids to prevent bowel distention

Correct Answer: B
Rationale: A high-fiber diet is recommended to prevent future diverticulitis episodes by
promoting regular bowel movements.

Question 277: Obstetrics

A nurse is caring for a patient in labor who is requesting pain relief. Which non-pharmacological
intervention can the nurse suggest?

 A) Intravenous analgesics
 B) Epidural anesthesia
 C) Breathing techniques
 D) Nitrous oxide

Correct Answer: C
Rationale: Breathing techniques are a safe and effective non-pharmacological method for
managing labor pain.

Question 278: Renal

A nurse is assessing a patient with nephrotic syndrome. Which finding is most characteristic of
this condition?

 A) Hyperkalemia
 B) Proteinuria
 C) Hematuria
 D) Azotemia

Correct Answer: B
Rationale: Proteinuria is a hallmark sign of nephrotic syndrome due to increased permeability of
the glomeruli.
Question 279: Infection Control

A nurse is caring for a patient diagnosed with scabies. What type of precautions should the nurse
implement?

 A) Droplet precautions
 B) Contact precautions
 C) Airborne precautions
 D) Standard precautions

Correct Answer: B
Rationale: Contact precautions are required to prevent the spread of scabies through skin-to-skin
contact.

Question 280: Cardiovascular

A nurse is assessing a patient with heart failure. Which sign would indicate worsening heart
failure?

 A) Decreased urine output

 B) Weight loss
 C) Increased energy levels
 D) Improved exercise tolerance

Correct Answer: A
Rationale: Decreased urine output can indicate worsening heart failure due to reduced cardiac
output and renal perfusion.

Question 281: Pharmacology

A nurse is teaching a patient about warfarin therapy. Which statement indicates that the patient
understands the teaching?

 A) “I need to avoid foods high in vitamin K.”

 B) “I can take aspirin to relieve my headaches.”
 C) “I should have my INR checked every month.”
 D) “I can stop the medication once my symptoms improve.”

Correct Answer: A
Rationale: Patients on warfarin need to avoid foods high in vitamin K to maintain stable INR
levels.
Question 282: Neurological

A nurse is assessing a patient who has just undergone a craniotomy. Which finding should be
reported immediately?

 A) Clear fluid drainage from the nose

 B) Increased heart rate
 C) Mild headache
 D) Slightly elevated temperature

Correct Answer: A
Rationale: Clear fluid drainage from the nose may indicate cerebrospinal fluid (CSF) leakage,
which is a serious complication.

Question 283: Cardiovascular

A patient presents to the emergency department with chest pain radiating to the left arm. What is
the priority nursing intervention?

 A) Administer nitroglycerin.
 B) Obtain a 12-lead ECG.
 C) Start IV fluids.
 D) Perform a focused assessment.

Correct Answer: B
Rationale: Obtaining a 12-lead ECG is the priority to assess for any cardiac ischemia or
infarction.

Question 284: Infection Control

A nurse is caring for a patient with a respiratory infection. Which intervention is most important
to prevent the spread of infection?

 A) Hand hygiene
 B) Wearing gloves
 C) Using a mask
 D) Limiting visitors

Correct Answer: A
Rationale: Hand hygiene is the most critical intervention for preventing the spread of infections.
Question 285: Mental Health

A nurse is assessing a patient with major depressive disorder. Which finding is most concerning?

 A) Expressing feelings of worthlessness

 B) Lack of energy
 C) Plan for suicide
 D) Difficulty concentrating

Correct Answer: C
Rationale: A plan for suicide is the most concerning finding and requires immediate
intervention.

Question 286: Pediatric Nursing

A nurse is caring for a child with a high fever and a history of febrile seizures. What should the
nurse educate the parents to do?

 A) Encourage the child to play actively.

 B) Use tepid baths to reduce fever.
 C) Administer aspirin for fever.
 D) Limit fluid intake.

Correct Answer: B
Rationale: Tepid baths can help reduce fever in children, but aspirin should be avoided due to
the risk of Reye's syndrome.

Question 287: Endocrine

A patient with diabetes mellitus is experiencing hypoglycemia. Which symptom might the nurse
expect to observe?

 A) Polyuria
 B) Weight loss
 C) Sweating and trembling
 D) Increased thirst

Correct Answer: C
Rationale: Sweating and trembling are common symptoms of hypoglycemia due to low blood
sugar levels.
Question 288: Gastrointestinal

A patient is diagnosed with peptic ulcer disease. Which lifestyle change should the nurse
encourage?

 A) Increase caffeine consumption.

 B) Avoid smoking.
 C) Eat larger meals to reduce acid secretion.
 D) Increase alcohol intake.

Correct Answer: B
Rationale: Avoiding smoking can help reduce the risk of ulcer recurrence and promote healing.

Question 289: Obstetrics

A nurse is caring for a pregnant patient at 28 weeks gestation. Which of the following findings
requires further evaluation?

 A) Mild swelling of the ankles

 B) Blood pressure of 140/90 mmHg
 C) Fetal heart rate of 150 bpm
 D) Weight gain of 2 pounds in the past week

Correct Answer: B
Rationale: A blood pressure of 140/90 mmHg may indicate hypertension, which requires further
evaluation.

Question 290: Renal

A patient with chronic kidney disease is on a low-protein diet. Which of the following foods
should the nurse encourage?

 A) Chicken
 B) Lentils
 C) Fruits and vegetables
 D) Fish

Correct Answer: C
Rationale: Fruits and vegetables are typically low in protein and can be included in a low-
protein diet for kidney disease.
Question 291: Infection Control

A nurse is caring for a patient with a confirmed methicillin-resistant Staphylococcus aureus

(MRSA) infection. What type of precautions should the nurse implement?

 A) Airborne precautions
 B) Droplet precautions
 C) Contact precautions
 D) Standard precautions only

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of MRSA.

Question 292: Cardiovascular

A patient with heart failure is being discharged. Which statement indicates the need for further
teaching?

 A) “I will weigh myself daily.”

 B) “I can eat as much salt as I want.”
 C) “I need to monitor for signs of worsening heart failure.”
 D) “I should take my medications as prescribed.”

Correct Answer: B
Rationale: Patients with heart failure should limit their salt intake to manage fluid retention.

Question 293: Neurological

A nurse is caring for a patient with Parkinson's disease. Which intervention should the nurse
prioritize to promote safety?

 A) Provide a low-fiber diet.

 B) Encourage slow movements.
 C) Ensure the environment is free of obstacles.
 D) Encourage the patient to walk unassisted.

Correct Answer: C
Rationale: Ensuring a safe environment free of obstacles is essential to prevent falls in patients
with Parkinson's disease.
Question 294: Pediatric Nursing

A nurse is teaching a parent about the administration of an EpiPen to their child with a known
severe allergy. Which statement indicates understanding?

 A) “I should inject the EpiPen into my child’s thigh and hold it for 5 seconds.”
 B) “I can administer the EpiPen through clothing if needed.”
 C) “I need to call 911 only if my child doesn't feel better after 10 minutes.”
 D) “I should store the EpiPen in the refrigerator.”

Correct Answer: B
Rationale: EpiPens can be administered through clothing if necessary, and it's critical to seek
medical help immediately after administration.

Question 295: Endocrine

A nurse is monitoring a patient with Addison's disease. Which laboratory finding would be
expected?

 A) Hyperglycemia
 B) Hyperkalemia
 C) Hypocalcemia
 D) Hypernatremia

Correct Answer: B
Rationale: Hyperkalemia is common in Addison's disease due to insufficient production of
aldosterone, which regulates potassium levels.

Question 296: Gastrointestinal

A nurse is caring for a patient with a history of pancreatitis. Which dietary instruction should the
nurse provide?

 A) Increase intake of fatty foods.

 B) Avoid alcohol consumption.
 C) Eat large meals less frequently.
 D) Increase intake of red meat.
Correct Answer: B
Rationale: Patients with a history of pancreatitis should avoid alcohol, as it can trigger an
episode.

Question 297: Obstetrics

A nurse is assessing a patient in labor. Which finding is concerning and requires immediate
intervention?

 A) Fetal heart rate of 140 bpm

 B) Contractions every 3 minutes lasting 60 seconds
 C) Variable decelerations in fetal heart rate
 D) Cervical dilation of 5 cm

Correct Answer: C
Rationale: Variable decelerations in fetal heart rate can indicate umbilical cord compression and
require immediate intervention.

Question 298: Renal

A nurse is caring for a patient undergoing hemodialysis. Which assessment finding requires
immediate intervention?

 A) Increased blood pressure

 B) Bruising at the access site
 C) Decreased urine output
 D) Increased thirst

Correct Answer: B
Rationale: Bruising at the access site may indicate bleeding and requires immediate assessment
and intervention.

Question 299: Infection Control

A nurse is caring for a patient diagnosed with viral meningitis. Which precaution should the
nurse implement?

 A) Standard precautions
 B) Droplet precautions
 C) Airborne precautions
  D) Contact precautions

Correct Answer: A
Rationale: Standard precautions are sufficient for caring for patients with viral meningitis, as it
is not transmitted through droplets or airborne particles.

Question 300: Cardiovascular

A nurse is teaching a patient about the signs of heart failure exacerbation. Which symptom
should the patient report immediately?

 A) Mild weight gain

 B) Increased fatigue
 C) Shortness of breath while lying flat
 D) Occasional swelling of the ankles

Correct Answer: C
Rationale: Shortness of breath while lying flat (orthopnea) indicates worsening heart failure and
should be reported immediately.

Question 301: Pharmacology

A patient is prescribed lisinopril for hypertension. Which side effect should the nurse monitor
for?

 A) Hypokalemia
 B) Angioedema
 C) Weight gain
 D) Increased appetite

Correct Answer: B
Rationale: Angioedema is a serious side effect associated with ACE inhibitors like lisinopril and
requires immediate medical attention.

Question 302: Neurological

A nurse is caring for a patient with a spinal cord injury. Which complication should the nurse
monitor for?

 A) Increased appetite
  B) Hypotension
 C) Bradycardia
 D) Autonomic dysreflexia

Correct Answer: D
Rationale: Autonomic dysreflexia is a serious complication that can occur in patients with spinal
cord injuries, particularly above T6.

Question 303: Cardiovascular

A nurse is assessing a patient who is post-operative following coronary artery bypass graft
(CABG) surgery. Which finding should be reported immediately?

 A) Heart rate of 80 bpm

 B) Decreased urine output
 C) Temperature of 99.5°F
 D) Slight swelling at the surgical site

Correct Answer: B
Rationale: Decreased urine output can indicate renal impairment, which may suggest
complications post-surgery.

Question 304: Infection Control

A patient is admitted with a diagnosis of tuberculosis. Which precautions should the nurse
implement?

 A) Standard precautions
 B) Airborne precautions
 C) Contact precautions
 D) Droplet precautions

Correct Answer: B
Rationale: Airborne precautions are necessary for patients with tuberculosis to prevent
transmission through the air.

Question 305: Mental Health

A nurse is caring for a patient with schizophrenia who exhibits disorganized speech. What is the
best initial nursing intervention?
  A) Redirect the patient to a calmer topic.
 B) Encourage the patient to express their feelings.
 C) Provide medication to manage symptoms.
 D) Use clear, simple instructions when communicating.

Correct Answer: D
Rationale: Using clear, simple instructions can help improve communication with a patient
experiencing disorganized speech.

Question 306: Pediatric Nursing

A nurse is teaching a parent about the care of a child with asthma. Which statement indicates a
need for further teaching?

 A) “I will monitor my child’s peak flow readings.”

 B) “I should give my child a bronchodilator during an asthma attack.”
 C) “I can let my child play outside during high pollen days.”
 D) “I will keep my child’s rescue inhaler nearby at all times.”

Correct Answer: C
Rationale: Children with asthma should avoid outdoor activities during high pollen days to
prevent asthma exacerbations.

Question 307: Endocrine

A patient with diabetes is found to have a blood glucose level of 50 mg/dL. What should the
nurse do first?

 A) Administer insulin.
 B) Give the patient a glass of orange juice.
 C) Recheck the blood glucose level in 15 minutes.
 D) Call the healthcare provider.

Correct Answer: B
Rationale: The first action should be to provide a fast-acting source of sugar, such as orange
juice, to treat hypoglycemia.

Question 308: Gastrointestinal

A patient is diagnosed with gastroesophageal reflux disease (GERD). Which dietary instruction
should the nurse provide?

 A) Eat large meals to prevent reflux.

 B) Limit high-fat foods.
 C) Increase caffeine intake.
 D) Avoid acidic foods.

Correct Answer: B
Rationale: Limiting high-fat foods can help decrease reflux symptoms in patients with GERD.

Question 309: Obstetrics

A nurse is caring for a laboring patient. Which finding should the nurse report to the healthcare
provider?

 A) Fetal heart rate of 130 bpm

 B) Uterine contractions every 5 minutes
 C) Maternal heart rate of 110 bpm
 D) Moderate uterine tenderness

Correct Answer: C
Rationale: A maternal heart rate of 110 bpm may indicate maternal stress or other complications
that require further evaluation.

Question 310: Renal

A patient with acute kidney injury is on a restricted fluid intake. Which intervention should the
nurse implement?

 A) Provide high-protein snacks.

 B) Encourage the patient to drink fluids freely.
 C) Monitor daily weight and intake/output.
 D) Offer frequent small meals.

Correct Answer: C
Rationale: Monitoring daily weight and intake/output helps assess fluid balance and kidney
function in patients with acute kidney injury.

Question 311: Infection Control

A nurse is caring for a patient with a known Clostridium difficile infection. Which action should
the nurse prioritize?

 A) Administer oral antibiotics.

 B) Ensure hand hygiene before and after patient contact.
 C) Wear a surgical mask when entering the room.
 D) Place the patient in a private room with negative pressure.

Correct Answer: B
Rationale: Proper hand hygiene is essential to prevent the spread of C. difficile, as it is
transmitted through the fecal-oral route.

Question 312: Cardiovascular

A patient is prescribed a statin medication. Which laboratory test should the nurse monitor
regularly?

 A) Liver function tests

 B) Complete blood count
 C) Serum electrolyte levels
 D) Thyroid function tests

Correct Answer: A
Rationale: Liver function tests should be monitored regularly in patients taking statins to detect
potential liver damage.

Question 313: Neurological

A nurse is assessing a patient who has had a stroke affecting the left hemisphere. Which
symptom would the nurse expect to observe?

 A) Left-sided weakness
 B) Impaired speech
 C) Visual field deficits on the right
 D) Loss of coordination

Correct Answer: B
Rationale: A stroke in the left hemisphere often affects speech and language abilities.

Question 314: Pediatric Nursing

A nurse is teaching a parent about administering acetaminophen to a child. Which statement by
the parent indicates a need for further education?

 A) “I will give the medication every 4-6 hours as needed.”

 B) “I can use any liquid measuring cup to measure the dose.”
 C) “I should not exceed the maximum daily dose for my child’s weight.”
 D) “I will notify the doctor if my child’s fever persists.”

Correct Answer: B
Rationale: Parents should use a proper measuring device (like a syringe or dosing cup)
specifically designed for medications to ensure accurate dosing.

Question 315: Endocrine

A patient with hyperthyroidism is prescribed radioactive iodine therapy. What should the nurse
include in the teaching plan?

 A) “You will need to increase your iodine intake.”

 B) “You should avoid contact with pregnant women.”
 C) “You may feel a lump in your throat after treatment.”
 D) “You will require lifelong thyroid medication.”

Correct Answer: B
Rationale: Patients receiving radioactive iodine therapy should avoid close contact with
pregnant women due to the risk of radiation exposure.

Question 316: Gastrointestinal

A patient with irritable bowel syndrome (IBS) is seeking dietary advice. Which food should the
nurse suggest the patient avoid?

 A) Fruits
 B) Whole grains
 C) Dairy products
 D) Lean meats

Correct Answer: C
Rationale: Many patients with IBS may be sensitive to lactose found in dairy products, so it's
often recommended to limit or avoid them.
Question 317: Obstetrics

A nurse is assessing a postpartum patient who is 2 days post-delivery. Which finding should the
nurse consider normal?

 A) Bright red lochia rubra

 B) A temperature of 101.5°F
 C) Moderate perineal swelling
 D) Fundus at the level of the umbilicus

Correct Answer: D
Rationale: The fundus is typically at the level of the umbilicus around 2 days postpartum; lochia
rubra can be expected but should not have foul odor or bright red color beyond the first few days.

Question 318: Renal

A nurse is caring for a patient with nephrotic syndrome. Which assessment finding is most
indicative of the condition?

 A) Oliguria
 B) Hematuria
 C) Proteinuria
 D) Hypercalcemia

Correct Answer: C
Rationale: Proteinuria is a key feature of nephrotic syndrome due to increased permeability of
the glomeruli.

Question 319: Infection Control

A nurse is caring for a patient with influenza. Which intervention is essential for the nurse to
implement?

 A) Use droplet precautions.

 B) Encourage high-fiber intake.
 C) Administer antibiotics.
 D) Limit visitors to the room.

Correct Answer: A
Rationale: Droplet precautions should be used to prevent the spread of influenza, which is
transmitted through respiratory droplets.
Question 320: Cardiovascular

A nurse is teaching a patient about lifestyle changes to manage hypertension. Which statement
indicates a need for further teaching?

 A) “I will reduce my sodium intake.”

 B) “I can eat as many fruits and vegetables as I want.”
 C) “I will exercise for at least 30 minutes most days of the week.”
 D) “I can continue to drink alcohol in moderation.”

Correct Answer: D
Rationale: While moderate alcohol consumption may be acceptable, it should be limited or
avoided altogether to help manage hypertension effectively.

Question 321: Pharmacology

A patient is prescribed metformin for type 2 diabetes. Which statement by the patient indicates a
need for further teaching?

 A) “I will take this medication with my meals.”

 B) “I should avoid alcohol while taking this medication.”
 C) “I can stop taking this medication if I feel well.”
 D) “I will have my kidney function monitored regularly.”

Correct Answer: C
Rationale: Patients should not stop taking metformin without consulting their healthcare
provider, as it is essential for managing diabetes.

Question 322: Neurological

A nurse is assessing a patient with suspected meningitis. Which finding would the nurse expect?

 A) Elevated blood pressure

 B) Positive Brudzinski's sign
 C) Decreased white blood cell count
 D) Decreased temperature

Correct Answer: B
Rationale: A positive Brudzinski's sign (involuntary lifting of the legs when the neck is flexed)
is indicative of meningitis.
Question 323: Cardiovascular

A nurse is monitoring a patient receiving a continuous IV infusion of heparin. What laboratory

value is most important to monitor?

 A) Prothrombin time (PT)

 B) Activated partial thromboplastin time (aPTT)
 C) Platelet count
 D) Hemoglobin and hematocrit

Correct Answer: B
Rationale: The activated partial thromboplastin time (aPTT) is monitored to assess the
effectiveness of heparin therapy.

Question 324: Infection Control

A patient with C. difficile is placed on contact precautions. What should the nurse include in the
plan of care?

 A) Wear a mask when entering the room.

 B) Use alcohol-based hand sanitizer after patient care.
 C) Use soap and water for hand hygiene after patient care.
 D) Place the patient in a room with negative pressure.

Correct Answer: C
Rationale: Soap and water should be used for hand hygiene after caring for patients with C.
difficile, as alcohol-based sanitizers are ineffective against spores.

Question 325: Mental Health

A patient with bipolar disorder is exhibiting manic behavior. Which intervention is most
appropriate?

 A) Encourage the patient to engage in group activities.

 B) Allow the patient to express feelings freely.
 C) Provide a quiet, structured environment.
 D) Increase stimulation to engage the patient.
Correct Answer: C
Rationale: A quiet, structured environment can help reduce stimulation and provide safety for
the patient during manic episodes.

Question 326: Pediatric Nursing

A nurse is caring for a child with a recent diagnosis of type 1 diabetes. Which of the following is
the priority nursing intervention?

 A) Teach the child about carbohydrate counting.

 B) Monitor the child’s blood glucose levels frequently.
 C) Encourage the child to exercise regularly.
 D) Discuss the importance of regular follow-up appointments.

Correct Answer: B
Rationale: Frequent monitoring of blood glucose levels is crucial for managing type 1 diabetes
effectively.

Question 327: Endocrine

A patient with hypothyroidism is being started on levothyroxine. Which instruction should the
nurse include in the teaching plan?

 A) “Take this medication at bedtime for best results.”

 B) “You can take this medication with food.”
 C) “It’s important to take this medication on an empty stomach.”
 D) “You should stop this medication if you feel nervous.”

Correct Answer: C
Rationale: Levothyroxine should be taken on an empty stomach to enhance absorption.

Question 328: Gastrointestinal

A nurse is caring for a patient with liver cirrhosis. Which assessment finding is a priority?

 A) Jaundice
 B) Ascites
 C) Altered mental status
 D) Anorexia
Correct Answer: C
Rationale: Altered mental status can indicate hepatic encephalopathy, a life-threatening
complication of liver cirrhosis that requires immediate intervention.

Question 329: Obstetrics

A postpartum patient is experiencing heavy vaginal bleeding. Which action should the nurse take
first?

 A) Assess the fundus for firmness.

 B) Notify the healthcare provider.
 C) Administer oxytocin as ordered.
 D) Document the findings.

Correct Answer: A
Rationale: Assessing the fundus for firmness is the first action, as a boggy fundus may indicate
uterine atony, a common cause of postpartum hemorrhage.

Question 330: Renal

A patient with chronic kidney disease is experiencing fatigue and weakness. Which laboratory
value should the nurse assess?

 A) Blood urea nitrogen (BUN)

 B) Hemoglobin
 C) Creatinine
 D) Electrolytes

Correct Answer: B
Rationale: Anemia is common in chronic kidney disease due to decreased erythropoietin
production, so hemoglobin levels should be assessed.

Question 331: Infection Control

A nurse is preparing to perform a dressing change on a patient with an open wound. Which
action is a priority?

 A) Apply a sterile dressing.

 B) Don gloves and a mask.
 C) Clean the wound with normal saline.
  D) Wash hands thoroughly before the procedure.

Correct Answer: D
Rationale: Hand hygiene is the most critical step in infection control before any clinical
procedure.

Question 332: Cardiovascular

A patient is diagnosed with congestive heart failure. Which assessment finding should the nurse
monitor for?

 A) Hypotension
 B) Bradypnea
 C) Edema
 D) Decreased heart rate

Correct Answer: C
Rationale: Edema is a common finding in congestive heart failure due to fluid overload.

Question 333: Neurological

A patient who is post-stroke exhibits weakness on the right side. Which term should the nurse
use to document this finding?

 A) Hemiplegia
 B) Hemiparesis
 C) Quadriplegia
 D) Diplegia

Correct Answer: B
Rationale: Hemiparesis refers to weakness on one side of the body, while hemiplegia indicates
complete paralysis.

Question 334: Pediatric Nursing

A nurse is assessing a child with suspected appendicitis. Which finding would most likely
indicate this condition?

 A) Bradycardia
 B) Abdominal rigidity
  C) Frequent urination
 D) Elevated blood pressure

Correct Answer: B
Rationale: Abdominal rigidity is a classic sign of appendicitis in children and should be
investigated further.

Question 335: Endocrine

A patient with Addison's disease is experiencing an adrenal crisis. Which medication should the
nurse prepare to administer?

 A) Hydrocortisone
 B) Methimazole
 C) Insulin
 D) Levothyroxine

Correct Answer: A
Rationale: Hydrocortisone is a glucocorticoid that should be administered to manage an adrenal
crisis in patients with Addison's disease.

Question 336: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which medication class is commonly
prescribed for this condition?

 A) Antihistamines
 B) Proton pump inhibitors
 C) Beta-blockers
 D) Diuretics

Correct Answer: B
Rationale: Proton pump inhibitors are commonly prescribed to reduce stomach acid and
promote healing of peptic ulcers.

Question 337: Obstetrics

A nurse is assessing a pregnant patient who reports persistent headaches. Which condition should
the nurse consider?
  A) Normal pregnancy symptom
 B) Preeclampsia
 C) Gestational diabetes
 D) Hyperemesis gravidarum

Correct Answer: B
Rationale: Persistent headaches in pregnancy can be a sign of preeclampsia and should be
evaluated promptly.

Question 338: Renal

A nurse is monitoring a patient who has undergone kidney transplantation. Which finding
requires immediate intervention?

 A) Slight fever
 B) Decreased urine output
 C) Elevated blood pressure
 D) Increased appetite

Correct Answer: B
Rationale: Decreased urine output can indicate transplant rejection or other complications and
should be addressed immediately.

Question 339: Infection Control

A patient diagnosed with an infection is started on broad-spectrum antibiotics. What is the

nurse's priority action?

 A) Educate the patient about the medication.

 B) Monitor the patient for side effects.
 C) Obtain a culture and sensitivity before administration.
 D) Document the administration of the medication.

Correct Answer: C
Rationale: It is crucial to obtain a culture and sensitivity before starting antibiotics to ensure the
appropriate medication is given.

Question 340: Cardiovascular

A nurse is teaching a patient about lifestyle modifications to prevent hypertension. Which
statement indicates a need for further teaching?

 A) “I will exercise regularly and maintain a healthy weight.”

 B) “I should limit my intake of processed foods.”
 C) “I can still have my morning coffee.”
 D) “I need to stop smoking completely.”

Correct Answer: C
Rationale: While moderate coffee consumption may be acceptable, patients should be educated
on caffeine’s potential effects on blood pressure.

Question 341: Pharmacology

A patient is prescribed warfarin for anticoagulation. Which lab value should the nurse monitor?

 A) Prothrombin time (PT) and International Normalized Ratio (INR)

 B) Activated partial thromboplastin time (aPTT)
 C) Complete blood count (CBC)
 D) Blood urea nitrogen (BUN)

Correct Answer: A
Rationale: The prothrombin time (PT) and International Normalized Ratio (INR) are monitored
to assess the effectiveness of warfarin therapy.

Question 342: Neurological

A nurse is assessing a patient who has had a seizure. Which finding is most indicative of
postictal state?

 A) Confusion and disorientation

 B) Weakness on one side of the body
 C) Loss of consciousness
 D) Nausea and vomiting

Correct Answer: A
Rationale: Confusion and disorientation are characteristic of the postictal state following a
seizure.

Question 343: Cardiovascular

A patient diagnosed with heart failure is prescribed furosemide. What is the most important
assessment the nurse should perform?

 A) Monitor for signs of dehydration

 B) Assess lung sounds
 C) Check blood glucose levels
 D) Evaluate the patient's potassium levels

Correct Answer: D
Rationale: Furosemide is a loop diuretic that can cause potassium loss, making it important to
monitor potassium levels.

Question 344: Infection Control

A nurse is caring for a patient with a respiratory infection. Which of the following should the
nurse implement?

 A) Place the patient in a room with negative pressure.

 B) Encourage the patient to wear a mask when outside the room.
 C) Use standard precautions only.
 D) Restrict all visitors from entering the room.

Correct Answer: B
Rationale: Encouraging the patient to wear a mask helps prevent the spread of respiratory
infections when they are outside their room.

Question 345: Mental Health

A nurse is caring for a patient with depression. Which statement by the patient indicates a
potential risk for suicide?

 A) “I have been feeling better lately.”

 B) “I don’t see the point in anything anymore.”
 C) “I want to talk about my future plans.”
 D) “I am grateful for my family’s support.”

Correct Answer: B
Rationale: Statements expressing hopelessness, such as not seeing the point in anything, can
indicate a risk for suicide.
Question 346: Pediatric Nursing

A nurse is assessing a child with suspected rheumatic fever. Which finding would the nurse
expect?

 A) Elevated white blood cell count

 B) Joint pain and swelling
 C) Jaundice
 D) Bradycardia

Correct Answer: B
Rationale: Joint pain and swelling are common manifestations of rheumatic fever following a
streptococcal infection.

Question 347: Endocrine

A patient with type 1 diabetes is experiencing hypoglycemia. Which symptom should the nurse
assess for?

 A) Increased thirst
 B) Sweating and tremors
 C) Blurred vision
 D) Nausea and vomiting

Correct Answer: B
Rationale: Sweating and tremors are common symptoms of hypoglycemia and indicate the need
for immediate intervention.

Question 348: Gastrointestinal

A nurse is caring for a patient with a history of pancreatitis. Which dietary modification should
the nurse recommend?

 A) High-fat diet
 B) Low-carbohydrate diet
 C) Low-protein diet
 D) Low-fat diet

Correct Answer: D
Rationale: A low-fat diet is recommended for patients with pancreatitis to reduce the workload
on the pancreas.
Question 349: Obstetrics

A nurse is assessing a laboring patient. What is the priority nursing action if the fetal heart rate
drops to 80 bpm?

 A) Administer oxygen to the mother.

 B) Change the mother's position.
 C) Notify the healthcare provider.
 D) Prepare for an emergency cesarean section.

Correct Answer: B
Rationale: Changing the mother's position can help relieve pressure on the umbilical cord,
potentially improving fetal heart rate.

Question 350: Renal

A patient undergoing dialysis presents with hypotension. What is the nurse's priority action?

 A) Administer fluid bolus as prescribed.

 B) Document the findings.
 C) Monitor vital signs every 15 minutes.
 D) Notify the healthcare provider.

Correct Answer: A
Rationale: Administering a fluid bolus can help stabilize blood pressure in patients experiencing
hypotension during dialysis.

Question 351: Infection Control

A nurse is caring for a patient diagnosed with herpes zoster. Which precaution should the nurse
take?

 A) Airborne precautions
 B) Contact precautions
 C) Droplet precautions
 D) Standard precautions only

Correct Answer: B
Rationale: Contact precautions should be implemented for herpes zoster to prevent the spread of
the virus.
Question 352: Cardiovascular

A patient with hypertension is prescribed lisinopril. Which statement indicates the need for
further teaching?

 A) “I should monitor my blood pressure regularly.”

 B) “I can stop taking this medication if I feel fine.”
 C) “I should avoid potassium supplements.”
 D) “I need to report any swelling in my face or throat.”

Correct Answer: B
Rationale: Patients should not stop taking antihypertensive medications without consulting their
healthcare provider, even if they feel fine.

Question 353: Neurological

A nurse is assessing a patient after a head injury. Which sign would most likely indicate
increased intracranial pressure?

 A) Decreased blood pressure

 B) Bradycardia
 C) Widening pulse pressure
 D) Pupillary constriction

Correct Answer: C
Rationale: Widening pulse pressure is a classic sign of increased intracranial pressure, often
accompanied by bradycardia.

Question 354: Pediatric Nursing

A nurse is teaching a parent about the administration of an epinephrine auto-injector for an

allergic reaction. Which statement by the parent indicates a need for further teaching?

 A) “I will inject it into the outer thigh.”

 B) “I can give a second dose if symptoms do not improve in 5-15 minutes.”
 C) “I will hold the auto-injector for 10 seconds.”
 D) “I should keep the auto-injector in the refrigerator.”
Correct Answer: D
Rationale: Epinephrine auto-injectors should be stored at room temperature, not in the
refrigerator.

Question 355: Endocrine

A patient with hyperthyroidism is receiving propylthiouracil (PTU). Which adverse effect should
the nurse monitor for?

 A) Weight gain
 B) Rash
 C) Bradycardia
 D) Hypoglycemia

Correct Answer: B
Rationale: Rash is a potential adverse effect of PTU, and any skin changes should be monitored.

Question 356: Gastrointestinal

A nurse is caring for a patient with a colostomy. Which statement indicates the need for further
teaching?

 A) “I will empty the pouch when it is one-third full.”

 B) “I need to change the pouch every day.”
 C) “I can use skin barriers to protect my skin.”
 D) “I should monitor for signs of leakage.”

Correct Answer: B
Rationale: Colostomy pouches do not need to be changed every day; they should be changed
based on the manufacturer's guidelines or when leaking.

Question 357: Obstetrics

A nurse is caring for a pregnant patient who is at 28 weeks gestation and reports feeling faint
when standing. What is the nurse's priority intervention?

 A) Encourage the patient to drink more fluids.

 B) Assess the patient's blood pressure and heart rate.
 C) Instruct the patient to avoid standing for long periods.
 D) Perform a fetal heart rate assessment.
Correct Answer: B
Rationale: Assessing blood pressure and heart rate is crucial to determine if the patient is
experiencing orthostatic hypotension, which is common in pregnancy.

Question 358: Renal

A patient diagnosed with chronic kidney disease is being treated with erythropoietin. Which lab
value should the nurse monitor closely?

 A) Calcium levels
 B) Hemoglobin levels
 C) Creatinine levels
 D) Potassium levels

Correct Answer: B
Rationale: Erythropoietin stimulates red blood cell production, so hemoglobin levels should be
monitored to assess the effectiveness of treatment.

Question 359: Infection Control

A nurse is caring for a patient diagnosed with influenza. Which intervention should the nurse
implement?

 A) Use droplet precautions.

 B) Administer antiviral medication.
 C) Isolate the patient in a negative pressure room.
 D) Limit visitors to family members only.

Correct Answer: A
Rationale: Droplet precautions are necessary to prevent the spread of influenza, as it is
transmitted through respiratory droplets.

Question 360: Cardiovascular

A patient with a history of myocardial infarction is prescribed aspirin. What is the primary
purpose of this medication?

 A) Pain relief
 B) Blood pressure control
 C) Anticoagulation
  D) Antiplatelet therapy

Correct Answer: D
Rationale: Aspirin is used for antiplatelet therapy to prevent further clot formation in patients
with a history of myocardial infarction.

Question 361: Pharmacology

A patient is prescribed amoxicillin for a bacterial infection. Which statement by the patient
indicates a need for further teaching?

 A) “I should complete the entire course of antibiotics.”

 B) “It’s okay to skip a dose if I forget it.”
 C) “I should take this medication with food to avoid stomach upset.”
 D) “I should notify my healthcare provider if I develop a rash.”

Correct Answer: B
Rationale: Patients should be instructed not to skip doses and to take the medication as
prescribed to ensure effectiveness.

Question 362: Neurological

A nurse is assessing a patient with suspected stroke. Which assessment finding is most
concerning?

 A) Weakness on one side of the body

 B) Sudden confusion or trouble speaking
 C) Severe headache with no known cause
 D) Difficulty walking or loss of balance

Correct Answer: C
Rationale: A severe headache with no known cause can indicate a hemorrhagic stroke, which is
a medical emergency.

Question 363: Cardiovascular

A patient with heart failure is experiencing edema. Which intervention should the nurse
implement first?

 A) Administer a diuretic as prescribed.

  B) Elevate the patient's legs.
 C) Monitor vital signs.
 D) Assess lung sounds.

Correct Answer: A
Rationale: Administering a diuretic will help reduce fluid overload and manage edema.

Question 364: Infection Control

A nurse is caring for a patient with a central line. Which intervention is essential for preventing
infection?

 A) Change the dressing weekly.

 B) Use an alcohol-based hand sanitizer before accessing the line.
 C) Clean the insertion site with hydrogen peroxide.
 D) Maintain the line's patency by flushing with saline only.

Correct Answer: B
Rationale: Hand hygiene is critical for preventing infection, especially when accessing a central
line.

Question 365: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia who is experiencing hallucinations.
Which intervention is most appropriate?

 A) Encourage the patient to express their feelings.

 B) Provide a quiet environment with minimal stimulation.
 C) Administer antipsychotic medications as ordered.
 D) Challenge the patient's hallucinations to help them see reality.

Correct Answer: B
Rationale: A quiet environment helps reduce stimulation and can lessen the intensity of
hallucinations.

Question 366: Pediatric Nursing

A nurse is assessing a child with asthma. Which finding indicates the child is experiencing an
asthma exacerbation?
  A) Clear lung sounds
 B) Normal respiratory rate
 C) Use of accessory muscles for breathing
 D) Ability to speak in full sentences

Correct Answer: C
Rationale: The use of accessory muscles for breathing is a sign of respiratory distress and
indicates an asthma exacerbation.

Question 367: Endocrine

A patient with diabetes mellitus is scheduled for surgery. Which medication should the nurse
clarify with the healthcare provider?

 A) Insulin
 B) Metformin
 C) Levothyroxine
 D) Lisinopril

Correct Answer: B
Rationale: Metformin should typically be held prior to surgery due to the risk of lactic acidosis,
especially if the patient is receiving contrast dye.

Question 368: Gastrointestinal

A nurse is teaching a patient about dietary modifications for managing gastroesophageal reflux
disease (GERD). Which statement indicates a need for further teaching?

 A) “I will avoid eating large meals before bedtime.”

 B) “I can eat spicy foods in moderation.”
 C) “I should elevate the head of my bed while sleeping.”
 D) “I need to avoid caffeine and alcohol.”

Correct Answer: B
Rationale: Spicy foods can exacerbate GERD symptoms and should generally be avoided.

Question 369: Obstetrics

A nurse is assessing a woman in labor. Which finding would indicate the need for immediate
intervention?
  A) Contractions every 5 minutes
 B) Fetal heart rate of 120 bpm
 C) Maternal blood pressure of 160/100 mmHg
 D) Presence of bloody show

Correct Answer: C
Rationale: A maternal blood pressure of 160/100 mmHg indicates hypertension, which can pose
risks to both mother and baby.

Question 370: Renal

A patient with chronic kidney disease is prescribed a low-protein diet. What is the primary goal
of this dietary modification?

 A) Prevent hyperkalemia
 B) Reduce protein waste accumulation
 C) Decrease fluid retention
 D) Promote weight loss

Correct Answer: B
Rationale: A low-protein diet helps to reduce the accumulation of nitrogenous waste products in
patients with chronic kidney disease.

Question 371: Infection Control

A nurse is caring for a patient with tuberculosis. Which precaution should the nurse implement?

 A) Airborne precautions
 B) Contact precautions
 C) Droplet precautions
 D) Standard precautions only

Correct Answer: A
Rationale: Airborne precautions are necessary for tuberculosis to prevent transmission through
airborne particles.

Question 372: Cardiovascular

A patient with atrial fibrillation is prescribed warfarin. What is the priority nursing intervention?
  A) Monitor the patient's heart rate.
 B) Educate the patient about dietary restrictions.
 C) Assess the patient's INR regularly.
 D) Administer digoxin as ordered.

Correct Answer: C
Rationale: Monitoring INR is essential to ensure therapeutic levels and prevent bleeding
complications with warfarin.

Question 373: Neurological

A nurse is assessing a patient who has just undergone a lumbar puncture. Which finding should
be reported immediately?

 A) Mild headache
 B) Clear, colorless cerebrospinal fluid
 C) Fever and increased heart rate
 D) Pain at the puncture site

Correct Answer: C
Rationale: Fever and increased heart rate may indicate infection or complications following a
lumbar puncture and should be reported immediately.

Question 374: Pediatric Nursing

A nurse is caring for a child with cystic fibrosis. Which statement indicates the child understands
the importance of enzyme replacement therapy?

 A) “I can skip my enzymes if I don’t eat much.”

 B) “I take my enzymes with every meal and snack.”
 C) “I only need to take enzymes for high-fat meals.”
 D) “I can take my enzymes any time during the day.”

Correct Answer: B
Rationale: Children with cystic fibrosis need to take enzyme replacements with every meal and
snack to aid digestion.

Question 375: Endocrine

A nurse is assessing a patient with acromegaly. Which finding is most characteristic of this
condition?

 A) Thin skin and hair loss

 B) Decreased growth hormone levels
 C) Enlarged hands and feet
 D) Weight loss and muscle wasting

Correct Answer: C
Rationale: Enlarged hands and feet are classic signs of acromegaly due to excess growth
hormone.

Question 376: Gastrointestinal

A nurse is caring for a patient with diverticulitis. Which dietary recommendation should the
nurse make?

 A) High-fiber diet
 B) Low-fiber diet
 C) Clear liquid diet
 D) High-protein diet

Correct Answer: C
Rationale: A clear liquid diet is often recommended during acute diverticulitis flare-ups to allow
the bowel to rest.

Question 377: Obstetrics

A nurse is monitoring a pregnant patient who is in the third trimester. Which finding would be
most concerning?

 A) Fetal heart rate of 150 bpm

 B) Maternal edema in the legs
 C) Severe headaches and visual changes
 D) Increased fetal movement

Correct Answer: C
Rationale: Severe headaches and visual changes may indicate preeclampsia, which is a serious
condition requiring immediate attention.
Question 378: Renal

A nurse is caring for a patient on dialysis. Which complication should the nurse monitor for
during treatment?

 A) Hypertension
 B) Hyperkalemia
 C) Hypotension
 D) Hypercalcemia

Correct Answer: C
Rationale: Hypotension is a common complication during dialysis due to rapid fluid removal.

Question 379: Infection Control

A patient diagnosed with Clostridium difficile infection is placed on isolation. Which type of
precautions should the nurse implement?

 A) Droplet precautions
 B) Airborne precautions
 C) Contact precautions
 D) Standard precautions only

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of C. difficile infection.

Question 380: Cardiovascular

A patient with heart failure is prescribed a beta-blocker. Which statement by the patient indicates
a need for further teaching?

 A) “I should monitor my heart rate and report if it’s too low.”

 B) “I can stop taking this medication if I feel better.”
 C) “I need to avoid sudden position changes.”
 D) “I should report any signs of dizziness or lightheadedness.”

Correct Answer: B
Rationale: Patients should not stop taking beta-blockers abruptly without consulting their
healthcare provider, even if they feel better.
Question 381: Pharmacology

A patient is prescribed digoxin for heart failure. Which symptom may indicate digoxin toxicity?

 A) Weight gain
 B) Nausea and vomiting
 C) Increased appetite
 D) Bradycardia

Correct Answer: B
Rationale: Nausea and vomiting are common symptoms of digoxin toxicity, along with
bradycardia.

Question 382: Neurological

A nurse is assessing a patient with Parkinson's disease. Which symptom should the nurse expect?

 A) Hyperactivity
 B) Tremors at rest
 C) Increased muscle tone
 D) Loss of appetite

Correct Answer: B
Rationale: Tremors at rest are a classic symptom of Parkinson's disease.

Question 383: Cardiovascular

A patient with heart failure is experiencing dyspnea. Which position should the nurse assist the
patient into for optimal comfort?

 A) Supine position
 B) Trendelenburg position
 C) High Fowler's position
 D) Lateral position

Correct Answer: C
Rationale: High Fowler's position helps to alleviate dyspnea by allowing for better lung
expansion.

Question 384: Infection Control

A nurse is caring for a patient diagnosed with influenza. Which action should the nurse take first
to prevent the spread of infection?

 A) Administer antiviral medications.

 B) Encourage the patient to wear a mask.
 C) Educate the patient about hand hygiene.
 D) Place the patient in a private room.

Correct Answer: C
Rationale: Educating the patient about hand hygiene is a crucial first step in preventing the
spread of influenza.

Question 385: Mental Health

A nurse is caring for a patient with major depressive disorder. Which symptom would indicate
the need for immediate intervention?

 A) Changes in appetite
 B) Loss of interest in activities
 C) Expressing thoughts of self-harm
 D) Difficulty concentrating

Correct Answer: C
Rationale: Expressing thoughts of self-harm is a critical symptom that requires immediate
intervention.

Question 386: Pediatric Nursing

A nurse is assessing a child with otitis media. Which finding would the nurse expect?

 A) Decreased appetite
 B) Elevated blood pressure
 C) Clear nasal drainage
 D) Increased energy levels

Correct Answer: A
Rationale: Decreased appetite is common in children with otitis media due to pain and
discomfort.

Question 387: Endocrine

A patient with hyperthyroidism is receiving radioactive iodine therapy. Which instruction should
the nurse provide?

 A) “You should avoid direct contact with others for a few days.”
 B) “You need to increase your caloric intake significantly.”
 C) “You can stop taking your thyroid medication after treatment.”
 D) “You should not worry about weight gain after therapy.”

Correct Answer: A
Rationale: Patients receiving radioactive iodine therapy should avoid close contact with others
for a few days to minimize radiation exposure.

Question 388: Gastrointestinal

A nurse is caring for a patient with peptic ulcer disease. Which dietary recommendation should
the nurse make?

 A) Consume high-fiber foods.

 B) Include spicy foods in moderation.
 C) Avoid caffeine and alcohol.
 D) Eat three large meals daily.

Correct Answer: C
Rationale: Avoiding caffeine and alcohol can help reduce irritation of the gastric mucosa and
manage peptic ulcer disease.

Question 389: Obstetrics

A nurse is assessing a pregnant patient who is at 12 weeks gestation. Which assessment finding
should be reported to the healthcare provider?

 A) Positive fetal heartbeat

 B) Severe abdominal pain
 C) Mild nausea
 D) Urinary frequency

Correct Answer: B
Rationale: Severe abdominal pain could indicate a complication, such as ectopic pregnancy or
miscarriage, and should be reported.
Question 390: Renal

A nurse is monitoring a patient with chronic kidney disease for signs of fluid overload. Which
finding would indicate fluid overload?

 A) Increased urine output

 B) Weight loss
 C) Shortness of breath
 D) Decreased blood pressure

Correct Answer: C
Rationale: Shortness of breath can indicate fluid overload, as it may lead to pulmonary edema.

Question 391: Infection Control

A patient diagnosed with hepatitis A is admitted to the hospital. Which type of precaution should
the nurse implement?

 A) Airborne precautions
 B) Contact precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: D
Rationale: Standard precautions are sufficient for managing hepatitis A, which is primarily
transmitted through the fecal-oral route.

Question 392: Cardiovascular

A patient with a history of myocardial infarction is prescribed atorvastatin. What is the primary
action of this medication?

 A) Increases blood pressure

 B) Lowers cholesterol levels
 C) Increases heart rate
 D) Prevents blood clotting

Correct Answer: B
Rationale: Atorvastatin is a statin that primarily works to lower cholesterol levels.
Question 393: Neurological

A nurse is caring for a patient with a head injury who is experiencing agitation and confusion.
Which nursing intervention is most appropriate?

 A) Restrain the patient to prevent injury.

 B) Provide a quiet environment and reorient the patient.
 C) Encourage the patient to express their feelings.
 D) Assess the patient for neurological deficits.

Correct Answer: B
Rationale: Providing a quiet environment and reorienting the patient can help reduce confusion
and agitation.

Question 394: Pediatric Nursing

A nurse is assessing a child with suspected appendicitis. Which finding is most characteristic of
this condition?

 A) Abdominal distension
 B) McBurney's point tenderness
 C) Diarrhea
 D) Increased bowel sounds

Correct Answer: B
Rationale: McBurney's point tenderness (located in the right lower quadrant) is a classic sign of
appendicitis.

Question 395: Endocrine

A nurse is teaching a patient with type 2 diabetes about the importance of weight loss. What is
the primary benefit of weight loss in this population?

 A) It eliminates the need for medication.

 B) It improves insulin sensitivity.
 C) It guarantees normal blood sugar levels.
 D) It prevents the development of diabetes.

Correct Answer: B
Rationale: Weight loss improves insulin sensitivity, which can help manage blood sugar levels
in patients with type 2 diabetes.
Question 396: Gastrointestinal

A nurse is caring for a patient with liver cirrhosis. Which lab value should the nurse monitor
closely?

 A) Elevated blood glucose

 B) Increased creatinine levels
 C) Elevated ammonia levels
 D) Decreased white blood cell count

Correct Answer: C
Rationale: Elevated ammonia levels can indicate hepatic encephalopathy, a serious complication
of liver cirrhosis.

Question 397: Obstetrics

A nurse is providing education to a pregnant patient about warning signs during pregnancy.
Which statement by the patient indicates understanding?

 A) “I should call my doctor if I experience swelling in my legs.”

 B) “It’s normal to have headaches throughout my pregnancy.”
 C) “I need to notify my doctor if I see any vision changes.”
 D) “I can ignore any abdominal pain as long as it’s not severe.”

Correct Answer: C
Rationale: Vision changes can indicate serious conditions such as preeclampsia and should be
reported to the healthcare provider.

Question 398: Renal

A patient with end-stage renal disease is receiving hemodialysis. Which electrolyte imbalance is
the nurse most concerned about?

 A) Hypernatremia
 B) Hypokalemia
 C) Hyperkalemia
 D) Hypocalcemia
Correct Answer: C
Rationale: Hyperkalemia is a common and dangerous complication in patients with end-stage
renal disease and is often monitored during dialysis.

Question 399: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). Which
type of precaution should the nurse implement?

 A) Droplet precautions
 B) Airborne precautions
 C) Contact precautions
 D) Standard precautions only

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of MRSA, which can be
transmitted through direct contact.

Question 400: Cardiovascular

A nurse is teaching a patient with hypertension about lifestyle changes. Which statement
indicates the patient understands the teaching?

 A) “I can eat as much salt as I want if I exercise regularly.”

 B) “I should aim to maintain a healthy weight.”
 C) “I don’t need to monitor my blood pressure at home.”
 D) “I can quit my blood pressure medication once I feel better.”

Correct Answer: B
Rationale: Maintaining a healthy weight is a crucial lifestyle change for managing hypertension.

Question 401: Pharmacology

A patient is prescribed lisinopril for hypertension. Which side effect should the nurse instruct the
patient to report?

 A) Dry cough
 B) Increased appetite
 C) Fatigue
 D) Weight gain
Correct Answer: A
Rationale: A dry cough is a common side effect of ACE inhibitors like lisinopril and should be
reported to the healthcare provider.

Question 402: Neurological

A nurse is assessing a patient who has experienced a seizure. Which assessment finding is most
critical?

 A) Patient's level of consciousness

 B) Presence of tongue biting
 C) Duration of the seizure
 D) Presence of incontinence

Correct Answer: C
Rationale: The duration of the seizure is critical, as prolonged seizures can lead to status
epilepticus, a medical emergency.

Question 403: Cardiovascular

A patient with a history of heart failure is being discharged. Which instruction should the nurse
include in the discharge teaching?

 A) "Limit fluid intake to 2-3 liters per day."

 B) "Monitor your weight daily and report any significant changes."
 C) "Avoid all salt in your diet."
 D) "Exercise vigorously to improve your heart health."

Correct Answer: B
Rationale: Daily weight monitoring helps detect fluid retention early in patients with heart
failure.

Question 404: Infection Control

A nurse is caring for a patient with a wound infected with methicillin-resistant Staphylococcus
aureus (MRSA). Which precaution is essential to prevent transmission?

 A) Handwashing before and after patient contact

 B) Wearing a surgical mask
 C) Placing the patient in a negative-pressure room
  D) Using a gown and gloves only when dressing the wound

Correct Answer: A
Rationale: Hand hygiene is the most important measure to prevent the spread of infections,
including MRSA.

Question 405: Mental Health

A nurse is caring for a patient diagnosed with generalized anxiety disorder. Which intervention is
most effective in helping the patient manage anxiety?

 A) Encourage the patient to avoid stressful situations.

 B) Teach relaxation techniques and coping strategies.
 C) Suggest that the patient focus on negative outcomes to prepare.
 D) Administer anxiolytics as prescribed without further teaching.

Correct Answer: B
Rationale: Teaching relaxation techniques and coping strategies can empower patients to
manage their anxiety effectively.

Question 406: Pediatric Nursing

A nurse is assessing a child with asthma. Which symptom would indicate the child is
experiencing an asthma attack?

 A) Wheezing
 B) Clear nasal discharge
 C) Normal respiratory rate
 D) Ability to speak in complete sentences

Correct Answer: A
Rationale: Wheezing is a common sign of airway obstruction during an asthma attack.

Question 407: Endocrine

A patient with type 1 diabetes is being discharged after a hospitalization. What should the nurse
emphasize during teaching?

 A) "You should eat a low-carbohydrate diet."

 B) "You can stop taking insulin once your blood sugar is normal."
  C) "Always carry a source of fast-acting glucose with you."
 D) "You only need to monitor your blood sugar when you feel unwell."

Correct Answer: C
Rationale: Carrying a source of fast-acting glucose is essential for managing hypoglycemia in
patients with type 1 diabetes.

Question 408: Gastrointestinal

A nurse is caring for a patient with Crohn’s disease. Which symptom would the nurse expect to
assess?

 A) Diarrhea
 B) Constipation
 C) Abdominal bloating
 D) Decreased appetite

Correct Answer: A
Rationale: Diarrhea is a common symptom of Crohn’s disease due to inflammation of the
intestinal lining.

Question 409: Obstetrics

A nurse is caring for a pregnant patient in her third trimester who reports a sudden onset of
severe abdominal pain and vaginal bleeding. What is the priority nursing action?

 A) Assess fetal heart tones.

 B) Place the patient in a lateral position.
 C) Obtain a blood sample for hemoglobin levels.
 D) Prepare the patient for an ultrasound.

Correct Answer: A
Rationale: Assessing fetal heart tones is critical to determine the status of the fetus in an
emergency situation.

Question 410: Renal

A nurse is caring for a patient receiving peritoneal dialysis. Which finding would indicate
potential complications of the treatment?
  A) Cloudy dialysate return
 B) Clear dialysate return
 C) Patient reports feeling well
 D) Stable vital signs

Correct Answer: A
Rationale: Cloudy dialysate return may indicate peritonitis, a serious complication of peritoneal
dialysis.

Question 411: Infection Control

A nurse is caring for a patient with a confirmed diagnosis of active tuberculosis. Which
precaution should the nurse implement?

 A) Airborne precautions
 B) Droplet precautions
 C) Contact precautions
 D) Standard precautions only

Correct Answer: A
Rationale: Airborne precautions are necessary for patients with active tuberculosis to prevent
transmission.

Question 412: Cardiovascular

A patient is diagnosed with hypertension and prescribed hydrochlorothiazide. What is the

primary action of this medication?

 A) Increases heart rate

 B) Reduces blood pressure by promoting diuresis
 C) Increases potassium levels
 D) Relaxes blood vessels

Correct Answer: B
Rationale: Hydrochlorothiazide is a thiazide diuretic that reduces blood pressure by promoting
the excretion of water and electrolytes.

Question 413: Neurological

A nurse is caring for a patient recovering from a stroke. Which goal is most appropriate for this
patient?

 A) Achieve complete independence in activities of daily living (ADLs).

 B) Improve mobility and strength in the affected side.
 C) Prevent any further strokes.
 D) Maintain a normal blood pressure.

Correct Answer: B
Rationale: Improving mobility and strength in the affected side is a critical rehabilitation goal
for stroke patients.

Question 414: Pediatric Nursing

A nurse is providing care for an infant diagnosed with failure to thrive. Which intervention is
appropriate?

 A) Allow the parents to care for the infant only.

 B) Provide small, frequent feedings with high-calorie formulas.
 C) Encourage the infant to eat independently.
 D) Limit physical contact with the infant to promote independence.

Correct Answer: B
Rationale: Providing small, frequent feedings with high-calorie formulas can help meet the
nutritional needs of an infant with failure to thrive.

Question 415: Endocrine

A patient with diabetes mellitus is prescribed metformin. What is the primary action of this
medication?

 A) Stimulates insulin release from the pancreas

 B) Increases glucose uptake by cells
 C) Decreases hepatic glucose production
 D) Promotes weight gain

Correct Answer: C
Rationale: Metformin primarily works by decreasing hepatic glucose production, making it
effective for managing type 2 diabetes.
Question 416: Gastrointestinal

A nurse is teaching a patient about a gluten-free diet due to celiac disease. Which food should the
nurse instruct the patient to avoid?

 A) Rice
 B) Corn
 C) Wheat
 D) Quinoa

Correct Answer: C
Rationale: Wheat contains gluten and should be avoided by patients with celiac disease.

Question 417: Obstetrics

A nurse is monitoring a pregnant patient in labor. Which fetal heart rate pattern would indicate
fetal distress?

 A) Baseline heart rate of 140 bpm

 B) Variable decelerations with a rapid return to baseline
 C) Late decelerations with decreasing baseline variability
 D) Accelerations in response to fetal movement

Correct Answer: C
Rationale: Late decelerations with decreasing baseline variability indicate fetal distress and may
suggest uteroplacental insufficiency.

Question 418: Renal

A nurse is assessing a patient with acute kidney injury. Which laboratory finding would the nurse
expect?

 A) Decreased serum creatinine

 B) Elevated blood urea nitrogen (BUN)
 C) Decreased potassium levels
 D) Low hemoglobin levels

Correct Answer: B
Rationale: Elevated blood urea nitrogen (BUN) is a common finding in acute kidney injury.
Question 419: Infection Control

A nurse is providing care for a patient with a suspected viral infection. Which type of
precautions should the nurse implement?

 A) Droplet precautions
 B) Contact precautions
 C) Airborne precautions
 D) Standard precautions only

Correct Answer: D
Rationale: Standard precautions are appropriate for managing patients with suspected viral
infections to prevent the spread of infection.

Question 420: Cardiovascular

A patient with atrial fibrillation is prescribed warfarin. Which statement by the patient indicates a
need for further education?

 A) “I will keep my follow-up appointments for INR monitoring.”

 B) “I need to avoid foods high in vitamin K.”
 C) “I can take aspirin and warfarin together without concern.”
 D) “I should report any signs of bleeding to my doctor.”

Correct Answer: C
Rationale: Patients should be educated that taking aspirin with warfarin increases the risk of
bleeding and should be done with caution and under medical advice.

Question 421: Pharmacology

A nurse is administering enalapril to a patient with heart failure. What should the nurse monitor
for as a potential side effect?

 A) Hyperkalemia
 B) Bradycardia
 C) Hypoglycemia
 D) Hypotension

Correct Answer: A
Rationale: Enalapril can cause hyperkalemia due to its effect on the renin-angiotensin-
aldosterone system.
Question 422: Neurological

A patient is diagnosed with multiple sclerosis (MS). Which symptom is most characteristic of
MS?

 A) Fluctuating blood pressure

 B) Vision problems
 C) Severe headaches
 D) Hypotonia

Correct Answer: B
Rationale: Vision problems, such as double vision or blurred vision, are common symptoms of
multiple sclerosis.

Question 423: Cardiovascular

A nurse is caring for a patient who has undergone cardiac catheterization. What is the priority
nursing action post-procedure?

 A) Assess the patient's pain level.

 B) Monitor the puncture site for bleeding.
 C) Encourage the patient to ambulate.
 D) Provide education on diet changes.

Correct Answer: B
Rationale: Monitoring the puncture site for bleeding is critical to ensure hemostasis following
cardiac catheterization.

Question 424: Infection Control

A nurse is caring for a patient diagnosed with Clostridium difficile infection. Which precaution
should the nurse implement?

 A) Standard precautions only

 B) Contact precautions
 C) Droplet precautions
 D) Airborne precautions
Correct Answer: B
Rationale: Contact precautions are necessary for preventing the spread of Clostridium difficile,
which is transmitted via the fecal-oral route.

Question 425: Mental Health

A nurse is caring for a patient with bipolar disorder experiencing a manic episode. Which
nursing intervention is most appropriate?

 A) Encourage participation in group therapy.

 B) Provide a structured environment with clear limits.
 C) Allow the patient to express all their thoughts freely.
 D) Suggest the patient avoid all social interactions.

Correct Answer: B
Rationale: Providing a structured environment with clear limits helps maintain safety and
manage behaviors during a manic episode.

Question 426: Pediatric Nursing

A nurse is assessing a 4-year-old child for developmental milestones. Which of the following
should the nurse expect?

 A) Ability to ride a bicycle

 B) Ability to jump in place
 C) Ability to write their name
 D) Ability to count to 100

Correct Answer: B
Rationale: At 4 years old, children typically can jump in place and perform other gross motor
skills.

Question 427: Endocrine

A patient with hyperthyroidism is being treated with methimazole. Which laboratory test should
the nurse monitor?

 A) Thyroid-stimulating hormone (TSH)

 B) Blood glucose levels
 C) Complete blood count (CBC)
  D) Liver function tests

Correct Answer: A
Rationale: Monitoring TSH levels is important to assess the effectiveness of treatment for
hyperthyroidism.

Question 428: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which dietary instruction should the nurse
provide?

 A) "You should eat large meals to avoid hunger."

 B) "Avoid spicy foods and caffeine."
 C) "You can have alcohol in moderation."
 D) "Incorporate high-fat foods into your diet."

Correct Answer: B
Rationale: Avoiding spicy foods and caffeine can help reduce irritation of the gastric mucosa in
patients with peptic ulcers.

Question 429: Obstetrics

A nurse is providing education to a pregnant patient about signs of preterm labor. Which
symptom should the nurse emphasize?

 A) Decreased fetal movement

 B) Regular contractions that are painful
 C) Increased appetite
 D) Mild backache

Correct Answer: B
Rationale: Regular painful contractions are a significant sign of preterm labor that should be
reported immediately.

Question 430: Renal

A patient with chronic kidney disease is receiving erythropoietin. Which laboratory value should
the nurse monitor closely?

 A) Hemoglobin levels
  B) Serum sodium
 C) Blood urea nitrogen (BUN)
 D) Serum creatinine

Correct Answer: A
Rationale: Erythropoietin stimulates red blood cell production, so monitoring hemoglobin levels
is essential to assess treatment effectiveness.

Question 431: Infection Control

A nurse is caring for a patient with pneumonia. Which type of precautions should the nurse
implement?

 A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions only

Correct Answer: B
Rationale: Droplet precautions are necessary for pneumonia caused by infectious agents spread
through respiratory droplets.

Question 432: Cardiovascular

A nurse is teaching a patient about dietary modifications for heart failure management. Which
food should the patient limit?

 A) Fresh fruits
 B) Whole grains
 C) Processed foods
 D) Lean proteins

Correct Answer: C
Rationale: Processed foods are often high in sodium, which should be limited in heart failure
management.

Question 433: Neurological

A patient with a spinal cord injury is being discharged. Which patient teaching point is most
important for preventing complications?
  A) "You can resume normal activities immediately."
 B) "You should change your position every two hours."
 C) "You do not need to worry about skin care."
 D) "You can drive as soon as you feel comfortable."

Correct Answer: B
Rationale: Changing position every two hours helps prevent pressure ulcers and other
complications in patients with spinal cord injuries.

Question 434: Pediatric Nursing

A nurse is teaching a parent about nutrition for a toddler. Which statement indicates a need for
further teaching?

 A) "I should provide whole milk until age 2."

 B) "My child needs a variety of foods for balanced nutrition."
 C) "I can give my toddler honey to enhance their diet."
 D) "My child may need vitamin supplements if their diet is limited."

Correct Answer: C
Rationale: Honey should be avoided in children under 1 year due to the risk of botulism.

Question 435: Endocrine

A nurse is caring for a patient with Addison's disease. Which finding should the nurse monitor
closely?

 A) Hypertension
 B) Hyperkalemia
 C) Hyperglycemia
 D) Increased appetite

Correct Answer: B
Rationale: Hyperkalemia is a common finding in patients with Addison's disease due to
decreased aldosterone secretion.

Question 436: Gastrointestinal

A nurse is caring for a patient with a diagnosis of diverticulitis. Which dietary recommendation
should the nurse provide during the acute phase?
  A) High-fiber diet
 B) Low-residue diet
 C) High-protein diet
 D) Gluten-free diet

Correct Answer: B
Rationale: A low-residue diet is recommended during the acute phase of diverticulitis to allow
the bowel to rest.

Question 437: Obstetrics

A nurse is assessing a laboring patient and notes a fetal heart rate of 180 bpm. What does this
finding indicate?

 A) Normal fetal heart rate

 B) Fetal bradycardia
 C) Fetal tachycardia
 D) Sign of fetal distress

Correct Answer: C
Rationale: A fetal heart rate greater than 160 bpm is considered fetal tachycardia and may
require further assessment.

Question 438: Renal

A nurse is caring for a patient undergoing hemodialysis. Which complication should the nurse
monitor for during the treatment?

 A) Hyperglycemia
 B) Hypotension
 C) Hyperkalemia
 D) Bradycardia

Correct Answer: B
Rationale: Hypotension is a common complication during hemodialysis due to fluid shifts.

Question 439: Infection Control

A patient with a respiratory infection is receiving antibiotics. Which intervention should the
nurse include to promote effective therapy?
  A) Encourage fluid intake.
 B) Administer medications only when symptoms worsen.
 C) Limit patient activity to bed rest.
 D) Use sterile techniques for all procedures.

Correct Answer: A
Rationale: Encouraging fluid intake can help thin secretions and promote better airway
clearance.

Question 440: Cardiovascular

A nurse is assessing a patient with congestive heart failure. Which finding is indicative of fluid
overload?

 A) Weight loss
 B) Peripheral edema
 C) Decreased heart rate
 D) Increased urine output

Correct Answer: B
Rationale: Peripheral edema is a classic sign of fluid overload in patients with congestive heart
failure.

Question 441: Pharmacology

A nurse is administering digoxin to a patient with heart failure. Which assessment is critical
before administration?

 A) Blood pressure
 B) Heart rate
 C) Respiratory rate
 D) Temperature

Correct Answer: B
Rationale: It is critical to assess the heart rate before administering digoxin, as the medication
can cause bradycardia.

Question 442: Neurological

A nurse is caring for a patient with a traumatic brain injury. Which assessment finding would
indicate increased intracranial pressure (ICP)?

 A) Hypotension
 B) Slowed heart rate
 C) Widened pulse pressure
 D) Pupil constriction

Correct Answer: C
Rationale: A widened pulse pressure is a classic sign of increased ICP and indicates potential
brain herniation.

Question 443: Cardiovascular

A patient with heart failure is prescribed furosemide. What should the nurse monitor for as a
potential side effect?

 A) Weight gain
 B) Hypokalemia
 C) Hypertension
 D) Bradycardia

Correct Answer: B
Rationale: Furosemide is a loop diuretic that can cause hypokalemia due to increased potassium
excretion.

Question 444: Infection Control

A nurse is caring for a patient with a wound infected with vancomycin-resistant Enterococcus
(VRE). Which precaution should the nurse implement?

 A) Airborne precautions
 B) Droplet precautions
 C) Contact precautions
 D) Standard precautions only

Correct Answer: C
Rationale: Contact precautions are required for VRE to prevent the spread of the infection.

Question 445: Mental Health

A nurse is developing a plan of care for a patient with depression. Which intervention is most
appropriate?

 A) Encourage isolation from others.

 B) Provide frequent and regular contact with the patient.
 C) Discourage expression of feelings.
 D) Allow the patient to make all decisions independently.

Correct Answer: B
Rationale: Frequent and regular contact helps support patients with depression and encourages
engagement.

Question 446: Pediatric Nursing

A nurse is assessing a 3-year-old child. Which of the following findings is concerning and should
be reported?

 A) Able to hop on one foot

 B) Limited speech development
 C) Difficulty following simple instructions
 D) Ability to dress independently

Correct Answer: B
Rationale: Limited speech development at age 3 may indicate a developmental delay that should
be evaluated further.

Question 447: Endocrine

A patient with diabetes is being taught about hypoglycemia. Which symptom should the nurse
include in the teaching?

 A) Nausea
 B) Headache
 C) Sweating
 D) Blurred vision

Correct Answer: C
Rationale: Sweating is a common symptom of hypoglycemia and should be recognized by
patients for early intervention.
Question 448: Gastrointestinal

A nurse is caring for a patient with liver cirrhosis. Which laboratory finding would the nurse
expect?

 A) Elevated bilirubin
 B) Decreased ammonia levels
 C) Elevated glucose
 D) Normal prothrombin time

Correct Answer: A
Rationale: Elevated bilirubin is expected in patients with liver cirrhosis due to impaired liver
function.

Question 449: Obstetrics

A nurse is monitoring a patient in labor who is receiving oxytocin. Which complication should
the nurse watch for?

 A) Hypertonic uterine contractions

 B) Prolonged labor
 C) Fetal bradycardia
 D) Maternal hypotension

Correct Answer: A
Rationale: Hypertonic uterine contractions can occur with oxytocin administration and require
careful monitoring.

Question 450: Renal

A patient with chronic kidney disease is prescribed a phosphate binder. Which teaching point
should the nurse emphasize?

 A) "Take this medication on an empty stomach."

 B) "Increase your intake of dairy products."
 C) "Take this medication with meals."
 D) "Avoid potassium-rich foods."

Correct Answer: C
Rationale: Phosphate binders should be taken with meals to effectively bind dietary phosphate.
Question 451: Infection Control

A patient is hospitalized with a confirmed diagnosis of influenza. Which precaution should the
nurse implement?

 A) Standard precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions

Correct Answer: C
Rationale: Droplet precautions are necessary for influenza to prevent transmission via
respiratory droplets.

Question 452: Cardiovascular

A nurse is teaching a patient with hypertension about lifestyle modifications. Which statement
indicates a need for further teaching?

 A) "I will start exercising regularly."

 B) "I can eat as much salt as I want as long as I take my medication."
 C) "I will reduce my alcohol intake."
 D) "I should monitor my blood pressure at home."

Correct Answer: B
Rationale: Patients with hypertension should limit sodium intake, regardless of medication use.

Question 453: Neurological

A nurse is caring for a patient who has just undergone a lumbar puncture. What is the priority
nursing action post-procedure?

 A) Position the patient in a high Fowler's position.

 B) Monitor for signs of infection.
 C) Encourage the patient to drink fluids.
 D) Assess the patient’s neurological status.

Correct Answer: D
Rationale: Assessing neurological status is critical after a lumbar puncture to detect any
complications.
Question 454: Pediatric Nursing

A nurse is teaching a parent about safety measures for a toddler. Which statement by the parent
indicates a need for further education?

 A) "I will keep small objects out of reach."

 B) "I will allow my child to play near the street."
 C) "I should supervise my child while they are eating."
 D) "I will secure furniture to the wall."

Correct Answer: B
Rationale: Allowing a child to play near the street is unsafe and indicates a need for further
education on safety measures.

Question 455: Endocrine

A nurse is monitoring a patient receiving insulin therapy. Which symptom should the nurse
instruct the patient to report immediately?

 A) Increased thirst
 B) Sweating and tremors
 C) Increased hunger
 D) Frequent urination

Correct Answer: B
Rationale: Sweating and tremors may indicate hypoglycemia and require immediate attention.

Question 456: Gastrointestinal

A patient is diagnosed with pancreatitis. Which dietary instruction should the nurse provide?

 A) "Increase your fat intake."

 B) "You should eat three large meals a day."
 C) "Avoid alcohol and caffeine."
 D) "Eat a high-protein diet."

Correct Answer: C
Rationale: Avoiding alcohol and caffeine is crucial in managing pancreatitis.

Question 457: Obstetrics

A nurse is monitoring a postpartum patient. Which finding should the nurse report immediately?

 A) Fundus firm and midline

 B) Moderate lochia rubra
 C) Severe abdominal pain
 D) Uterine involution

Correct Answer: C
Rationale: Severe abdominal pain could indicate complications such as uterine atony or
hemorrhage and requires immediate assessment.

Question 458: Renal

A nurse is caring for a patient receiving continuous ambulatory peritoneal dialysis (CAPD).
What should the nurse monitor for?

 A) Signs of infection at the catheter site

 B) Increased blood pressure
 C) Decreased urine output
 D) Increased hemoglobin levels

Correct Answer: A
Rationale: Monitoring for signs of infection at the catheter site is essential to prevent peritonitis.

Question 459: Infection Control

A nurse is caring for a patient with a respiratory infection. Which action should the nurse
prioritize to prevent transmission?

 A) Wearing gloves
 B) Using an N95 respirator
 C) Hand hygiene before and after patient contact
 D) Administering antibiotics

Correct Answer: C
Rationale: Hand hygiene is the most effective way to prevent the transmission of infections.

Question 460: Cardiovascular

A patient with atrial fibrillation is prescribed anticoagulants. What is the primary purpose of
anticoagulant therapy in this patient?

 A) To control heart rate

 B) To prevent thrombus formation
 C) To reduce blood pressure
 D) To increase blood flow

Correct Answer: B
Rationale: Anticoagulants are used to prevent thrombus formation in patients with atrial
fibrillation, which can lead to stroke.

Question 461: Pharmacology

A patient receiving warfarin therapy is being discharged. Which instruction should the nurse
provide to the patient?

 A) "You can take aspirin as needed for pain."

 B) "Avoid eating green leafy vegetables."
 C) "Have your INR levels checked regularly."
 D) "You can stop the medication if you feel better."

Correct Answer: C
Rationale: Patients on warfarin need regular INR monitoring to ensure therapeutic levels and
prevent complications.

Question 462: Neurological

A nurse is caring for a patient with a stroke. Which sign would indicate a left-sided stroke?

 A) Left-sided weakness
 B) Difficulty speaking
 C) Loss of vision in the right eye
 D) Loss of coordination on the right side

Correct Answer: B
Rationale: Difficulty speaking (aphasia) is often associated with left-sided strokes due to
damage in the left hemisphere of the brain.

Question 463: Cardiovascular

A nurse is assessing a patient for signs of heart failure. Which symptom should the nurse expect?

 A) Weight loss
 B) Peripheral edema
 C) Increased energy levels
 D) Bradycardia

Correct Answer: B
Rationale: Peripheral edema is a common symptom of heart failure due to fluid retention.

Question 464: Infection Control

A patient with tuberculosis (TB) is placed in isolation. Which type of precaution should the nurse
implement?

 A) Standard precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Contact precautions

Correct Answer: C
Rationale: Airborne precautions are necessary for tuberculosis to prevent transmission of
infectious droplets.

Question 465: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia. Which behavior would indicate a
potential need for intervention?

 A) Participating in group therapy

 B) Expressing feelings about their illness
 C) Talking to themselves in public
 D) Maintaining personal hygiene

Correct Answer: C
Rationale: Talking to oneself in public may indicate disorganized thinking or impaired reality
testing and may require intervention.

Question 466: Pediatric Nursing

A nurse is assessing a 2-year-old child. Which developmental milestone should the nurse expect
the child to achieve?

 A) Ability to stack six blocks

 B) Ability to run smoothly
 C) Ability to dress independently
 D) Ability to draw a circle

Correct Answer: B
Rationale: By age 2, children typically can run smoothly, while other milestones like stacking
blocks or dressing independently are usually achieved later.

Question 467: Endocrine

A patient with type 1 diabetes is experiencing hypoglycemia. Which symptom should the nurse
expect?

 A) Increased thirst
 B) Fatigue
 C) Confusion
 D) Weight gain

Correct Answer: C
Rationale: Confusion is a common symptom of hypoglycemia, as low blood sugar affects
cognitive function.

Question 468: Gastrointestinal

A nurse is teaching a patient about the low-fiber diet prescribed for diverticulitis. Which food
should the patient avoid?

 A) White bread
 B) Brown rice
 C) Fresh fruits
 D) Cooked vegetables

Correct Answer: C
Rationale: Fresh fruits are high in fiber and should be avoided during an acute diverticulitis
flare-up.
Question 469: Obstetrics

A nurse is assessing a pregnant patient at 28 weeks gestation. Which assessment finding should
the nurse report immediately?

 A) Mild edema of the lower extremities

 B) Elevated blood pressure
 C) Fetal heart rate of 150 bpm
 D) Increased appetite

Correct Answer: B
Rationale: Elevated blood pressure may indicate the development of gestational hypertension or
preeclampsia, which requires immediate evaluation.

Question 470: Renal

A nurse is monitoring a patient undergoing hemodialysis. Which complication should the nurse
be alert for during the treatment?

 A) Hypercalcemia
 B) Hypertension
 C) Hypotension
 D) Hypernatremia

Correct Answer: C
Rationale: Hypotension is a common complication during hemodialysis due to fluid shifts and
volume removal.

Question 471: Infection Control

A nurse is caring for a patient with a confirmed diagnosis of methicillin-resistant Staphylococcus

aureus (MRSA). Which precautions should the nurse implement?

 A) Standard precautions only

 B) Airborne precautions
 C) Contact precautions
 D) Droplet precautions

Correct Answer: C
Rationale: Contact precautions are necessary for MRSA to prevent the spread of the infection
through direct or indirect contact.
Question 472: Cardiovascular

A nurse is assessing a patient with hypertension. Which lifestyle modification should the nurse
prioritize?

 A) Increasing caffeine intake

 B) Engaging in regular physical activity
 C) Reducing fluid intake
 D) Consuming a high-sodium diet

Correct Answer: B
Rationale: Regular physical activity is a key lifestyle modification that can help lower blood
pressure.

Question 473: Neurological

A patient is admitted with a head injury and is exhibiting signs of confusion and disorientation.
What should the nurse prioritize in the assessment?

 A) Vital signs
 B) Glasgow Coma Scale (GCS) score
 C) Pupil reaction to light
 D) Blood glucose levels

Correct Answer: B
Rationale: Assessing the GCS score is crucial for determining the level of consciousness and
severity of the head injury.

Question 474: Pediatric Nursing

A nurse is providing care for a child with asthma. Which teaching point is most important to
include in the discharge instructions?

 A) "Your child can skip doses of the medication if symptoms are controlled."
 B) "Monitor your child for signs of worsening symptoms."
 C) "Encourage your child to engage in high-intensity exercise."
 D) "Asthma attacks are not preventable."
Correct Answer: B
Rationale: Monitoring for worsening symptoms is crucial for asthma management and early
intervention.

Question 475: Endocrine

A patient with Addison's disease is receiving hydrocortisone therapy. Which symptom indicates
the need for dosage adjustment?

 A) Increased appetite
 B) Weight loss
 C) Elevated blood pressure
 D) Hyperactivity

Correct Answer: B
Rationale: Weight loss may indicate inadequate corticosteroid replacement in Addison's disease,
suggesting a need for dosage adjustment.

Question 476: Gastrointestinal

A nurse is caring for a patient with a newly placed colostomy. Which nursing intervention is
most appropriate?

 A) Assess the stoma for color and swelling.

 B) Apply a tight dressing to the stoma.
 C) Instruct the patient to avoid all foods for 24 hours.
 D) Teach the patient to irrigate the stoma immediately.

Correct Answer: A
Rationale: Assessing the stoma for color and swelling is important for ensuring proper healing
and function.

Question 477: Obstetrics

A nurse is providing care for a postpartum patient. Which finding should be reported to the
healthcare provider?

 A) Fundus located at the umbilicus

 B) Moderate lochia serosa
 C) Severe abdominal pain
  D) Stable vital signs

Correct Answer: C
Rationale: Severe abdominal pain could indicate complications such as uterine atony or
infection and should be reported immediately.

Question 478: Renal

A patient with chronic kidney disease is prescribed erythropoietin. What should the nurse
monitor?

 A) Hemoglobin levels
 B) Serum creatinine
 C) Electrolyte levels
 D) Blood pressure

Correct Answer: A
Rationale: Monitoring hemoglobin levels is crucial for assessing the effectiveness of
erythropoietin therapy.

Question 479: Infection Control

A nurse is caring for a patient with a wound infected with Clostridium difficile. Which
intervention is the priority?

 A) Administering antibiotics
 B) Implementing contact precautions
 C) Encouraging oral hydration
 D) Monitoring vital signs

Correct Answer: B
Rationale: Implementing contact precautions is essential to prevent the spread of C. difficile
infection.

Question 480: Cardiovascular

A nurse is caring for a patient with heart failure. Which symptom would indicate worsening heart
failure?

 A) Increased energy levels

  B) Decreased urinary output
 C) Weight loss
 D) Normal heart rhythm

Correct Answer: B
Rationale: Decreased urinary output can indicate fluid retention and worsening heart failure.

Question 481: Pharmacology

A nurse is administering lisinopril to a patient with hypertension. Which side effect should the
nurse monitor for?

 A) Hyperkalemia
 B) Hypoglycemia
 C) Weight gain
 D) Bradycardia

Correct Answer: A
Rationale: Lisinopril, an ACE inhibitor, can cause hyperkalemia due to decreased potassium
excretion.

Question 482: Neurological

A patient is experiencing a seizure. What is the priority nursing action during the seizure?

 A) Restrain the patient to prevent injury.

 B) Position the patient on their side.
 C) Place a padded tongue blade in the patient's mouth.
 D) Document the duration of the seizure.

Correct Answer: B
Rationale: Positioning the patient on their side helps maintain an open airway and prevent
aspiration during a seizure.

Question 483: Cardiovascular

A nurse is teaching a patient with coronary artery disease about lifestyle changes. Which
statement indicates a need for further teaching?

 A) "I will quit smoking."

  B) "I can continue to eat a high-fat diet as long as I exercise."
 C) "I will manage my stress levels."
 D) "I should monitor my cholesterol levels."

Correct Answer: B
Rationale: Patients with coronary artery disease should limit dietary fat intake, regardless of
exercise.

Question 484: Infection Control

A nurse is caring for a patient with a respiratory infection. Which method is the most effective
way to prevent the spread of infection?

 A) Wearing gloves
 B) Hand hygiene
 C) Using a mask
 D) Disinfecting surfaces

Correct Answer: B
Rationale: Hand hygiene is the most effective way to prevent the transmission of infections.

Question 485: Mental Health

A nurse is caring for a patient diagnosed with depression. Which intervention is most
appropriate?

 A) Encourage isolation to prevent stress.

 B) Promote participation in group therapy.
 C) Discourage discussions about feelings.
 D) Suggest that the patient think positively.

Correct Answer: B
Rationale: Promoting participation in group therapy encourages social interaction and support,
which is beneficial for patients with depression.

Question 486: Pediatric Nursing

A nurse is assessing a child with suspected croup. Which symptom would support this diagnosis?

 A) High fever
  B) Barking cough
 C) Wheezing
 D) Bradycardia

Correct Answer: B
Rationale: A barking cough is characteristic of croup, which is caused by inflammation of the
upper airway.

Question 487: Endocrine

A nurse is teaching a patient about managing diabetes. Which statement indicates a need for
further education?

 A) "I should check my blood sugar levels regularly."

 B) "I can eat whatever I want as long as I take my insulin."
 C) "I should maintain a balanced diet."
 D) "I need to exercise regularly."

Correct Answer: B
Rationale: While insulin can help manage blood sugar, it is important for diabetic patients to
maintain a healthy diet and not eat whatever they want.

Question 488: Gastrointestinal

A nurse is caring for a patient with acute pancreatitis. Which assessment finding would indicate a
complication?

 A) Abdominal tenderness
 B) Elevated serum lipase
 C) Jaundice
 D) Nausea

Correct Answer: C
Rationale: Jaundice may indicate a complication such as biliary obstruction, which can occur
with pancreatitis.

Question 489: Obstetrics

A nurse is caring for a pregnant woman at 36 weeks of gestation who reports severe headache
and blurred vision. What should the nurse do first?
  A) Assess fetal heart rate
 B) Take the patient's blood pressure
 C) Administer pain medication
 D) Notify the healthcare provider

Correct Answer: B
Rationale: Severe headache and blurred vision can indicate hypertension or preeclampsia,
making blood pressure assessment a priority.

Question 490: Renal

A patient with chronic kidney disease is receiving hemodialysis. Which dietary restriction should
the nurse emphasize?

 A) Low-carbohydrate diet
 B) High-sodium diet
 C) Low-potassium diet
 D) Low-protein diet

Correct Answer: C
Rationale: Patients with chronic kidney disease often need to follow a low-potassium diet to
prevent hyperkalemia.

Question 491: Infection Control

A patient with a known history of Clostridium difficile infection is being admitted to a healthcare
facility. Which precaution should the nurse implement?

 A) Standard precautions only

 B) Airborne precautions
 C) Contact precautions
 D) Droplet precautions

Correct Answer: C
Rationale: Contact precautions should be implemented to prevent the spread of C. difficile
infection.

Question 492: Cardiovascular

A nurse is assessing a patient who is experiencing chest pain. Which assessment finding is most
concerning?

 A) Blood pressure of 120/80 mmHg

 B) Heart rate of 110 bpm
 C) Respiratory rate of 22 breaths/min
 D) ST segment elevation on the ECG

Correct Answer: D
Rationale: ST segment elevation on the ECG can indicate myocardial ischemia or infarction and
is a critical finding.

Question 493: Neurological

A nurse is caring for a patient with a spinal cord injury at the C6 level. Which finding should the
nurse anticipate?

 A) Increased mobility of the lower extremities

 B) Paralysis of the upper extremities
 C) Intact reflexes in the lower extremities
 D) Ability to walk independently

Correct Answer: B
Rationale: A C6 spinal cord injury typically results in paralysis of the upper extremities, while
some function may remain in the shoulders and hands.

Question 494: Pediatric Nursing

A nurse is teaching a parent about the administration of a new medication to their child. Which
statement by the parent indicates a need for further teaching?

 A) "I will give the medication at the same time every day."
 B) "I can crush the tablet and mix it with food."
 C) "I should store the medication in the refrigerator."
 D) "I will call the doctor if my child has a rash."

Correct Answer: C
Rationale: Not all medications need to be refrigerated; the parent should check specific storage
instructions.
Question 495: Endocrine

A nurse is caring for a patient with diabetes who is experiencing hyperglycemia. Which
intervention is the priority?

 A) Administer insulin as prescribed.

 B) Encourage oral fluids.
 C) Monitor blood glucose levels frequently.
 D) Teach about dietary modifications.

Correct Answer: A
Rationale: Administering insulin is the priority intervention to lower blood glucose levels and
prevent complications.

Question 496: Pharmacology

A patient is prescribed metformin for type 2 diabetes. Which statement by the patient indicates a
need for further education?

 A) "I can take this medication with my meals."

 B) "I need to monitor my blood sugar levels regularly."
 C) "I can stop taking the medication if I feel better."
 D) "I should report any unusual muscle pain to my doctor."

Correct Answer: C
Rationale: Patients should not stop taking metformin without consulting their healthcare
provider, as it is essential for managing diabetes.

Question 497: Neurological

A nurse is caring for a patient with a history of seizures. What is the most important nursing
intervention to implement?

 A) Administer anticonvulsant medications as prescribed.

 B) Provide a quiet environment to reduce stimulation.
 C) Educate the patient about seizure triggers.
 D) Ensure the patient has a medical alert bracelet.

Correct Answer: A
Rationale: Administering anticonvulsant medications as prescribed is crucial to preventing
seizures.
Question 498: Cardiovascular

A nurse is monitoring a patient after a myocardial infarction. Which finding is most indicative of
heart failure?

 A) Bradycardia
 B) Decreased urine output
 C) Hypotension
 D) Elevated blood pressure

Correct Answer: B
Rationale: Decreased urine output can indicate fluid retention and worsening heart failure.

Question 499: Infection Control

A nurse is caring for a patient with suspected meningitis. Which precaution should the nurse
implement?

 A) Standard precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions

Correct Answer: C
Rationale: Droplet precautions are necessary for meningitis to prevent the spread of infectious
droplets.

Question 500: Mental Health

A nurse is assessing a patient with generalized anxiety disorder. Which symptom is commonly
associated with this condition?

 A) Hallucinations
 B) Excessive worry
 C) Hyperactivity
 D) Memory loss

Correct Answer: B
Rationale: Excessive worry is a hallmark symptom of generalized anxiety disorder.
Question 501: Pediatric Nursing

A nurse is caring for a child with asthma. Which teaching point is essential for the child and
family?

 A) "You should avoid using the inhaler during an asthma attack."

 B) "Always carry your rescue inhaler with you."
 C) "Asthma can be cured with medication."
 D) "You should avoid all physical activity."

Correct Answer: B
Rationale: Carrying a rescue inhaler is essential for managing asthma and preventing severe
attacks.

Question 502: Endocrine

A patient with hypothyroidism is prescribed levothyroxine. What is the most important teaching
point for this medication?

 A) Take the medication with food.

 B) Take the medication at the same time each day.
 C) Stop taking the medication if you feel better.
 D) Avoid taking it with other medications.

Correct Answer: B
Rationale: Taking levothyroxine at the same time each day helps maintain consistent thyroid
hormone levels.

Question 503: Gastrointestinal

A nurse is caring for a patient with ulcerative colitis. Which symptom would the nurse expect to
assess?

 A) Diarrhea with blood

 B) Constipation
 C) Abdominal rigidity
 D) Steatorrhea
Correct Answer: A
Rationale: Diarrhea with blood is a common symptom of ulcerative colitis due to inflammation
of the colon.

Question 504: Obstetrics

A nurse is caring for a postpartum patient. Which assessment finding is expected within the first
24 hours after delivery?

 A) Firm and midline uterus

 B) Moderate lochia rubra
 C) Fever of 100.5°F
 D) Absent bowel sounds

Correct Answer: A
Rationale: A firm and midline uterus is expected and indicates good uterine tone post-delivery.

Question 505: Renal

A patient with chronic kidney disease is on a renal diet. Which food should the nurse encourage?

 A) Bananas
 B) Green beans
 C) Oranges
 D) Potatoes

Correct Answer: B
Rationale: Green beans are lower in potassium and are appropriate for a renal diet, unlike the
other options.

Question 506: Infection Control

A nurse is caring for a patient with a viral respiratory infection. What is the most appropriate
type of precaution to implement?

 A) Standard precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions
Correct Answer: C
Rationale: Droplet precautions are necessary for viral respiratory infections to prevent
transmission.

Question 507: Cardiovascular

A nurse is caring for a patient with heart failure who is experiencing shortness of breath. What is
the priority nursing intervention?

 A) Administer diuretics as prescribed.

 B) Provide supplemental oxygen.
 C) Monitor vital signs closely.
 D) Encourage deep breathing exercises.

Correct Answer: B
Rationale: Providing supplemental oxygen is the priority intervention to alleviate shortness of
breath.

Question 508: Neurological

A nurse is caring for a patient with a history of Parkinson's disease. Which symptom should the
nurse monitor for?

 A) Hyperactivity
 B) Bradykinesia
 C) Impulsivity
 D) Euphoria

Correct Answer: B
Rationale: Bradykinesia, or slowness of movement, is a common symptom of Parkinson's
disease.

Question 509: Pediatric Nursing

A nurse is educating a parent about the signs of dehydration in a child. Which statement by the
parent indicates understanding?

 A) "My child will have a higher energy level."

 B) "Decreased urination is a sign of dehydration."
 C) "Dehydration only happens in hot weather."
  D) "My child will have a normal appetite if they are dehydrated."

Correct Answer: B
Rationale: Decreased urination is a common sign of dehydration in children.

Question 510: Endocrine

A nurse is assessing a patient with Cushing's syndrome. Which finding is consistent with this
condition?

 A) Weight loss
 B) Thin, fragile skin
 C) Hypoglycemia
 D) Decreased body hair

Correct Answer: B
Rationale: Thin, fragile skin is a common manifestation of Cushing's syndrome due to excess
cortisol.

Question 511: Gastrointestinal

A patient with cirrhosis is at risk for hepatic encephalopathy. Which sign should the nurse
monitor for?

 A) Increased alertness
 B) Asterixis (flapping tremors)
 C) Weight gain
 D) Jaundice

Correct Answer: B
Rationale: Asterixis is a classic sign of hepatic encephalopathy, indicating impaired liver
function.

Question 512: Obstetrics

A nurse is assessing a pregnant woman who is at 32 weeks of gestation. Which finding should
the nurse report immediately?

 A) Mild edema of the ankles

 B) Elevated blood pressure
  C) Fetal movement felt by the mother
 D) Heartburn

Correct Answer: B
Rationale: Elevated blood pressure could indicate gestational hypertension or preeclampsia,
which require immediate attention.

Question 513: Renal

A nurse is caring for a patient receiving peritoneal dialysis. Which complication should the nurse
monitor for?

 A) Hypertension
 B) Infection
 C) Hyperkalemia
 D) Hypoglycemia

Correct Answer: B
Rationale: Infection, particularly peritonitis, is a common complication of peritoneal dialysis.

Question 514: Infection Control

A patient with a respiratory infection is placed on isolation. Which type of precaution should the
nurse implement?

 A) Standard precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions

Correct Answer: C
Rationale: Droplet precautions are appropriate for respiratory infections to prevent the spread of
infectious droplets.

Question 515: Cardiovascular

A nurse is assessing a patient who has just had a cardiac catheterization. What is the priority
nursing action?

 A) Monitor vital signs.

  B) Assess the puncture site for bleeding.
 C) Encourage fluid intake.
 D) Provide pain management.

Correct Answer: B
Rationale: Assessing the puncture site for bleeding is critical to prevent complications following
cardiac catheterization.

Question 516: Neurological

A nurse is caring for a patient with multiple sclerosis. Which symptom should the nurse monitor
for?

 A) Sudden vision loss

 B) Peripheral edema
 C) Abdominal pain
 D) Hypotension

Correct Answer: A
Rationale: Sudden vision loss can occur due to optic neuritis, a common symptom of multiple
sclerosis.

Question 517: Pediatric Nursing

A nurse is assessing a child with a suspected case of appendicitis. Which symptom is the most
classic sign of this condition?

 A) Diarrhea
 B) Abdominal pain in the right lower quadrant
 C) Constipation
 D) Elevated temperature

Correct Answer: B
Rationale: Abdominal pain in the right lower quadrant is a classic symptom of appendicitis.

Question 518: Endocrine

A patient with hyperthyroidism is receiving radioactive iodine therapy. Which statement by the
patient indicates understanding of the treatment?
  A) "I will not need to change my diet."
 B) "I may experience a temporary increase in my symptoms."
 C) "This treatment is a cure for my hyperthyroidism."
 D) "I can stop my medication after this treatment."

Correct Answer: B
Rationale: Patients may experience a temporary increase in symptoms as the radioactive iodine
works to reduce thyroid function.

Question 519: Gastrointestinal

A nurse is teaching a patient about managing gastroesophageal reflux disease (GERD). Which
statement indicates understanding?

 A) "I should eat large meals before bedtime."

 B) "I need to elevate the head of my bed."
 C) "I can drink citrus juices as much as I want."
 D) "I should avoid wearing loose clothing."

Correct Answer: B
Rationale: Elevating the head of the bed can help prevent reflux during sleep.

Question 520: Obstetrics

A nurse is caring for a pregnant woman who is in labor. What is the priority nursing
intervention?

 A) Assess the fetal heart rate.

 B) Provide comfort measures.
 C) Monitor maternal vital signs.
 D) Prepare for delivery.

Correct Answer: A
Rationale: Assessing the fetal heart rate is a priority to ensure fetal well-being during labor.

Question 521: Pharmacology

A nurse is administering digoxin to a patient. Which assessment finding requires the nurse to
withhold the medication?
  A) Heart rate of 70 bpm
 B) Blood pressure of 110/70 mmHg
 C) Heart rate of 58 bpm
 D) Respiratory rate of 20 breaths/min

Correct Answer: C
Rationale: A heart rate of 58 bpm is bradycardic and could indicate digoxin toxicity; the nurse
should withhold the medication and notify the provider.

Question 522: Neurological

A patient presents to the emergency department with sudden onset of weakness on the right side
and slurred speech. What should the nurse do first?

 A) Obtain a CT scan of the head.

 B) Assess the patient's vital signs.
 C) Start an IV for medication administration.
 D) Administer oxygen.

Correct Answer: B
Rationale: Assessing vital signs is crucial to establish a baseline and identify any immediate
threats to life before further interventions.

Question 523: Cardiovascular

A nurse is caring for a patient with a diagnosis of heart failure. Which symptom would indicate
worsening heart failure?

 A) Increased appetite
 B) Decreased fatigue
 C) Sudden weight gain
 D) Improved exercise tolerance

Correct Answer: C
Rationale: Sudden weight gain can indicate fluid retention, which is a sign of worsening heart
failure.

Question 524: Infection Control

A patient is diagnosed with tuberculosis (TB). Which precaution should the nurse implement?
  A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions

Correct Answer: C
Rationale: Airborne precautions are necessary for TB to prevent the spread of the infectious
agent.

Question 525: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia. Which behavior should the nurse
document as a positive symptom of the disorder?

 A) Apathy
 B) Anhedonia
 C) Hallucinations
 D) Flat affect

Correct Answer: C
Rationale: Hallucinations are considered a positive symptom of schizophrenia, representing an
excess or distortion of normal functions.

Question 526: Pediatric Nursing

A nurse is assessing a 5-year-old child who is experiencing difficulty breathing. Which finding
would be most concerning?

 A) Audible wheezing
 B) Use of accessory muscles
 C) Coughing
 D) Clear lung sounds

Correct Answer: B
Rationale: The use of accessory muscles indicates significant respiratory distress and requires
immediate attention.

Question 527: Endocrine

A patient with diabetes is experiencing hypoglycemia. Which symptom should the nurse
anticipate?

 A) Increased thirst
 B) Confusion
 C) Polyuria
 D) Weight gain

Correct Answer: B
Rationale: Confusion is a common symptom of hypoglycemia due to insufficient glucose supply
to the brain.

Question 528: Gastrointestinal

A nurse is caring for a patient who has just undergone a cholecystectomy. Which assessment
finding should the nurse monitor for postoperatively?

 A) Increased abdominal pain

 B) Decreased bowel sounds
 C) Yellowing of the skin
 D) Fever

Correct Answer: C
Rationale: Yellowing of the skin could indicate bile duct injury or obstruction, which are serious
complications after a cholecystectomy.

Question 529: Obstetrics

A nurse is caring for a patient in the third trimester of pregnancy who reports decreased fetal
movement. What should the nurse do first?

 A) Perform a non-stress test.

 B) Encourage the patient to eat something sweet.
 C) Assess the patient's vital signs.
 D) Ask about any recent stressors.

Correct Answer: A
Rationale: A non-stress test is necessary to assess fetal well-being when decreased fetal
movement is reported.
Question 530: Renal

A patient with chronic kidney disease is on a renal diet. Which food should the nurse encourage
the patient to consume?

 A) Apples
 B) Oranges
 C) Bananas
 D) Spinach

Correct Answer: A
Rationale: Apples are lower in potassium compared to the other options and are appropriate for
a renal diet.

Question 531: Infection Control

A patient is hospitalized with a Clostridium difficile infection. Which precaution should the
nurse implement?

 A) Airborne precautions
 B) Standard precautions
 C) Contact precautions
 D) Droplet precautions

Correct Answer: C
Rationale: Contact precautions should be implemented to prevent the spread of C. difficile.

Question 532: Cardiovascular

A patient is prescribed a beta-blocker for hypertension. Which assessment should the nurse
prioritize?

 A) Respiratory rate
 B) Blood pressure
 C) Heart rate
 D) Oxygen saturation

Correct Answer: C
Rationale: Beta-blockers can cause bradycardia, so monitoring heart rate is a priority.
Question 533: Neurological

A nurse is caring for a patient with a stroke. Which intervention should the nurse prioritize?

 A) Assist with physical therapy exercises.

 B) Monitor neurological status.
 C) Encourage the patient to eat a high-protein diet.
 D) Assess for urinary incontinence.

Correct Answer: B
Rationale: Monitoring neurological status is crucial to detect any changes or deterioration in the
patient's condition.

Question 534: Pediatric Nursing

A nurse is teaching a parent about recognizing signs of croup in a child. Which statement by the
parent indicates understanding?

 A) "I should watch for a high fever."

 B) "A barking cough is a key sign of croup."
 C) "Croup is only serious during the daytime."
 D) "I should use cough syrup to treat croup."

Correct Answer: B
Rationale: A barking cough is a hallmark sign of croup.

Question 535: Endocrine

A patient with Addison's disease is experiencing an adrenal crisis. What is the priority nursing
intervention?

 A) Administer hydrocortisone IV.

 B) Monitor vital signs closely.
 C) Encourage oral fluids.
 D) Assess electrolyte levels.

Correct Answer: A
Rationale: Administering hydrocortisone is critical to managing an adrenal crisis due to
insufficient cortisol levels.
Question 536: Gastrointestinal

A nurse is caring for a patient diagnosed with diverticulitis. Which dietary modification should
the nurse recommend during recovery?

 A) High-fiber diet
 B) Low-residue diet
 C) Clear liquid diet
 D) High-fat diet

Correct Answer: B
Rationale: A low-residue diet is often recommended during recovery from diverticulitis to allow
the bowel to rest.

Question 537: Obstetrics

A nurse is assessing a pregnant patient at 28 weeks gestation. Which finding should be reported
to the healthcare provider?

 A) Fundal height of 28 cm
 B) Mild swelling of the ankles
 C) Severe headache
 D) Fetal heart rate of 140 bpm

Correct Answer: C
Rationale: A severe headache may indicate preeclampsia and should be reported immediately.

Question 538: Renal

A patient with end-stage renal disease is on hemodialysis. Which electrolyte imbalance should
the nurse monitor for?

 A) Hypernatremia
 B) Hyperkalemia
 C) Hypocalcemia
 D) Hypermagnesemia

Correct Answer: B
Rationale: Patients on dialysis are at risk for hyperkalemia due to impaired potassium excretion.
Question 539: Infection Control

A nurse is caring for a patient diagnosed with influenza. Which type of precaution should the
nurse implement?

 A) Standard precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions

Correct Answer: C
Rationale: Droplet precautions are appropriate for influenza to prevent the spread of respiratory
droplets.

Question 540: Cardiovascular

A patient with hypertension is prescribed a thiazide diuretic. Which electrolyte should the nurse
monitor closely?

 A) Potassium
 B) Calcium
 C) Sodium
 D) Magnesium

Correct Answer: A
Rationale: Thiazide diuretics can cause hypokalemia, so potassium levels should be monitored
closely.

Question 541: Neurological

A nurse is caring for a patient with a traumatic brain injury. Which assessment finding would
indicate increased intracranial pressure?

 A) Bradycardia
 B) Hypotension
 C) Altered level of consciousness
 D) Hyperthermia

Correct Answer: C
Rationale: An altered level of consciousness is a common sign of increased intracranial
pressure.
Question 542: Pediatric Nursing

A nurse is assessing a child with suspected allergic rhinitis. Which symptom is characteristic of
this condition?

 A) Dry cough
 B) Nasal congestion with clear drainage
 C) Fever
 D) Productive cough with thick mucus

Correct Answer: B
Rationale: Nasal congestion with clear drainage is a common symptom of allergic rhinitis.

Question 543: Endocrine

A nurse is caring for a patient with hyperglycemia. Which finding would indicate effective
management of the condition?

 A) Blood glucose level of 180 mg/dL

 B) Blood glucose level of 90 mg/dL
 C) Blood glucose level of 130 mg/dL
 D) Blood glucose level of 220 mg/dL

Correct Answer: B
Rationale: A blood glucose level of 90 mg/dL is within the normal range and indicates effective
management.

Question 544: Gastrointestinal

A nurse is providing discharge teaching for a patient with a peptic ulcer. Which statement
indicates that the patient understands the teaching?

 A) "I can eat spicy foods as long as I take my medication."

 B) "I should avoid taking NSAIDs."
 C) "I can drink alcohol as long as it is in moderation."
 D) "I can eat three large meals a day."

Correct Answer: B
Rationale: Patients with peptic ulcers should avoid NSAIDs as they can worsen the condition.
Question 545: Obstetrics

A nurse is monitoring a patient in active labor. Which finding would indicate fetal distress?

 A) Fetal heart rate of 120-160 bpm

 B) Decelerations in fetal heart rate
 C) Maternal contractions every 3-5 minutes
 D) Clear amniotic fluid

Correct Answer: B
Rationale: Decelerations in fetal heart rate can indicate fetal distress and require further
evaluation.

Question 546: Pharmacology

A patient is prescribed warfarin for atrial fibrillation. Which lab value is most important for the
nurse to monitor?

 A) INR
 B) CBC
 C) APTT
 D) PT

Correct Answer: A
Rationale: The INR (International Normalized Ratio) is crucial for monitoring the effectiveness
and safety of warfarin therapy.

Question 547: Neurological

A patient with multiple sclerosis (MS) is experiencing fatigue and muscle weakness. Which
nursing intervention is most appropriate?

 A) Encourage the patient to rest and conserve energy.

 B) Advise the patient to engage in strenuous exercise.
 C) Increase the patient's intake of protein-rich foods.
 D) Schedule frequent assessments of muscle strength.

Correct Answer: A
Rationale: Rest and energy conservation are important in managing fatigue associated with MS.
Question 548: Cardiovascular

A patient diagnosed with congestive heart failure (CHF) presents with shortness of breath and
edema. Which medication should the nurse expect to administer?

 A) Digoxin
 B) Furosemide
 C) Lisinopril
 D) Metoprolol

Correct Answer: B
Rationale: Furosemide is a diuretic used to reduce fluid overload in patients with CHF.

Question 549: Infection Control

A nurse is caring for a patient with a suspected bacterial infection. Which type of precaution
should the nurse implement?

 A) Contact precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: D
Rationale: Standard precautions should always be used when caring for patients with any
infection.

Question 550: Mental Health

A nurse is assessing a patient diagnosed with major depressive disorder. Which symptom should
the nurse expect to find?

 A) Euphoric mood
 B) Increased energy levels
 C) Anhedonia
 D) Hyperactivity

Correct Answer: C
Rationale: Anhedonia, or the loss of pleasure in normally enjoyable activities, is a common
symptom of depression.
Question 551: Pediatric Nursing

A nurse is assessing a 3-year-old child. Which finding should the nurse report to the healthcare
provider?

 A) Weight gain of 2 pounds in 6 months

 B) Ability to ride a tricycle
 C) Stuttering during conversation
 D) Ability to dress self with assistance

Correct Answer: C
Rationale: Stuttering can indicate a speech delay and should be evaluated further.

Question 552: Endocrine

A patient with type 1 diabetes is experiencing signs of ketoacidosis. Which finding should the
nurse expect to assess?

 A) Hypoglycemia
 B) Increased urination
 C) Weight gain
 D) Bradycardia

Correct Answer: B
Rationale: Increased urination is a common symptom of diabetic ketoacidosis due to osmotic
diuresis.

Question 553: Gastrointestinal

A nurse is teaching a patient about dietary modifications for a low-fiber diet. Which food should
the nurse recommend?

 A) Whole grain bread

 B) Brown rice
 C) White rice
 D) Fresh fruits

Correct Answer: C
Rationale: White rice is low in fiber and appropriate for a low-fiber diet.
Question 554: Obstetrics

A nurse is caring for a postpartum patient who had a vaginal delivery. Which assessment finding
should the nurse report immediately?

 A) Fundus firm and at the level of the umbilicus

 B) Moderate lochia rubra
 C) Severe abdominal pain
 D) Temperature of 100.4°F

Correct Answer: C
Rationale: Severe abdominal pain may indicate a complication such as uterine atony or
hemorrhage.

Question 555: Renal

A patient with acute kidney injury is experiencing hyperkalemia. Which medication should the
nurse anticipate administering?

 A) Insulin and glucose

 B) Calcium carbonate
 C) Furosemide
 D) Sodium bicarbonate

Correct Answer: A
Rationale: Insulin and glucose help to temporarily lower potassium levels by shifting potassium
into cells.

Question 556: Infection Control

A patient diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) is placed in

isolation. Which precaution should the nurse implement?

 A) Standard precautions only

 B) Contact precautions
 C) Airborne precautions
 D) Droplet precautions

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of MRSA.
Question 557: Cardiovascular

A nurse is caring for a patient receiving antihypertensive medication. Which symptom should the
nurse teach the patient to report?

 A) Dizziness
 B) Headache
 C) Dry mouth
 D) Nausea

Correct Answer: A
Rationale: Dizziness may indicate hypotension and should be reported.

Question 558: Neurological

A nurse is assessing a patient for signs of a stroke using the FAST acronym. What does the "A"
stand for?

 A) Ask the patient to smile

 B) Arm weakness
 C) Assess speech
 D) Altered consciousness

Correct Answer: B
Rationale: The "A" in FAST stands for Arm weakness, a common sign of stroke.

Question 559: Pediatric Nursing

A nurse is preparing to administer an immunization to a toddler. Which action should the nurse
take to minimize the child's anxiety?

 A) Explain the procedure in detail.

 B) Allow the child to select the injection site.
 C) Use a distraction technique, such as a toy.
 D) Administer the injection in the parent's presence.

Correct Answer: C
Rationale: Using distraction techniques can help reduce anxiety and make the procedure less
intimidating for the child.
Question 560: Endocrine

A patient with diabetes is planning to exercise. Which instruction should the nurse give?

 A) "You should skip meals before exercising."

 B) "Check your blood sugar before and after exercise."
 C) "It is safe to exercise anytime, even if you feel hypoglycemic."
 D) "Exercise will always lower your blood sugar."

Correct Answer: B
Rationale: Checking blood sugar before and after exercise is important for preventing
hypoglycemia.

Question 561: Gastrointestinal

A nurse is caring for a patient with a history of peptic ulcers. Which medication should the nurse
anticipate administering?

 A) Antacids
 B) Opioids
 C) Corticosteroids
 D) Antibiotics

Correct Answer: A
Rationale: Antacids help neutralize stomach acid and provide symptomatic relief for peptic
ulcers.

Question 562: Obstetrics

A nurse is monitoring a pregnant patient in the third trimester. Which finding should be reported
immediately?

 A) Swelling of the ankles

 B) Occasional headaches
 C) Blurred vision
 D) Back pain

Correct Answer: C
Rationale: Blurred vision can indicate preeclampsia and should be reported immediately.
Question 563: Renal

A patient with chronic kidney disease is receiving erythropoietin therapy. Which lab value
should the nurse monitor closely?

 A) Hemoglobin
 B) Potassium
 C) Calcium
 D) Phosphorus

Correct Answer: A
Rationale: Erythropoietin therapy is used to increase hemoglobin levels in patients with anemia
due to chronic kidney disease.

Question 564: Infection Control

A patient diagnosed with chickenpox is admitted to the hospital. Which precaution should the
nurse implement?

 A) Droplet precautions
 B) Airborne precautions
 C) Contact precautions
 D) Standard precautions

Correct Answer: B
Rationale: Airborne precautions are necessary for chickenpox due to the risk of airborne
transmission.

Question 565: Cardiovascular

A nurse is monitoring a patient with heart failure who is receiving a potassium-sparing diuretic.
Which lab value is most important to assess?

 A) Sodium
 B) Calcium
 C) Potassium
 D) Chloride
Correct Answer: C
Rationale: Potassium-sparing diuretics can lead to hyperkalemia, so potassium levels must be
monitored closely.

Question 566: Neurological

A nurse is caring for a patient who has experienced a seizure. Which nursing action is the
priority immediately following the seizure?

 A) Document the seizure in the patient's chart.

 B) Assess the patient's airway and breathing.
 C) Place the patient in a lateral position.
 D) Call the healthcare provider.

Correct Answer: B
Rationale: Assessing the airway and breathing is the priority to ensure the patient is safe and to
prevent aspiration.

Question 567: Pediatric Nursing

A nurse is assessing a child for signs of dehydration. Which finding is most indicative of
moderate dehydration?

 A) Mild thirst
 B) Slightly dry mucous membranes
 C) Sunken eyes
 D) Normal skin turgor

Correct Answer: C
Rationale: Sunken eyes are a sign of moderate to severe dehydration in children.

Question 568: Endocrine

A nurse is teaching a patient with hypothyroidism about medication management. Which

statement indicates that the patient understands the teaching?

 A) "I will take my medication with food."

 B) "I should take my medication at the same time every day."
 C) "I can stop taking the medication when I feel better."
 D) "I need to take the medication only in the morning."
Correct Answer: B
Rationale: Consistency in taking thyroid medication at the same time each day helps maintain
stable hormone levels.

Question 569: Gastrointestinal

A patient with irritable bowel syndrome (IBS) is discussing dietary changes with the nurse.
Which food should the nurse recommend avoiding?

 A) Apples
 B) White rice
 C) Yogurt
 D) Oatmeal

Correct Answer: A
Rationale: Apples are high in fiber and can exacerbate IBS symptoms in some patients.

Question 570: Obstetrics

A nurse is assessing a laboring patient and notes late decelerations in the fetal heart rate. What
should be the nurse's immediate priority?

 A) Increase IV fluid rate

 B) Position the patient on her left side
 C) Prepare for emergency delivery
 D) Notify the healthcare provider

Correct Answer: B
Rationale: Positioning the patient on her left side can help improve placental blood flow and
fetal oxygenation.

Question 571: Pharmacology

A patient is prescribed levothyroxine for hypothyroidism. Which instruction should the nurse
provide regarding the timing of the medication?

 A) Take it with food.

 B) Take it at bedtime.
 C) Take it first thing in the morning on an empty stomach.
 D) Take it twice a day.
Correct Answer: C
Rationale: Levothyroxine should be taken first thing in the morning on an empty stomach to
enhance absorption.

Question 572: Neurological

A nurse is assessing a patient who has just undergone a craniotomy. Which finding would be a
priority for the nurse to report?

 A) Clear drainage from the nose

 B) Slightly elevated temperature
 C) Glasgow Coma Scale score of 15
 D) Pulsating headache

Correct Answer: A
Rationale: Clear drainage from the nose could indicate cerebrospinal fluid leakage, which
requires immediate attention.

Question 573: Cardiovascular

A nurse is monitoring a patient who received a thrombolytic agent for a myocardial infarction.
Which finding would indicate a potential complication?

 A) Hypotension
 B) Bradycardia
 C) Slight fever
 D) Headache

Correct Answer: A
Rationale: Hypotension can indicate a bleeding complication associated with thrombolytic
therapy.

Question 574: Infection Control

A nurse is caring for a patient with tuberculosis (TB). Which precaution should the nurse
implement?

 A) Contact precautions
 B) Standard precautions
 C) Airborne precautions
  D) Droplet precautions

Correct Answer: C
Rationale: Airborne precautions are necessary for tuberculosis due to its transmission through
respiratory droplets.

Question 575: Mental Health

A patient diagnosed with schizophrenia is exhibiting hallucinations. Which nursing intervention

is most appropriate?

 A) Encourage the patient to ignore the hallucinations.

 B) Reassure the patient and provide a calm environment.
 C) Confront the patient about the hallucinations.
 D) Tell the patient that the hallucinations are not real.

Correct Answer: B
Rationale: Reassuring the patient and providing a calm environment can help reduce anxiety
and fear associated with hallucinations.

Question 576: Pediatric Nursing

A nurse is assessing a 2-year-old child. Which developmental milestone should the nurse expect
the child to achieve?

 A) Jumping in place
 B) Speaking in complete sentences
 C) Building a tower of 6 blocks
 D) Riding a tricycle

Correct Answer: A
Rationale: Jumping in place is a common gross motor milestone for a 2-year-old child.

Question 577: Endocrine

A patient with type 2 diabetes is prescribed metformin. Which teaching point is important for the
nurse to include?

 A) "Take this medication only when your blood sugar is high."

 B) "This medication can cause weight gain."
  C) "You should avoid alcohol while taking this medication."
 D) "This medication should be taken with a high-carb meal."

Correct Answer: C
Rationale: Patients should avoid alcohol while taking metformin due to the risk of lactic
acidosis.

Question 578: Gastrointestinal

A nurse is caring for a patient after a cholecystectomy. Which assessment finding should the
nurse report to the healthcare provider?

 A) Mild abdominal pain

 B) Clear liquid diet tolerated
 C) Dark brown urine
 D) Slight jaundice

Correct Answer: D
Rationale: Slight jaundice may indicate a complication such as bile duct injury and should be
reported.

Question 579: Obstetrics

A nurse is providing education to a pregnant woman about signs of preterm labor. Which
symptom should the nurse emphasize as needing immediate medical attention?

 A) Braxton Hicks contractions

 B) Mild lower back pain
 C) Increase in vaginal discharge
 D) Regular contractions occurring every 10 minutes

Correct Answer: D
Rationale: Regular contractions occurring every 10 minutes may indicate preterm labor and
require immediate evaluation.

Question 580: Renal

A patient with chronic kidney disease is scheduled for hemodialysis. Which assessment should
the nurse prioritize before the procedure?
  A) Weight
 B) Blood pressure
 C) Heart rate
 D) Temperature

Correct Answer: B
Rationale: Blood pressure is critical to assess before hemodialysis due to the risk of hypotension
during the procedure.

Question 581: Infection Control

A nurse is teaching a patient about preventing the spread of influenza. Which statement by the
patient indicates a need for further teaching?

 A) "I will wash my hands regularly."

 B) "I should cover my mouth when I cough."
 C) "I can go to work as long as I feel well."
 D) "I will get the flu vaccine every year."

Correct Answer: C
Rationale: Patients should avoid work and stay home when feeling unwell to prevent spreading
influenza.

Question 582: Cardiovascular

A patient with a history of hypertension is prescribed a beta-blocker. Which assessment should

the nurse monitor closely?

 A) Heart rate
 B) Respiratory rate
 C) Blood glucose level
 D) Temperature

Correct Answer: A
Rationale: Beta-blockers can lower heart rate, so the nurse should monitor this closely.

Question 583: Neurological

A patient presents to the emergency department with confusion and slurred speech after
consuming alcohol. Which lab test should the nurse prioritize?
  A) Liver function tests
 B) Blood alcohol level
 C) Complete blood count
 D) Electrolyte panel

Correct Answer: B
Rationale: A blood alcohol level will help assess the extent of alcohol intoxication.

Question 584: Pediatric Nursing

A nurse is teaching parents about the MMR vaccine. Which statement should the nurse include?

 A) "Your child may experience a mild fever after the vaccine."

 B) "This vaccine is given at 6 months of age."
 C) "The MMR vaccine is given only once."
 D) "Your child will not need any additional vaccines after this."

Correct Answer: A
Rationale: A mild fever is a common side effect after the MMR vaccine.

Question 585: Endocrine

A patient with diabetes is scheduled for surgery. Which medication should the nurse discuss with
the healthcare provider regarding possible adjustment?

 A) Insulin
 B) Metformin
 C) Sulfonylureas
 D) DPP-4 inhibitors

Correct Answer: A
Rationale: Insulin doses may need adjustment around the time of surgery to maintain glycemic
control.

Question 586: Gastrointestinal

A nurse is assessing a patient with a suspected bowel obstruction. Which finding would support
this diagnosis?

 A) Diarrhea
  B) Abdominal distention
 C) Normal bowel sounds
 D) Weight loss

Correct Answer: B
Rationale: Abdominal distention is a common finding in patients with bowel obstruction.

Question 587: Obstetrics

A nurse is providing discharge teaching to a postpartum patient. Which statement indicates a

need for further teaching?

 A) "I should report any signs of infection, such as fever or foul-smelling discharge."
 B) "It's normal to have heavy bleeding for the first two weeks."
 C) "I can resume sexual activity when I feel ready."
 D) "I need to follow up with my doctor in 6 weeks."

Correct Answer: B
Rationale: Heavy bleeding (lochia rubra) after the first few days may indicate a complication
and should be reported.

Question 588: Renal

A patient with end-stage renal disease is being educated about dietary restrictions. Which food
should the nurse advise avoiding?

 A) Apples
 B) Potatoes
 C) Chicken
 D) Brown rice

Correct Answer: B
Rationale: Potatoes are high in potassium and should be limited in patients with renal disease.

Question 589: Infection Control

A nurse is caring for a patient with a surgical wound. Which practice is essential for preventing
infection?

 A) Change the dressing once a week.

  B) Clean the wound with hydrogen peroxide.
 C) Use sterile technique when changing the dressing.
 D) Leave the wound uncovered to promote air circulation.

Correct Answer: C
Rationale: Using sterile technique is essential to prevent infection when caring for surgical
wounds.

Question 590: Cardiovascular

A patient is being treated for heart failure and is prescribed digoxin. Which assessment finding
would require immediate intervention?

 A) Heart rate of 58 bpm

 B) Slightly elevated blood pressure
 C) Edema in the lower extremities
 D) Shortness of breath on exertion

Correct Answer: A
Rationale: A heart rate of 58 bpm may indicate bradycardia, which can be a sign of digoxin
toxicity.

Question 591: Neurological

A nurse is caring for a patient who has had a stroke and is experiencing right-sided hemiparesis.
Which intervention is appropriate to promote independence?

 A) Provide complete assistance with activities of daily living (ADLs).

 B) Encourage the use of the left arm for all tasks.
 C) Provide adaptive devices for feeding and grooming.
 D) Limit mobility to prevent falls.

Correct Answer: C
Rationale: Providing adaptive devices can promote independence and encourage the patient to
participate in self-care activities.

Question 592: Mental Health

A patient is diagnosed with major depressive disorder. Which statement indicates a risk for
suicide?
  A) "I feel sad but can still enjoy my hobbies."
 B) "I have a lot of things to look forward to."
 C) "I don't think anyone would miss me if I were gone."
 D) "I plan to talk to my therapist about my feelings."

Correct Answer: C
Rationale: Expressing that no one would miss them indicates hopelessness and a potential risk
for suicide.

Question 593: Gastrointestinal

A nurse is assessing a patient with suspected appendicitis. Which finding is most indicative of
this condition?

 A) Diffuse abdominal pain

 B) Pain in the right lower quadrant
 C) Constipation
 D) Vomiting

Correct Answer: B
Rationale: Pain in the right lower quadrant is a classic sign of appendicitis.

Question 594: Pediatric Nursing

A nurse is monitoring a child with asthma. Which finding would indicate that the child is in
respiratory distress?

 A) Wheezing
 B) Coughing
 C) Normal respiratory rate
 D) Clear lung sounds

Correct Answer: A
Rationale: Wheezing indicates airway narrowing and respiratory distress in children with
asthma.

Question 595: Endocrine

A patient with diabetes is experiencing hypoglycemia. Which symptom should the nurse
anticipate?
  A) Nausea
 B) Confusion
 C) Frequent urination
 D) Blurred vision

Correct Answer: B
Rationale: Confusion is a common symptom of hypoglycemia due to decreased glucose
availability to the brain.

Question 596: Pharmacology

A patient is prescribed warfarin. Which statement by the patient indicates a need for further
teaching?

 A) "I should avoid foods high in vitamin K."

 B) "I will take this medication at the same time every day."
 C) "I can stop taking the medication once my INR is stable."
 D) "I need to have my INR checked regularly."

Correct Answer: C
Rationale: Warfarin therapy requires ongoing management and monitoring; the patient should
not stop taking it without consulting a healthcare provider.

Question 597: Neurological

A nurse is assessing a patient who has experienced a seizure. Which finding would be most
concerning postictally?

 A) Disorientation
 B) Headache
 C) Slurred speech
 D) Hypotension

Correct Answer: C
Rationale: Slurred speech may indicate a transient ischemic attack (TIA) or another neurological
issue and should be evaluated further.

Question 598: Cardiovascular

A nurse is caring for a patient with congestive heart failure (CHF). Which assessment finding is
expected in this condition?

 A) Decreased blood pressure

 B) Increased heart rate
 C) Peripheral edema
 D) All of the above

Correct Answer: D
Rationale: Patients with CHF typically exhibit decreased blood pressure, increased heart rate,
and peripheral edema due to fluid overload.

Question 599: Infection Control

A patient with Clostridium difficile infection is in isolation. Which type of precautions should
the nurse implement?

 A) Airborne precautions
 B) Droplet precautions
 C) Contact precautions
 D) Standard precautions

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of C. difficile, which is
transmitted through contaminated surfaces and direct contact.

Question 600: Mental Health

A nurse is caring for a patient who is exhibiting symptoms of anxiety. Which intervention is
most appropriate?

 A) Encourage the patient to talk about their fears.

 B) Discourage any discussion of anxiety to avoid escalating it.
 C) Suggest relaxation techniques to the patient.
 D) Provide the patient with a sedative.

Correct Answer: C
Rationale: Teaching relaxation techniques can help manage anxiety and promote coping
strategies.
Question 601: Pediatric Nursing

A nurse is assessing a 4-year-old child. Which developmental milestone should the nurse expect
the child to achieve?

 A) Hop on one foot

 B) Tie shoelaces
 C) Speak in complex sentences
 D) Dress independently

Correct Answer: A
Rationale: Hopping on one foot is a gross motor skill typically achieved by 4-year-olds.

Question 602: Endocrine

A patient is diagnosed with hyperthyroidism. Which symptom would the nurse expect to find
during the assessment?

 A) Weight gain
 B) Cold intolerance
 C) Heat intolerance
 D) Fatigue

Correct Answer: C
Rationale: Heat intolerance is a common symptom of hyperthyroidism due to increased
metabolism.

Question 603: Gastrointestinal

A patient with a history of chronic pancreatitis is experiencing abdominal pain. Which dietary
change should the nurse recommend?

 A) High-protein diet
 B) Low-fat diet
 C) High-carbohydrate diet
 D) Gluten-free diet

Correct Answer: B
Rationale: A low-fat diet is recommended for patients with chronic pancreatitis to reduce
pancreatic stimulation.
Question 604: Obstetrics

A nurse is providing education to a pregnant patient regarding the signs of preeclampsia. Which
symptom should the nurse emphasize as concerning?

 A) Mild headaches
 B) Swelling of the hands and face
 C) Weight gain of 5 pounds in a week
 D) Occasional blurred vision

Correct Answer: B
Rationale: Swelling of the hands and face may indicate preeclampsia and should be reported
immediately.

Question 605: Renal

A patient with chronic kidney disease is prescribed erythropoietin. What is the primary purpose
of this medication?

 A) To reduce blood pressure

 B) To stimulate red blood cell production
 C) To decrease potassium levels
 D) To prevent infection

Correct Answer: B
Rationale: Erythropoietin stimulates the production of red blood cells in patients with anemia
due to chronic kidney disease.

Question 606: Infection Control

A nurse is teaching a patient about preventing urinary tract infections (UTIs). Which statement
indicates that the patient understands the teaching?

 A) "I should drink plenty of fluids."

 B) "I can hold my urine for long periods."
 C) "Using bubble bath is fine as long as I rinse well."
 D) "I can wear tight-fitting clothing."

Correct Answer: A
Rationale: Drinking plenty of fluids helps flush bacteria from the urinary tract, reducing the risk
of UTIs.
Question 607: Cardiovascular

A patient is diagnosed with atrial fibrillation. Which medication is commonly prescribed for this
condition to prevent thromboembolic events?

 A) Digoxin
 B) Warfarin
 C) Lisinopril
 D) Furosemide

Correct Answer: B
Rationale: Warfarin is often prescribed to prevent blood clots in patients with atrial fibrillation.

Question 608: Neurological

A nurse is caring for a patient who has suffered a stroke and is experiencing difficulty
swallowing. What is the priority nursing intervention?

 A) Provide thickened liquids.

 B) Refer the patient for a speech therapy evaluation.
 C) Encourage the patient to eat solid foods.
 D) Monitor the patient for weight loss.

Correct Answer: B
Rationale: Referring the patient for a speech therapy evaluation is crucial to assess and manage
swallowing difficulties safely.

Question 609: Mental Health

A nurse is caring for a patient diagnosed with bipolar disorder who is currently in a manic
episode. Which behavior should the nurse anticipate?

 A) Excessive sleeping
 B) Decreased energy
 C) Racing thoughts and rapid speech
 D) Withdrawal from social interactions

Correct Answer: C
Rationale: During a manic episode, patients typically exhibit racing thoughts and rapid speech
due to heightened energy levels.
Question 610: Pediatric Nursing

A nurse is assessing a newborn. Which finding should be reported as abnormal?

 A) Grasp reflex
 B) Positive Babinski reflex
 C) Cyanosis of the hands and feet
 D) Jaundice appearing after the first 24 hours

Correct Answer: D
Rationale: Jaundice that appears after the first 24 hours of life can indicate an underlying
pathology and should be reported.

Question 611: Endocrine

A nurse is teaching a patient with diabetes about foot care. Which statement by the patient
indicates understanding of the teaching?

 A) "I should soak my feet daily."

 B) "I will wear tight-fitting shoes to prevent blisters."
 C) "I need to check my feet daily for cuts or sores."
 D) "It's okay to go barefoot around the house."

Correct Answer: C
Rationale: Daily foot checks are essential for patients with diabetes to identify and address any
injuries early.

Question 612: Gastrointestinal

A patient with peptic ulcer disease is prescribed an H2 receptor antagonist. Which medication is
commonly prescribed for this condition?

 A) Omeprazole
 B) Ranitidine
 C) Sucralfate
 D) Metoclopramide

Correct Answer: B
Rationale: Ranitidine is an H2 receptor antagonist used to reduce stomach acid and treat peptic
ulcer disease.
Question 613: Obstetrics

A nurse is assessing a pregnant patient in the third trimester. Which finding requires immediate
evaluation?

 A) Decreased fetal movement

 B) Mild edema in the lower extremities
 C) Occasional shortness of breath
 D) Increased frequency of urination

Correct Answer: A
Rationale: Decreased fetal movement may indicate fetal distress and requires immediate
evaluation.

Question 614: Renal

A patient with nephrotic syndrome is experiencing significant edema. Which dietary

modification should the nurse recommend?

 A) High-sodium diet
 B) Low-protein diet
 C) Low-sodium diet
 D) High-calcium diet

Correct Answer: C
Rationale: A low-sodium diet helps manage edema in patients with nephrotic syndrome.

Question 615: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). Which
type of precautions should the nurse implement?

 A) Standard precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions

Correct Answer: D
Rationale: Contact precautions are necessary to prevent the spread of MRSA.
Question 616: Cardiovascular

A patient with hypertension is prescribed a calcium channel blocker. Which teaching point
should the nurse include?

 A) "This medication may cause weight gain."

 B) "Avoid grapefruit juice while taking this medication."
 C) "You should take this medication at bedtime."
 D) "This medication can cause bradycardia."

Correct Answer: B
Rationale: Grapefruit juice can interact with calcium channel blockers and increase their effects,
leading to potential toxicity.

Question 617: Neurological

A patient with Parkinson's disease is experiencing tremors. Which intervention should the nurse
implement to assist with mobility?

 A) Encourage the patient to walk fast.

 B) Provide a walker for support.
 C) Limit physical activity to reduce fatigue.
 D) Suggest the patient use a cane only when necessary.

Correct Answer: B
Rationale: A walker can provide stability and support, helping the patient maintain mobility
safely.

Question 618: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia. Which symptom should the nurse
recognize as a positive symptom of the disorder?

 A) Apathy
 B) Anhedonia
 C) Hallucinations
 D) Social withdrawal
Correct Answer: C
Rationale: Hallucinations are considered positive symptoms of schizophrenia, indicating the
presence of abnormal experiences.

Question 619: Pediatric Nursing

A nurse is assessing a child with a suspected respiratory infection. Which finding would be most
concerning?

 A) Nasal congestion
 B) Mild cough
 C) Stridor
 D) Low-grade fever

Correct Answer: C
Rationale: Stridor indicates upper airway obstruction and requires immediate assessment and
intervention.

Question 620: Endocrine

A nurse is caring for a patient with Cushing's syndrome. Which symptom is characteristic of this
condition?

 A) Weight loss
 B) Hyperpigmentation
 C) Moon facies
 D) Cold intolerance

Correct Answer: C
Rationale: Moon facies, characterized by rounded facial features, is a common physical
manifestation of Cushing's syndrome.

Question 621: Pharmacology

A patient with chronic obstructive pulmonary disease (COPD) is prescribed a beta-agonist

inhaler. Which side effect should the nurse monitor for?

 A) Bradycardia
 B) Tachycardia
 C) Hypotension
  D) Drowsiness

Correct Answer: B
Rationale: Beta-agonists can cause tachycardia due to their stimulatory effects on the
cardiovascular system.

Question 622: Neurological

A nurse is caring for a patient with a head injury who exhibits changes in consciousness. What is
the priority nursing action?

 A) Document the findings.

 B) Prepare the patient for a CT scan.
 C) Assess the patient's vital signs.
 D) Notify the healthcare provider.

Correct Answer: C
Rationale: Assessing vital signs is crucial for identifying any deterioration in the patient's
condition and for making timely interventions.

Question 623: Gastrointestinal

A patient is admitted with a diagnosis of acute cholecystitis. Which assessment finding would be
expected?

 A) Pain in the left upper quadrant

 B) Murphy's sign positive
 C) Steatorrhea
 D) Hypoactive bowel sounds

Correct Answer: B
Rationale: A positive Murphy's sign, which indicates pain during palpation of the right upper
quadrant, is associated with acute cholecystitis.

Question 624: Cardiovascular

A nurse is monitoring a patient who has received digoxin. Which finding indicates potential
digoxin toxicity?

 A) Hypokalemia
  B) Bradycardia
 C) Nausea
 D) All of the above

Correct Answer: D
Rationale: All of these findings can indicate digoxin toxicity; the nurse should monitor for these
symptoms.

Question 625: Mental Health

A patient with generalized anxiety disorder is prescribed an SSRI. What is an important teaching
point regarding this medication?

 A) It is habit-forming.
 B) It may take several weeks to notice improvement.
 C) It should be taken only when feeling anxious.
 D) It causes immediate relief of symptoms.

Correct Answer: B
Rationale: SSRIs typically take several weeks to achieve their full therapeutic effect.

Question 626: Obstetrics

A nurse is providing discharge teaching to a postpartum patient. Which statement by the patient
indicates a need for further teaching?

 A) "I will continue to take my iron supplements."

 B) "I can resume sexual activity as soon as I feel ready."
 C) "I should not lift anything heavier than my baby."
 D) "I can stop my prenatal vitamins now that I am no longer pregnant."

Correct Answer: D
Rationale: It is often recommended that postpartum patients continue taking prenatal vitamins,
especially folic acid, for several weeks after delivery.

Question 627: Pediatric Nursing

A nurse is caring for a 2-year-old child. Which developmental milestone should the nurse expect
the child to achieve?
  A) Jumping in place
 B) Riding a tricycle
 C) Printing letters
 D) Telling a coherent story

Correct Answer: A
Rationale: Jumping in place is a gross motor skill typically achieved by 2-year-olds.

Question 628: Renal

A nurse is caring for a patient with acute renal failure. Which laboratory value would the nurse
expect to be elevated?

 A) Blood urea nitrogen (BUN)

 B) Albumin
 C) Hemoglobin
 D) Potassium

Correct Answer: A
Rationale: BUN levels are typically elevated in acute renal failure due to decreased kidney
function.

Question 629: Infection Control

A nurse is caring for a patient with tuberculosis (TB). Which precaution should the nurse
implement?

 A) Contact precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: B
Rationale: Airborne precautions are necessary to prevent the spread of TB through inhaled
droplets.

Question 630: Cardiovascular

A patient with heart failure is prescribed a diuretic. What should the nurse monitor for as a
potential side effect?
  A) Hyperkalemia
 B) Hyponatremia
 C) Weight gain
 D) Increased urine output

Correct Answer: B
Rationale: Diuretics can lead to electrolyte imbalances, including hyponatremia.

Question 631: Neurological

A nurse is assessing a patient with multiple sclerosis (MS). Which symptom would be
characteristic of this condition?

 A) Rapid weight gain

 B) Visual disturbances
 C) Hypoglycemia
 D) Fever

Correct Answer: B
Rationale: Visual disturbances, such as double vision or blurred vision, are common symptoms
of multiple sclerosis.

Question 632: Mental Health

A nurse is caring for a patient with depression who is prescribed an antidepressant. Which
dietary restriction is important to discuss with a patient on a monoamine oxidase inhibitor
(MAOI)?

 A) Avoiding dairy products

 B) Limiting caffeine intake
 C) Avoiding foods high in tyramine
 D) Reducing carbohydrate intake

Correct Answer: C
Rationale: Foods high in tyramine can cause hypertensive crises when taken with MAOIs.

Question 633: Gastrointestinal

A patient with cirrhosis is at risk for hepatic encephalopathy. Which assessment finding should
the nurse monitor?
  A) Bradycardia
 B) Confusion
 C) Hyperglycemia
 D) Increased appetite

Correct Answer: B
Rationale: Confusion and altered mental status can indicate hepatic encephalopathy due to the
accumulation of toxins in the bloodstream.

Question 634: Obstetrics

A nurse is assessing a pregnant patient at 36 weeks gestation. Which finding is a cause for
concern?

 A) Fundal height measuring 34 cm

 B) Positive fetal heart rate
 C) Edema of the lower extremities
 D) Severe headache with visual changes

Correct Answer: D
Rationale: Severe headache with visual changes can indicate preeclampsia and requires
immediate evaluation.

Question 635: Renal

A patient with chronic kidney disease is experiencing hyperphosphatemia. Which dietary change
should the nurse recommend?

 A) Increase dairy products

 B) Decrease protein intake
 C) Limit phosphorus-containing foods
 D) Increase fluid intake

Correct Answer: C
Rationale: Limiting phosphorus-containing foods can help manage hyperphosphatemia in
chronic kidney disease.

Question 636: Infection Control

A nurse is caring for a patient with influenza. Which precaution is appropriate for this patient?
  A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions

Correct Answer: B
Rationale: Droplet precautions are necessary to prevent the spread of influenza.

Question 637: Cardiovascular

A patient is receiving treatment for heart failure and presents with shortness of breath and a
productive cough with pink frothy sputum. What is the priority nursing intervention?

 A) Administer diuretics as prescribed.

 B) Assess the patient's oxygen saturation.
 C) Position the patient in a low Fowler's position.
 D) Notify the healthcare provider.

Correct Answer: B
Rationale: Assessing oxygen saturation is critical in determining the severity of respiratory
distress and the need for further intervention.

Question 638: Neurological

A patient with Alzheimer’s disease is wandering and appears agitated. What is the best nursing
intervention?

 A) Restrain the patient for safety.

 B) Redirect the patient to a calming activity.
 C) Leave the patient alone to calm down.
 D) Speak harshly to the patient to get their attention.

Correct Answer: B
Rationale: Redirecting the patient to a calming activity can help alleviate agitation and provide a
sense of security.

Question 639: Mental Health

A nurse is conducting a mental health assessment on a patient. Which behavior might indicate
the presence of suicidal ideation?
  A) Excessive talking
 B) Withdrawal from social activities
 C) Increased appetite
 D) Energetic behavior

Correct Answer: B
Rationale: Withdrawal from social activities can be a warning sign of depression and potential
suicidal ideation.

Question 640: Pediatric Nursing

A nurse is teaching a parent about the care of a child with attention-deficit/hyperactivity disorder
(ADHD). Which statement indicates a need for further teaching?

 A) "I should provide a structured environment for my child."

 B) "I can use rewards to encourage positive behavior."
 C) "It's okay to yell at my child when they misbehave."
 D) "I should set clear expectations and consequences."

Correct Answer: C
Rationale: Yelling can escalate the situation and may not be effective; positive reinforcement
and consistent expectations are recommended.

Question 641: Pharmacology

A patient is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor to
assess the effectiveness of the medication?

 A) Platelet count
 B) Prothrombin time (PT)/International Normalized Ratio (INR)
 C) Activated partial thromboplastin time (aPTT)
 D) Hemoglobin and hematocrit

Correct Answer: B
Rationale: The INR is used to monitor the effectiveness of warfarin therapy and to adjust dosing
as necessary.

Question 642: Neurological

A nurse is assessing a patient after a stroke. Which finding indicates that the patient is
experiencing a right-sided stroke?
  A) Left-sided weakness
 B) Slurred speech
 C) Neglect of the left side
 D) Impaired vision in the right eye

Correct Answer: C
Rationale: Neglect of the left side is indicative of a right-sided stroke, as the right hemisphere
controls spatial awareness.

Question 643: Gastrointestinal

A patient with a history of chronic pancreatitis is admitted with abdominal pain. Which
laboratory finding is likely to be elevated?

 A) Amylase
 B) Albumin
 C) Lipase
 D) Both A and C

Correct Answer: D
Rationale: Both amylase and lipase levels are often elevated in cases of pancreatitis.

Question 644: Cardiovascular

A patient with heart failure is prescribed a potassium-sparing diuretic. Which laboratory value is
the nurse most concerned about?

 A) Hypokalemia
 B) Hyperkalemia
 C) Hyponatremia
 D) Hypocalcemia

Correct Answer: B
Rationale: Potassium-sparing diuretics can lead to hyperkalemia due to their action of
conserving potassium in the body.

Question 645: Mental Health

A patient with bipolar disorder is in a manic episode. Which behavior should the nurse expect to
observe?
  A) Social withdrawal
 B) Increased need for sleep
 C) Racing thoughts and distractibility
 D) Lack of energy

Correct Answer: C
Rationale: Racing thoughts and distractibility are common symptoms during a manic episode.

Question 646: Obstetrics

A nurse is caring for a woman in labor who is 8 cm dilated. Which action should the nurse take
first if the fetal heart rate drops to 80 beats per minute?

 A) Prepare for an emergency cesarean section.

 B) Administer oxygen to the mother.
 C) Change the mother’s position.
 D) Call for the healthcare provider.

Correct Answer: C
Rationale: Changing the mother's position can help alleviate pressure on the umbilical cord and
improve fetal heart rate.

Question 647: Pediatric Nursing

A nurse is assessing a 5-year-old child with asthma. Which symptom indicates that the child is
experiencing an asthma exacerbation?

 A) Clear nasal drainage

 B) Wheezing
 C) Occasional dry cough
 D) Good activity tolerance

Correct Answer: B
Rationale: Wheezing is a classic sign of bronchospasm associated with asthma exacerbations.

Question 648: Renal

A patient diagnosed with nephrotic syndrome is at risk for which complication?

 A) Hypotension
  B) Hyperkalemia
 C) Thrombosis
 D) Respiratory failure

Correct Answer: C
Rationale: Patients with nephrotic syndrome are at risk for thrombosis due to loss of
anticoagulant proteins in urine.

Question 649: Infection Control

A nurse is caring for a patient with clostridium difficile (C. diff) infection. Which precaution is
essential for the nurse to follow?

 A) Hand hygiene with soap and water

 B) Wearing gloves only
 C) Using alcohol-based hand sanitizer
 D) Implementing airborne precautions

Correct Answer: A
Rationale: Hand hygiene with soap and water is essential for C. diff, as alcohol-based sanitizers
are ineffective against this organism.

Question 650: Cardiovascular

A patient presents with chest pain and an elevated troponin level. What is the priority nursing
intervention?

 A) Obtain a 12-lead ECG.

 B) Administer nitroglycerin.
 C) Start an intravenous line.
 D) Assess the patient's vital signs.

Correct Answer: A
Rationale: Obtaining a 12-lead ECG is critical to assess the patient's heart status and determine
the need for further interventions.

Question 651: Neurological

A nurse is caring for a patient who has had a seizure. Which assessment is the nurse's priority
immediately after the seizure?
  A) Check the patient's blood pressure.
 B) Assess the patient for injuries.
 C) Document the duration of the seizure.
 D) Monitor the patient's airway.

Correct Answer: D
Rationale: Ensuring the patient's airway is patent is the priority after a seizure, as they may be at
risk for aspiration or airway obstruction.

Question 652: Mental Health

A patient is being treated for major depressive disorder and expresses feelings of hopelessness.
What is the best response by the nurse?

 A) "You should try to think positively."

 B) "Let's talk about your feelings."
 C) "You have no reason to feel hopeless."
 D) "Many people feel this way at times."

Correct Answer: B
Rationale: Encouraging the patient to discuss feelings allows for therapeutic communication and
validation of their experiences.

Question 653: Gastrointestinal

A nurse is caring for a patient with acute gastroenteritis. Which dietary intervention is
appropriate?

 A) Encourage high-fiber foods.

 B) Offer clear fluids.
 C) Provide whole grains.
 D) Recommend full-fat dairy products.

Correct Answer: B
Rationale: Clear fluids help to prevent dehydration and are often the first step in dietary
management of gastroenteritis.

Question 654: Obstetrics

A nurse is caring for a postpartum patient who is experiencing heavy vaginal bleeding. Which
intervention should be the priority?

 A) Encourage the patient to ambulate.

 B) Assess the patient's fundus.
 C) Administer pain medication.
 D) Document the findings.

Correct Answer: B
Rationale: Assessing the fundus is crucial to determine if uterine atony is the cause of the
bleeding and to implement appropriate interventions.

Question 655: Renal

A patient with chronic kidney disease is receiving erythropoietin (Epogen). Which lab value
should the nurse monitor to evaluate the effectiveness of this treatment?

 A) Hemoglobin
 B) BUN
 C) Creatinine
 D) Potassium

Correct Answer: A
Rationale: Erythropoietin is administered to stimulate red blood cell production, so monitoring
hemoglobin levels is essential.

Question 656: Pediatric Nursing

A nurse is assessing a child with an ear infection. Which symptom would be most indicative of
acute otitis media?

 A) Nausea
 B) Drainage from the ear
 C) Tugging at the ear
 D) Fever

Correct Answer: C
Rationale: Tugging at the ear is a common behavior in children experiencing discomfort from
an ear infection.
Question 657: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). Which
precautions should the nurse implement?

 A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions only

Correct Answer: A
Rationale: Contact precautions are essential to prevent the spread of MRSA.

Question 658: Cardiovascular

A patient diagnosed with hypertension is prescribed a thiazide diuretic. What is a common side
effect the nurse should monitor for?

 A) Hypoglycemia
 B) Hyperkalemia
 C) Hypokalemia
 D) Hyponatremia

Correct Answer: C
Rationale: Thiazide diuretics can lead to hypokalemia due to increased potassium excretion.

Question 659: Neurological

A nurse is assessing a patient with a traumatic brain injury. Which finding is an early sign of
increased intracranial pressure (ICP)?

 A) Bradycardia
 B) Nausea and vomiting
 C) Altered level of consciousness
 D) Hyperventilation

Correct Answer: C
Rationale: An altered level of consciousness is one of the earliest signs of increased ICP.

Question 660: Mental Health

A nurse is caring for a patient diagnosed with obsessive-compulsive disorder (OCD). Which
therapeutic intervention should be included in the patient's care plan?

 A) Encouraging avoidance of compulsions

 B) Cognitive-behavioral therapy
 C) Providing reassurance that their fears are unfounded
 D) Limiting discussion about obsessions

Correct Answer: B
Rationale: Cognitive-behavioral therapy is an effective treatment for OCD, helping patients
learn to manage their compulsions.

Question 681: Pharmacology

A patient is prescribed digoxin (Lanoxin). Which laboratory value is most important for the
nurse to monitor?

 A) Serum potassium
 B) Serum calcium
 C) Serum sodium
 D) Serum glucose

Correct Answer: A
Rationale: Digoxin can cause toxicity, and low serum potassium levels can increase the risk of
digoxin toxicity.

Question 682: Neurological

A nurse is caring for a patient who has just had a stroke and has left-sided hemiplegia. Which
intervention should the nurse prioritize?

 A) Assist the patient in performing activities of daily living.

 B) Encourage the patient to verbalize feelings about their condition.
 C) Teach the patient about stroke prevention.
 D) Maintain safety by ensuring the environment is free of hazards.

Correct Answer: D
Rationale: Maintaining safety is crucial for patients with hemiplegia to prevent falls and
injuries.
Question 683: Gastrointestinal

A nurse is caring for a patient who has just undergone an appendectomy. Which assessment
finding would be concerning?

 A) Mild abdominal tenderness

 B) Absent bowel sounds
 C) A temperature of 101°F (38.3°C)
 D) Dark red drainage on the dressing

Correct Answer: D
Rationale: Dark red drainage may indicate bleeding and should be reported to the healthcare
provider immediately.

Question 684: Cardiovascular

A patient is receiving a blood transfusion. Which finding indicates a potential transfusion

reaction?

 A) Increased temperature of 0.5°C (1°F)

 B) Shortness of breath
 C) Mild headache
 D) Flushed skin

Correct Answer: B
Rationale: Shortness of breath can indicate a transfusion reaction and requires immediate
intervention.

Question 685: Mental Health

A nurse is assessing a patient with anxiety who expresses feelings of being out of control. What
is the best nursing intervention?

 A) Suggest deep breathing exercises.

 B) Encourage the patient to avoid stressors.
 C) Tell the patient to calm down.
 D) Administer medication as prescribed.

Correct Answer: A
Rationale: Deep breathing exercises can help the patient regain a sense of control and reduce
anxiety.
Question 686: Obstetrics

A nurse is caring for a postpartum patient who is breastfeeding. Which teaching point should the
nurse emphasize regarding nutrition?

 A) Decrease caloric intake to lose weight.

 B) Drink plenty of fluids to maintain milk production.
 C) Avoid all caffeine products.
 D) Increase protein intake only.

Correct Answer: B
Rationale: Adequate fluid intake is essential for maintaining breast milk production while
breastfeeding.

Question 687: Pediatric Nursing

A nurse is assessing a 6-year-old child with asthma. Which statement by the parent indicates a
need for further education?

 A) "We always have the rescue inhaler available."

 B) "My child can skip their controller medication if they feel fine."
 C) "I monitor my child's peak flow readings."
 D) "I will keep a diary of my child's asthma symptoms."

Correct Answer: B
Rationale: Parents should be instructed to administer controller medications as prescribed, even
if the child feels well.

Question 688: Renal

A patient with chronic kidney disease is receiving a phosphate binder. What is the nurse’s
priority assessment?

 A) Monitor blood pressure.

 B) Assess bowel habits.
 C) Check serum phosphate levels.
 D) Evaluate dietary intake of protein.
Correct Answer: C
Rationale: Monitoring serum phosphate levels is important to evaluate the effectiveness of the
phosphate binder and prevent complications.

Question 689: Infection Control

A nurse is caring for a patient with tuberculosis. What type of isolation precautions should be
implemented?

 A) Standard precautions
 B) Contact precautions
 C) Airborne precautions
 D) Droplet precautions

Correct Answer: C
Rationale: Airborne precautions are necessary for patients with tuberculosis to prevent the
spread of the bacteria.

Question 690: Cardiovascular

A patient is prescribed an ACE inhibitor. Which side effect should the nurse inform the patient to
report immediately?

 A) Dry cough
 B) Fatigue
 C) Dizziness
 D) Swelling of the face or lips

Correct Answer: D
Rationale: Swelling of the face or lips may indicate angioedema, a serious side effect of ACE
inhibitors that requires immediate attention.

Question 691: Neurological

A nurse is assessing a patient with a spinal cord injury at the level of C4. Which complication is
the patient most at risk for?

 A) Autonomic dysreflexia
 B) Respiratory distress
 C) Deep vein thrombosis
  D) Pressure ulcers

Correct Answer: B
Rationale: A C4 spinal cord injury can impair respiratory function, putting the patient at risk for
respiratory distress.

Question 692: Mental Health

A patient is being treated for major depressive disorder and asks the nurse about the expected
effects of the prescribed selective serotonin reuptake inhibitor (SSRI). What is the nurse's best
response?

 A) "You will feel better immediately."

 B) "It may take several weeks to feel the full effect."
 C) "You will need to take this medication for life."
 D) "This medication can be stopped if you feel better."

Correct Answer: B
Rationale: SSRIs often take several weeks to reach their full therapeutic effect.

Question 693: Gastrointestinal

A nurse is providing education to a patient with gastroesophageal reflux disease (GERD). Which
dietary change should the nurse recommend?

 A) Eat large meals to avoid hunger.

 B) Include spicy foods in the diet.
 C) Avoid eating before bedtime.
 D) Increase caffeine intake.

Correct Answer: C
Rationale: Avoiding eating before bedtime can help reduce nighttime reflux and improve
symptoms.

Question 694: Obstetrics

A nurse is assessing a pregnant woman at 32 weeks' gestation who reports sudden onset of
severe headache and visual disturbances. What condition should the nurse suspect?

 A) Preeclampsia
  B) Gestational diabetes
 C) Braxton Hicks contractions
 D) Normal pregnancy symptoms

Correct Answer: A
Rationale: Severe headache and visual disturbances in pregnancy can be signs of preeclampsia
and require immediate evaluation.

Question 695: Renal

A patient with acute kidney injury is experiencing hyperkalemia. Which dietary restriction
should the nurse prioritize?

 A) Low-sodium diet
 B) High-protein diet
 C) Low-potassium diet
 D) Low-calcium diet

Correct Answer: C
Rationale: A low-potassium diet is essential to manage hyperkalemia and prevent
complications.

Question 696: Pediatric Nursing

A nurse is assessing a child with a fever and sore throat. Which symptom would indicate a
potential streptococcal infection?

 A) Cough
 B) Rash
 C) White patches on the tonsils
 D) Nasal congestion

Correct Answer: C
Rationale: White patches on the tonsils are indicative of a streptococcal infection, warranting
further evaluation.

Question 697: Infection Control

A nurse is caring for a patient who is immunocompromised due to chemotherapy. What is the
priority nursing intervention to prevent infection?
  A) Educate the patient on hand hygiene.
 B) Encourage a high-protein diet.
 C) Limit visitors to family only.
 D) Administer prophylactic antibiotics.

Correct Answer: A
Rationale: Hand hygiene is the most effective measure to prevent infection in
immunocompromised patients.

Question 698: Cardiovascular

A nurse is assessing a patient who has just had a myocardial infarction. Which assessment
finding is most concerning?

 A) Heart rate of 90 beats per minute

 B) Blood pressure of 100/60 mmHg
 C) Chest pain rated 6 on a scale of 0 to 10
 D) Respiratory rate of 22 breaths per minute

Correct Answer: B
Rationale: A blood pressure of 100/60 mmHg may indicate inadequate perfusion and could be
concerning after a myocardial infarction.

Question 699: Neurological

A patient with multiple sclerosis is experiencing fatigue. Which intervention should the nurse
recommend?

 A) Increase physical activity to build endurance.

 B) Limit rest periods throughout the day.
 C) Schedule activities during times of peak energy.
 D) Avoid all physical activity.

Correct Answer: C
Rationale: Scheduling activities during peak energy times can help the patient manage fatigue
more effectively.

Question 700: Mental Health

A nurse is assessing a patient with a history of substance abuse. What is the priority nursing
action?

 A) Educate the patient about the effects of drugs.

 B) Establish a trusting relationship.
 C) Refer the patient to a rehabilitation program.
 D) Discuss the patient's family history.

Correct Answer: B
Rationale: Establishing a trusting relationship is crucial for effective communication and
treatment in patients with substance abuse issues.

Question 701: Pharmacology

A patient receiving warfarin (Coumadin) has an INR of 4.5. What is the appropriate nursing
action?

 A) Administer the next dose of warfarin.

 B) Hold the warfarin dose and notify the healthcare provider.
 C) Increase the dose of warfarin.
 D) Document the INR level and continue monitoring.

Correct Answer: B
Rationale: An INR of 4.5 indicates a risk of bleeding; the warfarin dose should be held, and the
healthcare provider should be notified.

Question 702: Neurological

A patient who has had a stroke is being discharged with a diagnosis of right-sided hemiplegia.
Which assistive device is most appropriate for this patient?

 A) Walker
 B) Crutches
 C) Cane
 D) Wheelchair

Correct Answer: A
Rationale: A walker is most appropriate for providing support and stability to a patient with
right-sided hemiplegia as they begin to regain mobility.
Question 703: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which medication should the nurse anticipate
administering?

 A) Antacids
 B) Antibiotics
 C) Proton pump inhibitors
 D) All of the above

Correct Answer: D
Rationale: All of these medications can be part of the treatment plan for a peptic ulcer,
depending on the underlying cause.

Question 704: Cardiovascular

A nurse is assessing a patient with a history of hypertension who presents with a headache and
blurred vision. Which condition should the nurse suspect?

 A) Hypoglycemia
 B) Hypertensive crisis
 C) Migraines
 D) Anemia

Correct Answer: B
Rationale: A headache and blurred vision in a patient with a history of hypertension may
indicate a hypertensive crisis, requiring immediate evaluation.

Question 705: Mental Health

A nurse is caring for a patient diagnosed with generalized anxiety disorder. What is the best
approach for the nurse to take?

 A) Encourage the patient to avoid discussing feelings.

 B) Teach relaxation techniques.
 C) Administer medication only.
 D) Suggest the patient participate in group therapy.

Correct Answer: B
Rationale: Teaching relaxation techniques can help the patient manage anxiety effectively.
Question 706: Obstetrics

A nurse is caring for a pregnant patient who is in labor. What is the priority nursing action when
the fetal heart rate is found to be 70 beats per minute?

 A) Prepare for delivery.

 B) Perform a vaginal examination.
 C) Place the patient in the left lateral position.
 D) Administer oxygen to the mother.

Correct Answer: C
Rationale: Placing the patient in the left lateral position can improve blood flow to the fetus and
may help resolve bradycardia.

Question 707: Pediatric Nursing

A nurse is assessing a child with cystic fibrosis. Which assessment finding is most concerning?

 A) Increased appetite
 B) Salty skin
 C) Persistent cough with thick mucus
 D) Frequent weight gain

Correct Answer: C
Rationale: A persistent cough with thick mucus can indicate lung infection or exacerbation of
cystic fibrosis, which is concerning.

Question 708: Renal

A nurse is educating a patient with chronic kidney disease about dietary restrictions. Which food
should the patient be advised to limit?

 A) Apples
 B) Bananas
 C) Carrots
 D) Broccoli

Correct Answer: B
Rationale: Bananas are high in potassium, which should be limited in patients with chronic
kidney disease to prevent hyperkalemia.
Question 709: Infection Control

A nurse is caring for a patient with Clostridium difficile. Which method is most effective for
preventing the spread of infection?

 A) Use of disposable gloves

 B) Hand hygiene with soap and water
 C) Alcohol-based hand sanitizers
 D) Isolation in a private room

Correct Answer: B
Rationale: Hand hygiene with soap and water is essential for effectively removing spores from
C. difficile.

Question 710: Cardiovascular

A patient is prescribed a beta-blocker for hypertension. What is the priority nursing action when
administering this medication?

 A) Monitor blood pressure and heart rate.

 B) Administer it with food.
 C) Teach the patient about potential side effects.
 D) Assess for respiratory status.

Correct Answer: A
Rationale: Monitoring blood pressure and heart rate is crucial, as beta-blockers can significantly
affect both.

Question 711: Neurological

A patient has just undergone a craniotomy for a brain tumor. Which finding would require
immediate intervention?

 A) Clear fluid drainage from the nose

 B) Complaints of a mild headache
 C) Unequal pupils
 D) Decreased level of consciousness

Correct Answer: D
Rationale: A decreased level of consciousness is a critical finding and could indicate increased
intracranial pressure or other complications.
Question 712: Mental Health

A nurse is caring for a patient with obsessive-compulsive disorder (OCD). Which statement by
the patient indicates a need for further teaching?

 A) "I have to perform my rituals to feel safe."

 B) "I know my thoughts are irrational, but I can't help it."
 C) "I can stop my compulsions whenever I want."
 D) "I try to manage my anxiety by engaging in my rituals."

Correct Answer: C
Rationale: Patients with OCD often struggle to control their compulsions, so believing they can
stop at will indicates a lack of understanding of their condition.

Question 713: Gastrointestinal

A nurse is teaching a patient about managing gastroesophageal reflux disease (GERD). Which
statement indicates the need for further education?

 A) "I will eat smaller meals throughout the day."

 B) "I should avoid lying down after eating."
 C) "I can eat my favorite spicy foods in moderation."
 D) "I will wear loose-fitting clothing."

Correct Answer: C
Rationale: Patients with GERD should avoid spicy foods as they can exacerbate symptoms.

Question 714: Obstetrics

A nurse is caring for a postpartum patient who is experiencing heavy vaginal bleeding. What is
the priority nursing action?

 A) Assess the patient's fundal height.

 B) Administer oxytocin as ordered.
 C) Notify the healthcare provider.
 D) Perform a perineal assessment.

Correct Answer: A
Rationale: Assessing fundal height is crucial to determine if uterine atony is the cause of the
bleeding.
Question 715: Renal

A patient with end-stage renal disease is scheduled for hemodialysis. Which assessment finding
would the nurse report before dialysis?

 A) Blood pressure of 130/80 mmHg

 B) Weight gain of 5 pounds since the last session
 C) Serum potassium level of 5.0 mEq/L
 D) Complaints of fatigue

Correct Answer: B
Rationale: A weight gain of 5 pounds since the last dialysis session indicates fluid retention,
which requires evaluation before proceeding with dialysis.

Question 716: Pediatric Nursing

A nurse is assessing a 10-year-old child with asthma. Which finding indicates a potential
exacerbation?

 A) Wheezing
 B) Clear lung sounds
 C) Heart rate of 80 beats per minute
 D) Mild cough

Correct Answer: A
Rationale: Wheezing is a sign of airway constriction and indicates a potential exacerbation of
asthma.

Question 717: Infection Control

A nurse is providing care to a patient with a respiratory infection. What type of precautions
should the nurse implement?

 A) Standard precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions
Correct Answer: C
Rationale: Droplet precautions are required for respiratory infections to prevent transmission
through respiratory droplets.

Question 718: Cardiovascular

A patient with a history of heart failure presents with shortness of breath and edema. What
should the nurse assess first?

 A) Lung sounds
 B) Blood pressure
 C) Heart rate
 D) Oxygen saturation

Correct Answer: A
Rationale: Assessing lung sounds is the priority to evaluate for pulmonary congestion, which
can occur in heart failure.

Question 719: Neurological

A patient is admitted with suspected meningitis. Which symptom would the nurse expect to find?

 A) Increased appetite
 B) Nuchal rigidity
 C) Peripheral edema
 D) Constipation

Correct Answer: B
Rationale: Nuchal rigidity (stiff neck) is a classic sign of meningitis.

Question 720: Mental Health

A nurse is caring for a patient diagnosed with bipolar disorder. The patient is in a manic episode
and displays impulsive behavior. What is the priority nursing intervention?

 A) Encourage the patient to express feelings.

 B) Provide a structured environment.
 C) Allow the patient to engage in activities.
 D) Administer mood-stabilizing medication.
Correct Answer: B
Rationale: Providing a structured environment helps manage impulsive behaviors and promotes
safety during a manic episode.

Question 721: Pharmacology

A patient is receiving furosemide (Lasix). Which laboratory value is most important for the nurse
to monitor?

 A) Serum potassium
 B) Serum calcium
 C) Serum sodium
 D) Serum glucose

Correct Answer: A
Rationale: Furosemide can cause potassium depletion, so monitoring serum potassium levels is
essential to prevent hypokalemia.

Question 722: Neurological

A nurse is caring for a patient with a traumatic brain injury who is exhibiting signs of increased
intracranial pressure (ICP). Which assessment finding is most concerning?

 A) Changes in level of consciousness

 B) Mild headache
 C) Vomiting
 D) Blurred vision

Correct Answer: A
Rationale: Changes in level of consciousness are critical and may indicate worsening ICP,
requiring immediate intervention.

Question 723: Gastrointestinal

A nurse is caring for a patient with ulcerative colitis. Which symptom should the nurse expect to
assess?

 A) Constipation
 B) Abdominal distention
 C) Diarrhea with blood and mucus
  D) Weight gain

Correct Answer: C
Rationale: Diarrhea with blood and mucus is a common symptom of ulcerative colitis.

Question 724: Cardiovascular

A patient with a history of coronary artery disease is prescribed atorvastatin (Lipitor). Which
instruction should the nurse provide?

 A) Take the medication with food.

 B) Avoid grapefruit juice.
 C) Discontinue the medication if muscle pain occurs.
 D) Monitor blood glucose levels regularly.

Correct Answer: B
Rationale: Grapefruit juice can increase the risk of statin side effects, so patients should be
advised to avoid it.

Question 725: Mental Health

A nurse is caring for a patient with schizophrenia. Which symptom should the nurse recognize as
a negative symptom?

 A) Hallucinations
 B) Delusions
 C) Lack of motivation
 D) Disorganized thinking

Correct Answer: C
Rationale: Lack of motivation is considered a negative symptom of schizophrenia, reflecting a
decrease in normal functioning.

Question 726: Obstetrics

A nurse is teaching a pregnant patient about signs of preterm labor. Which statement by the
patient indicates a need for further education?

 A) "I should call my doctor if I have contractions every 10 minutes."

 B) "I need to be aware of lower back pain and pelvic pressure."
  C) "I will ignore any changes in my discharge."
 D) "I should report any fluid leaking from my vagina."

Correct Answer: C
Rationale: Changes in discharge can indicate preterm labor and should not be ignored; this
statement shows a need for further education.

Question 727: Pediatric Nursing

A nurse is assessing a child with asthma. Which finding would indicate that the child is
experiencing an asthma exacerbation?

 A) Clear lung sounds

 B) Coughing at night
 C) Normal peak flow reading
 D) No shortness of breath

Correct Answer: B
Rationale: Coughing at night can be a sign of asthma exacerbation, indicating the need for
further assessment and intervention.

Question 728: Renal

A patient with chronic kidney disease is prescribed erythropoietin (Epogen). What is the priority
nursing action?

 A) Monitor blood pressure.

 B) Assess for signs of infection.
 C) Check hemoglobin levels.
 D) Educate the patient about dietary restrictions.

Correct Answer: C
Rationale: Monitoring hemoglobin levels is essential to assess the effectiveness of
erythropoietin therapy in treating anemia.

Question 729: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). What
type of precautions should be implemented?
  A) Standard precautions
 B) Contact precautions
 C) Airborne precautions
 D) Droplet precautions

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of MRSA.

Question 730: Cardiovascular

A patient is experiencing chest pain and shortness of breath. An electrocardiogram (ECG) shows
ST-segment elevation. What is the priority nursing action?

 A) Administer nitroglycerin.
 B) Call for a code blue.
 C) Prepare for cardiac catheterization.
 D) Assess vital signs.

Correct Answer: C
Rationale: ST-segment elevation indicates an ST-elevation myocardial infarction (STEMI), and
preparing for cardiac catheterization is a priority intervention.

Question 731: Neurological

A nurse is caring for a patient with a history of seizures. Which medication should the nurse
anticipate administering to prevent seizures?

 A) Phenytoin (Dilantin)
 B) Carbamazepine (Tegretol)
 C) Lamotrigine (Lamictal)
 D) All of the above

Correct Answer: D
Rationale: All of these medications can be used to prevent seizures, depending on the type and
cause.

Question 732: Mental Health

A patient with depression expresses feelings of worthlessness. What is the most appropriate
nursing response?
  A) "You should feel grateful for what you have."
 B) "It's not that bad; you'll feel better soon."
 C) "Tell me more about how you're feeling."
 D) "You need to focus on the positive aspects of your life."

Correct Answer: C
Rationale: Encouraging the patient to express feelings fosters communication and provides
insight into their emotional state.

Question 733: Gastrointestinal

A nurse is caring for a patient with cirrhosis. Which symptom should the nurse monitor for that
indicates worsening liver function?

 A) Jaundice
 B) Increased appetite
 C) Clear urine
 D) Weight loss

Correct Answer: A
Rationale: Jaundice is a sign of worsening liver function and should be closely monitored in
patients with cirrhosis.

Question 734: Obstetrics

A nurse is caring for a laboring patient with an epidural. Which assessment is the priority?

 A) Maternal heart rate

 B) Fetal heart rate
 C) Contraction pattern
 D) Urinary output

Correct Answer: B
Rationale: Continuous monitoring of the fetal heart rate is essential to ensure the well-being of
the fetus during labor, especially with the use of an epidural.

Question 735: Pediatric Nursing

A nurse is assessing a 4-year-old child for developmental milestones. Which milestone should
the child have achieved?
  A) Skipping
 B) Drawing a circle
 C) Writing their name
 D) Balancing on one foot for 10 seconds

Correct Answer: B
Rationale: Drawing a circle is a developmental milestone that typically occurs around age 4.

Question 736: Renal

A nurse is caring for a patient on hemodialysis. What is the priority nursing assessment before
starting dialysis?

 A) Assessing the patient’s weight.

 B) Checking the vascular access site.
 C) Monitoring blood pressure.
 D) Evaluating laboratory values.

Correct Answer: B
Rationale: Checking the vascular access site is critical to ensure patency and prevent
complications during dialysis.

Question 737: Infection Control

A nurse is caring for a patient with a viral infection. Which precaution is essential to prevent
transmission?

 A) Airborne precautions
 B) Droplet precautions
 C) Standard precautions
 D) Contact precautions

Correct Answer: C
Rationale: Standard precautions should always be used when caring for any patient to prevent
transmission of infections.

Question 738: Cardiovascular

A patient is receiving amiodarone for atrial fibrillation. What is the most important nursing
consideration?
  A) Monitor liver function tests.
 B) Assess for signs of pulmonary toxicity.
 C) Monitor blood glucose levels.
 D) Assess heart rate regularly.

Correct Answer: B
Rationale: Amiodarone can cause pulmonary toxicity, so monitoring for respiratory symptoms
is critical.

Question 739: Neurological

A nurse is caring for a patient who has just undergone a lumbar puncture. What is the priority
nursing intervention?

 A) Encourage fluid intake.

 B) Assess for headache and back pain.
 C) Monitor vital signs.
 D) Instruct the patient to lie flat.

Correct Answer: D
Rationale: Instructing the patient to lie flat can help prevent a post-lumbar puncture headache.

Question 740: Mental Health

A nurse is providing care for a patient diagnosed with borderline personality disorder. What
behavior should the nurse be most concerned about?

 A) Mood swings
 B) Impulsive spending
 C) Self-harm behaviors
 D) Fear of abandonment

Correct Answer: C
Rationale: Self-harm behaviors are concerning and require immediate attention to ensure patient
safety.

Question 741: Pharmacology

A patient is prescribed lisinopril for hypertension. Which side effect should the nurse educate the
patient about?
  A) Constipation
 B) Cough
 C) Hypoglycemia
 D) Tachycardia

Correct Answer: B
Rationale: A persistent dry cough is a common side effect of lisinopril, an ACE inhibitor.

Question 742: Neurological

A nurse is caring for a patient with a spinal cord injury. Which finding would indicate autonomic
dysreflexia?

 A) Bradycardia
 B) Severe headache
 C) Flushed skin above the level of injury
 D) All of the above

Correct Answer: D
Rationale: All these symptoms (bradycardia, severe headache, and flushed skin) can indicate
autonomic dysreflexia, a medical emergency.

Question 743: Gastrointestinal

A patient with chronic pancreatitis is being discharged with dietary instructions. Which
statement indicates the need for further education?

 A) "I should eat a low-fat diet."

 B) "I can drink alcohol in moderation."
 C) "I will take pancreatic enzymes with meals."
 D) "I should avoid heavy meals."

Correct Answer: B
Rationale: Patients with chronic pancreatitis should avoid alcohol completely as it can
exacerbate the condition.

Question 744: Cardiovascular

A patient presents to the emergency department with chest pain and diaphoresis. Which
assessment should the nurse prioritize?
  A) Lung sounds
 B) Heart sounds
 C) Peripheral pulses
 D) Vital signs

Correct Answer: D
Rationale: Vital signs are critical to assess immediately in a patient with chest pain to monitor
for any signs of hemodynamic instability.

Question 745: Mental Health

A patient diagnosed with depression is prescribed sertraline (Zoloft). Which side effect should
the nurse monitor for?

 A) Weight loss
 B) Hypertension
 C) Suicidal thoughts
 D) Increased energy

Correct Answer: C
Rationale: Antidepressants can increase the risk of suicidal thoughts, especially in young adults
when starting the medication.

Question 746: Obstetrics

A nurse is assessing a pregnant woman at 32 weeks' gestation. Which finding should the nurse
report to the healthcare provider?

 A) Fetal movement 10 times in 2 hours

 B) Blood pressure of 120/80 mmHg
 C) Severe headache
 D) Weight gain of 2 pounds in one week

Correct Answer: C
Rationale: Severe headache can be a sign of preeclampsia and should be reported immediately.

Question 747: Pediatric Nursing

A nurse is assessing a child with chickenpox. Which symptom would indicate the need for
further teaching regarding home care?
  A) Keeping fingernails trimmed short
 B) Administering antihistamines for itching
 C) Allowing the child to scratch the lesions
 D) Encouraging fluid intake

Correct Answer: C
Rationale: Allowing the child to scratch the lesions can lead to infection; the nurse should
educate the parent to prevent scratching.

Question 748: Renal

A nurse is caring for a patient on peritoneal dialysis. Which finding should the nurse report to the
healthcare provider?

 A) Cloudy effluent
 B) Clear effluent
 C) Decreased blood pressure
 D) Weight loss

Correct Answer: A
Rationale: Cloudy effluent may indicate infection (peritonitis) and should be reported
immediately.

Question 749: Infection Control

A nurse is caring for a patient with a known influenza infection. Which precaution should the
nurse implement?

 A) Contact precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: C
Rationale: Droplet precautions are necessary for patients with influenza to prevent transmission
through respiratory droplets.

Question 750: Cardiovascular

A nurse is caring for a patient with heart failure who has gained 3 pounds in one day. What is the
priority nursing action?

 A) Notify the healthcare provider.

 B) Assess the patient's lung sounds.
 C) Monitor vital signs.
 D) Administer diuretics as ordered.

Correct Answer: B
Rationale: Assessing lung sounds is essential to determine if the patient is experiencing fluid
overload, which is common in heart failure.

Question 751: Neurological

A nurse is caring for a patient recovering from a stroke. Which outcome indicates that the patient
is making progress?

 A) The patient is able to recognize family members.

 B) The patient has no change in muscle strength.
 C) The patient is unable to follow commands.
 D) The patient remains in a supine position.

Correct Answer: A
Rationale: Recognizing family members is a positive indicator of cognitive function and
recovery after a stroke.

Question 752: Mental Health

A nurse is caring for a patient with an anxiety disorder. Which intervention is most appropriate?

 A) Suggesting the patient avoid stressful situations

 B) Encouraging the patient to use deep-breathing exercises
 C) Telling the patient to "calm down"
 D) Ignoring the patient's anxious behaviors

Correct Answer: B
Rationale: Encouraging the use of deep-breathing exercises can help the patient manage anxiety
effectively.

Question 753: Gastrointestinal

A nurse is caring for a patient with hepatitis C. Which laboratory result would indicate the need
for further teaching regarding the patient's condition?

 A) Positive hepatitis C antibody

 B) Elevated liver function tests
 C) Negative hepatitis C RNA
 D) Elevated bilirubin levels

Correct Answer: C
Rationale: A negative hepatitis C RNA indicates that the virus is not currently present,
suggesting the patient does not have an active infection, which contrasts with the other results.

Question 754: Obstetrics

A nurse is monitoring a pregnant patient who received magnesium sulfate for preterm labor.
Which assessment finding would require immediate intervention?

 A) Urinary output of 30 mL/hr

 B) Respiratory rate of 12 breaths/min
 C) Reflexes 1+ on deep tendon reflex assessment
 D) Serum magnesium level of 9 mg/dL

Correct Answer: B
Rationale: A respiratory rate of 12 breaths/min is concerning and may indicate magnesium
toxicity, requiring immediate intervention.

Question 755: Pediatric Nursing

A nurse is assessing a toddler with suspected otitis media. Which sign would the nurse expect to
find?

 A) Complaints of a sore throat

 B) Pulling at the ears
 C) Coughing and sneezing
 D) High fever

Correct Answer: B
Rationale: Pulling at the ears is a common sign of otitis media in toddlers.

Question 756: Renal

A nurse is caring for a patient with acute kidney injury. Which finding indicates a need for
further evaluation?

 A) Increased serum creatinine

 B) Decreased urine output
 C) Hypertension
 D) Hyperkalemia

Correct Answer: C
Rationale: Hypertension can indicate fluid overload or other complications in a patient with
acute kidney injury and requires further evaluation.

Question 757: Infection Control

A nurse is providing care for a patient on contact precautions. Which action should the nurse
take?

 A) Place the patient in a private room.

 B) Use a surgical mask when entering the room.
 C) Wear gloves when entering the room and remove them before leaving.
 D) Perform hand hygiene only before patient contact.

Correct Answer: C
Rationale: Gloves should be worn when entering the room and removed before leaving to
prevent the spread of infection.

Question 758: Cardiovascular

A patient is prescribed digoxin (Lanoxin). Which assessment finding would require immediate
intervention?

 A) Heart rate of 58 beats per minute

 B) Blood pressure of 110/70 mmHg
 C) Serum potassium level of 4.5 mEq/L
 D) Increased urine output

Correct Answer: A
Rationale: A heart rate of 58 beats per minute is bradycardic and may indicate digoxin toxicity,
requiring immediate intervention.
Question 759: Neurological

A nurse is caring for a patient with Parkinson's disease. Which medication should the nurse
expect to administer?

 A) Donepezil (Aricept)
 B) Levodopa/carbidopa (Sinemet)
 C) Baclofen (Lioresal)
 D) Rivastigmine (Exelon)

Correct Answer: B
Rationale: Levodopa/carbidopa is commonly prescribed for Parkinson's disease to help manage
symptoms.

Question 760: Mental Health

A patient with post-traumatic stress disorder (PTSD) is experiencing flashbacks. What is the
most appropriate nursing intervention?

 A) Encourage the patient to talk about the trauma.

 B) Redirect the patient’s attention to a safe environment.
 C) Tell the patient to stop thinking about the past.
 D) Provide information about support groups.

Correct Answer: B
Rationale: Redirecting the patient’s attention to a safe environment can help them cope during a
flashback episode.

Question 761: Pharmacology

A patient diagnosed with atrial fibrillation is prescribed warfarin (Coumadin). Which statement
by the patient indicates a need for further education?

 A) "I need to have my INR levels checked regularly."

 B) "I can take aspirin along with my warfarin."
 C) "I should avoid eating foods high in vitamin K."
 D) "I need to watch for signs of bleeding."

Correct Answer: B
Rationale: Patients on warfarin should avoid taking aspirin unless specifically directed by their
healthcare provider, as it can increase the risk of bleeding.
Question 762: Neurological

A patient with multiple sclerosis is experiencing muscle weakness and fatigue. Which teaching
point should the nurse emphasize?

 A) Increase physical activity to build strength.

 B) Take frequent rest periods throughout the day.
 C) Limit fluid intake to prevent bladder issues.
 D) Avoid all physical activity.

Correct Answer: B
Rationale: Frequent rest periods can help manage fatigue and muscle weakness in patients with
multiple sclerosis.

Question 763: Gastrointestinal

A nurse is assessing a patient with a peptic ulcer. Which symptom is most characteristic of a
gastric ulcer?

 A) Pain that occurs 2-3 hours after eating

 B) Pain that is relieved by eating
 C) Pain that worsens at night
 D) Pain that occurs immediately after eating

Correct Answer: D
Rationale: Gastric ulcer pain often occurs shortly after eating, whereas duodenal ulcer pain
typically occurs 2-3 hours after a meal.

Question 764: Cardiovascular

A nurse is monitoring a patient who has just received a dose of intravenous furosemide (Lasix).
What is the most critical assessment the nurse should perform?

 A) Heart rate
 B) Serum potassium level
 C) Blood pressure
 D) Respiratory rate
Correct Answer: C
Rationale: Blood pressure is critical to monitor after administering furosemide, as it can cause
rapid fluid loss and hypotension.

Question 765: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia who is experiencing hallucinations.
Which nursing intervention is most appropriate?

 A) Encourage the patient to talk about the hallucinations.

 B) Reassure the patient that the hallucinations will stop soon.
 C) Distract the patient with activities.
 D) Tell the patient to ignore the hallucinations.

Correct Answer: C
Rationale: Distracting the patient with activities can help manage hallucinations and redirect
their focus.

Question 766: Obstetrics

A nurse is caring for a patient in labor who is requesting pain relief. Which intervention should
the nurse prioritize?

 A) Administering an epidural
 B) Offering breathing techniques
 C) Providing a warm bath
 D) Encouraging walking

Correct Answer: A
Rationale: If the patient requests pain relief, administering an epidural may provide effective
pain control during labor.

Question 767: Pediatric Nursing

A nurse is caring for a 5-year-old child with asthma. Which statement by the child's parent
indicates a need for further education?

 A) "I will keep my child away from smoke."

 B) "We will use the inhaler before exercise."
 C) "It's okay to use the inhaler only when my child has symptoms."
  D) "I should monitor my child's peak flow readings regularly."

Correct Answer: C
Rationale: The inhaler should be used as a preventative measure before exercise, not just when
symptoms occur.

Question 768: Renal

A nurse is assessing a patient with chronic kidney disease. Which finding would indicate that the
patient is developing complications?

 A) Serum creatinine of 1.5 mg/dL

 B) Proteinuria
 C) Decreased urine output
 D) Elevated blood urea nitrogen (BUN)

Correct Answer: C
Rationale: Decreased urine output can indicate worsening kidney function and complications in
a patient with chronic kidney disease.

Question 769: Infection Control

A nurse is caring for a patient with Clostridium difficile (C. diff) infection. Which type of
precautions should be implemented?

 A) Standard precautions
 B) Contact precautions
 C) Airborne precautions
 D) Droplet precautions

Correct Answer: B
Rationale: Contact precautions are essential for preventing the spread of C. diff, which can be
transmitted via contaminated surfaces.

Question 770: Cardiovascular

A nurse is caring for a patient receiving anticoagulation therapy. Which finding should be
reported immediately?

 A) APTT of 35 seconds
  B) INR of 4.0
 C) Platelet count of 150,000/mm³
 D) Blood pressure of 130/80 mmHg

Correct Answer: B
Rationale: An INR of 4.0 indicates a high risk of bleeding and requires immediate reporting to
the healthcare provider.

Question 771: Neurological

A nurse is assessing a patient with a head injury. Which assessment finding is most concerning?

 A) Clear nasal discharge

 B) Slurred speech
 C) Unequal pupils
 D) Mild headache

Correct Answer: C
Rationale: Unequal pupils can indicate increased intracranial pressure or brain injury and
requires immediate evaluation.

Question 772: Mental Health

A nurse is caring for a patient with major depressive disorder who expresses hopelessness. What
is the best response by the nurse?

 A) "You have so much to be grateful for."

 B) "Let’s talk about what’s bothering you."
 C) "You should try to stay positive."
 D) "Things will get better eventually."

Correct Answer: B
Rationale: Encouraging the patient to talk about their feelings can help them process their
emotions and promote therapeutic communication.

Question 773: Gastrointestinal

A nurse is teaching a patient about dietary modifications for diverticulitis. Which statement
indicates that the patient needs further education?
  A) "I will include more fiber in my diet."
 B) "I can eat nuts and seeds."
 C) "I need to avoid spicy foods."
 D) "I will drink plenty of fluids."

Correct Answer: B
Rationale: Patients with diverticulitis are generally advised to avoid nuts and seeds due to the
risk of exacerbating the condition.

Question 774: Obstetrics

A nurse is providing care for a postpartum patient who had a cesarean delivery. Which nursing
intervention is the highest priority?

 A) Encouraging ambulation
 B) Assessing the surgical incision
 C) Monitoring vital signs
 D) Educating about breastfeeding

Correct Answer: C
Rationale: Monitoring vital signs is a priority after surgery to detect any signs of complications
such as infection or hemorrhage.

Question 775: Pediatric Nursing

A nurse is assessing a school-age child for developmental milestones. Which finding indicates
normal development for a 7-year-old?

 A) The child can tie shoelaces.

 B) The child can ride a bicycle with training wheels.
 C) The child can skip rope.
 D) The child can write in cursive.

Correct Answer: A
Rationale: Being able to tie shoelaces is an expected developmental milestone for a 7-year-old
child.

Question 776: Renal

A nurse is caring for a patient with nephrotic syndrome. Which finding should the nurse expect?
  A) Decreased serum albumin
 B) Hyperkalemia
 C) Hypertension
 D) Hematuria

Correct Answer: A
Rationale: Nephrotic syndrome is characterized by decreased serum albumin due to protein loss
in the urine.

Question 777: Infection Control

A nurse is caring for a patient with tuberculosis. Which precaution should the nurse implement?

 A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions

Correct Answer: C
Rationale: Airborne precautions are necessary for tuberculosis to prevent the spread of the
bacteria through the air.

Question 778: Cardiovascular

A patient is experiencing symptoms of heart failure. Which finding would the nurse expect
during assessment?

 A) Decreased blood pressure

 B) Dry cough
 C) Bradycardia
 D) Jugular vein distension

Correct Answer: D
Rationale: Jugular vein distension is a common sign of heart failure due to fluid overload.

Question 779: Neurological

A nurse is caring for a patient with a history of transient ischemic attacks (TIAs). Which
statement indicates a need for further education?
  A) "I need to monitor my blood pressure."
 B) "I should avoid smoking."
 C) "I can stop taking my medication when I feel better."
 D) "I need to eat a heart-healthy diet."

Correct Answer: C
Rationale: Patients should be educated that medications should not be stopped without
consulting their healthcare provider, even if they feel better.

Question 780: Mental Health

A nurse is caring for a patient diagnosed with bipolar disorder. Which behavior indicates that the
patient may be entering a manic episode?

 A) Increased need for sleep

 B) Social withdrawal
 C) Excessive talking and racing thoughts
 D) Decreased energy

Correct Answer: C
Rationale: Excessive talking and racing thoughts are characteristic of a manic episode in bipolar
disorder.

Question 781: Pharmacology

A patient diagnosed with chronic obstructive pulmonary disease (COPD) is prescribed a

corticosteroid inhaler. What is the most important teaching point for this patient?

 A) Rinse the mouth after use.

 B) Use the inhaler only when experiencing shortness of breath.
 C) Avoid taking any other medications.
 D) Limit fluid intake to reduce swelling.

Correct Answer: A
Rationale: Rinsing the mouth after using a corticosteroid inhaler helps prevent oral thrush and
other oral complications.

Question 782: Neurological

A nurse is caring for a patient who has just undergone a craniotomy. Which finding should the
nurse report immediately?

 A) Clear drainage from the nose

 B) Increased heart rate
 C) Pupils equal and reactive
 D) Blood pressure of 130/80 mmHg

Correct Answer: A
Rationale: Clear drainage from the nose may indicate cerebrospinal fluid (CSF) leakage, which
is a complication that requires immediate attention.

Question 783: Gastrointestinal

A patient with liver cirrhosis is being discharged with dietary instructions. Which statement by
the patient indicates a need for further teaching?

 A) "I will limit my sodium intake."

 B) "I can eat large amounts of protein."
 C) "I will avoid alcohol completely."
 D) "I need to eat small, frequent meals."

Correct Answer: B
Rationale: Patients with liver cirrhosis often require a protein-restricted diet to reduce the risk of
hepatic encephalopathy.

Question 784: Cardiovascular

A nurse is assessing a patient with heart failure who is taking digoxin (Lanoxin). Which
symptom would indicate digoxin toxicity?

 A) Bradycardia
 B) Increased appetite
 C) Weight loss
 D) Elevated blood pressure

Correct Answer: A
Rationale: Bradycardia is a common symptom of digoxin toxicity and should be reported
immediately.
Question 785: Mental Health

A nurse is caring for a patient with generalized anxiety disorder. Which intervention is most
appropriate for this patient?

 A) Provide reassurance that there is nothing to worry about.

 B) Encourage the patient to discuss their anxiety in detail.
 C) Teach relaxation techniques.
 D) Suggest that the patient avoid all stressors.

Correct Answer: C
Rationale: Teaching relaxation techniques can help the patient manage anxiety symptoms
effectively.

Question 786: Obstetrics

A nurse is caring for a pregnant woman at 28 weeks' gestation who reports sudden swelling of
the hands and face. What is the priority nursing action?

 A) Obtain a urine sample for protein.

 B) Assess fetal heart tones.
 C) Measure blood pressure.
 D) Administer IV fluids.

Correct Answer: C
Rationale: Measuring blood pressure is the priority action to assess for potential preeclampsia.

Question 787: Pediatric Nursing

A nurse is assessing a 4-year-old child with asthma. Which finding indicates the child is
experiencing an asthma exacerbation?

 A) Wheezing during expiration

 B) Breath sounds are clear
 C) Normal respiratory rate
 D) No cough

Correct Answer: A
Rationale: Wheezing during expiration is a classic sign of an asthma exacerbation.
Question 788: Renal

A patient with end-stage renal disease (ESRD) is receiving dialysis. Which laboratory value
would the nurse expect to monitor closely?

 A) Hemoglobin
 B) Serum creatinine
 C) Serum glucose
 D) Serum sodium

Correct Answer: B
Rationale: Serum creatinine levels are critical to monitor in patients with ESRD as they indicate
kidney function.

Question 789: Infection Control

A nurse is caring for a patient with an open wound. Which nursing action is most important in
preventing infection?

 A) Providing education on hand hygiene.

 B) Applying a dry dressing to the wound.
 C) Ensuring the patient is on antibiotics.
 D) Regularly changing the bed linens.

Correct Answer: A
Rationale: Hand hygiene is the most effective way to prevent infection.

Question 790: Cardiovascular

A patient with atrial fibrillation is prescribed anticoagulation therapy. What is the priority
nursing action?

 A) Monitor for signs of bleeding.

 B) Educate the patient about dietary restrictions.
 C) Schedule regular INR checks.
 D) Administer vitamin K as needed.

Correct Answer: A
Rationale: Monitoring for signs of bleeding is the priority action due to the increased risk
associated with anticoagulation therapy.
Question 791: Neurological

A nurse is assessing a patient with Parkinson’s disease. Which finding would be characteristic of
this condition?

 A) Bradykinesia
 B) Hyperreflexia
 C) Increased coordination
 D) Decreased muscle tone

Correct Answer: A
Rationale: Bradykinesia, or slow movement, is a hallmark symptom of Parkinson’s disease.

Question 792: Mental Health

A nurse is caring for a patient experiencing a panic attack. Which intervention should the nurse
implement first?

 A) Encourage the patient to breathe into a paper bag.

 B) Administer anti-anxiety medication.
 C) Stay with the patient and provide reassurance.
 D) Encourage the patient to talk about their feelings.

Correct Answer: C
Rationale: Staying with the patient and providing reassurance is essential to help them feel safe
during a panic attack.

Question 793: Gastrointestinal

A nurse is caring for a patient with gastroesophageal reflux disease (GERD). Which lifestyle
modification should the nurse recommend?

 A) Eating three large meals per day

 B) Lying down immediately after eating
 C) Avoiding caffeine and spicy foods
 D) Wearing tight clothing around the abdomen

Correct Answer: C
Rationale: Avoiding caffeine and spicy foods can help reduce GERD symptoms.
Question 794: Obstetrics

A nurse is caring for a pregnant patient who is experiencing contractions every 5 minutes. Which
action should the nurse take next?

 A) Assess the patient's cervix.

 B) Notify the healthcare provider.
 C) Monitor fetal heart rate.
 D) Provide comfort measures.

Correct Answer: C
Rationale: Monitoring fetal heart rate is crucial to assess fetal well-being during contractions.

Question 795: Pediatric Nursing

A nurse is teaching the parents of a child with ADHD about medication management. Which
statement by the parents indicates a need for further education?

 A) "We will monitor our child for side effects."

 B) "We should give the medication at the same time each day."
 C) "It's okay to stop the medication if our child feels better."
 D) "We will keep regular follow-up appointments with the doctor."

Correct Answer: C
Rationale: The medication should not be stopped without consulting the healthcare provider,
even if the child feels better.

Question 796: Renal

A patient with chronic kidney disease is experiencing fluid overload. Which assessment finding
would the nurse expect?

 A) Weight loss
 B) Decreased blood pressure
 C) Peripheral edema
 D) Increased urine output

Correct Answer: C
Rationale: Peripheral edema is a common finding in patients experiencing fluid overload due to
chronic kidney disease.
Question 797: Infection Control

A nurse is providing care for a patient with a multidrug-resistant infection. Which precaution
should the nurse implement?

 A) Airborne precautions
 B) Standard precautions
 C) Contact precautions
 D) Droplet precautions

Correct Answer: C
Rationale: Contact precautions should be implemented to prevent the spread of multidrug-
resistant infections.

Question 798: Cardiovascular

A nurse is teaching a patient with heart failure about the importance of daily weight monitoring.
What should the nurse explain?

 A) A weight gain of more than 2 pounds in a day may indicate fluid retention.
 B) Weight monitoring is only necessary during hospitalizations.
 C) Weight gain is not a concern if the patient feels well.
 D) Daily weights are not needed unless there are dietary changes.

Correct Answer: A
Rationale: A weight gain of more than 2 pounds in a day can indicate fluid retention and
worsening heart failure.

Question 799: Neurological

A nurse is caring for a patient with a stroke who has weakness on one side of the body. Which
intervention should the nurse prioritize?

 A) Encourage the patient to participate in physical therapy.

 B) Place the patient in a high Fowler’s position.
 C) Assist the patient with activities of daily living.
 D) Educate the patient about stroke prevention.

Correct Answer: C
Rationale: Assisting the patient with activities of daily living is crucial for ensuring safety and
promoting independence.
Question 800: Mental Health

A nurse is assessing a patient with major depressive disorder. Which assessment finding would
be of most concern?

 A) Lack of energy
 B) Changes in sleep patterns
 C) Suicidal ideation
 D) Changes in appetite

Correct Answer: C
Rationale: Suicidal ideation is a serious concern and requires immediate intervention.

Question 801: Pharmacology

A nurse is administering an intravenous antibiotic to a patient with a known penicillin allergy.

Which action should the nurse take?

 A) Administer the medication as ordered.

 B) Ask the patient about previous allergic reactions.
 C) Choose a different route for administration.
 D) Notify the healthcare provider before administration.

Correct Answer: D
Rationale: The nurse should notify the healthcare provider before administering any medication
to a patient with a known allergy to avoid a potentially life-threatening reaction.

Question 802: Endocrine

A patient with diabetes mellitus is being educated about managing hypoglycemia. Which
statement by the patient indicates a correct understanding of the teaching?

 A) "I will avoid eating sweets and sugary foods."

 B) "I can treat low blood sugar with 15 grams of carbohydrates."
 C) "I should wait at least an hour before checking my blood sugar again."
 D) "I can skip my next meal if I feel low."

Correct Answer: B
Rationale: The patient should treat hypoglycemia with 15 grams of fast-acting carbohydrates
and recheck blood sugar levels after 15 minutes.
Question 803: Respiratory

A nurse is assessing a patient with pneumonia. Which finding would indicate that the patient's
condition is improving?

 A) Increased respiratory rate

 B) Decreased wheezing
 C) Decreased oxygen saturation
 D) Productive cough with green sputum

Correct Answer: B
Rationale: Decreased wheezing indicates improvement in the patient's respiratory status,
whereas an increased respiratory rate and decreased oxygen saturation would indicate
deterioration.

Question 804: Gastrointestinal

A nurse is caring for a patient with peptic ulcer disease. Which dietary recommendation should
the nurse provide?

 A) Avoid spicy foods and caffeine.

 B) Increase intake of carbonated beverages.
 C) Eat three large meals daily.
 D) Include high-fat foods in the diet.

Correct Answer: A
Rationale: Avoiding spicy foods and caffeine can help reduce irritation to the stomach lining in
patients with peptic ulcer disease.

Question 805: Mental Health

A nurse is providing care for a patient diagnosed with obsessive-compulsive disorder (OCD).
Which intervention is most appropriate?

 A) Encourage the patient to ignore compulsive thoughts.

 B) Assist the patient in completing compulsive behaviors.
 C) Allow the patient to express feelings about their obsessions.
 D) Reassure the patient that they are not mentally ill.
Correct Answer: C
Rationale: Allowing the patient to express feelings about their obsessions can provide
therapeutic support and help the nurse understand the patient’s experience.

Question 806: Obstetrics

A nurse is monitoring a pregnant woman in labor. Which finding should be reported

immediately?

 A) Fetal heart rate of 140 beats per minute

 B) Contractions occurring every 4 minutes
 C) Maternal temperature of 100.4°F (38°C)
 D) Cervical dilation of 4 centimeters

Correct Answer: C
Rationale: A maternal temperature of 100.4°F may indicate an infection, which should be
reported immediately.

Question 807: Pediatric Nursing

A nurse is assessing a 3-year-old child for developmental milestones. Which finding would
indicate a delay in gross motor skills?

 A) The child can jump in place.

 B) The child can walk up and down stairs using alternate feet.
 C) The child can kick a ball forward.
 D) The child can ride a tricycle.

Correct Answer: B
Rationale: A 3-year-old should be able to walk up and down stairs using alternate feet. If they
cannot, this may indicate a delay in gross motor skills.

Question 808: Renal

A nurse is caring for a patient with acute kidney injury (AKI). Which assessment finding is most
concerning?

 A) Decreased urine output

 B) Elevated blood urea nitrogen (BUN)
 C) Hyperkalemia
  D) Weight loss

Correct Answer: C
Rationale: Hyperkalemia is a critical concern in AKI, as it can lead to life-threatening cardiac
complications.

Question 809: Infection Control

A nurse is providing care for a patient with a surgical wound. Which intervention is the most
important to prevent infection?

 A) Changing the dressing daily

 B) Teaching the patient about wound care
 C) Performing hand hygiene before dressing changes
 D) Administering prophylactic antibiotics

Correct Answer: C
Rationale: Performing hand hygiene is the most important action to prevent infection in patients
with surgical wounds.

Question 810: Cardiovascular

A patient with hypertension is prescribed lisinopril (Zestril). Which instruction should the nurse
provide?

 A) "Avoid potassium-rich foods."

 B) "You can stop taking this medication if your blood pressure is normal."
 C) "It’s okay to skip doses if you feel well."
 D) "Report any persistent cough to your healthcare provider."

Correct Answer: D
Rationale: A persistent cough can be a side effect of ACE inhibitors like lisinopril and should be
reported.

Question 811: Neurological

A nurse is caring for a patient with a stroke who has expressive aphasia. Which intervention is
most appropriate?

 A) Encourage the patient to speak as much as possible.

  B) Use gestures and pictures to facilitate communication.
 C) Limit communication to yes/no questions only.
 D) Avoid discussing difficult topics.

Correct Answer: B
Rationale: Using gestures and pictures can help facilitate communication for patients with
expressive aphasia.

Question 812: Endocrine

A patient with hyperthyroidism is prescribed methimazole (Tapazole). Which assessment finding

indicates the medication is effective?

 A) Decreased heart rate

 B) Increased appetite
 C) Weight gain
 D) Increased energy levels

Correct Answer: A
Rationale: A decreased heart rate indicates effective management of hyperthyroidism, as the
condition often causes tachycardia.

Question 813: Gastrointestinal

A nurse is caring for a patient with chronic pancreatitis. Which dietary modification should be
recommended?

 A) High-fat diet
 B) Increased protein intake
 C) Low-carbohydrate diet
 D) Avoiding alcohol

Correct Answer: D
Rationale: Avoiding alcohol is crucial for managing chronic pancreatitis, as it can exacerbate
the condition.

Question 814: Pediatric Nursing

A nurse is teaching parents about caring for a child with a new diagnosis of type 1 diabetes.
Which statement indicates a need for further education?
  A) "My child will need insulin injections every day."
 B) "I should monitor my child's blood sugar levels regularly."
 C) "My child can eat anything as long as they take enough insulin."
 D) "I can help my child manage their diabetes through diet and exercise."

Correct Answer: C
Rationale: While insulin helps manage blood sugar, dietary choices still matter, and not all
foods can be consumed freely without consideration.

Question 815: Renal

A nurse is assessing a patient with nephrotic syndrome. Which finding is most indicative of this
condition?

 A) Elevated blood glucose

 B) Proteinuria
 C) Hematuria
 D) Oliguria

Correct Answer: B
Rationale: Proteinuria is a hallmark sign of nephrotic syndrome, resulting from increased
permeability of the glomeruli.

Question 816: Mental Health

A nurse is caring for a patient experiencing severe depression. Which nursing intervention is
most appropriate?

 A) Encourage the patient to socialize.

 B) Provide structured routine and activities.
 C) Offer unsolicited advice.
 D) Discourage expressions of feelings.

Correct Answer: B
Rationale: Providing a structured routine can help the patient feel more secure and engaged,
which is important in managing severe depression.

Question 817: Cardiovascular

A patient with heart failure is prescribed a diuretic. Which laboratory value should the nurse
monitor closely?

 A) Hemoglobin
 B) Serum potassium
 C) Serum calcium
 D) Blood glucose

Correct Answer: B
Rationale: Monitoring serum potassium is essential as diuretics can lead to electrolyte
imbalances, particularly hypokalemia.

Question 818: Infection Control

A nurse is caring for a patient on contact precautions for a viral infection. Which action should
the nurse take?

 A) Use gloves when entering the room.

 B) Place the patient in a negative pressure room.
 C) Wear a mask when providing care.
 D) Limit visitors to one per day.

Correct Answer: A
Rationale: Gloves should be used when caring for a patient on contact precautions to prevent the
spread of the infection.

Question 819: Neurological

A patient presents with slurred speech, right-sided weakness, and facial droop. What is the
priority nursing action?

 A) Administer aspirin.
 B) Call the healthcare provider immediately.
 C) Perform a neurological assessment.
 D) Prepare the patient for a CT scan.

Correct Answer: B
Rationale: Calling the healthcare provider is crucial as these symptoms may indicate a stroke,
requiring immediate intervention.
Question 820: Pediatric Nursing

A nurse is assessing a child with cystic fibrosis. Which finding would be expected?

 A) Decreased respiratory secretions

 B) Frequent respiratory infections
 C) Normal growth patterns
 D) Decreased appetite

Correct Answer: B
Rationale: Children with cystic fibrosis often have thick mucus that predisposes them to
frequent respiratory infections.

Question 821: Pharmacology

A nurse is administering warfarin (Coumadin) to a patient. What is the priority nursing action
before administering this medication?

 A) Check the patient's blood pressure.

 B) Obtain the patient's INR results.
 C) Assess for signs of bleeding.
 D) Verify the patient's allergies.

Correct Answer: B
Rationale: It is crucial to check the INR results before administering warfarin to ensure it is
within the therapeutic range to prevent bleeding.

Question 822: Endocrine

A patient with type 2 diabetes is prescribed metformin (Glucophage). What is the most important
teaching point for this medication?

 A) Take the medication on an empty stomach.

 B) Monitor for signs of hypoglycemia.
 C) Avoid alcohol while taking this medication.
 D) Increase carbohydrate intake.

Correct Answer: C
Rationale: Patients should avoid alcohol while taking metformin to reduce the risk of lactic
acidosis.
Question 823: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
finding indicates a worsening of the patient's condition?

 A) Decreased breath sounds

 B) Increased oxygen saturation
 C) Clear lung sounds
 D) Productive cough with clear sputum

Correct Answer: A
Rationale: Decreased breath sounds may indicate worsening airflow obstruction or respiratory
failure in patients with COPD.

Question 824: Gastrointestinal

A patient is scheduled for a colonoscopy. Which instruction should the nurse provide regarding
the preparation for this procedure?

 A) "You will need to take a laxative the night before."

 B) "You will be on a clear liquid diet for 24 hours prior."
 C) "You should avoid all fluids after midnight."
 D) "You will need to remain NPO for 8 hours before the procedure."

Correct Answer: B
Rationale: A clear liquid diet for 24 hours before the procedure is typically required to ensure
the colon is clear for examination.

Question 825: Mental Health

A patient diagnosed with bipolar disorder is experiencing a manic episode. Which behavior
would the nurse expect to observe?

 A) Excessive sleeping
 B) Depressed mood
 C) Increased talkativeness
 D) Withdrawal from social activities

Correct Answer: C
Rationale: Increased talkativeness is a common behavior during a manic episode in bipolar
disorder.
Question 826: Obstetrics

A nurse is monitoring a laboring patient. Which finding would indicate the need for further
evaluation?

 A) Contractions lasting 60 seconds and occurring every 3-5 minutes

 B) Fetal heart rate of 120-160 beats per minute
 C) Sudden increase in maternal heart rate
 D) Cervical dilation of 6 centimeters

Correct Answer: C
Rationale: A sudden increase in maternal heart rate may indicate stress or complications and
requires further evaluation.

Question 827: Pediatric Nursing

A nurse is assessing a 2-year-old child for developmental milestones. Which finding indicates a
delay?

 A) The child can stack five blocks.

 B) The child can kick a ball forward.
 C) The child cannot jump with both feet.
 D) The child can speak in two-word phrases.

Correct Answer: C
Rationale: A 2-year-old should be able to jump with both feet. Inability to do so may indicate a
delay in gross motor skills.

Question 828: Renal

A patient with chronic kidney disease is on a low-protein diet. What is the rationale for this
dietary restriction?

 A) To promote weight loss

 B) To reduce urea and nitrogen waste products
 C) To prevent hypoglycemia
 D) To encourage muscle building
Correct Answer: B
Rationale: A low-protein diet helps reduce the buildup of urea and nitrogen waste products in
the body when kidney function is impaired.

Question 829: Infection Control

A nurse is caring for a patient with tuberculosis (TB). Which precaution should the nurse
implement?

 A) Standard precautions
 B) Droplet precautions
 C) Contact precautions
 D) Airborne precautions

Correct Answer: D
Rationale: Airborne precautions are necessary for patients with tuberculosis due to the risk of
transmission through the air.

Question 830: Cardiovascular

A patient is being monitored for heart failure. Which assessment finding would indicate
worsening heart failure?

 A) Decreased respiratory rate

 B) Increased weight by 2 pounds in 24 hours
 C) Normal blood pressure
 D) Improved exercise tolerance

Correct Answer: B
Rationale: An increase in weight by 2 pounds in 24 hours may indicate fluid retention, a sign of
worsening heart failure.

Question 831: Neurological

A nurse is assessing a patient with multiple sclerosis (MS). Which symptom would the nurse
expect to find?

 A) Sudden onset of severe headache

 B) Muscle weakness and fatigue
 C) Fluctuating blood pressure
  D) Severe vomiting

Correct Answer: B
Rationale: Muscle weakness and fatigue are common symptoms of multiple sclerosis due to
demyelination of nerve fibers.

Question 832: Endocrine

A patient with Addison's disease is experiencing an adrenal crisis. Which symptom would the
nurse expect to observe?

 A) Hypotension
 B) Weight gain
 C) Increased energy levels
 D) Hyperglycemia

Correct Answer: A
Rationale: Hypotension is a common symptom of an adrenal crisis due to insufficient cortisol
levels.

Question 833: Gastrointestinal

A nurse is caring for a patient with a history of peptic ulcer disease. Which medication should
the nurse anticipate being prescribed?

 A) Antibiotics
 B) Antacids
 C) Proton pump inhibitors
 D) Laxatives

Correct Answer: C
Rationale: Proton pump inhibitors are commonly prescribed to reduce gastric acid production
and promote healing in peptic ulcer disease.

Question 834: Mental Health

A nurse is caring for a patient with schizophrenia who is exhibiting paranoid delusions. Which
intervention is most appropriate?

 A) Encourage the patient to talk about their delusions.

  B) Validate the patient's feelings of fear.
 C) Reassure the patient that they are safe.
 D) Redirect the patient to a different topic.

Correct Answer: C
Rationale: Reassuring the patient that they are safe can help alleviate anxiety and provide a
sense of security.

Question 835: Obstetrics

A pregnant patient at 36 weeks’ gestation is complaining of severe headaches and visual

disturbances. What is the nurse's priority action?

 A) Provide the patient with a cold compress.

 B) Measure the patient's blood pressure.
 C) Notify the healthcare provider.
 D) Encourage the patient to rest.

Correct Answer: B
Rationale: Measuring blood pressure is crucial in assessing for potential preeclampsia, which
can present with these symptoms.

Question 836: Pediatric Nursing

A nurse is caring for a child with asthma. Which statement indicates the child understands their
condition?

 A) "I will only use my inhaler when I feel fine."

 B) "I should avoid my asthma triggers."
 C) "I can stop my medication when I feel better."
 D) "It's okay to skip my follow-up appointments."

Correct Answer: B
Rationale: Avoiding asthma triggers is essential for managing asthma effectively.

Question 837: Renal

A patient receiving dialysis presents with hypotension and dizziness. Which action should the
nurse take first?
  A) Administer IV fluids.
 B) Check the patient's blood pressure.
 C) Increase the dialysis rate.
 D) Notify the healthcare provider.

Correct Answer: B
Rationale: Checking the patient's blood pressure is the first action to assess the severity of
hypotension and determine appropriate interventions.

Question 838: Infection Control

A nurse is caring for a patient in isolation due to a viral infection. Which precaution should the
nurse implement?

 A) Wear gloves and a gown only.

 B) Use a mask when entering the room.
 C) Follow standard precautions only.
 D) Avoid close contact with the patient.

Correct Answer: B
Rationale: Using a mask when entering the room is important to prevent the spread of the viral
infection, depending on the type of virus.

Question 839: Neurological

A nurse is assessing a patient with a suspected stroke. Which assessment finding would indicate
a left-sided stroke?

 A) Right-sided weakness
 B) Difficulty speaking
 C) Left-sided facial droop
 D) Poor coordination on the right side

Correct Answer: A
Rationale: A left-sided stroke affects the right side of the body, resulting in right-sided
weakness.

Question 840: Cardiovascular

A nurse is caring for a patient with a history of hypertension who has been prescribed a beta-
blocker. What is the priority assessment for this patient?

 A) Monitor respiratory rate.

 B) Assess for chest pain.
 C) Check heart rate and blood pressure.
 D) Evaluate for signs of depression.

Correct Answer: C
Rationale: Checking heart rate and blood pressure is essential as beta-blockers can cause
bradycardia and hypotension.

Question 841: Pharmacology

A nurse is preparing to administer digoxin (Lanoxin) to a patient. What is the priority assessment
before giving this medication?

 A) Assess the patient for allergic reactions.

 B) Measure the patient's apical pulse for one full minute.
 C) Check the patient's blood pressure.
 D) Review the patient's renal function.

Correct Answer: B
Rationale: It is essential to measure the apical pulse for one full minute before administering
digoxin, as it can cause bradycardia.

Question 842: Endocrine

A patient with hypothyroidism is prescribed levothyroxine (Synthroid). Which statement by the

patient indicates a need for further teaching?

 A) "I will take this medication on an empty stomach."

 B) "I can stop taking this medication when I feel better."
 C) "I will have my thyroid levels checked regularly."
 D) "I need to inform my doctor if I experience chest pain."

Correct Answer: B
Rationale: Patients with hypothyroidism should not stop their medication without consulting
their healthcare provider, as lifelong treatment is typically required.
Question 843: Respiratory

A nurse is caring for a patient with asthma who is experiencing an acute asthma attack. What is
the priority intervention?

 A) Administer a long-acting beta agonist.

 B) Encourage the patient to use their peak flow meter.
 C) Administer a short-acting beta agonist via nebulizer.
 D) Obtain a pulse oximetry reading.

Correct Answer: C
Rationale: Administering a short-acting beta agonist is the priority intervention during an acute
asthma attack to quickly relieve bronchospasm.

Question 844: Gastrointestinal

A patient with a history of cholecystitis is experiencing severe abdominal pain. Which

assessment finding would the nurse expect?

 A) Right upper quadrant tenderness

 B) Decreased bowel sounds
 C) Bradycardia
 D) Diarrhea

Correct Answer: A
Rationale: Right upper quadrant tenderness is a classic sign of cholecystitis due to inflammation
of the gallbladder.

Question 845: Mental Health

A nurse is caring for a patient diagnosed with major depressive disorder. Which statement by the
patient indicates a potential risk for suicide?

 A) "I am feeling a little better today."

 B) "I feel hopeless and like I can't go on."
 C) "I am trying to find ways to cope with my feelings."
 D) "I have been spending more time with friends."

Correct Answer: B
Rationale: Expressing feelings of hopelessness is a significant risk factor for suicide and should
be taken seriously.
Question 846: Obstetrics

A nurse is monitoring a patient in labor who is receiving epidural anesthesia. Which finding
would require immediate intervention?

 A) Blood pressure of 90/60 mmHg

 B) Contractions every 2-3 minutes
 C) Fetal heart rate of 150 beats per minute
 D) Maternal heart rate of 80 beats per minute

Correct Answer: A
Rationale: A blood pressure of 90/60 mmHg indicates hypotension, which can occur with
epidural anesthesia and may require intervention.

Question 847: Pediatric Nursing

A nurse is assessing a 6-month-old infant. Which finding would be concerning for

developmental delay?

 A) The infant can sit with support.

 B) The infant has not yet rolled over.
 C) The infant babbles and coos.
 D) The infant recognizes familiar faces.

Correct Answer: B
Rationale: By 6 months, infants should be able to roll over. Not rolling over may indicate a
developmental delay.

Question 848: Renal

A patient in end-stage renal disease is receiving hemodialysis. Which finding would indicate the
need for immediate intervention?

 A) Blood pressure of 140/80 mmHg

 B) Weight gain of 3 pounds since the last treatment
 C) Complaints of headache
 D) Serum potassium level of 6.2 mEq/L
Correct Answer: D
Rationale: A serum potassium level of 6.2 mEq/L indicates hyperkalemia, which is a critical
condition that requires immediate intervention.

Question 849: Infection Control

A nurse is caring for a patient with a Clostridium difficile infection. Which precaution should the
nurse implement?

 A) Airborne precautions
 B) Droplet precautions
 C) Contact precautions
 D) Standard precautions

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of Clostridium difficile,
which is transmitted through fecal-oral contact.

Question 850: Cardiovascular

A patient is being discharged after a myocardial infarction. Which statement by the patient
indicates a need for further education?

 A) "I will take my medications as prescribed."

 B) "I can continue to smoke as long as I cut back."
 C) "I will follow a heart-healthy diet."
 D) "I will exercise regularly as advised."

Correct Answer: B
Rationale: Continuing to smoke, even if reduced, is not acceptable for a patient recovering from
a myocardial infarction.

Question 851: Neurological

A patient has a new diagnosis of Parkinson's disease. Which symptom should the nurse expect to
assess?

 A) Hyperactivity
 B) Bradykinesia
 C) Increased reflexes
  D) Memory loss

Correct Answer: B
Rationale: Bradykinesia, or slowness of movement, is a characteristic symptom of Parkinson's
disease.

Question 852: Endocrine

A patient with hyperthyroidism is being treated with radioactive iodine. What is the priority
nursing intervention?

 A) Monitor for signs of hypothyroidism.

 B) Encourage increased fluid intake.
 C) Educate the patient about dietary restrictions.
 D) Assess for anxiety and emotional support.

Correct Answer: A
Rationale: Patients receiving radioactive iodine are at risk for developing hypothyroidism, so
monitoring for signs is crucial.

Question 853: Gastrointestinal

A patient is recovering from an appendectomy. Which assessment finding would be a concern

for the nurse?

 A) Incisional pain rated as 3/10

 B) Presence of bowel sounds
 C) Temperature of 100.2°F (37.9°C)
 D) Abdominal distension and tenderness

Correct Answer: D
Rationale: Abdominal distension and tenderness may indicate complications such as bowel
obstruction or peritonitis and should be investigated.

Question 854: Mental Health

A patient diagnosed with generalized anxiety disorder is prescribed lorazepam (Ativan). Which
statement by the patient indicates an understanding of the medication?

 A) "I can take this medication as needed."

  B) "I may become dependent on this medication."
 C) "I should stop taking this medication if I feel better."
 D) "I can drink alcohol while on this medication."

Correct Answer: B
Rationale: Patients should be aware of the potential for dependence on benzodiazepines like
lorazepam.

Question 855: Obstetrics

A nurse is assessing a pregnant patient in the third trimester. Which finding would be concerning
and require immediate intervention?

 A) Decreased fetal movement

 B) Mild swelling of the feet
 C) Occasional Braxton Hicks contractions
 D) Weight gain of 4 pounds in one week

Correct Answer: A
Rationale: Decreased fetal movement may indicate fetal distress and requires immediate
evaluation.

Question 856: Pediatric Nursing

A nurse is assessing a child with cystic fibrosis. Which finding would indicate that the child is
not managing the condition effectively?

 A) Frequent respiratory infections

 B) Normal growth and weight gain
 C) Clear lung sounds upon auscultation
 D) Increased exercise tolerance

Correct Answer: A
Rationale: Frequent respiratory infections in a child with cystic fibrosis indicate poor
management of the condition and may require further intervention.

Question 857: Renal

A nurse is caring for a patient on peritoneal dialysis. Which finding would indicate that the
dialysis is effective?
  A) Increased blood pressure
 B) Decreased abdominal girth
 C) Elevated potassium levels
 D) Decreased urine output

Correct Answer: B
Rationale: Decreased abdominal girth indicates that excess fluid is being removed effectively
during peritoneal dialysis.

Question 858: Infection Control

A nurse is caring for a patient with a respiratory syncytial virus (RSV) infection. Which
precaution should the nurse take?

 A) Standard precautions
 B) Airborne precautions
 C) Contact precautions
 D) Droplet precautions

Correct Answer: D
Rationale: Droplet precautions should be used for RSV to prevent transmission through
respiratory secretions.

Question 859: Neurological

A nurse is assessing a patient with a recent stroke. Which finding would indicate a right-sided
stroke?

 A) Left-sided weakness
 B) Difficulty swallowing
 C) Impaired judgment
 D) Expressive aphasia

Correct Answer: A
Rationale: A right-sided stroke typically affects the left side of the body, resulting in left-sided
weakness.

Question 860: Cardiovascular

A patient diagnosed with congestive heart failure is receiving furosemide (Lasix). Which
electrolyte imbalance should the nurse monitor for?

 A) Hyperkalemia
 B) Hypercalcemia
 C) Hypomagnesemia
 D) Hypokalemia

Correct Answer: D
Rationale: Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia.

Question 861: Pharmacology

A nurse is preparing to administer a dose of insulin to a patient with diabetes. What is the
priority nursing action before administering the insulin?

 A) Check the patient's blood pressure.

 B) Assess the patient's blood glucose level.
 C) Obtain the patient's weight.
 D) Review the patient's diet history.

Correct Answer: B
Rationale: Checking the patient's blood glucose level is crucial to determine the appropriate
dose of insulin to administer.

Question 862: Endocrine

A patient with diabetes insipidus is receiving desmopressin (DDAVP). Which finding indicates
that the medication is effective?

 A) Increased urine output

 B) Decreased thirst
 C) Elevated blood glucose levels
 D) Increased appetite

Correct Answer: B
Rationale: Desmopressin is effective if the patient experiences decreased thirst due to better
regulation of fluid balance.

Question 863: Respiratory

A nurse is caring for a patient with chronic bronchitis. Which assessment finding would the
nurse expect?

 A) Productive cough with purulent sputum

 B) Increased respiratory rate
 C) Wheezing on expiration
 D) Prolonged expiration

Correct Answer: A
Rationale: A productive cough with purulent sputum is a common symptom of chronic
bronchitis.

Question 864: Gastrointestinal

A nurse is teaching a patient about dietary modifications for managing peptic ulcer disease.
Which food should the nurse recommend avoiding?

 A) Whole grain bread

 B) Lean proteins
 C) Caffeinated beverages
 D) Steamed vegetables

Correct Answer: C
Rationale: Caffeinated beverages can increase gastric acid production and should be avoided in
peptic ulcer disease.

Question 865: Mental Health

A nurse is caring for a patient with obsessive-compulsive disorder (OCD). Which intervention is
most appropriate?

 A) Encourage the patient to suppress compulsive behaviors.

 B) Allow the patient to discuss their obsessions and compulsions.
 C) Redirect the patient whenever they mention their obsessions.
 D) Encourage group therapy to minimize isolation.

Correct Answer: B
Rationale: Allowing the patient to discuss their obsessions and compulsions helps in
understanding and managing their condition.
Question 866: Obstetrics

A nurse is assessing a postpartum patient. Which finding would require immediate intervention?

 A) Uterine fundus palpated at the level of the umbilicus

 B) Moderate lochia rubra with a few small clots
 C) Heart rate of 110 beats per minute
 D) Hemoglobin level of 10 g/dL

Correct Answer: C
Rationale: A heart rate of 110 beats per minute may indicate hypovolemia or infection and
requires further evaluation.

Question 867: Pediatric Nursing

A nurse is assessing a 3-year-old child. Which developmental milestone should the child be able
to perform?

 A) Hop on one foot

 B) Draw a circle
 C) Tie shoelaces
 D) Use complete sentences

Correct Answer: B
Rationale: By age 3, children should be able to draw a circle, indicating fine motor
development.

Question 868: Renal

A patient with chronic kidney disease is being educated about dietary restrictions. Which food
should the nurse advise the patient to limit?

 A) Apples
 B) Chicken
 C) Spinach
 D) Rice

Correct Answer: C
Rationale: Spinach is high in potassium and should be limited in patients with chronic kidney
disease.
Question 869: Infection Control

A nurse is caring for a patient diagnosed with influenza. Which precaution should the nurse
implement?

 A) Standard precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions

Correct Answer: C
Rationale: Droplet precautions are necessary to prevent the spread of influenza through
respiratory droplets.

Question 870: Cardiovascular

A nurse is monitoring a patient with heart failure. Which symptom would indicate worsening
heart failure?

 A) Increased appetite
 B) Decreased fatigue
 C) Weight gain of 3 pounds in 2 days
 D) Improved exercise tolerance

Correct Answer: C
Rationale: A weight gain of 3 pounds in 2 days may indicate fluid retention and worsening heart
failure.

Question 871: Neurological

A patient with a traumatic brain injury is showing signs of increased intracranial pressure (ICP).
Which assessment finding is most concerning?

 A) Headache
 B) Vomiting
 C) Slurred speech
 D) Lethargy

Correct Answer: B
Rationale: Vomiting is a concerning sign of increased ICP and may indicate a worsening
condition.
Question 872: Endocrine

A patient is being treated for Cushing's syndrome. Which assessment finding would the nurse
expect?

 A) Weight loss
 B) Hypotension
 C) Moon facies
 D) Decreased body hair

Correct Answer: C
Rationale: Moon facies (rounded face) is a characteristic feature of Cushing's syndrome due to
excess cortisol.

Question 873: Gastrointestinal

A patient with a history of liver cirrhosis is experiencing ascites. Which intervention should the
nurse implement first?

 A) Administer diuretics as prescribed.

 B) Monitor abdominal girth daily.
 C) Restrict fluid intake.
 D) Encourage high-protein foods.

Correct Answer: A
Rationale: Administering diuretics will help reduce fluid retention and alleviate ascites.

Question 874: Mental Health

A nurse is assessing a patient who has just been diagnosed with bipolar disorder. Which
statement indicates a need for further education?

 A) "I may experience mood swings."

 B) "I can manage my symptoms without medication."
 C) "I will attend regular therapy sessions."
 D) "I need to monitor my mood closely."

Correct Answer: B
Rationale: Patients with bipolar disorder typically require medication for effective management
of symptoms.
Question 875: Obstetrics

A pregnant patient in labor is requesting pain relief. Which option should the nurse discuss with
the patient?

 A) General anesthesia
 B) Epidural anesthesia
 C) Oral analgesics
 D) Nitrous oxide

Correct Answer: B
Rationale: Epidural anesthesia is commonly used for pain relief during labor and is effective in
managing pain.

Question 876: Pediatric Nursing

A nurse is caring for a child with a viral infection. Which assessment finding would indicate a
need for further evaluation?

 A) Mild fever
 B) Increased irritability
 C) Decreased urine output
 D) Clear nasal discharge

Correct Answer: C
Rationale: Decreased urine output may indicate dehydration and requires further evaluation and
intervention.

Question 877: Renal

A nurse is teaching a patient about the signs of nephrotoxicity related to aminoglycoside

antibiotics. Which symptom should the nurse emphasize?

 A) Hearing loss
 B) Increased appetite
 C) Weight gain
 D) Frequent urination
Correct Answer: A
Rationale: Hearing loss can indicate nephrotoxicity associated with aminoglycoside antibiotics
and should be monitored.

Question 878: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis (TB). What is the most appropriate
nursing intervention?

 A) Place the patient in a private room with negative pressure.

 B) Use a surgical mask when caring for the patient.
 C) Implement droplet precautions.
 D) Encourage the patient to ambulate in the hallway.

Correct Answer: A
Rationale: A private room with negative pressure is necessary to prevent the spread of TB to
other patients.

Question 879: Neurological

A nurse is caring for a patient with multiple sclerosis (MS). Which symptom should the nurse
expect to find?

 A) Fever
 B) Spasticity
 C) Decreased appetite
 D) Skin rashes

Correct Answer: B
Rationale: Spasticity is a common symptom of multiple sclerosis due to the damage to the nerve
pathways.

Question 880: Cardiovascular

A nurse is monitoring a patient receiving anticoagulation therapy. Which laboratory test is

essential to evaluate the effectiveness of therapy?

 A) Prothrombin time (PT)

 B) Complete blood count (CBC)
 C) Serum creatinine
  D) Blood glucose level

Correct Answer: A
Rationale: Prothrombin time (PT) is essential to evaluate the effectiveness of anticoagulation
therapy, especially with warfarin.

Question 881: Pharmacology

A nurse is administering warfarin (Coumadin) to a patient. Which laboratory test should the
nurse monitor regularly?

 A) Activated partial thromboplastin time (aPTT)

 B) International normalized ratio (INR)
 C) Platelet count
 D) Prothrombin time (PT)

Correct Answer: B
Rationale: The International normalized ratio (INR) is monitored to ensure the effectiveness and
safety of warfarin therapy.

Question 882: Endocrine

A patient with type 1 diabetes is being discharged with a new prescription for insulin. Which
statement by the patient indicates a need for further teaching?

 A) "I should rotate injection sites to prevent lipodystrophy."

 B) "I can skip my insulin if I don't eat."
 C) "I need to check my blood sugar before meals."
 D) "I should carry glucose tablets in case of low blood sugar."

Correct Answer: B
Rationale: Patients with type 1 diabetes should never skip insulin doses, even if they do not eat,
as it can lead to hyperglycemia.

Question 883: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
receiving oxygen therapy. Which oxygen delivery method should the nurse anticipate using for
this patient?
  A) Non-rebreather mask
 B) Nasal cannula
 C) Venturi mask
 D) Bag-valve mask

Correct Answer: C
Rationale: A Venturi mask is often used for COPD patients to deliver a precise concentration of
oxygen and prevent carbon dioxide retention.

Question 884: Gastrointestinal

A nurse is caring for a patient with peptic ulcer disease. Which medication class should the nurse
anticipate administering to reduce gastric acid secretion?

 A) Antacids
 B) Proton pump inhibitors
 C) H2-receptor antagonists
 D) Antimicrobials

Correct Answer: B
Rationale: Proton pump inhibitors (PPIs) effectively reduce gastric acid secretion and are
commonly used to treat peptic ulcer disease.

Question 885: Mental Health

A patient with schizophrenia is exhibiting disorganized thinking. Which statement by the patient
might indicate this symptom?

 A) "I feel like I'm being followed."

 B) "I'm going to the store to buy groceries, and I need to get some air."
 C) "The sky is purple, and I can hear it talking to me."
 D) "I enjoy going for walks in the evening."

Correct Answer: C
Rationale: Disorganized thinking can lead to nonsensical statements, such as attributing human
characteristics to inanimate objects.

Question 886: Obstetrics

A nurse is monitoring a pregnant patient during labor. Which finding would indicate a potential
complication?

 A) Contractions every 3-5 minutes

 B) Fetal heart rate of 120-160 beats per minute
 C) Meconium-stained amniotic fluid
 D) Uterine contractions lasting 60 seconds

Correct Answer: C
Rationale: Meconium-stained amniotic fluid may indicate fetal distress and requires careful
monitoring.

Question 887: Pediatric Nursing

A nurse is assessing a 12-month-old infant. Which developmental milestone should the nurse
expect the infant to have achieved?

 A) Walks independently
 B) Says "mama" and "dada" specifically
 C) Stacks two blocks
 D) Understands simple commands

Correct Answer: C
Rationale: By 12 months, infants typically can stack two blocks and may say "mama" and
"dada," but not necessarily with meaning.

Question 888: Renal

A patient with end-stage renal disease is on dialysis. Which symptom would indicate the patient
may need to be evaluated for dialysis complications?

 A) Increased appetite
 B) Fatigue
 C) Sudden weight loss
 D) Decreased urine output

Correct Answer: C
Rationale: Sudden weight loss may indicate complications such as excessive fluid removal
during dialysis.
Question 889: Infection Control

A nurse is caring for a patient with a surgical wound infected with methicillin-resistant
Staphylococcus aureus (MRSA). Which precaution should the nurse implement?

 A) Standard precautions
 B) Contact precautions
 C) Droplet precautions
 D) Airborne precautions

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of MRSA, which can be
transmitted through direct contact.

Question 890: Neurological

A nurse is caring for a patient with a history of stroke. Which assessment finding would suggest
the patient is experiencing a transient ischemic attack (TIA)?

 A) Persistent weakness on one side of the body

 B) Sudden severe headache
 C) Temporary vision loss in one eye
 D) Difficulty speaking that lasts more than 24 hours

Correct Answer: C
Rationale: Temporary vision loss in one eye is a common symptom of a transient ischemic
attack (TIA) and typically resolves quickly.

Question 891: Cardiovascular

A patient with heart failure is prescribed a low-sodium diet. Which food choice should the nurse
advise the patient to avoid?

 A) Fresh fruits and vegetables

 B) Processed meats
 C) Whole grains
 D) Plain rice

Correct Answer: B
Rationale: Processed meats are typically high in sodium and should be avoided on a low-sodium
diet.
Question 892: Endocrine

A nurse is teaching a patient about signs of hypoglycemia. Which symptom should the nurse
include in the teaching?

 A) Increased thirst
 B) Blurred vision
 C) Sweating and trembling
 D) Frequent urination

Correct Answer: C
Rationale: Sweating and trembling are common symptoms of hypoglycemia, and patients
should be educated to recognize them.

Question 893: Gastrointestinal

A nurse is assessing a patient with appendicitis. Which symptom would the nurse expect to find?

 A) Right upper quadrant pain

 B) Severe diarrhea
 C) Left lower quadrant tenderness
 D) Rebound tenderness in the right lower quadrant

Correct Answer: D
Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis.

Question 894: Mental Health

A patient diagnosed with major depressive disorder is prescribed fluoxetine (Prozac). Which
statement indicates that the patient understands the medication?

 A) "I can stop taking this medication once I feel better."

 B) "I should expect to feel better within a few days."
 C) "I need to take this medication every day as prescribed."
 D) "I can drink alcohol while on this medication."

Correct Answer: C
Rationale: Patients should take fluoxetine daily as prescribed to maintain therapeutic levels and
avoid withdrawal symptoms.
Question 895: Obstetrics

A nurse is teaching a pregnant woman about the signs of preterm labor. Which statement
indicates a need for further education?

 A) "I should call my doctor if I have regular contractions."

 B) "If I notice any bleeding, I need to go to the hospital."
 C) "It’s normal to have some back pain during pregnancy."
 D) "I shouldn’t worry unless my water breaks."

Correct Answer: D
Rationale: Patients should be educated that any signs of preterm labor, including contractions
and changes in discharge, warrant immediate evaluation, not just the breaking of water.

Question 896: Pediatric Nursing

A nurse is caring for a child with asthma. Which intervention is most appropriate for managing
an acute asthma attack?

 A) Administer a long-acting beta-agonist.

 B) Encourage the child to take deep breaths.
 C) Administer a short-acting beta-agonist.
 D) Use a peak flow meter to assess lung function.

Correct Answer: C
Rationale: Administering a short-acting beta-agonist is the first-line treatment during an acute
asthma attack to relieve bronchospasm.

Question 897: Renal

A patient with chronic kidney disease is being educated about dietary restrictions. Which food
should the nurse advise the patient to limit?

 A) Oranges
 B) Apples
 C) Carrots
 D) Potatoes
Correct Answer: A
Rationale: Oranges are high in potassium and should be limited in patients with chronic kidney
disease.

Question 898: Infection Control

A nurse is caring for a patient with Clostridium difficile infection. Which precaution should the
nurse implement?

 A) Airborne precautions
 B) Droplet precautions
 C) Contact precautions
 D) Standard precautions

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of Clostridium difficile,
which is transmitted via the fecal-oral route.

Question 899: Neurological

A nurse is assessing a patient with a spinal cord injury. Which assessment finding would suggest
autonomic dysreflexia?

 A) Flushed skin above the level of injury

 B) Hypotension
 C) Bradycardia
 D) Increased bowel sounds

Correct Answer: A
Rationale: Flushed skin above the level of the injury is a key indicator of autonomic dysreflexia,
often triggered by a noxious stimulus below the level of injury.

Question 900: Cardiovascular

A nurse is caring for a patient post-myocardial infarction. Which intervention is the priority in
the immediate post-operative period?

 A) Administer pain medication as prescribed.

 B) Monitor vital signs every 15 minutes.
 C) Encourage the patient to ambulate.
  D) Assess the patient’s surgical site for bleeding.

Correct Answer: B
Rationale: Monitoring vital signs every 15 minutes is critical in the immediate post-operative
period to detect any complications early.

Question 901: Pharmacology

A patient with hypertension is prescribed lisinopril. Which common side effect should the nurse
educate the patient about?

 A) Dry cough
 B) Dizziness
 C) Weight gain
 D) Increased urination

Correct Answer: A
Rationale: A dry cough is a common side effect of lisinopril, an ACE inhibitor.

Question 902: Endocrine

A nurse is assessing a patient with Addison's disease. Which finding would the nurse expect?

 A) Hyperglycemia
 B) Weight loss
 C) Moon facies
 D) Hypertension

Correct Answer: B
Rationale: Weight loss is a common finding in Addison's disease due to insufficient cortisol
production.

Question 903: Respiratory

A nurse is caring for a patient with pneumonia. Which assessment finding would indicate the
patient is responding well to treatment?

 A) Increased respiratory rate

 B) Decreased oxygen saturation
 C) Clear lung sounds
  D) Persistent cough

Correct Answer: C
Rationale: Clear lung sounds indicate improvement in lung function and response to treatment
for pneumonia.

Question 904: Gastrointestinal

A patient is receiving TPN (total parenteral nutrition). Which complication should the nurse
monitor for?

 A) Hypoglycemia
 B) Hyperglycemia
 C) Dehydration
 D) Hypertension

Correct Answer: B
Rationale: Patients receiving TPN are at risk for hyperglycemia due to the high concentration of
glucose in the solution.

Question 905: Mental Health

A patient diagnosed with generalized anxiety disorder is prescribed buspirone (Buspar). Which
statement by the patient indicates an understanding of the medication?

 A) "I can take this medication as needed for anxiety."

 B) "This medication will help me sleep better."
 C) "It may take a few weeks for this medication to start working."
 D) "I can stop taking it once I feel less anxious."

Correct Answer: C
Rationale: Buspirone may take several weeks to reach its full effect, which is important for
patients to understand.

Question 906: Obstetrics

A nurse is assessing a patient in the second trimester of pregnancy. Which assessment finding
would be considered normal?

 A) Fundal height below the umbilicus

  B) Fetal heart rate of 180 beats per minute
 C) Quickening (fetal movement) felt by the mother
 D) Swelling of the lower extremities

Correct Answer: C
Rationale: Quickening is a normal finding in the second trimester as the mother begins to feel
fetal movements.

Question 907: Pediatric Nursing

A nurse is assessing a child with croup. Which sign would indicate the need for immediate
intervention?

 A) Barking cough
 B) Stridor at rest
 C) Low-grade fever
 D) Hoarseness

Correct Answer: B
Rationale: Stridor at rest is a sign of severe airway obstruction and requires immediate
intervention.

Question 908: Renal

A nurse is caring for a patient undergoing hemodialysis. Which complication should the nurse
monitor for during the procedure?

 A) Hypotension
 B) Hyperkalemia
 C) Hypertension
 D) Hypoglycemia

Correct Answer: A
Rationale: Hypotension is a common complication during hemodialysis due to fluid removal.

Question 909: Infection Control

A nurse is caring for a patient with varicella (chickenpox). Which precaution should the nurse
implement?
  A) Airborne precautions
 B) Droplet precautions
 C) Contact precautions
 D) Standard precautions

Correct Answer: A
Rationale: Airborne precautions are necessary for varicella due to the virus's ability to remain
suspended in the air.

Question 910: Neurological

A nurse is assessing a patient with Parkinson's disease. Which symptom would the nurse expect
to find?

 A) Bradykinesia
 B) Hyperactivity
 C) Impulsivity
 D) Increased appetite

Correct Answer: A
Rationale: Bradykinesia (slowness of movement) is a characteristic symptom of Parkinson's
disease.

Question 911: Cardiovascular

A patient is diagnosed with heart failure and prescribed digoxin. Which sign would indicate
digoxin toxicity?

 A) Bradycardia
 B) Increased appetite
 C) Hypotension
 D) Clear lung sounds

Correct Answer: A
Rationale: Bradycardia is a sign of digoxin toxicity, and the patient should be monitored closely.

Question 912: Endocrine

A nurse is teaching a patient with type 2 diabetes about dietary modifications. Which food
should the nurse recommend limiting?
  A) Lean proteins
 B) Whole grains
 C) Sugary beverages
 D) Non-starchy vegetables

Correct Answer: C
Rationale: Sugary beverages can lead to spikes in blood sugar and should be limited in patients
with diabetes.

Question 913: Gastrointestinal

A patient is being prepared for a colonoscopy. Which instruction should the nurse give?

 A) "You can eat solid foods up until the procedure."

 B) "You will need to drink a clear liquid diet the day before."
 C) "You can take your medications as usual."
 D) "You will need to drink a contrast solution."

Correct Answer: B
Rationale: Patients typically need to follow a clear liquid diet the day before a colonoscopy to
prepare the bowel.

Question 914: Mental Health

A patient diagnosed with major depressive disorder expresses feelings of hopelessness. Which
nursing intervention is most appropriate?

 A) Encourage the patient to think positively.

 B) Offer to help the patient develop a plan to manage symptoms.
 C) Dismiss the patient's feelings as temporary.
 D) Suggest the patient participate in group activities.

Correct Answer: B
Rationale: Helping the patient develop a plan to manage symptoms is a supportive intervention
that acknowledges their feelings.

Question 915: Obstetrics

A nurse is monitoring a patient who just received epidural anesthesia. Which assessment finding
would be a priority?
  A) Maternal blood pressure
 B) Fetal heart rate
 C) Uterine contractions
 D) Patient's level of pain

Correct Answer: A
Rationale: Maternal blood pressure is a priority to monitor because epidural anesthesia can
cause hypotension.

Question 916: Pediatric Nursing

A nurse is educating the parents of a child with asthma about medication administration. Which
statement indicates a need for further teaching?

 A) "I should give my child their inhaler before exercise."

 B) "We will use the nebulizer only when symptoms worsen."
 C) "I need to ensure my child takes their corticosteroid as prescribed."
 D) "It's okay to share my child's inhaler with others if they need it."

Correct Answer: D
Rationale: Sharing an inhaler can spread infections and is not advised.

Question 917: Renal

A patient with chronic kidney disease is being educated about fluid restrictions. Which statement
by the patient indicates understanding?

 A) "I can drink as much fluid as I want."

 B) "I will limit my fluid intake as advised."
 C) "It's okay to have soda and juice whenever I want."
 D) "I can choose to not limit fluid intake at all."

Correct Answer: B
Rationale: Understanding and adhering to fluid restrictions is crucial in managing chronic
kidney disease.

Question 918: Infection Control

A nurse is preparing to care for a patient diagnosed with influenza. What type of mask should the
nurse wear?
  A) Surgical mask
 B) N95 respirator
 C) Face shield
 D) Standard mask

Correct Answer: A
Rationale: A surgical mask is appropriate for caring for a patient with influenza to prevent
droplet transmission.

Question 919: Neurological

A nurse is assessing a patient for signs of a stroke. Which acronym should the nurse remember to
identify potential symptoms?

 A) FAST
 B) ABC
 C) DRS
 D) CAB

Correct Answer: A
Rationale: The acronym FAST (Face, Arms, Speech, Time) helps identify symptoms of a stroke
and the need for urgent action.

Question 920: Cardiovascular

A nurse is monitoring a patient receiving IV furosemide (Lasix). Which electrolyte imbalance

should the nurse monitor for?

 A) Hyperkalemia
 B) Hypercalcemia
 C) Hypomagnesemia
 D) Hypokalemia

Correct Answer: D
Rationale: Furosemide can cause potassium loss, leading to hypokalemia.

Question 921: Pharmacology

A nurse is administering metformin to a patient with type 2 diabetes. Which assessment finding
is a potential side effect of this medication?
  A) Increased thirst
 B) Weight gain
 C) Gastrointestinal upset
 D) Hair loss

Correct Answer: C
Rationale: Gastrointestinal upset is a common side effect of metformin, especially when
initiating therapy.

Question 922: Endocrine

A patient with diabetes is experiencing signs of hypoglycemia. Which intervention should the
nurse implement first?

 A) Administer glucagon
 B) Provide 15 grams of fast-acting carbohydrate
 C) Check the patient's blood glucose level
 D) Contact the healthcare provider

Correct Answer: B
Rationale: Providing 15 grams of fast-acting carbohydrate is the first intervention for
hypoglycemia.

Question 923: Respiratory

A nurse is caring for a patient with asthma who is experiencing wheezing and shortness of
breath. Which medication should the nurse expect to administer?

 A) Corticosteroid
 B) Beta-agonist
 C) Anticholinergic
 D) Leukotriene receptor antagonist

Correct Answer: B
Rationale: A beta-agonist (such as albuterol) is a bronchodilator used for immediate relief of
asthma symptoms.

Question 924: Gastrointestinal

A nurse is caring for a patient with cirrhosis. Which laboratory value should the nurse monitor
closely?

 A) Blood glucose
 B) Serum ammonia
 C) Serum calcium
 D) Serum potassium

Correct Answer: B
Rationale: Elevated serum ammonia levels can indicate hepatic encephalopathy in patients with
cirrhosis.

Question 925: Mental Health

A patient diagnosed with bipolar disorder is experiencing a manic episode. Which behavior
would the nurse most likely observe?

 A) Withdrawal from social interactions

 B) Increased need for sleep
 C) Grandiosity and racing thoughts
 D) Lack of energy

Correct Answer: C
Rationale: Grandiosity and racing thoughts are characteristic of a manic episode in bipolar
disorder.

Question 926: Obstetrics

A nurse is caring for a pregnant patient at 28 weeks gestation. Which assessment finding is a
cause for concern?

 A) Weight gain of 2 pounds in the last week

 B) Fundal height measuring 28 cm
 C) Fetal heart rate of 150 beats per minute
 D) Severe headaches with visual disturbances

Correct Answer: D
Rationale: Severe headaches with visual disturbances can indicate potential complications like
preeclampsia.
Question 927: Pediatric Nursing

A nurse is teaching a child's parents about the management of a child with asthma. Which
statement by the parents indicates a need for further education?

 A) "We will keep the child's rescue inhaler with us at all times."
 B) "We can give the child a bath in hot water to help with symptoms."
 C) "We will avoid triggers such as pets and smoke."
 D) "We should monitor the peak flow meter readings daily."

Correct Answer: B
Rationale: Hot water baths can trigger asthma symptoms; warm showers are recommended
instead.

Question 928: Renal

A patient with chronic kidney disease is prescribed erythropoietin. What should the nurse
monitor for in this patient?

 A) Signs of infection
 B) Hemoglobin and hematocrit levels
 C) Electrolyte levels
 D) Urine output

Correct Answer: B
Rationale: Erythropoietin is used to increase red blood cell production, so monitoring
hemoglobin and hematocrit levels is important.

Question 929: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis. What type of precautions should the
nurse implement?

 A) Contact precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: B
Rationale: Airborne precautions are required for tuberculosis due to the infectious nature of the
bacteria.
Question 930: Neurological

A nurse is assessing a patient with a traumatic brain injury. Which finding would indicate
increased intracranial pressure (ICP)?

 A) Hypotension
 B) Bradycardia
 C) Decreased respiratory rate
 D) Pupillary constriction

Correct Answer: B
Rationale: Bradycardia can occur as a late sign of increased ICP and indicates the need for
urgent assessment.

Question 931: Cardiovascular

A patient is diagnosed with heart failure and is prescribed a diuretic. Which lab value should the
nurse monitor closely?

 A) Hemoglobin
 B) Potassium
 C) Calcium
 D) Sodium

Correct Answer: B
Rationale: Diuretics can lead to potassium depletion, so potassium levels should be monitored
regularly.

Question 932: Endocrine

A nurse is teaching a patient about the signs of hyperthyroidism. Which symptom should the
nurse include?

 A) Weight gain
 B) Cold intolerance
 C) Increased appetite
 D) Fatigue
Correct Answer: C
Rationale: Increased appetite is a common symptom of hyperthyroidism, along with weight loss
and heat intolerance.

Question 933: Gastrointestinal

A nurse is caring for a patient with pancreatitis. Which assessment finding would the nurse
expect?

 A) Abdominal rigidity
 B) Elevated blood glucose
 C) Jaundice
 D) Diarrhea

Correct Answer: A
Rationale: Abdominal rigidity is a common finding in patients with pancreatitis due to
inflammation and irritation.

Question 934: Mental Health

A patient in a psychiatric unit is experiencing auditory hallucinations. Which nursing

intervention is appropriate?

 A) Tell the patient to ignore the hallucinations.

 B) Reassure the patient that the hallucinations will go away.
 C) Validate the patient's feelings and redirect the conversation.
 D) Encourage the patient to talk about the hallucinations in detail.

Correct Answer: C
Rationale: Validating feelings and redirecting the conversation is a therapeutic approach to
managing hallucinations.

Question 935: Obstetrics

A nurse is teaching a pregnant woman about the importance of prenatal vitamins. Which vitamin
is crucial for preventing neural tube defects?

 A) Vitamin D
 B) Iron
 C) Folic acid
  D) Calcium

Correct Answer: C
Rationale: Folic acid is essential for the prevention of neural tube defects in developing fetuses.

Question 936: Pediatric Nursing

A nurse is caring for a child with a high fever. Which medication should the nurse expect to
administer to reduce the fever?

 A) Ibuprofen
 B) Acetaminophen
 C) Aspirin
 D) Naproxen

Correct Answer: B
Rationale: Acetaminophen is commonly used to reduce fever in children, while aspirin is
contraindicated due to the risk of Reye's syndrome.

Question 937: Renal

A patient with acute kidney injury is at risk for which electrolyte imbalance?

 A) Hypocalcemia
 B) Hypernatremia
 C) Hyperkalemia
 D) Hypomagnesemia

Correct Answer: C
Rationale: Hyperkalemia is a common complication of acute kidney injury due to the kidneys'
inability to excrete potassium.

Question 938: Infection Control

A nurse is caring for a patient with a resistant bacterial infection. Which type of isolation
precaution should the nurse implement?

 A) Airborne isolation
 B) Contact isolation
 C) Droplet isolation
  D) Reverse isolation

Correct Answer: B
Rationale: Contact isolation is used for patients with infections caused by resistant bacteria to
prevent transmission.

Question 939: Neurological

A nurse is teaching a patient about the signs of a stroke. Which sign is associated with a right-
sided stroke?

 A) Impaired judgment
 B) Weakness on the right side
 C) Difficulty speaking
 D) Visual field deficits in the left eye

Correct Answer: D
Rationale: A right-sided stroke can cause visual field deficits in the left eye due to the crossover
of visual pathways.

Question 940: Cardiovascular

A patient with a history of coronary artery disease is prescribed atorvastatin. What is the primary
purpose of this medication?

 A) Decrease heart rate

 B) Lower blood pressure
 C) Reduce cholesterol levels
 D) Prevent blood clots

Correct Answer: C
Rationale: Atorvastatin is a statin used to lower cholesterol levels and reduce the risk of
cardiovascular disease.

Question 941: Pharmacology

A patient is prescribed warfarin (Coumadin). Which lab test should the nurse monitor to evaluate
the effectiveness of this medication?

 A) PT/INR
  B) PTT
 C) CBC
 D) BMP

Correct Answer: A
Rationale: The PT/INR (Prothrombin Time/International Normalized Ratio) is used to monitor
the effectiveness of warfarin therapy.

Question 942: Endocrine

A nurse is educating a patient with hypothyroidism about the importance of medication

adherence. What medication is most commonly prescribed for this condition?

 A) Levothyroxine (Synthroid)
 B) Metformin (Glucophage)
 C) Insulin
 D) Prednisone

Correct Answer: A
Rationale: Levothyroxine is the standard treatment for hypothyroidism to replace deficient
thyroid hormone.

Question 943: Respiratory

A patient is experiencing an acute asthma attack. Which assessment finding indicates the need
for immediate intervention?

 A) Expiratory wheezing
 B) Oxygen saturation of 88%
 C) Increased respiratory rate
 D) Mild use of accessory muscles

Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia and requires immediate
intervention.

Question 944: Gastrointestinal

A nurse is caring for a patient with peptic ulcer disease. Which medication is most effective for
promoting healing of the ulcer?
  A) Antacids
 B) Proton pump inhibitors
 C) H2 receptor antagonists
 D) Sucralfate

Correct Answer: B
Rationale: Proton pump inhibitors (PPIs) are effective in reducing stomach acid and promoting
healing of peptic ulcers.

Question 945: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia. Which symptom would be
classified as a positive symptom?

 A) Social withdrawal
 B) Anhedonia
 C) Hallucinations
 D) Apathy

Correct Answer: C
Rationale: Hallucinations are considered a positive symptom, as they represent an excess or
distortion of normal functioning.

Question 946: Obstetrics

A nurse is monitoring a patient who is in active labor. Which assessment finding is a sign of
potential fetal distress?

 A) Moderate variability in fetal heart rate

 B) Fetal heart rate of 160 bpm
 C) Persistent late decelerations
 D) Early decelerations with contractions

Correct Answer: C
Rationale: Persistent late decelerations indicate potential fetal distress and require further
assessment and intervention.

Question 947: Pediatric Nursing

A nurse is assessing a child for signs of dehydration. Which finding would be most concerning?
  A) Dry mucous membranes
 B) Increased thirst
 C) Decreased urine output
 D) Cool, clammy skin

Correct Answer: D
Rationale: Cool, clammy skin can indicate severe dehydration and requires immediate
intervention.

Question 948: Renal

A patient with chronic kidney disease is prescribed a phosphate binder. Which food should the
nurse advise the patient to avoid?

 A) Apples
 B) Spinach
 C) Chicken
 D) Rice

Correct Answer: B
Rationale: Spinach is high in phosphorus and should be limited in patients taking phosphate
binders.

Question 949: Infection Control

A nurse is caring for a patient with a C. difficile infection. Which precaution should the nurse
implement?

 A) Airborne precautions
 B) Contact precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of C. difficile, which is
transmitted via the fecal-oral route.

Question 950: Neurological

A patient is experiencing a seizure. What is the nurse's priority action?

  A) Assess the patient’s airway
 B) Administer benzodiazepines
 C) Place a padded tongue blade in the patient’s mouth
 D) Document the seizure activity

Correct Answer: A
Rationale: Assessing and securing the patient’s airway is the priority during a seizure to prevent
aspiration.

Question 951: Cardiovascular

A nurse is monitoring a patient who has undergone a cardiac catheterization. Which assessment
finding requires immediate attention?

 A) Moderate bruising at the insertion site

 B) Increased heart rate
 C) Coolness of the affected limb
 D) Slight bleeding at the site

Correct Answer: C
Rationale: Coolness of the affected limb may indicate compromised blood flow and requires
immediate intervention.

Question 952: Endocrine

A nurse is teaching a patient about the symptoms of hyperglycemia. Which symptom should the
nurse include?

 A) Sweating
 B) Tremors
 C) Increased urination
 D) Dizziness

Correct Answer: C
Rationale: Increased urination (polyuria) is a common symptom of hyperglycemia.

Question 953: Gastrointestinal

A nurse is assessing a patient with a history of chronic gastritis. Which symptom is most
commonly associated with this condition?
  A) Diarrhea
 B) Abdominal pain
 C) Fever
 D) Hematemesis

Correct Answer: B
Rationale: Abdominal pain is a common symptom of chronic gastritis.

Question 954: Mental Health

A patient with depression is started on an SSRI. Which common side effect should the nurse
educate the patient about?

 A) Weight loss
 B) Insomnia
 C) Sexual dysfunction
 D) Increased appetite

Correct Answer: C
Rationale: Sexual dysfunction is a common side effect of SSRIs and should be discussed with
the patient.

Question 955: Obstetrics

A nurse is caring for a postpartum patient who is experiencing excessive bleeding. Which
assessment finding would be most concerning?

 A) Fundus firm at the umbilicus

 B) Saturation of a pad in 15 minutes
 C) Moderate cramping
 D) Presence of lochia rubra

Correct Answer: B
Rationale: Saturation of a pad in 15 minutes indicates excessive bleeding and requires
immediate assessment.

Question 956: Pediatric Nursing

A nurse is administering immunizations to a child. Which immunization should the nurse give
first according to the recommended schedule?
  A) DTaP
 B) MMR
 C) Hib
 D) Varicella

Correct Answer: A
Rationale: DTaP (Diphtheria, Tetanus, Pertussis) is typically administered in infancy as part of
the routine immunization schedule.

Question 957: Renal

A patient with end-stage renal disease is on hemodialysis. Which dietary modification should the
nurse emphasize?

 A) High protein intake

 B) Low potassium diet
 C) High sodium diet
 D) Increased fluid intake

Correct Answer: B
Rationale: A low potassium diet is important in patients on hemodialysis to prevent
hyperkalemia.

Question 958: Infection Control

A nurse is caring for a patient with MRSA. Which precaution should the nurse implement?

 A) Airborne precautions
 B) Contact precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of MRSA.

Question 959: Neurological

A nurse is assessing a patient for signs of increased intracranial pressure. Which symptom would
be a late sign?
  A) Headache
 B) Vomiting
 C) Bradycardia
 D) Disorientation

Correct Answer: C
Rationale: Bradycardia is a late sign of increased intracranial pressure and indicates severe
deterioration.

Question 960: Cardiovascular

A patient is diagnosed with atrial fibrillation. Which medication should the nurse anticipate
administering?

 A) Amiodarone
 B) Warfarin
 C) Aspirin
 D) Digoxin

Correct Answer: B
Rationale: Warfarin is often used in atrial fibrillation to reduce the risk of stroke due to blood
clot formation.

Question 961: Pharmacology

A nurse is teaching a patient about the side effects of furosemide (Lasix). Which side effect
should the nurse emphasize?

 A) Hyperkalemia
 B) Weight gain
 C) Hypokalemia
 D) Drowsiness

Correct Answer: C
Rationale: Furosemide is a loop diuretic that can cause hypokalemia (low potassium levels).

Question 962: Endocrine

A patient with type 1 diabetes is experiencing symptoms of hypoglycemia. Which intervention

should the nurse implement first?
  A) Administer insulin
 B) Provide 15 grams of fast-acting carbohydrate
 C) Check blood glucose level
 D) Call the healthcare provider

Correct Answer: B
Rationale: Providing 15 grams of fast-acting carbohydrate is the first step in treating
hypoglycemia.

Question 963: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
experiencing difficulty breathing. Which position should the nurse encourage the patient to
assume?

 A) Supine
 B) Prone
 C) High Fowler's
 D) Lateral

Correct Answer: C
Rationale: High Fowler's position promotes lung expansion and facilitates breathing in patients
with COPD.

Question 964: Gastrointestinal

A nurse is caring for a patient with a history of liver cirrhosis. Which laboratory finding should
the nurse expect?

 A) Elevated ammonia levels

 B) Decreased bilirubin levels
 C) Increased glucose levels
 D) Normal coagulation profile

Correct Answer: A
Rationale: Elevated ammonia levels are common in liver cirrhosis due to impaired liver
function.

Question 965: Mental Health

A patient diagnosed with major depressive disorder is prescribed sertraline (Zoloft). Which
common side effect should the nurse inform the patient about?

 A) Weight loss
 B) Increased energy
 C) Sexual dysfunction
 D) Drowsiness

Correct Answer: C
Rationale: Sexual dysfunction is a common side effect of SSRIs like sertraline.

Question 966: Obstetrics

A nurse is assessing a laboring patient. Which finding indicates the need for further evaluation of
fetal well-being?

 A) Fetal heart rate of 140 bpm

 B) Presence of variable decelerations
 C) Fundal height consistent with gestational age
 D) Moderate variability in fetal heart rate

Correct Answer: B
Rationale: Variable decelerations may indicate umbilical cord compression and require further
evaluation.

Question 967: Pediatric Nursing

A nurse is assessing a child with suspected appendicitis. Which finding is characteristic of this
condition?

 A) Right upper quadrant pain

 B) Left lower quadrant pain
 C) Rebound tenderness in the right lower quadrant
 D) Absent bowel sounds

Correct Answer: C
Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis.

Question 968: Renal

A nurse is caring for a patient on dialysis. Which electrolyte imbalance is the patient at risk for
after dialysis?

 A) Hypokalemia
 B) Hyperkalemia
 C) Hyponatremia
 D) Hypercalcemia

Correct Answer: A
Rationale: Patients on dialysis are at risk for hypokalemia due to the removal of potassium
during the procedure.

Question 969: Infection Control

A nurse is caring for a patient with tuberculosis. What type of room should the patient be placed
in?

 A) Private room with negative pressure

 B) Private room with positive pressure
 C) Semi-private room
 D) Isolation room with standard precautions

Correct Answer: A
Rationale: Patients with tuberculosis should be placed in a private room with negative pressure
to prevent airborne transmission.

Question 970: Neurological

A patient with a history of seizures is being discharged with a prescription for phenytoin
(Dilantin). Which statement by the patient indicates a need for further teaching?

 A) "I will have my blood levels checked regularly."

 B) "I can stop taking the medication if I feel fine."
 C) "I need to maintain good oral hygiene."
 D) "I should avoid alcohol while taking this medication."

Correct Answer: B
Rationale: Patients should not stop taking phenytoin abruptly without consulting their healthcare
provider.
Question 971: Cardiovascular

A patient diagnosed with heart failure is prescribed a beta-blocker. What is the nurse's priority
assessment?

 A) Heart rate
 B) Blood pressure
 C) Respiratory rate
 D) Electrolyte levels

Correct Answer: A
Rationale: Heart rate should be monitored closely as beta-blockers can decrease heart rate
significantly.

Question 972: Endocrine

A nurse is caring for a patient with adrenal insufficiency. Which medication should the nurse
anticipate administering?

 A) Prednisone
 B) Levothyroxine
 C) Insulin
 D) Metformin

Correct Answer: A
Rationale: Prednisone is a corticosteroid that is commonly prescribed for adrenal insufficiency.

Question 973: Gastrointestinal

A nurse is assessing a patient with peptic ulcer disease. Which symptom is most commonly
associated with this condition?

 A) Nausea
 B) Hematemesis
 C) Abdominal cramping
 D) Epigastric pain

Correct Answer: D
Rationale: Epigastric pain is a classic symptom of peptic ulcer disease, often described as
burning or gnawing.
Question 974: Mental Health

A nurse is caring for a patient with anxiety who is prescribed lorazepam (Ativan). What is an
important consideration when administering this medication?

 A) It can cause hyperactivity.

 B) It may lead to dependency with long-term use.
 C) It should be taken on an empty stomach.
 D) It can be used as a first-line treatment for depression.

Correct Answer: B
Rationale: Long-term use of benzodiazepines like lorazepam can lead to physical and
psychological dependence.

Question 975: Obstetrics

A nurse is assessing a postpartum patient for signs of infection. Which finding is most
concerning?

 A) Fever of 100.4°F
 B) Lochia serosa
 C) Increased heart rate
 D) Fundus firm and midline

Correct Answer: C
Rationale: Increased heart rate can be a sign of infection and warrants further evaluation.

Question 976: Pediatric Nursing

A nurse is caring for a child with a respiratory infection. Which symptom should the nurse
monitor for potential complications?

 A) Barking cough
 B) Mild wheezing
 C) Increased respiratory effort
 D) Intermittent fever

Correct Answer: C
Rationale: Increased respiratory effort can indicate respiratory distress and requires close
monitoring.
Question 977: Renal

A nurse is teaching a patient with chronic kidney disease about dietary restrictions. Which food
should the patient limit?

 A) Apples
 B) Bananas
 C) Carrots
 D) Rice

Correct Answer: B
Rationale: Bananas are high in potassium and should be limited in patients with chronic kidney
disease.

Question 978: Infection Control

A nurse is caring for a patient with a wound infected with MRSA. Which intervention is most
important to prevent transmission?

 A) Wearing gloves during care

 B) Hand hygiene before and after contact
 C) Using a mask
 D) Placing the patient in a private room

Correct Answer: B
Rationale: Hand hygiene is the most effective way to prevent the transmission of infections,
including MRSA.

Question 979: Neurological

A nurse is caring for a patient with a traumatic brain injury. Which assessment finding would
indicate increased intracranial pressure (ICP)?

 A) Increased alertness
 B) Pupil constriction
 C) Projectile vomiting
 D) Hyperactivity

Correct Answer: C
Rationale: Projectile vomiting can be a sign of increased ICP and requires immediate
evaluation.
Question 980: Cardiovascular

A patient is experiencing chest pain and is suspected to have angina. Which medication should
the nurse anticipate administering?

 A) Nitroglycerin
 B) Aspirin
 C) Beta-blocker
 D) Statin

Correct Answer: A
Rationale: Nitroglycerin is used to relieve angina by dilating coronary arteries and improving
blood flow.

Question 981: Pharmacology

A patient is prescribed metformin (Glucophage) for type 2 diabetes. Which side effect should the
nurse inform the patient about?

 A) Hypoglycemia
 B) Weight gain
 C) Gastrointestinal upset
 D) Increased appetite

Correct Answer: C
Rationale: Gastrointestinal upset is a common side effect of metformin.

Question 982: Endocrine

A patient with diabetes is experiencing polyuria, polydipsia, and polyphagia. Which condition
should the nurse suspect?

 A) Hypoglycemia
 B) Hyperglycemia
 C) DKA (Diabetic Ketoacidosis)
 D) HHS (Hyperglycemic Hyperosmolar State)

Correct Answer: B
Rationale: Polyuria, polydipsia, and polyphagia are classic symptoms of hyperglycemia.
Question 983: Respiratory

A nurse is caring for a patient with pneumonia. Which finding indicates that the patient's
condition is worsening?

 A) Decreased cough reflex

 B) Increased sputum production
 C) Oxygen saturation of 92%
 D) Mild fever

Correct Answer: A
Rationale: A decreased cough reflex can indicate worsening respiratory status and impaired
ability to clear secretions.

Question 984: Gastrointestinal

A nurse is caring for a patient with ulcerative colitis. Which diet should the nurse recommend?

 A) High-fiber diet
 B) Low-fiber diet
 C) Gluten-free diet
 D) High-protein diet

Correct Answer: B
Rationale: A low-fiber diet is recommended during flare-ups of ulcerative colitis to minimize
bowel irritation.

Question 985: Mental Health

A patient with bipolar disorder is experiencing a manic episode. Which behavior might the nurse
observe?

 A) Withdrawal from social activities

 B) Decreased energy levels
 C) Excessive talking and high energy
 D) Insomnia

Correct Answer: C
Rationale: Excessive talking and high energy levels are characteristic of a manic episode.
Question 986: Obstetrics

A nurse is assessing a pregnant patient in her third trimester. Which finding would be
concerning?

 A) Fetal heart rate of 140 bpm

 B) Fundal height measuring 34 cm
 C) Severe lower abdominal pain
 D) Edema in lower extremities

Correct Answer: C
Rationale: Severe lower abdominal pain could indicate complications such as placental
abruption or preterm labor.

Question 987: Pediatric Nursing

A nurse is caring for a 3-year-old child with asthma. Which assessment finding is most
concerning?

 A) Expiratory wheezing
 B) Intercostal retractions
 C) Mild shortness of breath
 D) Coughing

Correct Answer: B
Rationale: Intercostal retractions indicate increased work of breathing and potential respiratory
distress.

Question 988: Renal

A patient with chronic kidney disease is prescribed erythropoietin (Epogen). What is the
expected outcome of this medication?

 A) Decrease in potassium levels

 B) Increase in red blood cell production
 C) Increase in blood glucose levels
 D) Decrease in blood pressure
Correct Answer: B
Rationale: Erythropoietin is used to stimulate red blood cell production in patients with anemia
due to chronic kidney disease.

Question 989: Infection Control

A nurse is caring for a patient diagnosed with a viral infection. Which precaution should the
nurse implement?

 A) Airborne precautions
 B) Contact precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: D
Rationale: Standard precautions should be used for all patients, regardless of the infection type.

Question 990: Neurological

A patient is admitted with a stroke. Which assessment finding would suggest a right-sided
stroke?

 A) Right-sided weakness
 B) Difficulty speaking
 C) Left-sided neglect
 D) Right-sided facial droop

Correct Answer: C
Rationale: Left-sided neglect is indicative of a right-sided stroke due to damage in the right
hemisphere of the brain.

Question 991: Cardiovascular

A patient with heart failure is prescribed digoxin. Which sign of digoxin toxicity should the
nurse monitor for?

 A) Bradycardia
 B) Hypertension
 C) Increased appetite
 D) Hyperkalemia
Correct Answer: A
Rationale: Bradycardia is a common sign of digoxin toxicity and requires prompt evaluation.

Question 992: Endocrine

A nurse is educating a patient with hyperthyroidism. Which statement indicates the patient needs
further teaching?

 A) "I should monitor my weight regularly."

 B) "I can eat a high-fiber diet."
 C) "I need to avoid foods high in iodine."
 D) "I should limit my fluid intake."

Correct Answer: D
Rationale: Patients with hyperthyroidism should not limit fluid intake, as dehydration can
exacerbate symptoms.

Question 993: Gastrointestinal

A nurse is caring for a patient with a nasogastric (NG) tube. Which finding indicates proper
placement of the tube?

 A) Auscultation of bowel sounds

 B) Absence of cough during insertion
 C) pH of gastric contents between 1 and 4
 D) Presence of a saline solution in the tube

Correct Answer: C
Rationale: A pH of gastric contents between 1 and 4 indicates proper placement of the NG tube
in the stomach.

Question 994: Mental Health

A nurse is caring for a patient experiencing a panic attack. Which intervention is the priority?

 A) Encourage deep breathing

 B) Administer prescribed medications
 C) Provide a calm environment
 D) Ask about the patient's feelings
Correct Answer: A
Rationale: Encouraging deep breathing helps to reduce anxiety and control the symptoms of a
panic attack.

Question 995: Obstetrics

A nurse is monitoring a patient for signs of preeclampsia. Which finding would be concerning?

 A) Elevated blood pressure

 B) Mild proteinuria
 C) Edema of the feet
 D) Fetal heart rate of 120 bpm

Correct Answer: A
Rationale: Elevated blood pressure is a key sign of preeclampsia and requires further assessment
and intervention.

Question 996: Pediatric Nursing

A nurse is assessing a child with chickenpox. Which symptom would be expected?

 A) Maculopapular rash
 B) Bullous lesions
 C) Vesicular lesions
 D) Scaly patches

Correct Answer: C
Rationale: Chickenpox is characterized by vesicular lesions that progress through stages of
macules, papules, vesicles, and crusts.

Question 997: Renal

A nurse is caring for a patient on continuous ambulatory peritoneal dialysis (CAPD). Which
finding may indicate peritonitis?

 A) Clear dialysate return

 B) Cloudy dialysate return
 C) Weight loss
 D) Decreased appetite
Correct Answer: B
Rationale: Cloudy dialysate return is a classic sign of peritonitis in patients undergoing CAPD.

Question 998: Infection Control

A nurse is caring for a patient with a respiratory infection. Which action is most important to
prevent the spread of infection?

 A) Wearing gloves
 B) Using a mask
 C) Performing hand hygiene
 D) Isolating the patient

Correct Answer: C
Rationale: Performing hand hygiene is the most effective way to prevent the spread of
infections.

Question 999: Neurological

A patient with a history of transient ischemic attacks (TIAs) is being discharged. Which
instruction should the nurse provide?

 A) Avoid all physical activity

 B) Take aspirin as prescribed
 C) Increase sodium intake
 D) Limit fluid intake

Correct Answer: B
Rationale: Taking aspirin as prescribed helps reduce the risk of future TIAs and strokes.

Question 1000: Cardiovascular

A nurse is monitoring a patient after myocardial infarction (MI). Which complication should the
nurse assess for in the first 24 hours?

 A) Heart failure
 B) Pericarditis
 C) Arrhythmias
 D) Cardiogenic shock
Correct Answer: C
Rationale: Arrhythmias are a common complication following an MI and should be monitored
closely in the first 24 hours.

Question 1001: Pharmacology

A patient is prescribed lisinopril (Zestril). What should the nurse monitor for as a potential side
effect?

 A) Hyperkalemia
 B) Hypertension
 C) Bradycardia
 D) Increased thirst

Correct Answer: A
Rationale: Lisinopril can cause hyperkalemia (high potassium levels), so monitoring potassium
levels is essential.

Question 1002: Endocrine

A nurse is teaching a patient with diabetes about the importance of foot care. Which statement
indicates a need for further education?

 A) "I should check my feet daily for cuts and sores."

 B) "I can use lotion between my toes."
 C) "I should wear shoes that fit well."
 D) "I need to see a podiatrist regularly."

Correct Answer: B
Rationale: Patients should avoid using lotion between their toes to prevent fungal infections.

Question 1003: Respiratory

A nurse is caring for a patient with asthma. Which intervention is a priority during an asthma
attack?

 A) Administer a corticosteroid
 B) Administer a bronchodilator
 C) Provide oxygen therapy
 D) Assess peak flow readings
Correct Answer: B
Rationale: Administering a bronchodilator is the priority during an asthma attack to relieve
bronchospasm.

Question 1004: Gastrointestinal

A nurse is caring for a patient with pancreatitis. Which dietary change should the nurse
recommend?

 A) High-fat diet
 B) Low-carb diet
 C) Low-protein diet
 D) Low-fat diet

Correct Answer: D
Rationale: A low-fat diet is recommended for patients with pancreatitis to reduce pancreatic
stimulation.

Question 1005: Mental Health

A patient with schizophrenia is prescribed clozapine (Clozaril). What is the most important lab
value for the nurse to monitor?

 A) Liver function tests

 B) Blood glucose levels
 C) White blood cell count
 D) Serum electrolyte levels

Correct Answer: C
Rationale: Clozapine can cause agranulocytosis, so monitoring the white blood cell count is
crucial.

Question 1006: Obstetrics

A nurse is assessing a postpartum patient. Which finding should the nurse report immediately?

 A) Moderate lochia rubra

 B) Fever of 101°F
 C) Fundus firm at the umbilicus
 D) Urine output of 100 mL in 4 hours
Correct Answer: B
Rationale: A fever of 101°F may indicate infection and should be reported immediately.

Question 1007: Pediatric Nursing

A nurse is assessing a child with suspected dehydration. Which finding would be most
concerning?

 A) Dry mucous membranes

 B) Decreased urine output
 C) Increased heart rate
 D) Sunken fontanelle

Correct Answer: D
Rationale: A sunken fontanelle is a sign of severe dehydration in infants and requires immediate
attention.

Question 1008: Renal

A nurse is caring for a patient with nephrotic syndrome. Which laboratory finding would the
nurse expect?

 A) Hypercalcemia
 B) Hypoalbuminemia
 C) Hyperglycemia
 D) Hyponatremia

Correct Answer: B
Rationale: Hypoalbuminemia (low albumin levels) is characteristic of nephrotic syndrome due
to increased protein loss.

Question 1009: Infection Control

A nurse is caring for a patient with C. difficile infection. Which precaution should the nurse
implement?

 A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions
Correct Answer: A
Rationale: Contact precautions are required to prevent the spread of C. difficile infection.

Question 1010: Neurological

A nurse is assessing a patient who has had a stroke. Which symptom would indicate that the
patient has had a left-sided stroke?

 A) Left-sided weakness
 B) Difficulty with speech
 C) Right-sided neglect
 D) Poor coordination

Correct Answer: B
Rationale: Difficulty with speech (aphasia) is often associated with a left-sided stroke due to
damage in the language centers of the brain.

Question 1011: Cardiovascular

A nurse is caring for a patient with hypertension who is prescribed amlodipine (Norvasc). Which
side effect should the nurse monitor for?

 A) Bradycardia
 B) Peripheral edema
 C) Weight loss
 D) Hypoglycemia

Correct Answer: B
Rationale: Peripheral edema is a common side effect of calcium channel blockers like
amlodipine.

Question 1012: Endocrine

A patient is receiving levothyroxine (Synthroid) for hypothyroidism. Which statement by the

patient indicates a need for further teaching?

 A) "I need to take this medication in the morning."

 B) "I can take this medication with food."
 C) "I will have my thyroid levels checked regularly."
 D) "I should report any symptoms of palpitations."
Correct Answer: B
Rationale: Levothyroxine should be taken on an empty stomach, preferably 30-60 minutes
before breakfast.

Question 1013: Gastrointestinal

A nurse is caring for a patient with a colostomy. Which statement indicates that the patient
understands how to care for the stoma?

 A) "I should clean the stoma with alcohol."

 B) "I will change the pouch every 3 to 5 days."
 C) "The stoma should be pink and moist."
 D) "I can use regular soap to clean the stoma."

Correct Answer: C
Rationale: The stoma should be pink and moist, indicating good blood supply and healthy
tissue.

Question 1014: Mental Health

A nurse is assessing a patient with major depressive disorder. Which behavior might indicate
suicidal ideation?

 A) Increased energy
 B) Giving away possessions
 C) Engaging in social activities
 D) Expressing feelings of hopelessness

Correct Answer: B
Rationale: Giving away possessions can indicate that a person may be contemplating suicide.

Question 1015: Obstetrics

A nurse is monitoring a woman in labor. Which finding would indicate fetal distress?

 A) Fetal heart rate of 140 bpm

 B) Variable decelerations
 C) Moderate variability
 D) Presence of accelerations
Correct Answer: B
Rationale: Variable decelerations may indicate umbilical cord compression, which can lead to
fetal distress.

Question 1016: Pediatric Nursing

A nurse is caring for a child with asthma who is using a peak flow meter. Which reading
indicates that the child is in the green zone?

 A) 50% of personal best

 B) 80% of personal best
 C) 100% of personal best
 D) 60% of personal best

Correct Answer: B
Rationale: A reading of 80% or higher of the personal best indicates that the child is in the green
zone and asthma is well controlled.

Question 1017: Renal

A nurse is caring for a patient with acute kidney injury (AKI). Which finding would indicate
improvement in renal function?

 A) Decreased blood urea nitrogen (BUN)

 B) Increased creatinine levels
 C) Increased potassium levels
 D) Decreased urine output

Correct Answer: A
Rationale: A decrease in blood urea nitrogen (BUN) indicates improvement in renal function in
a patient with AKI.

Question 1018: Infection Control

A nurse is caring for a patient who has a wound infected with MRSA. What is the most
important precaution to prevent transmission?

 A) Hand hygiene
 B) Wearing gloves
 C) Wearing a mask
  D) Isolation

Correct Answer: A
Rationale: Hand hygiene is the most effective method to prevent the transmission of infections,
including MRSA.

Question 1019: Neurological

A nurse is assessing a patient with a suspected seizure disorder. Which finding would suggest a
focal seizure?

 A) Loss of consciousness
 B) Uncontrolled muscle spasms
 C) Staring and unresponsiveness
 D) Jerking movements of one limb

Correct Answer: D
Rationale: Jerking movements of one limb are indicative of a focal seizure, which originates in
one area of the brain.

Question 1020: Cardiovascular

A patient with heart failure is prescribed a diuretic. Which symptom would indicate that the
medication is effective?

 A) Increased heart rate

 B) Decreased weight
 C) Increased blood pressure
 D) Increased edema

Correct Answer: B
Rationale: A decreased weight indicates that fluid retention is being effectively managed with
the diuretic.

Question 1021: Pharmacology

A nurse is teaching a patient about the use of atorvastatin (Lipitor). Which statement by the
patient indicates an understanding of the medication's purpose?

 A) "This medication will lower my blood sugar."

  B) "I need to watch for signs of liver damage."
 C) "I should take this medication only when my cholesterol is high."
 D) "This medication will help me lose weight."

Correct Answer: B
Rationale: Patients taking atorvastatin should be monitored for liver function as it can affect the
liver.

Question 1022: Endocrine

A patient with diabetes is prescribed insulin glargine (Lantus). What is the appropriate nursing
action regarding the timing of this medication?

 A) Administer with meals

 B) Administer at bedtime
 C) Administer when blood sugar is high
 D) Administer before exercise

Correct Answer: B
Rationale: Insulin glargine is a long-acting insulin that is typically administered at bedtime to
provide a stable insulin level throughout the night.

Question 1023: Gastrointestinal

A nurse is caring for a patient with cirrhosis. Which assessment finding is most concerning?

 A) Jaundice
 B) Ascites
 C) Altered mental status
 D) Dark urine

Correct Answer: C
Rationale: Altered mental status may indicate hepatic encephalopathy, which is a critical
condition requiring immediate intervention.

Question 1024: Mental Health

A patient in a psychiatric unit expresses feelings of worthlessness. What is the nurse's best
response?
  A) "You shouldn't feel that way."
 B) "Why do you feel worthless?"
 C) "Tell me more about those feelings."
 D) "You will feel better soon."

Correct Answer: C
Rationale: Encouraging the patient to share more about their feelings provides support and helps
assess their mental state.

Question 1025: Obstetrics

A nurse is providing education on signs of labor. Which statement by the patient indicates
understanding?

 A) "I should call my doctor if I have a headache."

 B) "I will come to the hospital if I have contractions every 10 minutes."
 C) "If my water breaks, I will stay at home until contractions start."
 D) "I should go to the hospital if I have a bloody show."

Correct Answer: D
Rationale: A bloody show can indicate that labor is approaching, and the patient should go to
the hospital.

Question 1026: Pharmacology

A patient with hypertension is prescribed a beta-blocker. The nurse should monitor the patient
for which of the following potential side effects? (Select all that apply.)

 A) Bradycardia
 B) Hypertension
 C) Dizziness
 D) Hyperglycemia
 E) Fatigue

Correct Answers: A, C, E
Rationale: Common side effects of beta-blockers include bradycardia, dizziness, and fatigue.
They can also mask symptoms of hypoglycemia but may not directly cause hyperglycemia or
hypertension.

Question 1027: Gastrointestinal

A nurse is providing dietary education to a patient with celiac disease. Which foods should the
nurse recommend avoiding? (Select all that apply.)

 A) Wheat bread
 B) Rice
 C) Oats
 D) Barley
 E) Quinoa

Correct Answers: A, C, D
Rationale: Patients with celiac disease should avoid gluten-containing grains, including wheat,
oats (unless labeled gluten-free), and barley. Rice and quinoa are gluten-free.

Question 1028: Cardiovascular

A nurse is monitoring a patient who has just received a dose of digoxin (Lanoxin). Which
findings would require immediate intervention? (Select all that apply.)

 A) Heart rate of 50 bpm

 B) Serum potassium level of 3.0 mEq/L
 C) Blood pressure of 120/80 mmHg
 D) ECG showing bradycardia
 E) Serum digoxin level of 0.5 ng/mL

Correct Answers: A, B, D
Rationale: A heart rate of 50 bpm and bradycardia on ECG indicate potential digoxin toxicity,
especially with a low potassium level, which increases the risk of toxicity.

Question 1029: Endocrine

A nurse is caring for a patient with type 1 diabetes who has been ill. The patient’s blood glucose
levels are elevated, and the patient shows signs of dehydration. What should the nurse do?
(Select all that apply.)

 A) Administer insulin as prescribed

 B) Encourage fluid intake
 C) Obtain a urine sample for ketone testing
 D) Withhold all oral medications
 E) Monitor blood glucose levels frequently

Correct Answers: A, B, C, E
Rationale: Administering insulin, encouraging fluid intake, obtaining a urine sample for ketone
testing, and frequent monitoring of blood glucose levels are all important interventions for
managing illness-related hyperglycemia.

Question 1030: Infection Control

A nurse is teaching a patient with a urinary tract infection (UTI) about home care. Which
statements indicate that the patient understands the teaching? (Select all that apply.)

 A) "I should drink plenty of fluids."

 B) "I will hold off on urinating until I get to the bathroom."
 C) "I should take my antibiotics until they are all gone."
 D) "I can wear tight-fitting clothing for comfort."
 E) "I should wipe from front to back after using the toilet."

Correct Answers: A, C, E
Rationale: Patients should drink plenty of fluids, complete the antibiotic course, and wipe from
front to back to prevent further infections. Holding urine and wearing tight clothing may
exacerbate symptoms.

Question 1031: Neurological

A nurse is assessing a patient who had a stroke. Which findings indicate that the patient may
have had a right-sided stroke? (Select all that apply.)

 A) Left-sided weakness
 B) Impulsive behavior
 C) Difficulty understanding speech
 D) Poor spatial awareness
 E) Right-sided neglect

Correct Answers: A, B, D
Rationale: Right-sided strokes typically result in left-sided weakness, impulsive behavior, and
poor spatial awareness. Difficulty understanding speech is more common with left-sided strokes.

Question 1032: Mental Health

A nurse is caring for a patient with major depressive disorder. Which statements by the patient
would indicate a need for further assessment? (Select all that apply.)

 A) "I feel tired all the time."

  B) "I have lost interest in activities I used to enjoy."
 C) "I think I would be better off dead."
 D) "I sleep too much lately."
 E) "I enjoy spending time with my friends."

Correct Answers: C
Rationale: The statement "I think I would be better off dead" indicates suicidal ideation and
requires immediate assessment and intervention.

Question 1033: Pediatric Nursing

A nurse is providing discharge teaching to the parents of a child with asthma. Which statements
indicate that further teaching is needed? (Select all that apply.)

 A) "I should use a peak flow meter to monitor my child's lung function."
 B) "I will keep my child's rescue inhaler in the car."
 C) "My child can stop taking medications when symptoms improve."
 D) "I need to avoid triggers like smoke and pets."
 E) "I will have my child do breathing exercises daily."

Correct Answers: B, C
Rationale: The rescue inhaler should be kept accessible, not in the car. Children with asthma
should not stop taking medications without consulting a healthcare provider, even when
symptoms improve.

Question 1034: Obstetrics

A nurse is assessing a postpartum woman. Which findings should prompt the nurse to take
immediate action? (Select all that apply.)

 A) Severe headache
 B) Fundus is above the umbilicus
 C) Large clots in the pad
 D) Heart rate of 110 bpm
 E) Breast tenderness

Correct Answers: A, B, C, D
Rationale: A severe headache may indicate postpartum preeclampsia, and a fundus above the
umbilicus or large clots can indicate postpartum hemorrhage. A heart rate of 110 bpm may
indicate hypovolemia.
Question 1035: Renal

A nurse is caring for a patient with chronic kidney disease. Which dietary modifications should
the nurse recommend? (Select all that apply.)

 A) Decrease protein intake

 B) Increase potassium intake
 C) Decrease sodium intake
 D) Increase fluid intake
 E) Monitor phosphorus intake

Correct Answers: A, C, E
Rationale: Patients with chronic kidney disease should decrease protein, sodium, and
phosphorus intake to help manage their condition, while potassium intake should be monitored
closely and typically limited.

Question 1036: Respiratory

A nurse is teaching a patient with COPD about the use of a metered-dose inhaler (MDI). Which
statements indicate that further education is needed? (Select all that apply.)

 A) "I should shake the inhaler before using it."

 B) "I need to inhale deeply while pressing the canister."
 C) "I can use my MDI without a spacer."
 D) "I will breathe in and hold my breath for 10 seconds."
 E) "I will use my inhaler only when I feel short of breath."

Correct Answers: B, C, E
Rationale: The patient should not inhale deeply while pressing the canister; instead, they should
take a normal breath. Using a spacer is recommended for more effective delivery, and the inhaler
should be used as prescribed, not just when short of breath.

Question 1037: Infection Control

A nurse is caring for a patient with a central line. Which interventions should the nurse
implement to prevent central line-associated bloodstream infections (CLABSIs)? (Select all that
apply.)

 A) Perform hand hygiene before and after contact

 B) Use sterile technique for dressing changes
 C) Flush the line with normal saline every shift
 D) Change the IV tubing every 48 hours
  E) Use an antimicrobial-impregnated catheter when possible

Correct Answers: A, B, E
Rationale: Hand hygiene, using sterile technique for dressing changes, and using antimicrobial-
impregnated catheters are all critical interventions to prevent CLABSIs.

Question 1038: Cardiovascular

A nurse is monitoring a patient receiving heparin. Which laboratory values should the nurse
review? (Select all that apply.)

 A) aPTT
 B) PT
 C) INR
 D) CBC
 E) Platelet count

Correct Answers: A, D, E
Rationale: The nurse should monitor aPTT to assess heparin therapy, along with CBC and
platelet count to watch for thrombocytopenia or bleeding.

Question 1039: Obstetrics

A nurse is assessing a newborn shortly after birth. Which findings are considered normal?
(Select all that apply.)

 A) Heart rate of 120 bpm

 B) Respiratory rate of 60 breaths per minute
 C) Axillary temperature of 99°F
 D) Capillary refill time of 5 seconds
 E) Weight of 6 pounds

Correct Answers: A, B, C, E
Rationale: A normal heart rate for a newborn is 120-160 bpm, respiratory rate is 30-60 breaths
per minute, and the normal axillary temperature is 97.7°F to 99.5°F. A capillary refill time of 5
seconds is concerning.

Question 1040: Endocrine

A patient with Addison's disease is receiving hydrocortisone. Which statement by the patient
indicates a need for further teaching? (Select all that apply.)

 A) "I can stop taking this medication if I feel better."

 B) "I need to take this medication with food."
 C) "I should monitor my blood pressure regularly."
 D) "It's okay to skip a dose if I forget."
 E) "I need to increase my dose during times of stress."

Correct Answers: A, D
Rationale: Patients with Addison's disease should not stop taking hydrocortisone abruptly or
skip doses, as this can lead to an adrenal crisis. They should take the medication with food and
increase the dose during stress as prescribed.

Question 1041: Pharmacology

A patient with heart failure is prescribed furosemide (Lasix). Which assessments are essential for
the nurse to perform? (Select all that apply.)

 A) Monitor potassium levels

 B) Assess blood pressure
 C) Evaluate renal function
 D) Check for signs of dehydration
 E) Assess for respiratory rate

Correct Answers: A, B, C, D
Rationale: Monitoring potassium levels is crucial due to the risk of hypokalemia with
furosemide. Blood pressure, renal function, and signs of dehydration are also essential
assessments.

Question 1042: Neurological

A patient with a seizure disorder is being discharged on phenytoin (Dilantin). Which instructions
should the nurse include? (Select all that apply.)

 A) "You should take this medication with food."

 B) "It’s okay to skip doses if you forget."
 C) "You will need regular blood tests to monitor drug levels."
 D) "Report any rash or skin changes to your doctor."
 E) "You can stop taking this medication when your seizures are controlled."
Correct Answers: A, C, D
Rationale: Patients should take phenytoin with food, undergo regular blood tests, and report any
rash, as it may indicate a serious reaction. Skipping doses or stopping medication is not
recommended.

Question 1043: Infection Control

A nurse is caring for a patient with Clostridium difficile (C. diff) infection. Which precautions
should the nurse implement? (Select all that apply.)

 A) Hand hygiene with soap and water

 B) Use of alcohol-based hand sanitizer
 C) Contact precautions
 D) Use of a dedicated stethoscope and thermometer
 E) Isolation in a private room

Correct Answers: A, C, D, E
Rationale: Hand hygiene with soap and water is essential for C. diff, along with contact
precautions, using dedicated equipment, and isolation in a private room.

Question 1044: Endocrine

A nurse is teaching a patient about managing type 2 diabetes. Which statements indicate the need
for further education? (Select all that apply.)

 A) "I can eat whatever I want as long as I take my medication."

 B) "I should check my blood sugar levels regularly."
 C) "It's fine to skip meals if I'm not hungry."
 D) "I will exercise regularly to help control my diabetes."
 E) "I need to monitor my foot health regularly."

Correct Answers: A, C
Rationale: Patients should not eat anything they want without considering their diabetes
management, and skipping meals can lead to unstable blood sugar levels.

Question 1045: Cardiovascular

A nurse is assessing a patient with heart failure. Which findings would indicate worsening heart
failure? (Select all that apply.)
  A) Increased shortness of breath
 B) Weight gain of 2 pounds in one day
 C) Decreased urine output
 D) Dry cough
 E) Blood pressure of 130/80 mmHg

Correct Answers: A, B, C, D
Rationale: Symptoms of worsening heart failure include increased shortness of breath, rapid
weight gain due to fluid retention, decreased urine output, and dry cough due to pulmonary
congestion.

Question 1046: Obstetrics

A nurse is assessing a woman in labor. Which findings would indicate that the fetus is in
distress? (Select all that apply.)

 A) Fetal heart rate of 180 bpm

 B) Presence of variable decelerations
 C) Maternal temperature of 99.5°F
 D) Fetal heart rate variability of 15 bpm
 E) Late decelerations with contractions

Correct Answers: A, B, E
Rationale: A fetal heart rate above 160 bpm, variable decelerations, and late decelerations
indicate fetal distress and require further evaluation and intervention.

Question 1047: Pediatric Nursing

A nurse is providing education to the parents of a child with asthma. Which statements indicate
that the parents need further teaching? (Select all that apply.)

 A) "We can keep the windows open during pollen season."

 B) "We will avoid giving our child aspirin."
 C) "Using a humidifier in the child's room is a good idea."
 D) "We can manage our child's asthma with just rescue inhalers."
 E) "It’s fine for our child to play sports as long as they take their inhaler."

Correct Answers: A, C, D
Rationale: Keeping windows open during pollen season can expose the child to triggers, and
relying solely on rescue inhalers is not adequate for long-term management. Using a humidifier
can worsen asthma in some cases.
Question 1048: Gastrointestinal

A nurse is caring for a patient with peptic ulcer disease. Which statements by the patient indicate
an understanding of dietary modifications? (Select all that apply.)

 A) "I should avoid spicy foods."

 B) "I can drink milk to soothe my stomach."
 C) "I will limit my caffeine intake."
 D) "I can eat three large meals a day."
 E) "I should avoid alcohol."

Correct Answers: A, C, E
Rationale: Patients should avoid spicy foods, limit caffeine, and avoid alcohol. Drinking milk
may temporarily soothe the stomach but can stimulate acid production, and smaller, more
frequent meals are often recommended.

Question 1049: Renal

A nurse is caring for a patient on dialysis. Which assessments are critical for the nurse to
perform? (Select all that apply.)

 A) Monitor blood pressure

 B) Assess for signs of infection
 C) Evaluate access site for patency
 D) Check for weight gain
 E) Measure urine output

Correct Answers: A, B, C, D
Rationale: Blood pressure monitoring, assessing for infection, evaluating access site patency,
and checking for weight gain are essential. Urine output is often minimal or absent in dialysis
patients.

Question 1050: Mental Health

A nurse is caring for a patient diagnosed with depression. Which interventions are appropriate?
(Select all that apply.)

 A) Encourage participation in group therapy

 B) Provide a safe environment
 C) Minimize interactions with family
  D) Establish a routine for daily activities
 E) Encourage the patient to express feelings

Correct Answers: A, B, D, E
Rationale: Encouraging participation in group therapy, providing a safe environment,
establishing routines, and encouraging expression of feelings are beneficial for patients with
depression. Minimizing family interactions is not appropriate.

Question 1051: Respiratory

A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which
findings indicate the patient may be in respiratory distress? (Select all that apply.)

 A) Use of accessory muscles for breathing

 B) Respiratory rate of 20 breaths per minute
 C) Cyanosis of the lips
 D) Barrel chest appearance
 E) Decreased oxygen saturation

Correct Answers: A, C, E
Rationale: Use of accessory muscles, cyanosis, and decreased oxygen saturation indicate
respiratory distress, while a respiratory rate of 20 is within normal limits and barrel chest is a
common finding in COPD.

Question 1052: Cardiology

A patient with a history of myocardial infarction is being discharged. Which instructions should
the nurse provide? (Select all that apply.)

 A) "Avoid all physical activity for the next month."

 B) "Take your medications as prescribed."
 C) "Report any chest pain or shortness of breath immediately."
 D) "You can eat anything you want now."
 E) "Join a cardiac rehabilitation program."

Correct Answers: B, C, E
Rationale: Patients should take medications as prescribed, report any concerning symptoms, and
join a cardiac rehabilitation program for safe recovery. Avoiding all activity and unrestricted
eating are not appropriate.
Question 1053: Hematological

A nurse is caring for a patient with anemia. Which assessments are critical to include? (Select all
that apply.)

 A) Monitor vital signs

 B) Assess for pallor and fatigue
 C) Check for signs of bleeding
 D) Evaluate dietary intake
 E) Perform a skin assessment for rashes

Correct Answers: A, B, C, D
Rationale: Monitoring vital signs, assessing for pallor and fatigue, checking for bleeding, and
evaluating dietary intake are essential for managing anemia. A skin assessment for rashes is less
relevant.

Question 1054: Obstetrics

A nurse is teaching a pregnant woman about signs of preterm labor. Which statements indicate a
need for further teaching? (Select all that apply.)

 A) "I should call my doctor if I have regular contractions."

 B) "Back pain is a normal part of pregnancy."
 C) "If I notice a change in vaginal discharge, I should call my doctor."
 D) "I can ignore mild cramps as they are just normal pregnancy pains."
 E) "I need to report any leaking of fluid."

Correct Answers: B, D
Rationale: While back pain can be normal, it should be assessed in the context of other
symptoms. Mild cramps should not be ignored, especially if they are persistent or increasing.

Question 1055: Pediatric Nursing

A nurse is providing education to the parents of a child diagnosed with asthma. Which
statements indicate an understanding of the teaching? (Select all that apply.)

 A) "We will keep a record of our child's peak flow readings."

 B) "Our child can have a cat since they are not allergic."
 C) "We should avoid triggers like smoke and pollen."
 D) "It’s important for our child to have a written asthma action plan."
 E) "We can allow our child to play outside during high pollen days."
Correct Answers: A, C, D
Rationale: Keeping track of peak flow readings, avoiding triggers, and having a written asthma
action plan are critical for managing asthma. Allowing pets in the home and playing outside
during high pollen days can worsen symptoms.

Question 1041: Pharmacology

A patient with heart failure is prescribed furosemide (Lasix). Which assessments are essential for
the nurse to perform? (Select all that apply.)

 A) Monitor potassium levels

 B) Assess blood pressure
 C) Evaluate renal function
 D) Check for signs of dehydration
 E) Assess for respiratory rate

Correct Answers: A, B, C, D
Rationale: Monitoring potassium levels is crucial due to the risk of hypokalemia with
furosemide. Blood pressure, renal function, and signs of dehydration are also essential
assessments.

Question 1042: Neurological

A patient with a seizure disorder is being discharged on phenytoin (Dilantin). Which instructions
should the nurse include? (Select all that apply.)

 A) "You should take this medication with food."

 B) "It’s okay to skip doses if you forget."
 C) "You will need regular blood tests to monitor drug levels."
 D) "Report any rash or skin changes to your doctor."
 E) "You can stop taking this medication when your seizures are controlled."

Correct Answers: A, C, D
Rationale: Patients should take phenytoin with food, undergo regular blood tests, and report any
rash, as it may indicate a serious reaction. Skipping doses or stopping medication is not
recommended.

Question 1043: Infection Control

A nurse is caring for a patient with Clostridium difficile (C. diff) infection. Which precautions
should the nurse implement? (Select all that apply.)

 A) Hand hygiene with soap and water

 B) Use of alcohol-based hand sanitizer
 C) Contact precautions
 D) Use of a dedicated stethoscope and thermometer
 E) Isolation in a private room

Correct Answers: A, C, D, E
Rationale: Hand hygiene with soap and water is essential for C. diff, along with contact
precautions, using dedicated equipment, and isolation in a private room.

Question 1044: Endocrine

A nurse is teaching a patient about managing type 2 diabetes. Which statements indicate the need
for further education? (Select all that apply.)

 A) "I can eat whatever I want as long as I take my medication."

 B) "I should check my blood sugar levels regularly."
 C) "It's fine to skip meals if I'm not hungry."
 D) "I will exercise regularly to help control my diabetes."
 E) "I need to monitor my foot health regularly."

Correct Answers: A, C
Rationale: Patients should not eat anything they want without considering their diabetes
management, and skipping meals can lead to unstable blood sugar levels.

Question 1045: Cardiovascular

A nurse is assessing a patient with heart failure. Which findings would indicate worsening heart
failure? (Select all that apply.)

 A) Increased shortness of breath

 B) Weight gain of 2 pounds in one day
 C) Decreased urine output
 D) Dry cough
 E) Blood pressure of 130/80 mmHg

Correct Answers: A, B, C, D
Rationale: Symptoms of worsening heart failure include increased shortness of breath, rapid
weight gain due to fluid retention, decreased urine output, and dry cough due to pulmonary
congestion.

Question 1046: Obstetrics

A nurse is assessing a woman in labor. Which findings would indicate that the fetus is in
distress? (Select all that apply.)

 A) Fetal heart rate of 180 bpm

 B) Presence of variable decelerations
 C) Maternal temperature of 99.5°F
 D) Fetal heart rate variability of 15 bpm
 E) Late decelerations with contractions

Correct Answers: A, B, E
Rationale: A fetal heart rate above 160 bpm, variable decelerations, and late decelerations
indicate fetal distress and require further evaluation and intervention.

Question 1047: Pediatric Nursing

A nurse is providing education to the parents of a child with asthma. Which statements indicate
that the parents need further teaching? (Select all that apply.)

 A) "We can keep the windows open during pollen season."

 B) "We will avoid giving our child aspirin."
 C) "Using a humidifier in the child's room is a good idea."
 D) "We can manage our child's asthma with just rescue inhalers."
 E) "It’s fine for our child to play sports as long as they take their inhaler."

Correct Answers: A, C, D
Rationale: Keeping windows open during pollen season can expose the child to triggers, and
relying solely on rescue inhalers is not adequate for long-term management. Using a humidifier
can worsen asthma in some cases.

Question 1048: Gastrointestinal

A nurse is caring for a patient with peptic ulcer disease. Which statements by the patient indicate
an understanding of dietary modifications? (Select all that apply.)

 A) "I should avoid spicy foods."

  B) "I can drink milk to soothe my stomach."
 C) "I will limit my caffeine intake."
 D) "I can eat three large meals a day."
 E) "I should avoid alcohol."

Correct Answers: A, C, E
Rationale: Patients should avoid spicy foods, limit caffeine, and avoid alcohol. Drinking milk
may temporarily soothe the stomach but can stimulate acid production, and smaller, more
frequent meals are often recommended.

Question 1049: Renal

A nurse is caring for a patient on dialysis. Which assessments are critical for the nurse to
perform? (Select all that apply.)

 A) Monitor blood pressure

 B) Assess for signs of infection
 C) Evaluate access site for patency
 D) Check for weight gain
 E) Measure urine output

Correct Answers: A, B, C, D
Rationale: Blood pressure monitoring, assessing for infection, evaluating access site patency,
and checking for weight gain are essential. Urine output is often minimal or absent in dialysis
patients.

Question 1050: Mental Health

A nurse is caring for a patient diagnosed with depression. Which interventions are appropriate?
(Select all that apply.)

 A) Encourage participation in group therapy

 B) Provide a safe environment
 C) Minimize interactions with family
 D) Establish a routine for daily activities
 E) Encourage the patient to express feelings

Correct Answers: A, B, D, E
Rationale: Encouraging participation in group therapy, providing a safe environment,
establishing routines, and encouraging expression of feelings are beneficial for patients with
depression. Minimizing family interactions is not appropriate.
Question 1051: Respiratory

A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which
findings indicate the patient may be in respiratory distress? (Select all that apply.)

 A) Use of accessory muscles for breathing

 B) Respiratory rate of 20 breaths per minute
 C) Cyanosis of the lips
 D) Barrel chest appearance
 E) Decreased oxygen saturation

Correct Answers: A, C, E
Rationale: Use of accessory muscles, cyanosis, and decreased oxygen saturation indicate
respiratory distress, while a respiratory rate of 20 is within normal limits and barrel chest is a
common finding in COPD.

Question 1052: Cardiology

A patient with a history of myocardial infarction is being discharged. Which instructions should
the nurse provide? (Select all that apply.)

 A) "Avoid all physical activity for the next month."

 B) "Take your medications as prescribed."
 C) "Report any chest pain or shortness of breath immediately."
 D) "You can eat anything you want now."
 E) "Join a cardiac rehabilitation program."

Correct Answers: B, C, E
Rationale: Patients should take medications as prescribed, report any concerning symptoms, and
join a cardiac rehabilitation program for safe recovery. Avoiding all activity and unrestricted
eating are not appropriate.

Question 1053: Hematological

A nurse is caring for a patient with anemia. Which assessments are critical to include? (Select all
that apply.)

 A) Monitor vital signs

 B) Assess for pallor and fatigue
 C) Check for signs of bleeding
  D) Evaluate dietary intake
 E) Perform a skin assessment for rashes

Correct Answers: A, B, C, D
Rationale: Monitoring vital signs, assessing for pallor and fatigue, checking for bleeding, and
evaluating dietary intake are essential for managing anemia. A skin assessment for rashes is less
relevant.

Question 1054: Obstetrics

A nurse is teaching a pregnant woman about signs of preterm labor. Which statements indicate a
need for further teaching? (Select all that apply.)

 A) "I should call my doctor if I have regular contractions."

 B) "Back pain is a normal part of pregnancy."
 C) "If I notice a change in vaginal discharge, I should call my doctor."
 D) "I can ignore mild cramps as they are just normal pregnancy pains."
 E) "I need to report any leaking of fluid."

Correct Answers: B, D
Rationale: While back pain can be normal, it should be assessed in the context of other
symptoms. Mild cramps should not be ignored, especially if they are persistent or increasing.

Question 1055: Pediatric Nursing

A nurse is providing education to the parents of a child diagnosed with asthma. Which
statements indicate an understanding of the teaching? (Select all that apply.)

 A) "We will keep a record of our child's peak flow readings."

 B) "Our child can have a cat since they are not allergic."
 C) "We should avoid triggers like smoke and pollen."
 D) "It’s important for our child to have a written asthma action plan."
 E) "We can allow our child to play outside during high pollen days."

Correct Answers: A, C, D
Rationale: Keeping track of peak flow readings, avoiding triggers, and having a written asthma
action plan are critical for managing asthma. Allowing pets in the home and playing outside
during high pollen days can worsen symptoms.

Question 1056: Neurological

A nurse is assessing a patient who experienced a stroke. Which findings indicate that the patient
may have developed dysphagia? (Select all that apply.)

 A) Coughing during meals

 B) Difficulty speaking
 C) Excessive drooling
 D) Complaints of a "lump" in the throat
 E) Clear speech

Correct Answers: A, C, D
Rationale: Coughing during meals, excessive drooling, and feeling a "lump" in the throat may
indicate dysphagia. Difficulty speaking is more related to aphasia than swallowing issues, and
clear speech would not suggest dysphagia.

Question 1057: Pharmacology

A nurse is administering warfarin (Coumadin) to a patient. Which laboratory tests should the
nurse monitor? (Select all that apply.)

 A) Prothrombin time (PT)

 B) International normalized ratio (INR)
 C) Partial thromboplastin time (PTT)
 D) Complete blood count (CBC)
 E) Liver function tests

Correct Answers: A, B
Rationale: PT and INR are essential for monitoring warfarin therapy. PTT is not typically
monitored for patients on warfarin. A CBC may be done for other reasons, and liver function
tests are relevant if there are concerns about drug metabolism.

Question 1058: Infection Control

A nurse is caring for a patient with tuberculosis (TB). Which precautions should the nurse
implement? (Select all that apply.)

 A) Airborne precautions
 B) N95 respirator mask for healthcare providers
 C) Isolation in a private room with negative pressure
 D) Contact precautions
 E) Hand hygiene before and after patient contact
Correct Answers: A, B, C, E
Rationale: TB requires airborne precautions, use of an N95 mask, negative pressure isolation,
and proper hand hygiene. Contact precautions are not necessary unless there are other factors at
play.

Question 1059: Cardiovascular

A nurse is monitoring a patient who has just undergone cardiac catheterization. Which findings
would indicate a complication? (Select all that apply.)

 A) Cool, pale extremities

 B) Chest pain
 C) Heart rate of 80 bpm
 D) Blood pressure of 110/70 mmHg
 E) Swelling at the catheter insertion site

Correct Answers: A, B, E
Rationale: Cool, pale extremities, chest pain, and swelling at the catheter site may indicate
complications such as thrombosis, hematoma, or compromised blood flow. The heart rate and
blood pressure are within acceptable limits.

Question 1060: Pediatric Nursing

A nurse is assessing a child with pneumonia. Which signs and symptoms would be consistent
with this diagnosis? (Select all that apply.)

 A) Fever
 B) Productive cough
 C) Bradycardia
 D) Increased respiratory rate
 E) Chest pain

Correct Answers: A, B, D, E
Rationale: Fever, productive cough, increased respiratory rate, and chest pain can all indicate
pneumonia. Bradycardia is not typical and would require further evaluation.

Question 1061: Gastrointestinal

A patient with liver cirrhosis is at risk for developing hepatic encephalopathy. Which
assessments are important for the nurse to monitor? (Select all that apply.)
  A) Level of consciousness
 B) Serum ammonia levels
 C) Nutritional intake
 D) Bowel movement frequency
 E) Blood glucose levels

Correct Answers: A, B, C
Rationale: Monitoring the level of consciousness and serum ammonia levels is crucial, as
elevated ammonia can lead to encephalopathy. Nutritional intake is also important to prevent
malnutrition, while bowel movements and blood glucose levels are less directly related.

Question 1062: Endocrine

A nurse is caring for a patient with diabetes insipidus. Which findings would indicate that the
patient is experiencing dehydration? (Select all that apply.)

 A) Increased urine output

 B) Dry mucous membranes
 C) Hypotension
 D) Weight gain
 E) Tachycardia

Correct Answers: B, C, E
Rationale: Dry mucous membranes, hypotension, and tachycardia are signs of dehydration.
Increased urine output is expected in diabetes insipidus, and weight gain would not be typical.

Question 1063: Maternity

A nurse is providing discharge teaching to a new mother. Which statements indicate a need for
further teaching about breastfeeding? (Select all that apply.)

 A) "I can stop breastfeeding if it becomes too painful."

 B) "I should nurse my baby every 2-3 hours."
 C) "I can use formula if I'm not producing enough milk."
 D) "It's okay to breastfeed if I have a cold."
 E) "I need to wash my nipples before each feeding."

Correct Answers: A, E
Rationale: Stopping breastfeeding due to pain without seeking help is not appropriate; the
mother should consult a lactation consultant. Washing nipples is not necessary; only washing
hands before feeding is essential.
Question 1064: Mental Health

A nurse is caring for a patient diagnosed with bipolar disorder. Which behaviors indicate the
patient may be experiencing mania? (Select all that apply.)

 A) Decreased need for sleep

 B) Increased talkativeness
 C) Withdrawal from social interactions
 D) Racing thoughts
 E) Inability to concentrate

Correct Answers: A, B, D
Rationale: Decreased need for sleep, increased talkativeness, and racing thoughts are indicative
of mania. Withdrawal from social interactions and inability to concentrate are more consistent
with depressive episodes.

Question 1065: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
interventions are appropriate? (Select all that apply.)

 A) Encourage smoking cessation

 B) Provide oxygen therapy as prescribed
 C) Teach pursed-lip breathing techniques
 D) Administer bronchodilators
 E) Encourage high levels of physical activity

Correct Answers: A, B, C, D
Rationale: Encouraging smoking cessation, providing prescribed oxygen, teaching pursed-lip
breathing, and administering bronchodilators are appropriate interventions. While physical
activity is important, it should be tailored to the patient’s tolerance level.

Question 1066: Hematological

A nurse is caring for a patient with a history of deep vein thrombosis (DVT). Which statements
by the patient indicate a need for further teaching about prevention strategies? (Select all that
apply.)

 A) "I can sit for long periods without moving."

 B) "I should wear compression stockings during long trips."
  C) "Drinking plenty of fluids can help prevent DVT."
 D) "I can stop taking my anticoagulant medication whenever I feel fine."
 E) "I will make sure to move my legs frequently when sitting."

Correct Answers: A, D
Rationale: Sitting for long periods and stopping anticoagulant medication without consulting a
healthcare provider are not appropriate practices for preventing DVT.

Question 1067: Gastrointestinal

A nurse is assessing a patient with acute pancreatitis. Which findings would the nurse expect?
(Select all that apply.)

 A) Severe abdominal pain

 B) Nausea and vomiting
 C) Jaundice
 D) Steatorrhea
 E) Decreased bowel sounds

Correct Answers: A, B, C, E
Rationale: Severe abdominal pain, nausea and vomiting, jaundice, and decreased bowel sounds
are common in acute pancreatitis. Steatorrhea (fatty stools) is more associated with chronic
pancreatitis.

Question 1068: Surgical

A nurse is preparing a patient for surgery. Which interventions are essential to include in the
preoperative checklist? (Select all that apply.)

 A) Verify informed consent

 B) Ensure the patient is NPO (nothing by mouth)
 C) Administer preoperative antibiotics as prescribed
 D) Mark the surgical site
 E) Provide the patient with a surgical gown

Correct Answers: A, B, C, D, E
Rationale: All listed interventions are essential preoperative tasks: verifying consent, ensuring
the patient is NPO, administering antibiotics, marking the surgical site, and providing
appropriate attire.
Question 1069: Endocrine

A nurse is teaching a patient about managing hyperthyroidism. Which statements indicate a need
for further teaching? (Select all that apply.)

 A) "I should monitor my weight regularly."

 B) "I can eat whatever I want."
 C) "I need to take my medication at the same time every day."
 D) "I should avoid foods high in iodine."
 E) "It's fine to skip doses if I feel better."

Correct Answers: B, E
Rationale: Patients with hyperthyroidism should monitor their diet and avoid foods high in
iodine. They should also take medication consistently and not skip doses.

Question 1070: Geriatric

A nurse is assessing an older adult patient. Which findings may indicate a risk for falls? (Select
all that apply.)

 A) History of previous falls

 B) Use of assistive devices
 C) Medications that cause dizziness
 D) Impaired vision
 E) Regular exercise program

Correct Answers: A, B, C, D
Rationale: A history of falls, use of assistive devices, dizziness from medications, and impaired
vision all increase fall risk. A regular exercise program typically reduces fall risk.

Question 1071: Pain Management

A patient is receiving morphine for pain management. Which assessments should the nurse
perform? (Select all that apply.)

 A) Respiratory rate
 B) Level of consciousness
 C) Blood pressure
 D) Pain scale assessment
 E) Temperature
Correct Answers: A, B, C, D
Rationale: Monitoring respiratory rate, level of consciousness, blood pressure, and pain level is
essential for a patient receiving morphine. Temperature is not directly related to morphine
administration.

Question 1072: Integumentary

A nurse is assessing a patient with a pressure ulcer. Which characteristics would indicate that the
ulcer is healing? (Select all that apply.)

 A) Granulation tissue formation

 B) Decreased size of the ulcer
 C) Increased drainage
 D) Erythema around the ulcer
 E) Pain reduction

Correct Answers: A, B, E
Rationale: Granulation tissue, decreased size, and pain reduction are positive signs of healing.
Increased drainage and erythema may indicate infection or complications.

Question 1073: Nutrition

A nurse is providing dietary teaching for a patient with hypertension. Which food choices
indicate an understanding of the teaching? (Select all that apply.)

 A) Fresh fruits and vegetables

 B) Whole grains
 C) Processed snacks
 D) Low-fat dairy products
 E) Cured meats

Correct Answers: A, B, D
Rationale: Fresh fruits, vegetables, whole grains, and low-fat dairy are recommended for
managing hypertension. Processed snacks and cured meats are high in sodium and should be
avoided.

Question 1074: Musculoskeletal

A nurse is caring for a patient with osteoarthritis. Which interventions should the nurse
implement to manage the patient's pain? (Select all that apply.)
  A) Encourage rest and joint protection
 B) Recommend hot or cold therapy
 C) Suggest weight loss if applicable
 D) Promote high-impact exercises
 E) Administer analgesics as prescribed

Correct Answers: A, B, C, E
Rationale: Rest, joint protection, hot or cold therapy, weight loss, and prescribed analgesics are
effective interventions for managing osteoarthritis pain. High-impact exercises are typically not
recommended.

Question 1075: Urology

A patient with acute renal failure is experiencing oliguria. Which nursing interventions are
appropriate? (Select all that apply.)

 A) Monitor vital signs

 B) Assess fluid balance
 C) Administer diuretics
 D) Monitor laboratory values (e.g., BUN, creatinine)
 E) Encourage high fluid intake

Correct Answers: A, B, D
Rationale: Monitoring vital signs, assessing fluid balance, and checking laboratory values are
important for a patient with acute renal failure. Administering diuretics is not typically
appropriate in oliguria, and encouraging high fluid intake may worsen fluid overload.

Question 1076: Cardiovascular

A patient is being assessed for hypertension. Which lifestyle modifications should the nurse
recommend? (Select all that apply.)

 A) Regular exercise
 B) Decreasing sodium intake
 C) Limiting alcohol consumption
 D) Increasing caffeine intake
 E) Maintaining a healthy weight

Correct Answers: A, B, C, E
Rationale: Regular exercise, decreasing sodium intake, limiting alcohol consumption, and
maintaining a healthy weight are all effective lifestyle modifications for managing hypertension.
Increasing caffeine intake is not recommended.
Question 1077: Endocrine

A nurse is teaching a patient with diabetes mellitus about hypoglycemia. Which statements
indicate an understanding of the teaching? (Select all that apply.)

 A) "I should carry a source of sugar with me at all times."

 B) "I can skip meals if I'm not hungry."
 C) "I need to check my blood glucose regularly."
 D) "I should avoid exercise if my blood sugar is low."
 E) "I can feel shaky and dizzy if my blood sugar drops."

Correct Answers: A, C, E
Rationale: Carrying a source of sugar, checking blood glucose regularly, and recognizing
symptoms of hypoglycemia (like shakiness and dizziness) are essential. Skipping meals and
avoiding exercise when blood sugar is low is not advisable.

Question 1078: Neurological

A nurse is caring for a patient with a traumatic brain injury. Which signs would indicate
increased intracranial pressure (ICP)? (Select all that apply.)

 A) Confusion
 B) Hypertension
 C) Bradycardia
 D) Increased temperature
 E) Pupillary changes

Correct Answers: A, B, C, D, E
Rationale: All listed signs can indicate increased ICP. Confusion, hypertension, bradycardia,
increased temperature, and pupillary changes are important assessments to monitor in such
patients.

Question 1079: Gastrointestinal

A patient with a peptic ulcer is being discharged. Which statements indicate the patient
understands the discharge teaching? (Select all that apply.)

 A) "I will take my medications as prescribed."

 B) "I can eat spicy foods if I want to."
 C) "I should avoid NSAIDs and aspirin."
  D) "I need to manage my stress levels."
 E) "I can drink alcohol in moderation."

Correct Answers: A, C, D
Rationale: Taking medications as prescribed, avoiding NSAIDs, and managing stress are
essential for ulcer management. Spicy foods and alcohol should be avoided as they can
exacerbate symptoms.

Question 1080: Maternity

A nurse is providing education to a pregnant woman about prenatal vitamins. Which statements
indicate a need for further teaching? (Select all that apply.)

 A) "I only need to take vitamins during the first trimester."

 B) "Folic acid is important to prevent neural tube defects."
 C) "I should continue taking prenatal vitamins while breastfeeding."
 D) "I can obtain all necessary nutrients from my diet alone."
 E) "Iron is important to prevent anemia during pregnancy."

Correct Answers: A, D
Rationale: Prenatal vitamins should be taken throughout pregnancy and while breastfeeding.
Nutritional needs may not be fully met through diet alone, especially during pregnancy.

Question 1081: Respiratory

A nurse is caring for a patient with asthma who is experiencing an acute asthma attack. Which
interventions should the nurse implement? (Select all that apply.)

 A) Administer bronchodilators as prescribed

 B) Place the patient in a supine position
 C) Encourage the patient to take slow, deep breaths
 D) Monitor oxygen saturation levels
 E) Provide reassurance and calm the patient

Correct Answers: A, D, E
Rationale: Administering bronchodilators, monitoring oxygen saturation, and providing
reassurance are key interventions during an asthma attack. The patient should be in a position of
comfort, often sitting up, not supine.

Question 1082: Infection Control

A nurse is caring for a patient with a suspected infection. Which interventions should the nurse
implement to prevent the spread of infection? (Select all that apply.)

 A) Perform hand hygiene before and after patient contact

 B) Use personal protective equipment (PPE) as needed
 C) Keep the patient's room door open
 D) Ensure proper disposal of contaminated materials
 E) Educate the patient on infection control measures

Correct Answers: A, B, D, E
Rationale: Performing hand hygiene, using PPE, proper disposal of contaminated materials, and
educating the patient are essential for infection control. Keeping the room door open can increase
the risk of spreading infection.

Question 1083: Musculoskeletal

A nurse is caring for a patient with rheumatoid arthritis. Which interventions should the nurse
include in the plan of care? (Select all that apply.)

 A) Encourage regular physical activity

 B) Apply heat or cold therapy as needed
 C) Suggest the use of assistive devices for daily activities
 D) Recommend a high-protein diet
 E) Teach joint protection techniques

Correct Answers: A, B, C, E
Rationale: Regular physical activity, applying heat/cold therapy, using assistive devices, and
teaching joint protection techniques are appropriate for managing rheumatoid arthritis. A high-
protein diet is not specifically indicated.

Question 1084: Pediatric Nursing

A nurse is assessing a child with croup. Which symptoms would the nurse expect to find? (Select
all that apply.)

 A) Barking cough
 B) Stridor
 C) High fever
 D) Hoarseness
 E) Difficulty breathing
Correct Answers: A, B, D, E
Rationale: A barking cough, stridor, hoarseness, and difficulty breathing are characteristic of
croup. A high fever is not typical; it may occur but is not a defining symptom.

Question 1085: Hematology

A patient with anemia is receiving iron supplements. Which statements indicate the patient
understands the teaching? (Select all that apply.)

 A) "I should take my iron supplements with orange juice."

 B) "I can take antacids at the same time as my iron."
 C) "I should expect my stools to be darker."
 D) "I need to continue taking these supplements for several months."
 E) "I can take my iron supplement before bedtime."

Correct Answers: A, C, D
Rationale: Taking iron with vitamin C (orange juice) enhances absorption, and darker stools are
a common side effect. Iron supplements are typically taken for several months. Antacids should
be spaced out from iron supplements, and taking iron before bed may lead to gastrointestinal
upset.

Question 1086: Urology

A nurse is assessing a patient with a urinary tract infection (UTI). Which signs and symptoms
would the nurse expect? (Select all that apply.)

 A) Frequent urination
 B) Burning sensation during urination
 C) Hematuria (blood in urine)
 D) Fever
 E) Elevated blood glucose

Correct Answers: A, B, C, D
Rationale: Frequent urination, burning sensation during urination, hematuria, and fever are
common signs of a UTI. Elevated blood glucose is not typically associated with UTIs.

Question 1087: Geriatric Nursing

A nurse is caring for an older adult patient. Which interventions are appropriate to prevent
complications of immobility? (Select all that apply.)
  A) Encourage frequent repositioning
 B) Promote ambulation as tolerated
 C) Provide a high-fiber diet
 D) Implement a skin care regimen
 E) Limit fluid intake

Correct Answers: A, B, C, D
Rationale: Frequent repositioning, promoting ambulation, providing a high-fiber diet, and
implementing a skin care regimen are all important to prevent complications. Limiting fluid
intake can lead to dehydration and other issues.

Question 1088: Pain Management

A nurse is caring for a patient receiving patient-controlled analgesia (PCA) for postoperative
pain management. Which assessments are essential? (Select all that apply.)

 A) Pain level assessment

 B) Respiratory rate monitoring
 C) Sedation level assessment
 D) Urinary output monitoring
 E) Blood glucose level monitoring

Correct Answers: A, B, C
Rationale: Assessing pain level, respiratory rate, and sedation level are critical for a patient on
PCA. Monitoring urinary output and blood glucose is not specific to PCA management.

Question 1089: Infection Control

A nurse is educating a patient about the importance of completing antibiotic therapy. Which
statements indicate understanding? (Select all that apply.)

 A) "Stopping the medication early can lead to antibiotic resistance."

 B) "I can save leftover antibiotics for later use."
 C) "I should take the full course even if I feel better."
 D) "It’s important to inform my doctor about any side effects."
 E) "I can share my antibiotics with family members if they have similar symptoms."

Correct Answers: A, C, D
Rationale: Stopping antibiotics early can lead to resistance, and completing the full course is
important even if the patient feels better. Informing the doctor of side effects is essential. Saving
leftovers and sharing medications are unsafe practices.
Question 1090: Mental Health

A nurse is assessing a patient diagnosed with depression. Which symptoms should the nurse
expect? (Select all that apply.)

 A) Anhedonia (loss of interest)

 B) Increased energy
 C) Sleep disturbances
 D) Feelings of worthlessness
 E) Rapid weight gain

Correct Answers: A, C, D
Rationale: Symptoms of depression often include anhedonia, sleep disturbances, and feelings of
worthlessness. Increased energy and rapid weight gain are not typical symptoms of depression.

Question 1091: Respiratory

A patient is diagnosed with chronic obstructive pulmonary disease (COPD). Which nursing
interventions are appropriate? (Select all that apply.)

 A) Encourage smoking cessation

 B) Administer bronchodilators as prescribed
 C) Promote high-flow oxygen therapy
 D) Teach pursed-lip breathing techniques
 E) Monitor for signs of respiratory infections

Correct Answers: A, B, D, E
Rationale: Encouraging smoking cessation, administering bronchodilators, teaching pursed-lip
breathing, and monitoring for respiratory infections are all key interventions. High-flow oxygen
is typically avoided unless specifically indicated.

Question 1092: Nutrition

A nurse is discussing dietary modifications with a patient diagnosed with heart failure. Which
dietary choices should the nurse recommend? (Select all that apply.)

 A) Low-sodium diet
 B) Fluid restriction as needed
 C) Increased intake of saturated fats
 D) High-fiber foods
  E) Adequate protein intake

Correct Answers: A, B, D, E
Rationale: A low-sodium diet, potential fluid restriction, high-fiber foods, and adequate protein
intake are recommended for heart failure management. Increased saturated fats should be
avoided.

Question 1093: Surgical

A nurse is preparing a patient for surgery. Which preoperative assessments are essential? (Select
all that apply.)

 A) Obtain a complete health history

 B) Assess the patient's understanding of the procedure
 C) Ensure the patient has signed the consent form
 D) Administer preoperative medications as prescribed
 E) Monitor vital signs only after surgery

Correct Answers: A, B, C, D
Rationale: A complete health history, understanding of the procedure, signed consent, and
administering preoperative medications are essential. Vital signs should be monitored
preoperatively as well.

Question 1094: Pediatrics

A nurse is caring for a child with asthma. Which teaching points should the nurse include in the
education plan? (Select all that apply.)

 A) Recognize and avoid triggers

 B) Use the rescue inhaler only when feeling unwell
 C) Monitor peak flow readings
 D) Take maintenance medication as prescribed
 E) Encourage physical activity to promote lung function

Correct Answers: A, C, D, E
Rationale: Recognizing and avoiding triggers, monitoring peak flow, taking maintenance
medication, and encouraging physical activity are essential for managing asthma. The rescue
inhaler should be used as needed, not just when feeling unwell.

Question 1095: Pain Management

A patient with chronic pain is being started on a transdermal fentanyl patch. What should the
nurse include in the teaching? (Select all that apply.)

 A) The patch should be applied to clean, dry skin.

 B) It is safe to use a heating pad over the patch.
 C) It may take several hours for the patch to take effect.
 D) The patch can be cut to adjust the dose.
 E) Dispose of the patch in the toilet after removal.

Correct Answers: A, C
Rationale: The patch should be applied to clean, dry skin, and it can take several hours for the
medication to take effect. Heating pads should not be used over the patch, and the patch should
not be cut or disposed of in the toilet.

Question 1096: Gastrointestinal

A nurse is caring for a patient with a bowel obstruction. Which assessment findings are
expected? (Select all that apply.)

 A) Abdominal distension
 B) Decreased bowel sounds
 C) Nausea and vomiting
 D) Diarrhea
 E) Fecal impaction

Correct Answers: A, B, C
Rationale: Abdominal distension, decreased bowel sounds, and nausea/vomiting are expected
findings in bowel obstruction. Diarrhea is typically not associated, and fecal impaction is a
separate condition.

Question 1097: Neurological

A patient has been diagnosed with multiple sclerosis (MS). Which nursing interventions should
be included in the plan of care? (Select all that apply.)

 A) Encourage fluid intake

 B) Promote regular exercise within tolerance
 C) Provide information about the disease process
 D) Suggest a high-protein diet
 E) Monitor for signs of depression
Correct Answers: A, B, C, E
Rationale: Encouraging fluid intake, promoting exercise, providing information about MS, and
monitoring for depression are essential nursing interventions. A high-protein diet is not
specifically indicated for MS.

Question 1098: Cardiac

A nurse is monitoring a patient for signs of heart failure. Which symptoms should the nurse
assess for? (Select all that apply.)

 A) Shortness of breath
 B) Weight gain
 C) Increased urination at night
 D) Cold extremities
 E) Fatigue

Correct Answers: A, B, C, E
Rationale: Shortness of breath, weight gain, nocturia (increased urination at night), and fatigue
are common symptoms of heart failure. Cold extremities are not typically indicative of heart
failure.

Question 1099: Ethics

A nurse is caring for a terminally ill patient who requests assistance with hastening death. What
should the nurse do? (Select all that apply.)

 A) Inform the patient that euthanasia is illegal in most places.

 B) Explore the patient's feelings and fears about death.
 C) Refer the patient to a palliative care specialist.
 D) Encourage the patient to consider their family’s wishes.
 E) Respect the patient’s autonomy and discuss options.

Correct Answers: A, B, C, E
Rationale: Informing the patient about legalities, exploring feelings, referring to palliative care,
and respecting autonomy are appropriate actions. Encouraging consideration of family wishes
may not support the patient's wishes and should be approached with care.

Question 1100: Surgical

A patient is recovering from a laparoscopic cholecystectomy. Which nursing interventions
should the nurse implement? (Select all that apply.)

 A) Assess for signs of infection at the incision site

 B) Encourage early ambulation
 C) Maintain a low-fat diet immediately postoperatively
 D) Monitor vital signs regularly
 E) Administer opioids as needed for pain management

Correct Answers: A, B, D, E
Rationale: Assessing for infection, encouraging ambulation, monitoring vital signs, and
administering pain medication as needed are essential. A low-fat diet is typically recommended
after the patient has recovered from anesthesia, not immediately postoperatively.

Question 1101: Endocrine

A nurse is educating a patient with diabetes about foot care. Which statements indicate a proper
understanding? (Select all that apply.)

 A) "I should inspect my feet daily for any cuts or sores."

 B) "I can use hot water to soak my feet."
 C) "I need to wear shoes at all times, even indoors."
 D) "I should apply lotion between my toes to keep them moisturized."
 E) "I must see a healthcare provider if I notice any changes."

Correct Answers: A, C, E
Rationale: Inspecting feet daily, wearing shoes at all times, and consulting a healthcare provider
for changes are crucial for diabetic foot care. Hot water and lotion between toes can lead to skin
damage and fungal infections.

Question 1102: Cardiovascular

A nurse is monitoring a patient who has just received a dose of furosemide (Lasix). Which
assessments should be prioritized? (Select all that apply.)

 A) Blood pressure
 B) Potassium level
 C) Heart rate
 D) Respiratory rate
 E) Urinary output
Correct Answers: A, B, C, E
Rationale: Blood pressure, potassium level, heart rate, and urinary output should be monitored
as furosemide can cause hypotension, hypokalemia, and increased urination.

Question 1103: Gastrointestinal

A nurse is caring for a patient with a nasogastric (NG) tube for gastric decompression. What
nursing interventions are appropriate? (Select all that apply.)

 A) Monitor the placement of the NG tube every shift

 B) Irrigate the NG tube with normal saline as prescribed
 C) Assess for bowel sounds every shift
 D) Administer medications through the NG tube as needed
 E) Provide oral care every 8 hours.

Correct Answers: A, B, C, E
Rationale: Monitoring placement, irrigating the tube, assessing bowel sounds, and providing
oral care are important. Medications should be carefully evaluated before administration through
the NG tube, as not all medications are suitable for this route.

Question 1104: Pharmacology

A nurse is educating a patient about taking atorvastatin (Lipitor). Which statements indicate the
patient understands the medication? (Select all that apply.)

 A) "I should have my liver function tested regularly."

 B) "I can stop taking this medication if my cholesterol levels improve."
 C) "I need to report any unexplained muscle pain to my doctor."
 D) "I should avoid drinking grapefruit juice."
 E) "This medication should be taken at bedtime for best results."

Correct Answers: A, C, D
Rationale: Regular liver function tests, reporting muscle pain, and avoiding grapefruit juice are
important for atorvastatin. Stopping the medication should only be done under medical
supervision, and while it can be taken at any time, some studies suggest evening dosing may be
more effective.

Question 1105: Mental Health

A patient is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which
interventions should the nurse prioritize? (Select all that apply.)

 A) Establish a therapeutic relationship

 B) Encourage the patient to participate in group activities
 C) Allow the patient to remain in bed all day
 D) Monitor for suicidal ideation
 E) Provide a structured daily routine.

Correct Answers: A, B, D, E
Rationale: Establishing a therapeutic relationship, encouraging participation in activities,
monitoring for suicidal ideation, and providing structure are critical in managing depression.
Allowing prolonged bed rest can exacerbate depressive symptoms.

Question 1106: Pediatrics

A nurse is assessing a 5-year-old child. Which developmental milestones should the nurse
expect? (Select all that apply.)

 A) The child can hop on one foot.

 B) The child can tie shoelaces.
 C) The child can count to 10.
 D) The child can ride a tricycle.
 E) The child can use complete sentences.

Correct Answers: A, C, D, E
Rationale: By age 5, children can hop, count, ride a tricycle, and use complete sentences. Tying
shoelaces typically develops around age 6 or 7.

Question 1107: Respiratory

A patient with chronic bronchitis is being discharged. Which instructions should the nurse
include? (Select all that apply.)

 A) "Avoid exposure to irritants, such as smoke."

 B) "It's okay to skip your flu vaccine this year."
 C) "Use bronchodilators as prescribed."
 D) "Increase your fluid intake."
 E) "Engage in regular physical activity."

Correct Answers: A, C, D, E
Rationale: Avoiding irritants, using bronchodilators, increasing fluid intake, and engaging in
physical activity are essential for managing chronic bronchitis. The flu vaccine is highly
recommended for these patients.

Question 1108: Infection Control

A patient in isolation for a multidrug-resistant infection is being discharged. What should the
nurse include in discharge teaching? (Select all that apply.)

 A) Practice good hand hygiene.

 B) Share personal items with family members.
 C) Complete prescribed antibiotic therapy.
 D) Notify healthcare providers of the infection.
 E) Follow up with appropriate healthcare services.

Correct Answers: A, C, D, E
Rationale: Good hand hygiene, completing antibiotics, notifying healthcare providers, and
following up are essential. Sharing personal items is not recommended to prevent transmission.

Question 1109: Cardiac

A nurse is teaching a patient about lifestyle changes to reduce the risk of cardiovascular disease.
Which recommendations should be included? (Select all that apply.)

 A) Engage in regular physical activity.

 B) Maintain a low-sodium diet.
 C) Limit alcohol consumption.
 D) Increase saturated fat intake.
 E) Manage stress levels.

Correct Answers: A, B, C, E
Rationale: Regular physical activity, a low-sodium diet, limiting alcohol, and managing stress
are vital for cardiovascular health. Increasing saturated fat intake is not recommended.

Question 1110: Neurological

A patient with a stroke is exhibiting right-sided weakness. What should the nurse do to assist this
patient? (Select all that apply.)

 A) Place the call light within the patient's left hand.

 B) Encourage the patient to use their right side for activities.
  C) Assist with transfers to the right side.
 D) Provide a safe environment to prevent falls.
 E) Instruct the patient to practice exercises for the affected side.

Correct Answers: A, D, E
Rationale: Placing the call light in the left hand, providing a safe environment, and instructing
exercises for the affected side are key to supporting a patient with stroke-related weakness.
Encouraging use of the affected side should be prioritized, and transfers should be managed
safely.

Question 1111: Gastrointestinal

A patient undergoing a colonoscopy is being educated about bowel preparation. Which

instructions should the nurse include? (Select all that apply.)

 A) "You should consume a high-fiber diet for three days before the procedure."
 B) "Drink only clear liquids the day before the procedure."
 C) "You may have a small breakfast on the morning of the procedure."
 D) "You will need to take a prescribed laxative to clear your bowel."
 E) "Report any abdominal pain to your healthcare provider."

Correct Answers: B, D, E
Rationale: Clear liquids the day before, taking prescribed laxatives, and reporting pain are
essential. A high-fiber diet should be avoided before a colonoscopy, and breakfast is typically
not allowed.

Question 1112: Maternity

A nurse is caring for a postpartum patient who is experiencing heavy bleeding. Which actions
should the nurse take? (Select all that apply.)

 A) Assess the fundus for firmness.

 B) Administer oxytocin as prescribed.
 C) Encourage the patient to ambulate.
 D) Monitor vital signs closely.
 E) Provide comfort measures.

Correct Answers: A, B, D, E
Rationale: Assessing the fundus, administering medications, monitoring vital signs, and
providing comfort are essential actions. Encouraging ambulation should be done cautiously in
the context of heavy bleeding.
Question 1113: Geriatrics

A nurse is assessing an older adult for signs of dehydration. Which symptoms should the nurse
monitor? (Select all that apply.)

 A) Dry mucous membranes

 B) Confusion or altered mental status
 C) Decreased urine output
 D) Elevated blood pressure
 E) Poor skin turgor

Correct Answers: A, B, C, E
Rationale: Dry mucous membranes, confusion, decreased urine output, and poor skin turgor are
indicators of dehydration. Blood pressure may decrease, not elevate, with dehydration.

Question 1114: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis (TB). Which precautions should the
nurse implement? (Select all that apply.)

 A) Use a surgical mask when in the patient's room.

 B) Place the patient in a private room with negative pressure.
 C) Wear gloves when handling the patient's belongings.
 D) Educate the patient about the importance of medication adherence.
 E) Allow visitors without any restrictions.

Correct Answers: B, D
Rationale: A private room with negative pressure and educating the patient about medication
adherence are essential. Surgical masks are not used in the patient’s room; N95 respirators are
recommended. Visitors should be limited to those who are screened.

Question 1115: Nutrition

A nurse is teaching a patient with renal failure about dietary restrictions. Which foods should the
nurse recommend avoiding? (Select all that apply.)

 A) Bananas
 B) Whole grains
 C) Red meat
 D) Processed foods
  E) Low-fat dairy products

Correct Answers: A, B, C, D
Rationale: Foods high in potassium (like bananas), phosphorus (found in whole grains and
processed foods), and protein (such as red meat) should be limited in renal failure. Low-fat dairy
can be consumed in moderation unless otherwise directed.

Question 1116: Surgical

A nurse is caring for a patient who has undergone a total hip replacement. Which nursing
interventions are essential in the immediate postoperative period? (Select all that apply.)

 A) Monitor for signs of deep vein thrombosis (DVT)

 B) Assess neurovascular status of the affected limb
 C) Encourage the patient to cross their legs for comfort
 D) Educate the patient about avoiding hip flexion greater than 90 degrees
 E) Administer anticoagulants as prescribed.

Correct Answers: A, B, D, E
Rationale: Monitoring for DVT, assessing neurovascular status, educating about hip flexion
limitations, and administering anticoagulants are key interventions. Crossing legs should be
avoided post-surgery.

Question 1117: Pain Management

A patient is receiving morphine for postoperative pain management. Which assessments are
important for the nurse to perform? (Select all that apply.)

 A) Monitor respiratory rate and depth

 B) Assess pain level every hour
 C) Evaluate for signs of constipation
 D) Check blood pressure only before administration
 E) Encourage fluid intake.

Correct Answers: A, B, C, E
Rationale: Monitoring respiratory rate, assessing pain levels, evaluating for constipation, and
encouraging fluid intake are crucial. Blood pressure should be monitored regularly, especially
when using opioids.

Question 1118: Mental Health

A patient with bipolar disorder is in the manic phase. What nursing interventions are
appropriate? (Select all that apply.)

 A) Provide a structured environment.

 B) Encourage the patient to participate in group therapy.
 C) Set limits on behavior.
 D) Allow the patient to make all decisions about care.
 E) Monitor the patient for signs of exhaustion.

Correct Answers: A, C, E
Rationale: Providing structure, setting behavior limits, and monitoring for exhaustion are
essential. Encouraging group therapy may not be effective during mania, and the nurse should
help guide decision-making.

Question 1119: Respiratory

A nurse is teaching a patient with asthma about using a metered-dose inhaler (MDI). Which
statements indicate proper understanding? (Select all that apply.)

 A) "I should shake the inhaler before use."

 B) "I can hold my breath for a count of 10 after inhaling."
 C) "I need to clean the inhaler with soap and water weekly."
 D) "I should prime the inhaler if I haven’t used it in a while."
 E) "I can take my inhaler while lying down."

Correct Answers: A, B, D
Rationale: Shaking the inhaler, holding the breath after inhaling, and priming if unused are
correct. The inhaler should be cleaned according to specific instructions, not with soap and
water, and it's best to use while sitting or standing.

Question 1120: Geriatrics

A nurse is assessing an older adult for signs of depression. Which symptoms should the nurse be
alert for? (Select all that apply.)

 A) Withdrawal from social activities

 B) Increased appetite
 C) Fatigue and low energy
 D) Insomnia or excessive sleeping
 E) Heightened interest in hobbies
Correct Answers: A, C, D
Rationale: Withdrawal, fatigue, and sleep disturbances are common in depression among older
adults. Increased appetite and heightened interest in hobbies are typically not associated with
depressive symptoms.

Question 1121: Infection Control

A nurse is caring for a patient with Clostridium difficile infection. What precautions should the
nurse implement? (Select all that apply.)

 A) Use alcohol-based hand sanitizers.

 B) Wear gloves and gowns when entering the patient's room.
 C) Place the patient in a private room.
 D) Use a regular mask when providing care.
 E) Implement contact precautions.

Correct Answers: B, C, E
Rationale: Gloves and gowns should be worn, the patient should be placed in a private room,
and contact precautions are essential. Alcohol-based sanitizers are ineffective against C. difficile;
soap and water are required.

Question 1122: Cardiovascular

A nurse is assessing a patient with heart failure. Which findings would indicate worsening heart
failure? (Select all that apply.)

 A) Increased shortness of breath

 B) Weight gain of more than 2 pounds in a day
 C) Decreased urine output
 D) Bradycardia
 E) Swelling in the ankles and feet

Correct Answers: A, B, C, E
Rationale: Increased shortness of breath, weight gain, decreased urine output, and swelling
indicate worsening heart failure. Bradycardia is not typically associated with heart failure
exacerbation.

Question 1123: Maternity

A nurse is caring for a postpartum patient who is breastfeeding. Which teaching points should be
included? (Select all that apply.)

 A) "You can skip feedings to allow your breasts to rest."

 B) "It's important to maintain a balanced diet."
 C) "You should increase your fluid intake."
 D) "Breastfeeding can help your uterus contract."
 E) "You can use any medication while breastfeeding."

Correct Answers: B, C, D
Rationale: A balanced diet, increased fluid intake, and the uterine contracting benefits of
breastfeeding should be emphasized. Skipping feedings is not recommended, and medications
should be discussed with a healthcare provider.

Question 1124: Neurological

A nurse is caring for a patient with a stroke affecting the right side of the body. Which
interventions should the nurse implement? (Select all that apply.)

 A) Encourage the patient to use their right hand for activities.

 B) Place the call light within reach of the left hand.
 C) Assist with feeding using the left hand.
 D) Promote independence in activities of daily living.
 E) Perform passive range of motion exercises on the right side.

Correct Answers: B, C, D, E
Rationale: The call light should be placed within reach of the unaffected side (left), feeding
should assist the affected side (right), promoting independence is vital, and passive range of
motion for the affected side is essential.

Question 1125: Gastrointestinal

A patient scheduled for a colonoscopy is instructed to prepare. Which statements indicate proper
understanding of bowel preparation? (Select all that apply.)

 A) "I can eat solid foods the day before the procedure."
 B) "I will drink only clear liquids after midnight."
 C) "I will take the prescribed laxatives as directed."
 D) "I should avoid red-colored drinks."
 E) "I can have coffee on the day of the procedure."
Correct Answers: B, C, D
Rationale: Clear liquids after midnight, taking laxatives, and avoiding red-colored drinks are
correct. Solid foods should not be consumed, and coffee may not be allowed due to its color and
acidity.

Question 1126: Respiratory

A patient with COPD is receiving education about self-management. Which statements indicate
correct understanding? (Select all that apply.)

 A) "I should avoid exposure to respiratory irritants."

 B) "It's important to get the flu vaccine every year."
 C) "I can stop using my inhaler once I feel better."
 D) "I should perform breathing exercises daily."
 E) "I need to monitor my oxygen saturation levels."

Correct Answers: A, B, D, E
Rationale: Avoiding irritants, getting the flu vaccine, performing breathing exercises, and
monitoring oxygen saturation are important. Patients should not stop using inhalers without
consulting their healthcare provider.

Question 1127: Pharmacology

A nurse is preparing to administer lisinopril to a patient. What should the nurse monitor after
administration? (Select all that apply.)

 A) Blood pressure
 B) Heart rate
 C) Serum potassium levels
 D) Respiratory rate
 E) Liver function tests

Correct Answers: A, C
Rationale: Blood pressure and serum potassium levels should be monitored because lisinopril
can cause hypotension and hyperkalemia. Heart rate, respiratory rate, and liver function tests are
not specifically required.

Question 1128: Pediatric

A nurse is assessing a 4-year-old child. Which developmental milestones should the nurse
expect? (Select all that apply.)

 A) The child can count to 15.

 B) The child can draw a person with three body parts.
 C) The child can hop on one foot.
 D) The child can tie shoelaces.
 E) The child can speak in full sentences.

Correct Answers: A, B, C, E
Rationale: Counting to 15, drawing a person with three body parts, hopping on one foot, and
speaking in full sentences are appropriate for a 4-year-old. Tying shoelaces typically develops
later.

Question 1129: Cardiac

A nurse is caring for a patient with atrial fibrillation. Which assessments are essential for this
patient? (Select all that apply.)

 A) Heart rate and rhythm

 B) Blood pressure
 C) Peripheral pulses
 D) Level of consciousness
 E) Respiratory rate

Correct Answers: A, B, C, D
Rationale: Monitoring heart rate and rhythm, blood pressure, peripheral pulses, and level of
consciousness is crucial in managing atrial fibrillation. Respiratory rate is important but not a
priority.

Question 1130: Nutrition

A nurse is providing dietary education to a patient with hypertension. Which recommendations

should the nurse include? (Select all that apply.)

 A) Increase sodium intake to enhance flavor.

 B) Eat more fruits and vegetables.
 C) Choose whole grains over refined grains.
 D) Limit processed foods.
 E) Drink alcohol in moderation.
Correct Answers: B, C, D, E
Rationale: Eating more fruits and vegetables, choosing whole grains, limiting processed foods,
and drinking alcohol in moderation are essential for managing hypertension. Sodium intake
should be reduced.

Question 1131: Mental Health

A patient diagnosed with anxiety is prescribed diazepam (Valium). What should the nurse
include in teaching about this medication? (Select all that apply.)

 A) "You may feel drowsy after taking this medication."

 B) "It is safe to drink alcohol while on this medication."
 C) "Do not stop this medication abruptly."
 D) "You should avoid driving or operating heavy machinery."
 E) "You can take this medication as needed for anxiety."

Correct Answers: A, C, D, E
Rationale: Patients should be aware of drowsiness, the need to avoid abrupt cessation, and the
risks of driving. Alcohol should be avoided as it can enhance sedation.

Question 1132: Geriatrics

A nurse is assessing an older adult for signs of elder abuse. Which signs should the nurse be alert
for? (Select all that apply.)

 A) Unexplained injuries or bruises

 B) Sudden changes in financial situation
 C) Withdrawal from social interactions
 D) Excessive fear of caregivers
 E) Consistent attendance at social events

Correct Answers: A, B, C, D
Rationale: Unexplained injuries, sudden financial changes, withdrawal, and fear of caregivers
are potential signs of elder abuse. Consistent attendance at social events is not indicative of
abuse.

Question 1133: Surgical

A nurse is caring for a patient who has undergone a laparoscopic cholecystectomy. Which
postoperative assessments are essential? (Select all that apply.)
  A) Monitor for signs of infection at the incision site.
 B) Assess bowel sounds.
 C) Encourage the patient to ambulate.
 D) Check for abdominal distension.
 E) Limit fluid intake until bowel sounds return.

Correct Answers: A, B, C, D
Rationale: Monitoring for infection, assessing bowel sounds, encouraging ambulation, and
checking for distension are critical postoperative assessments. Fluid intake is typically
encouraged.

Question 1134: Pain Management

A nurse is caring for a patient with chronic pain. Which interventions should be included in the
care plan? (Select all that apply.)

 A) Encourage the patient to use relaxation techniques.

 B) Administer analgesics as prescribed.
 C) Focus on the pain rather than distractions.
 D) Teach the patient about alternative therapies.
 E) Limit physical activity to reduce pain.

Correct Answers: A, B, D
Rationale: Encouraging relaxation, administering medications, and teaching alternative
therapies are appropriate. Focusing on pain is not helpful, and limiting activity is not usually
recommended in managing chronic pain.

Question 1135: Pediatric

A nurse is assessing a 2-year-old child. Which developmental milestones should the nurse
expect? (Select all that apply.)

 A) The child can run.

 B) The child can stack four blocks.
 C) The child can use a spoon.
 D) The child can say two to three-word phrases.
 E) The child can jump on one foot.

Correct Answers: A, B, C, D
Rationale: Running, stacking blocks, using a spoon, and saying phrases are expected milestones
for a 2-year-old. Jumping on one foot typically develops later.
Question 1136: Endocrine

A patient with diabetes is experiencing hypoglycemia. Which symptoms should the nurse assess
for? (Select all that apply.)

 A) Sweating
 B) Confusion
 C) Nausea
 D) Tachycardia
 E) Dry skin

Correct Answers: A, B, C, D
Rationale: Symptoms of hypoglycemia include sweating, confusion, nausea, and tachycardia.
Dry skin is not typically associated with hypoglycemia.

Question 1137: Gastrointestinal

A nurse is caring for a patient with pancreatitis. Which dietary modifications should the nurse
recommend? (Select all that apply.)

 A) Increase protein intake.

 B) Limit fat intake.
 C) Avoid alcohol.
 D) Eat small, frequent meals.
 E) Consume high-fiber foods.

Correct Answers: B, C, D
Rationale: Limiting fat, avoiding alcohol, and eating small meals are essential for managing
pancreatitis. Protein intake should be moderate, and high fiber is typically not recommended
during flare-ups.

Question 1138: Immunology

A nurse is educating a patient about the influenza vaccine. Which statements indicate proper
understanding? (Select all that apply.)

 A) "I need to get vaccinated every year."

 B) "I should avoid the vaccine if I had a severe allergic reaction to eggs."
 C) "I can receive the vaccine even if I have a cold."
 D) "The vaccine can cause the flu."
  E) "Pregnant women should consult their healthcare provider before receiving the
vaccine."

Correct Answers: A, B, C, E
Rationale: Annual vaccination is necessary, avoidance in case of severe egg allergy is crucial,
vaccination with a mild cold is acceptable, and pregnant women should seek advice. The vaccine
does not cause influenza.

Question 1139: Psychiatric

A nurse is caring for a patient experiencing a manic episode. Which interventions are
appropriate? (Select all that apply.)

 A) Maintain a low-stimulus environment.

 B) Set clear and consistent limits on behavior.
 C) Encourage the patient to talk about their feelings.
 D) Provide frequent meals and snacks.
 E) Allow the patient to make all decisions about care.

Correct Answers: A, B, D
Rationale: A low-stimulus environment, setting limits, and providing frequent meals are
essential. Encouraging emotional expression may not be effective, and patients should not make
all decisions during mania.

Question 1140: Neurological

A nurse is assessing a patient with suspected meningitis. Which symptoms should the nurse
expect? (Select all that apply.)

 A) Fever
 B) Stiff neck
 C) Photophobia
 D) Bradycardia
 E) Headache

Correct Answers: A, B, C, E
Rationale: Fever, stiff neck, photophobia, and headache are classic signs of meningitis.
Bradycardia is not typically associated with this condition.

Question 1141: Pharmacology

A nurse is preparing to administer warfarin to a patient. Which laboratory test should the nurse
monitor? (Select all that apply.)

 A) Prothrombin time (PT)

 B) Partial thromboplastin time (PTT)
 C) International normalized ratio (INR)
 D) Hemoglobin level
 E) Platelet count

Correct Answers: A, C
Rationale: Prothrombin time (PT) and International normalized ratio (INR) are crucial for
monitoring the effectiveness of warfarin therapy. PTT is primarily monitored for heparin
therapy.

Question 1142: Pediatric

A nurse is assessing a 6-month-old infant. Which developmental milestones should the nurse
expect? (Select all that apply.)

 A) The infant can sit without support.

 B) The infant can roll over.
 C) The infant can transfer objects between hands.
 D) The infant can say "mama" or "dada."
 E) The infant can respond to their name.

Correct Answers: B, C, E
Rationale: By 6 months, infants typically can roll over, transfer objects, and respond to their
name. Sitting without support, saying "mama" or "dada" usually develops later.

Question 1143: Nutrition

A nurse is providing dietary education to a patient with renal failure. Which dietary
recommendations should the nurse include? (Select all that apply.)

 A) Limit potassium intake.

 B) Increase protein intake.
 C) Limit phosphorus intake.
 D) Increase fluid intake.
 E) Choose low-sodium options.

Correct Answers: A, C, E
Rationale: Limiting potassium and phosphorus, as well as choosing low-sodium options, are
essential. Protein intake may need to be adjusted based on dialysis status, and fluid intake should
be limited, not increased.

Question 1144: Cardiac

A nurse is caring for a patient with congestive heart failure (CHF). Which symptoms should the
nurse monitor for worsening heart failure? (Select all that apply.)

 A) Increased fatigue
 B) Rapid weight gain
 C) Orthopnea
 D) Decreased appetite
 E) Elevated blood pressure

Correct Answers: A, B, C, D
Rationale: Symptoms of worsening CHF include increased fatigue, rapid weight gain,
orthopnea, and decreased appetite. Elevated blood pressure can vary.

Question 1145: Infection Control

A nurse is caring for a patient with tuberculosis (TB). Which precautions should the nurse
implement? (Select all that apply.)

 A) Wear a regular surgical mask.

 B) Place the patient in a private, negative pressure room.
 C) Use gloves when handling the patient’s linens.
 D) Limit visitors to the patient.
 E) Wear an N95 respirator when entering the room.

Correct Answers: B, C, E
Rationale: Patients with TB require private, negative pressure rooms, gloves for handling linens,
and N95 respirators for staff. Regular masks are insufficient for TB protection.

Question 1146: Mental Health

A nurse is caring for a patient diagnosed with major depressive disorder. Which interventions are
appropriate? (Select all that apply.)

 A) Encourage participation in physical activities.

 B) Establish a regular sleep routine.
  C) Provide opportunities for social interaction.
 D) Minimize discussions about feelings.
 E) Administer antidepressant medications as prescribed.

Correct Answers: A, B, C, E
Rationale: Encouraging physical activity, establishing a sleep routine, providing social
interaction, and administering medications are essential. Discussions about feelings should be
supportive and open.

Question 1147: Respiratory

A nurse is teaching a patient with asthma about using a peak flow meter. Which statements
indicate proper understanding? (Select all that apply.)

 A) "I will use the meter every morning before taking my medication."
 B) "I should take my deepest breath before blowing into the meter."
 C) "I need to record my peak flow readings daily."
 D) "If my peak flow is below my personal best, I should use my rescue inhaler."
 E) "I can stop using the peak flow meter once I feel better."

Correct Answers: B, C, D
Rationale: A deep breath before blowing, recording daily readings, and using a rescue inhaler
for low readings are correct. The peak flow meter should be used regularly, even when feeling
well.

Question 1148: Geriatrics

A nurse is assessing an older adult for signs of dehydration. Which findings should the nurse
monitor? (Select all that apply.)

 A) Dry mucous membranes

 B) Decreased skin turgor
 C) Confusion or altered mental status
 D) Increased urine output
 E) Low blood pressure

Correct Answers: A, B, C, E
Rationale: Dry mucous membranes, decreased skin turgor, confusion, and low blood pressure
indicate dehydration. Increased urine output is not consistent with dehydration.
Question 1149: Endocrine

A patient with diabetes is experiencing hyperglycemia. Which interventions should the nurse
implement? (Select all that apply.)

 A) Encourage fluid intake.

 B) Administer insulin as prescribed.
 C) Monitor blood glucose levels frequently.
 D) Provide high-sugar snacks.
 E) Assess for symptoms of diabetic ketoacidosis (DKA).

Correct Answers: A, B, C, E
Rationale: Encouraging fluids, administering insulin, monitoring glucose levels, and assessing
for DKA symptoms are important. High-sugar snacks should be avoided.

Question 1150: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which dietary recommendations should the
nurse provide? (Select all that apply.)

 A) Avoid spicy foods.

 B) Limit caffeine intake.
 C) Eat frequent, small meals.
 D) Include dairy products.
 E) Avoid alcohol.

Correct Answers: A, B, C, E
Rationale: Avoiding spicy foods, limiting caffeine, eating small meals, and avoiding alcohol are
beneficial for managing peptic ulcers. Dairy products should be consumed with caution, as they
may cause discomfort for some.

Question 1151: Surgical

A nurse is preparing a patient for a preoperative procedure. Which assessments are essential
before surgery? (Select all that apply.)

 A) Review the patient's allergies.

 B) Assess vital signs.
 C) Obtain informed consent.
 D) Evaluate the patient's understanding of the procedure.
 E) Administer preoperative medications.
Correct Answers: A, B, C, D
Rationale: Reviewing allergies, assessing vital signs, obtaining consent, and evaluating
understanding are critical. Administering preoperative medications is done later in the process.

Question 1152: Cardiovascular

A nurse is teaching a patient about heart failure management. Which statements indicate proper
understanding? (Select all that apply.)

 A) "I should weigh myself daily at the same time."

 B) "I can stop taking my medications if I feel better."
 C) "I need to limit my salt intake."
 D) "I should call my doctor if I gain more than 2 pounds in a day."
 E) "I can engage in high-intensity exercise whenever I want."

Correct Answers: A, C, D
Rationale: Daily weighing, limiting salt intake, and monitoring for rapid weight gain are crucial.
Medications should not be stopped without consulting a healthcare provider, and exercise
intensity should be discussed with a provider.

Question 1153: Infection Control

A nurse is caring for a patient with a healthcare-associated infection (HAI). What interventions
should the nurse implement? (Select all that apply.)

 A) Implement strict hand hygiene practices.

 B) Use gloves when handling bodily fluids.
 C) Place the patient on contact precautions.
 D) Educate the patient about proper hygiene.
 E) Limit visitors to the patient.

Correct Answers: A, B, C, D
Rationale: Hand hygiene, using gloves, implementing contact precautions, and patient education
are key interventions. Limiting visitors may be necessary depending on the situation.

Question 1154: Neurological

A nurse is caring for a patient with Parkinson's disease. Which symptoms should the nurse
monitor? (Select all that apply.)
  A) Tremors at rest
 B) Bradykinesia
 C) Postural instability
 D) Increased appetite
 E) Muscle rigidity

Correct Answers: A, B, C, E
Rationale: Tremors, bradykinesia, postural instability, and muscle rigidity are common
symptoms of Parkinson's disease. Increased appetite is not typically associated.

Question 1155: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is prescribed supplemental

oxygen. Which statements indicate proper understanding? (Select all that apply.)

 A) "I should use oxygen even when I am feeling well."

 B) "I need to report any signs of increased shortness of breath."
 C) "I can smoke while using oxygen as long as I’m careful."
 D) "I should wear my oxygen at night while I sleep."
 E) "I can adjust my oxygen flow rate as I see fit."

Correct Answers: B, D
Rationale: Reporting increased shortness of breath and using oxygen at night are correct.
Oxygen should not be used while smoking, and the flow rate should only be adjusted by
healthcare providers.

Question 1156: Cardiovascular

A nurse is caring for a patient with heart failure. Which assessment findings should the nurse
report immediately? (Select all that apply.)

 A) Shortness of breath at rest

 B) Peripheral edema
 C) Weight gain of 3 pounds in one week
 D) Jugular vein distention
 E) Heart rate of 92 bpm

Correct Answers: A, C, D
Rationale: Shortness of breath at rest, rapid weight gain, and jugular vein distention indicate
worsening heart failure and should be reported. Peripheral edema and a heart rate of 92 bpm can
be common in heart failure.
Question 1157: Pharmacology

A nurse is administering digoxin to a patient with atrial fibrillation. Which findings should the
nurse assess before administering the medication? (Select all that apply.)

 A) Heart rate
 B) Blood pressure
 C) Serum potassium level
 D) Weight
 E) Respiratory rate

Correct Answers: A, C
Rationale: The heart rate must be assessed because digoxin can cause bradycardia, and serum
potassium levels are important to monitor since hypokalemia can increase the risk of digoxin
toxicity.

Question 1158: Obstetrics

A nurse is assessing a postpartum patient. Which findings should the nurse monitor for signs of
complications? (Select all that apply.)

 A) Severe abdominal pain

 B) Excessive vaginal bleeding
 C) Fever above 100.4°F (38°C)
 D) Fundus firm and midline
 E) Presence of clots in lochia

Correct Answers: A, B, C
Rationale: Severe abdominal pain, excessive vaginal bleeding, and fever are signs of potential
complications. A firm, midline fundus is normal, and small clots in lochia can be expected.

Question 1159: Gastrointestinal

A nurse is educating a patient about a high-fiber diet to manage constipation. Which foods
should the nurse recommend? (Select all that apply.)

 A) Whole grain bread

 B) Brown rice
 C) Apples with skin
 D) Chicken breast
  E) Lentils

Correct Answers: A, B, C, E
Rationale: Whole grains, fruits with skin, and legumes like lentils are high in fiber. Chicken
breast is low in fiber and not recommended for this purpose.

Question 1160: Mental Health

A nurse is caring for a patient experiencing a panic attack. Which interventions should the nurse
implement? (Select all that apply.)

 A) Remain with the patient and offer reassurance.

 B) Encourage the patient to express their feelings.
 C) Teach the patient relaxation techniques.
 D) Minimize environmental stimuli.
 E) Suggest the patient leave the room to calm down.

Correct Answers: A, C, D
Rationale: Remaining with the patient, teaching relaxation techniques, and minimizing stimuli
are key interventions. Encouraging expression of feelings may not be effective during a panic
attack, and suggesting leaving may increase anxiety.

Question 1161: Respiratory

A nurse is caring for a patient with pneumonia. Which assessments are important for monitoring
respiratory status? (Select all that apply.)

 A) Oxygen saturation levels

 B) Breath sounds
 C) Respiratory rate and rhythm
 D) Capillary refill time
 E) Temperature

Correct Answers: A, B, C
Rationale: Monitoring oxygen saturation, breath sounds, and respiratory rate and rhythm are
crucial in assessing respiratory status. Capillary refill time and temperature are less specific to
respiratory issues.

Question 1162: Neurological

A nurse is caring for a patient with a recent stroke. Which assessments should the nurse
prioritize? (Select all that apply.)

 A) Level of consciousness
 B) Motor function
 C) Speech and language abilities
 D) Nutritional intake
 E) Skin integrity

Correct Answers: A, B, C
Rationale: Level of consciousness, motor function, and speech abilities are critical assessments
following a stroke. Nutritional intake and skin integrity are important but secondary in this acute
phase.

Question 1163: Endocrine

A patient with diabetes is prescribed a new medication. Which statements by the patient indicate
understanding of the medication regimen? (Select all that apply.)

 A) "I will monitor my blood glucose regularly."

 B) "I should always carry a source of sugar with me."
 C) "I can take this medication with my other medications."
 D) "It's okay to skip doses if I feel fine."
 E) "I will follow up with my healthcare provider regularly."

Correct Answers: A, B, C, E
Rationale: Monitoring blood glucose, carrying sugar, and following up are vital for managing
diabetes. Skipping doses is unsafe, regardless of how the patient feels.

Question 1164: Pediatric

A nurse is assessing a toddler. Which developmental milestones should the nurse expect at this
age? (Select all that apply.)

 A) The toddler can walk independently.

 B) The toddler can say "no" consistently.
 C) The toddler can stack six blocks.
 D) The toddler can feed themselves with a fork.
 E) The toddler can run.
Correct Answers: A, B, C, E
Rationale: Toddlers typically walk independently, use "no," stack blocks, and can run. Feeding
with a fork typically develops later.

Question 1165: Infection Control

A nurse is caring for a patient diagnosed with C. difficile infection. What precautions should the
nurse implement? (Select all that apply.)

 A) Implement contact precautions.

 B) Use soap and water for hand hygiene.
 C) Use an alcohol-based hand sanitizer.
 D) Limit the patient's visitors.
 E) Disinfect the patient's environment regularly.

Correct Answers: A, B, E
Rationale: Contact precautions, soap and water for hand hygiene (not alcohol-based), and
disinfecting the environment are necessary. Visitor limitations are not typically required.

Question 1166: Pharmacology

A patient is prescribed a thiazide diuretic. Which side effects should the nurse educate the patient
about? (Select all that apply.)

 A) Hypokalemia
 B) Hyperglycemia
 C) Dehydration
 D) Weight gain
 E) Dizziness

Correct Answers: A, B, C, E
Rationale: Thiazide diuretics can cause hypokalemia, hyperglycemia, dehydration, and
dizziness. Weight gain is not a common side effect.

Question 1167: Geriatrics

A nurse is assessing an older adult for signs of depression. Which symptoms should the nurse be
alert for? (Select all that apply.)

 A) Social withdrawal
  B) Loss of interest in activities
 C) Increased energy levels
 D) Difficulty concentrating
 E) Changes in appetite or weight

Correct Answers: A, B, D, E
Rationale: Social withdrawal, loss of interest, difficulty concentrating, and changes in
appetite/weight are signs of depression. Increased energy levels are typically not associated with
depression.

Question 1168: Cardiovascular

A nurse is caring for a patient after a myocardial infarction (MI). Which interventions are
appropriate? (Select all that apply.)

 A) Administer prescribed anticoagulants.

 B) Monitor vital signs closely.
 C) Encourage the patient to ambulate immediately.
 D) Educate the patient about lifestyle modifications.
 E) Allow the patient to take a hot bath for relaxation.

Correct Answers: A, B, D
Rationale: Administering anticoagulants, monitoring vital signs, and educating on lifestyle
changes are essential. Immediate ambulation and hot baths should be avoided post-MI.

Question 1169: Surgical

A nurse is preparing a patient for surgery. Which information is essential to provide to the
patient before the procedure? (Select all that apply.)

 A) Explanation of the procedure

 B) Description of anesthesia type
 C) Risks and benefits of the procedure
 D) Postoperative care expectations
 E) The length of the surgery

Correct Answers: A, B, C, D
Rationale: Providing information about the procedure, anesthesia, risks/benefits, and
postoperative care is essential. The exact length of the surgery can vary and may not be
necessary to specify.
Question 1170: Mental Health

A nurse is caring for a patient with schizophrenia. Which interventions are appropriate? (Select
all that apply.)

 A) Establish a therapeutic relationship.

 B) Challenge the patient's delusions directly.
 C) Provide a structured environment.
 D) Encourage participation in group therapy.
 E) Avoid discussing the patient's symptoms.

Correct Answers: A, C, D
Rationale: Establishing rapport, providing structure, and encouraging group therapy are
beneficial. Challenging delusions directly may increase defensiveness, and discussing symptoms
should be approached sensitively.

Question 1171: Respiratory

A nurse is assessing a patient with asthma who is experiencing an acute exacerbation. Which
findings should the nurse anticipate? (Select all that apply.)

 A) Wheezing
 B) Decreased respiratory rate
 C) Use of accessory muscles
 D) Cyanosis
 E) Increased heart rate

Correct Answers: A, C, D, E
Rationale: Wheezing, use of accessory muscles, cyanosis, and increased heart rate are common
in asthma exacerbations. A decreased respiratory rate is not typical during an acute attack.

Question 1172: Endocrine

A patient with type 1 diabetes is experiencing hypoglycemia. Which symptoms should the nurse
monitor for? (Select all that apply.)

 A) Sweating
 B) Shakiness
 C) Confusion
 D) Frequent urination
 E) Increased thirst
Correct Answers: A, B, C
Rationale: Sweating, shakiness, and confusion are classic symptoms of hypoglycemia. Frequent
urination and increased thirst are more associated with hyperglycemia.

Question 1173: Pediatric

A nurse is preparing to discharge a child with cystic fibrosis. Which statements indicate that the
parents understand the discharge instructions? (Select all that apply.)

 A) "We need to give the pancreatic enzyme with every meal."

 B) "My child can have a normal diet without restrictions."
 C) "We should keep track of my child's weight regularly."
 D) "We need to increase my child's salt intake in hot weather."
 E) "Regular exercise is important for my child."

Correct Answers: A, C, D, E
Rationale: Giving pancreatic enzymes, monitoring weight, increasing salt intake in heat, and
encouraging exercise are all important. A normal diet may not be appropriate due to specific
nutritional needs in cystic fibrosis.

Question 1174: Infection Control

A nurse is caring for a patient diagnosed with viral meningitis. Which precautions should the
nurse implement? (Select all that apply.)

 A) Standard precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Contact precautions
 E) Hand hygiene before and after patient contact

Correct Answers: A, E
Rationale: Standard precautions and good hand hygiene are essential for all patients. Droplet
precautions may be necessary for certain viruses, but viral meningitis does not typically require
droplet or airborne precautions.

Question 1175: Cardiovascular

A nurse is monitoring a patient receiving heparin. Which laboratory test is essential to evaluate
the effectiveness of the therapy? (Select all that apply.)
  A) Prothrombin time (PT)
 B) Partial thromboplastin time (PTT)
 C) International normalized ratio (INR)
 D) Hemoglobin level
 E) Platelet count

Correct Answers: B
Rationale: The partial thromboplastin time (PTT) is the primary test to monitor heparin therapy.
PT and INR are used for warfarin monitoring, while hemoglobin and platelet counts can provide
additional information but are not primary tests for heparin.

Question 1176: Neurological

A nurse is caring for a patient with a spinal cord injury. Which assessments should the nurse
prioritize? (Select all that apply.)

 A) Level of consciousness
 B) Motor function assessment
 C) Sensory function assessment
 D) Bowel and bladder function
 E) Skin integrity

Correct Answers: A, B, C, D, E
Rationale: All these assessments are critical for monitoring a patient with a spinal cord injury,
including consciousness, motor and sensory function, bowel and bladder function, and skin
integrity.

Question 1177: Pharmacology

A nurse is teaching a patient about the use of beta-blockers. Which statements indicate proper
understanding? (Select all that apply.)

 A) "I should check my heart rate before taking this medication."

 B) "It’s okay to stop this medication suddenly if I feel better."
 C) "I should report any new or worsening shortness of breath."
 D) "This medication may help lower my blood pressure."
 E) "I can take this medication with any other prescription."

Correct Answers: A, C, D
Rationale: Patients should check their heart rate, report shortness of breath, and understand that
beta-blockers can lower blood pressure. They should not stop the medication suddenly, and
interactions with other prescriptions should be discussed.
Question 1178: Gastrointestinal

A nurse is educating a patient with irritable bowel syndrome (IBS) about dietary changes. Which
recommendations should the nurse include? (Select all that apply.)

 A) Increase fiber intake gradually.

 B) Limit dairy products if lactose intolerant.
 C) Eat small, frequent meals.
 D) Avoid caffeine and alcohol.
 E) Increase red meat consumption.

Correct Answers: A, B, C, D
Rationale: Gradually increasing fiber, limiting dairy if lactose intolerant, eating small meals,
and avoiding caffeine and alcohol can help manage IBS. Increasing red meat is not typically
recommended.

Question 1179: Surgical

A nurse is preparing a patient for a cholecystectomy. Which preoperative assessments are

essential? (Select all that apply.)

 A) Assessing for allergies to shellfish

 B) Checking for previous surgeries
 C) Evaluating laboratory values for liver function
 D) Assessing the patient's understanding of the procedure
 E) Reviewing the patient's medication list for anticoagulants

Correct Answers: A, C, D, E
Rationale: Assessing for shellfish allergies, evaluating liver function, understanding the
procedure, and reviewing medications for anticoagulants are all critical preoperative
assessments.

Question 1180: Mental Health

A nurse is caring for a patient diagnosed with bipolar disorder. Which interventions are
appropriate for managing acute mania? (Select all that apply.)

 A) Provide a structured environment.

 B) Encourage participation in group activities.
 C) Monitor for signs of exhaustion.
  D) Limit stimuli in the environment.
 E) Allow the patient to make their own decisions regarding treatment.

Correct Answers: A, C, D
Rationale: Providing structure, monitoring for exhaustion, and limiting stimuli are important.
Encouraging group activities and allowing decisions can increase agitation and may not be
appropriate during acute mania.

Question 1181: Pediatric

A nurse is assessing a toddler's development. Which milestones should the nurse expect at this
age? (Select all that apply.)

 A) The toddler can throw a ball overhand.

 B) The toddler can say two to three words.
 C) The toddler can jump in place.
 D) The toddler can stack four to six blocks.
 E) The toddler can follow simple instructions.

Correct Answers: A, C, D, E
Rationale: Throwing a ball, jumping in place, stacking blocks, and following simple instructions
are expected at this age. Saying two to three words may develop later.

Question 1182: Infection Control

A nurse is caring for a patient with a wound infected with Methicillin-resistant Staphylococcus
aureus (MRSA). Which precautions should the nurse implement? (Select all that apply.)

 A) Standard precautions
 B) Contact precautions
 C) Airborne precautions
 D) Droplet precautions
 E) Hand hygiene before and after patient contact

Correct Answers: A, B, E
Rationale: Standard precautions and contact precautions are necessary for MRSA. Hand hygiene
is critical, while airborne and droplet precautions are not required.

Question 1183: Cardiovascular

A nurse is teaching a patient about hypertension management. Which lifestyle modifications
should the nurse recommend? (Select all that apply.)

 A) Increase physical activity.

 B) Limit sodium intake.
 C) Reduce alcohol consumption.
 D) Increase intake of processed foods.
 E) Maintain a healthy weight.

Correct Answers: A, B, C, E
Rationale: Increasing activity, limiting sodium, reducing alcohol, and maintaining a healthy
weight are key. Processed foods are generally high in sodium and should be limited.

Question 1184: Neurological

A nurse is caring for a patient with multiple sclerosis (MS). Which symptoms should the nurse
monitor? (Select all that apply.)

 A) Visual disturbances
 B) Muscle weakness
 C) Numbness or tingling
 D) Increased appetite
 E) Difficulty with coordination

Correct Answers: A, B, C, E
Rationale: Visual disturbances, muscle weakness, numbness, and difficulty with coordination
are common in MS. Increased appetite is not typically associated with this condition.

Question 1185: Endocrine

A nurse is teaching a patient about thyroid hormone replacement therapy. Which statements
indicate the patient understands the instructions? (Select all that apply.)

 A) "I should take this medication on an empty stomach."

 B) "I will have my thyroid levels checked regularly."
 C) "I can stop taking this medication when I feel better."
 D) "I should avoid taking this medication with iron supplements."
 E) "I will need to take this medication for the rest of my life."

Correct Answers: A, B, D, E
Rationale: Taking medication on an empty stomach, regular thyroid level checks, avoiding iron
supplements, and lifelong therapy are essential components of managing hypothyroidism.
Question 1186: Gastrointestinal

A nurse is assessing a patient with liver cirrhosis. Which findings should the nurse expect?
(Select all that apply.)

 A) Jaundice
 B) Ascites
 C) Hypoalbuminemia
 D) Hypertension
 E) Asterixis

Correct Answers: A, B, C, E
Rationale: Jaundice, ascites, hypoalbuminemia, and asterixis are common in liver cirrhosis.
Hypertension is not typically associated with cirrhosis.

Question 1187: Surgical

A nurse is preparing a patient for a hip replacement. Which preoperative teaching is essential?
(Select all that apply.)

 A) Deep breathing exercises

 B) Leg exercises to prevent DVT
 C) Information about the surgical procedure
 D) Discussing postoperative pain management
 E) Avoiding all physical activity until discharge

Correct Answers: A, B, C, D
Rationale: Teaching about deep breathing, leg exercises, information on the procedure, and pain
management are critical. Avoiding all physical activity until discharge is not appropriate.

Question 1188: Mental Health

A nurse is developing a care plan for a patient with generalized anxiety disorder. Which
interventions should be included? (Select all that apply.)

 A) Encourage relaxation techniques.

 B) Schedule regular follow-up appointments.
 C) Limit the patient’s social interactions.
 D) Educate about medication options.
 E) Promote physical activity.
Correct Answers: A, B, D, E
Rationale: Encouraging relaxation techniques, follow-ups, medication education, and promoting
physical activity are effective interventions. Limiting social interactions is not helpful.

Question 1189: Pediatric

A nurse is assessing a child with a fever. Which assessment findings are important to monitor?
(Select all that apply.)

 A) Temperature
 B) Hydration status
 C) Respiratory rate
 D) Skin rash
 E) Appetite

Correct Answers: A, B, C, D, E
Rationale: All of these assessments are important when monitoring a child with a fever to
evaluate for potential complications.

Question 1190: Infection Control

A nurse is caring for a patient on antibiotic therapy for pneumonia. Which assessments should
the nurse prioritize? (Select all that apply.)

 A) Respiratory status
 B) Temperature
 C) Bowel sounds
 D) Urine output
 E) Skin integrity

Correct Answers: A, B, C, D, E
Rationale: Monitoring respiratory status, temperature, bowel sounds (to assess for antibiotic-
associated diarrhea), urine output, and skin integrity are all important during antibiotic therapy.

Question 1191: Cardiovascular

A patient is prescribed atorvastatin for hyperlipidemia. Which statement by the patient indicates
a need for further teaching?

 A) "I should have my liver function tests checked regularly."

  B) "I can stop taking this medication if my cholesterol levels are normal."
 C) "I need to avoid grapefruit juice while taking this medication."
 D) "This medication can help lower my risk of heart disease."

Correct Answer: B
Rationale: Patients should not stop taking statins without consulting their healthcare provider,
even if cholesterol levels normalize.

Question 1192: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
nursing interventions are appropriate? (Select all that apply.)

 A) Encourage the patient to practice pursed-lip breathing.

 B) Instruct the patient to limit fluid intake.
 C) Teach the patient about the use of bronchodilators.
 D) Monitor for signs of respiratory infection.
 E) Encourage high-protein diets.

Correct Answers: A, C, D, E
Rationale: Pursed-lip breathing, education about bronchodilators, monitoring for infection, and
encouraging a high-protein diet are essential. Fluid intake should not be excessively limited.

Question 1193: Gastrointestinal

A nurse is assessing a patient with a diagnosis of peptic ulcer disease. Which symptoms should
the nurse expect? (Select all that apply.)

 A) Abdominal pain that improves after eating

 B) Nausea and vomiting
 C) Weight loss
 D) Bloating and belching
 E) Diarrhea

Correct Answers: B, C, D
Rationale: Symptoms of peptic ulcer disease often include nausea, weight loss, bloating, and
belching. Abdominal pain typically worsens after eating, not improves.

Question 1194: Neurological

A patient is recovering from a stroke and has difficulty speaking. Which type of aphasia is
characterized by the patient being unable to produce speech, but still understands language?

 A) Broca's aphasia
 B) Wernicke's aphasia
 C) Global aphasia
 D) Anomic aphasia

Correct Answer: A
Rationale: Broca's aphasia involves difficulty producing speech but retaining comprehension
abilities.

Question 1195: Pediatric

A nurse is educating the parents of a toddler about safety measures. Which statements indicate
proper understanding? (Select all that apply.)

 A) "I will keep small objects out of reach to prevent choking."

 B) "It’s safe to use a baby walker on the stairs."
 C) "I should install safety gates at the top and bottom of the stairs."
 D) "I will never leave my child unattended in the bathtub."
 E) "It’s fine to allow my child to play outside alone."

Correct Answers: A, C, D
Rationale: Keeping small objects out of reach, using safety gates, and supervising during bath
time are critical for safety. Baby walkers should never be used on stairs, and children should not
be left alone outside.

Question 1196: Infection Control

A patient with a Clostridium difficile infection is placed on contact precautions. Which actions
should the nurse take? (Select all that apply.)

 A) Use gloves and gown when entering the patient's room.

 B) Place the patient in a private room.
 C) Perform hand hygiene with soap and water after patient contact.
 D) Use alcohol-based hand sanitizer before leaving the room.
 E) Disinfect all equipment after use.

Correct Answers: A, B, C, E
Rationale: Gloves and gowns are necessary for contact precautions, the patient should be in a
private room, hand hygiene should be performed with soap and water, and equipment should be
disinfected. Alcohol-based sanitizers are ineffective against C. difficile spores.

Question 1197: Endocrine

A nurse is caring for a patient with Addison's disease. Which findings would the nurse expect?
(Select all that apply.)

 A) Hyperkalemia
 B) Hyponatremia
 C) Hyperglycemia
 D) Fatigue
 E) Darkened skin pigmentation

Correct Answers: A, B, D, E
Rationale: Addison's disease is characterized by hyperkalemia, hyponatremia, fatigue, and
hyperpigmentation. Hyperglycemia is not typical.

Question 1198: Mental Health

A nurse is caring for a patient with depression who is starting fluoxetine (Prozac). Which
statement indicates a need for further teaching?

 A) "I should expect to feel better within a few days."

 B) "I need to report any suicidal thoughts to my doctor."
 C) "I should not drink alcohol while taking this medication."
 D) "I may experience some side effects as my body adjusts."

Correct Answer: A
Rationale: Antidepressants like fluoxetine typically take several weeks to have a therapeutic
effect, not just a few days.

Question 1199: Pharmacology

A nurse is administering digoxin to a patient with heart failure. Which assessments should the
nurse perform before giving the medication? (Select all that apply.)

 A) Assess the apical pulse for one full minute.

 B) Check for signs of peripheral edema.
 C) Monitor serum potassium levels.
  D) Review the patient's blood pressure.
 E) Obtain a 12-lead ECG.

Correct Answers: A, C, D
Rationale: The nurse should assess the apical pulse (hold if <60 bpm), monitor potassium levels
(digoxin toxicity risk), and check blood pressure. While peripheral edema and ECG may be
relevant, they are not mandatory for administering digoxin.

Question 1200: Surgical

A patient is being discharged after a laparoscopic cholecystectomy. Which instructions should

the nurse provide? (Select all that apply.)

 A) "You can resume normal activities immediately."

 B) "You may have some shoulder pain due to gas used during the surgery."
 C) "Avoid heavy lifting for at least two weeks."
 D) "It’s normal to have a small amount of drainage from your incisions."
 E) "You should take your pain medication as prescribed."

Correct Answers: B, C, D, E
Rationale: Patients may experience shoulder pain, should avoid heavy lifting, can expect
minimal drainage, and should take pain medication as prescribed. Resuming normal activities
should be gradual.

Question 1201: Respiratory

A nurse is caring for a patient with asthma who is experiencing an acute exacerbation. Which
intervention should the nurse implement first?

 A) Administer a bronchodilator.
 B) Position the patient in a high-Fowler's position.
 C) Assess the patient's lung sounds.
 D) Administer oxygen therapy.

Correct Answer: A
Rationale: Administering a bronchodilator is the priority intervention during an acute asthma
exacerbation to relieve bronchospasm.

Question 1202: Neurological

A nurse is assessing a patient with a recent stroke. Which finding would indicate the need for
immediate intervention?

 A) Slurred speech
 B) Weakness on one side
 C) Sudden onset of a severe headache
 D) Difficulty in walking

Correct Answer: C
Rationale: A sudden, severe headache may indicate complications such as a hemorrhagic stroke
and requires immediate intervention.

Question 1203: Cardiovascular

A patient diagnosed with congestive heart failure (CHF) is being discharged. Which statement
indicates the patient understands their discharge instructions?

 A) "I can weigh myself once a week."

 B) "I will limit my fluid intake to 3 liters per day."
 C) "I need to monitor my weight daily and report any gain over 2 pounds in one day."
 D) "I can continue to take my medications as prescribed, even if I feel better."

Correct Answer: C
Rationale: Daily weight monitoring is crucial for patients with CHF to detect fluid retention. A
weight gain of more than 2 pounds in one day should be reported.

Question 1204: Endocrine

A nurse is teaching a patient with type 1 diabetes about insulin administration. Which statement
by the patient indicates a need for further teaching?

 A) "I should rotate my injection sites to prevent lipodystrophy."

 B) "I can store my unopened insulin vials in the refrigerator."
 C) "I should only use a syringe with a needle that is 18 gauge."
 D) "I need to administer my insulin at the same time each day."

Correct Answer: C
Rationale: Insulin should be administered with a syringe that is typically 25 to 31 gauge, as a
larger gauge like 18 would be inappropriate.
Question 1205: Infection Control

A patient is in contact precautions due to a methicillin-resistant Staphylococcus aureus (MRSA)

infection. Which intervention should the nurse implement?

 A) Use an N95 mask when entering the room.

 B) Use gloves and gown when caring for the patient.
 C) Place the patient in a semi-private room with another patient.
 D) Perform hand hygiene with alcohol-based sanitizer after patient contact.

Correct Answer: B
Rationale: Contact precautions require gloves and gowns when caring for the patient. An N95
mask is not required for MRSA, and hand hygiene should be performed with soap and water.

Question 1206: Gastrointestinal

A nurse is caring for a patient who underwent a gastrectomy. Which finding should the nurse
report immediately?

 A) Abdomen soft and non-tender

 B) Bowel sounds present in all quadrants
 C) A sudden increase in abdominal distension
 D) Incisional drainage of serous fluid

Correct Answer: C
Rationale: A sudden increase in abdominal distension may indicate a complication such as an
obstruction or perforation and should be reported immediately.

Question 1207: Mental Health

A nurse is assessing a patient with schizophrenia. Which behavior might indicate the presence of
positive symptoms? (Select all that apply.)

 A) Hallucinations
 B) Social withdrawal
 C) Disorganized thinking
 D) Flat affect
 E) Delusions

Correct Answers: A, C, E
Rationale: Positive symptoms of schizophrenia include hallucinations, disorganized thinking,
and delusions, while social withdrawal and flat affect are considered negative symptoms.
Question 1208: Pediatric

A nurse is teaching a parent about caring for a child with cystic fibrosis. Which statement
indicates a correct understanding?

 A) "I will give my child a high-fat, high-calorie diet."

 B) "I need to restrict my child’s salt intake."
 C) "I should avoid pancreatic enzyme supplements."
 D) "I can let my child engage in vigorous physical activity without precautions."

Correct Answer: A
Rationale: Children with cystic fibrosis require a high-fat, high-calorie diet to meet their
nutritional needs. Salt intake should not be restricted, pancreatic enzyme supplements are
necessary, and physical activity should be encouraged with appropriate precautions.

Question 1209: Surgical

A nurse is caring for a postoperative patient who is receiving morphine via a patient-controlled
analgesia (PCA) pump. Which assessment is a priority?

 A) Pain level
 B) Respiratory rate
 C) Level of consciousness
 D) IV site

Correct Answer: B
Rationale: Respiratory rate is the priority assessment for a patient receiving morphine due to the
risk of respiratory depression.

Question 1210: Cardiovascular

A nurse is monitoring a patient receiving furosemide (Lasix) for heart failure. Which electrolyte
imbalance should the nurse assess for?

 A) Hyperkalemia
 B) Hypercalcemia
 C) Hyponatremia
 D) Hypomagnesemia
Correct Answer: C
Rationale: Furosemide is a loop diuretic that can cause hyponatremia (low sodium levels) as it
promotes sodium excretion.

Question 1211: Gastrointestinal

A nurse is caring for a patient diagnosed with Crohn's disease. Which dietary recommendation
should the nurse make?

 A) Increase fiber intake to improve bowel function.

 B) Avoid dairy products if lactose intolerant.
 C) Consume large meals to increase calorie intake.
 D) Follow a strict vegetarian diet.

Correct Answer: B
Rationale: Patients with Crohn's disease should avoid dairy products if they are lactose
intolerant. Increasing fiber intake may exacerbate symptoms, and small, frequent meals are
typically recommended.

Question 1212: Neurological

A nurse is assessing a patient with Parkinson’s disease. Which symptom should the nurse
expect?

 A) Unilateral weakness
 B) Tremors at rest
 C) Hyperactive reflexes
 D) Visual hallucinations

Correct Answer: B
Rationale: Tremors at rest are a classic symptom of Parkinson’s disease, while unilateral
weakness and hyperactive reflexes are not typical.

Question 1213: Infection Control

A nurse is caring for a patient with tuberculosis (TB). Which action is essential to prevent the
spread of the infection?

 A) Place the patient in a semi-private room.

 B) Wear a surgical mask when entering the room.
  C) Ensure the patient wears a mask when leaving the room.
 D) Use gloves when providing personal care.

Correct Answer: C
Rationale: Patients with TB should wear a mask when leaving their room to prevent the spread
of infection. The patient should be in a negative pressure room, and healthcare providers should
wear N95 respirators.

Question 1214: Endocrine

A patient with hyperthyroidism is being treated with methimazole. Which laboratory value
should the nurse monitor?

 A) Serum glucose levels

 B) Serum calcium levels
 C) Thyroid hormone levels
 D) Serum potassium levels

Correct Answer: C
Rationale: The nurse should monitor thyroid hormone levels to assess the effectiveness of
methimazole in treating hyperthyroidism.

Question 1215: Surgical

A patient who underwent a total knee replacement is being discharged. Which statement
indicates that the patient needs further teaching?

 A) "I can take a shower the day after surgery."

 B) "I will perform my exercises to strengthen my leg."
 C) "I should report any signs of infection at the incision site."
 D) "I will use a walker until I can walk without assistance."

Correct Answer: A
Rationale: Patients are typically advised to avoid soaking the surgical site and may not shower
until cleared by the healthcare provider, often a few days after surgery.

Question 1216: Pediatric

A nurse is teaching a parent about care for a child with asthma. Which statement indicates a need
for further teaching?
  A) "I can use a peak flow meter to monitor my child’s lung function."
 B) "I should keep my child away from triggers like smoke and dust."
 C) "It’s fine to use the rescue inhaler as often as needed."
 D) "I will teach my child how to use their inhaler properly."

Correct Answer: C
Rationale: While rescue inhalers can be used during asthma exacerbations, they should not be
used excessively. The parent should be educated on recognizing when to use it and when to seek
medical attention.

Question 1217: Infection Control

A nurse is caring for a patient diagnosed with a viral respiratory infection. Which intervention
should the nurse prioritize?

 A) Administer antibiotics as prescribed.

 B) Encourage the patient to rest and hydrate.
 C) Place the patient in isolation.
 D) Perform deep suctioning every four hours.

Correct Answer: B
Rationale: For viral infections, supportive care such as rest and hydration is crucial, as
antibiotics are ineffective against viruses, and isolation is not typically necessary.

Question 1218: Cardiovascular

A patient with a history of myocardial infarction is prescribed a beta-blocker. Which instruction

should the nurse provide?

 A) "You may experience a rapid heartbeat."

 B) "You should take this medication only when you feel chest pain."
 C) "Do not stop taking this medication abruptly."
 D) "It is safe to take this medication with alcohol."

Correct Answer: C
Rationale: Patients should not stop taking beta-blockers abruptly due to the risk of rebound
tachycardia and other cardiovascular events.

Question 1219: Mental Health

A nurse is caring for a patient diagnosed with generalized anxiety disorder. Which intervention
would be most effective in helping the patient manage anxiety?

 A) Encourage the patient to avoid stressful situations.

 B) Teach relaxation techniques and coping strategies.
 C) Provide high-stimulation activities to distract the patient.
 D) Suggest the patient focus on their worries.

Correct Answer: B
Rationale: Teaching relaxation techniques and coping strategies is an effective intervention for
managing anxiety.

Question 1220: Gastrointestinal

A nurse is caring for a patient who is scheduled for a colonoscopy. Which statement by the
patient indicates a need for further teaching?

 A) "I will need to fast for 24 hours before the procedure."

 B) "I can take my usual medications the morning of the test."
 C) "I need to drink the prep solution the night before the procedure."
 D) "I should avoid solid foods the day before the procedure."

Correct Answer: B
Rationale: Patients may need specific instructions regarding medications, including whether to
hold them before the procedure, especially blood thinners or other critical medications.

Question 1221: Neurological

A patient is experiencing a seizure. Which action should the nurse take first?

 A) Administer oxygen.
 B) Move objects away from the patient.
 C) Place the patient in a recovery position.
 D) Document the duration of the seizure.

Correct Answer: B
Rationale: The first action should be to move objects away from the patient to prevent injury.
Administering oxygen and placing the patient in a recovery position are important but should
follow ensuring the area is safe.
Question 1222: Cardiovascular

A nurse is monitoring a patient who has just received a dose of nitroglycerin for chest pain.
Which finding would be a priority for the nurse to assess?

 A) Blood pressure
 B) Heart rate
 C) Level of consciousness
 D) Oxygen saturation

Correct Answer: A
Rationale: Nitroglycerin can cause hypotension, so monitoring blood pressure is the priority.

Question 1223: Endocrine

A patient with diabetes is being taught about managing their condition. Which statement
indicates that the teaching was effective?

 A) "I will only check my blood sugar when I feel symptoms."

 B) "I should rotate my insulin injection sites to prevent tissue damage."
 C) "I can eat whatever I want as long as I take my insulin."
 D) "I need to check my feet for any cuts or sores every day."

Correct Answer: B
Rationale: Rotating injection sites is essential to prevent lipodystrophy. Checking blood sugar
should be routine, dietary choices should be balanced, and daily foot checks are critical in
diabetes management.

Question 1224: Infection Control

A nurse is caring for a patient diagnosed with influenza. What precautions should the nurse
implement?

 A) Droplet precautions
 B) Airborne precautions
 C) Contact precautions
 D) Standard precautions

Correct Answer: A
Rationale: Influenza is transmitted via droplets; therefore, droplet precautions should be
implemented.
Question 1225: Gastrointestinal

A nurse is teaching a patient about a low-residue diet. Which food item is appropriate for this
diet?

 A) Whole grain bread

 B) Brown rice
 C) Applesauce
 D) Raw vegetables

Correct Answer: C
Rationale: Applesauce is low in residue and suitable for a low-residue diet. Whole grains, brown
rice, and raw vegetables are typically avoided.

Question 1226: Mental Health

A patient diagnosed with major depressive disorder has been prescribed an antidepressant.
Which symptom should the nurse monitor for as a potential side effect?

 A) Increased energy
 B) Sedation
 C) Hyperactivity
 D) Weight loss

Correct Answer: B
Rationale: Sedation is a common side effect of many antidepressants, especially at the
beginning of treatment.

Question 1227: Pediatric

A nurse is caring for a child with acute glomerulonephritis. Which symptom should the nurse
monitor for?

 A) Hyperactivity
 B) Edema
 C) Diarrhea
 D) Weight gain

Correct Answer: B
Rationale: Edema is a common symptom of acute glomerulonephritis due to fluid retention.
Question 1228: Respiratory

A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which
finding indicates an exacerbation of the condition?

 A) Increased respiratory rate

 B) Decreased oxygen saturation
 C) Productive cough with increased sputum
 D) All of the above

Correct Answer: D
Rationale: All of the listed findings indicate an exacerbation of COPD and should be monitored
closely.

Question 1229: Cardiovascular

A patient is prescribed aspirin for the prevention of cardiovascular disease. What should the
nurse instruct the patient to do?

 A) Take aspirin with an antacid.

 B) Stop taking aspirin if nausea occurs.
 C) Report any unusual bruising or bleeding.
 D) Discontinue aspirin before dental procedures.

Correct Answer: C
Rationale: Patients taking aspirin should report unusual bruising or bleeding as it may indicate
bleeding complications.

Question 1230: Surgical

A patient is scheduled for surgery and is to receive preoperative sedation. Which nursing
intervention is most important prior to administering the sedative?

 A) Check for allergies.

 B) Obtain informed consent.
 C) Assess the patient's vital signs.
 D) Ensure the patient has voided.
Correct Answer: B
Rationale: Obtaining informed consent is critical before administering any sedative or
anesthetic.

Question 1231: Pharmacology

A nurse is preparing to administer warfarin (Coumadin) to a patient. Which laboratory test

should the nurse check before administering this medication?

 A) Complete blood count (CBC)

 B) Prothrombin time (PT) and international normalized ratio (INR)
 C) Serum electrolyte levels
 D) Liver function tests

Correct Answer: B
Rationale: PT and INR are crucial for monitoring the effectiveness and safety of warfarin
therapy.

Question 1232: Infection Control

A nurse is caring for a patient with a confirmed case of COVID-19. Which precaution should the
nurse implement?

 A) Standard precautions only

 B) Airborne precautions
 C) Droplet precautions
 D) Contact precautions

Correct Answer: C
Rationale: COVID-19 is primarily spread via respiratory droplets; therefore, droplet precautions
are necessary.

Question 1233: Endocrine

A patient with hypothyroidism is being treated with levothyroxine (Synthroid). Which symptom
indicates that the dosage may be too high?

 A) Cold intolerance
 B) Weight gain
 C) Increased heart rate
  D) Fatigue

Correct Answer: C
Rationale: An increased heart rate may indicate that the dosage of levothyroxine is too high.

Question 1234: Neurological

A patient is being assessed for signs of increased intracranial pressure (ICP). Which finding
should the nurse monitor for?

 A) Bradypnea
 B) Sudden onset of headache
 C) Decreased level of consciousness
 D) All of the above

Correct Answer: D
Rationale: All of these findings can indicate increased ICP and should be monitored closely.

Question 1235: Pediatric

A nurse is educating parents about the MMR vaccine. Which statement by the parent indicates a
need for further teaching?

 A) "This vaccine protects against measles, mumps, and rubella."

 B) "My child will need this vaccine at 12 months of age."
 C) "It's safe for my child to receive this vaccine if they have a cold."
 D) "My child will need a booster shot every year."

Correct Answer: D
Rationale: The MMR vaccine is not given annually; it typically requires a booster only once
after the initial doses.

Question 1236: Gastrointestinal

A nurse is caring for a patient with acute pancreatitis. Which intervention is most important for
the nurse to implement?

 A) Encourage a high-fat diet.

 B) Administer pain medication as prescribed.
 C) Provide oral fluids to promote hydration.
  D) Monitor for signs of infection.

Correct Answer: B
Rationale: Pain management is crucial in acute pancreatitis as the patient may experience
significant discomfort.

Question 1237: Infection Control

A nurse is caring for a patient with a catheter-associated urinary tract infection (CAUTI). Which
nursing intervention is most appropriate?

 A) Change the catheter every 24 hours.

 B) Encourage increased fluid intake.
 C) Perform a sterile dressing change.
 D) Limit the patient’s mobility.

Correct Answer: B
Rationale: Encouraging increased fluid intake helps flush bacteria from the urinary tract and is
an appropriate intervention for a CAUTI.

Question 1238: Mental Health

A nurse is caring for a patient experiencing a panic attack. Which intervention should the nurse
prioritize?

 A) Encourage deep breathing exercises.

 B) Discuss the patient’s feelings.
 C) Use a calm and reassuring voice.
 D) Provide distraction techniques.

Correct Answer: A
Rationale: Encouraging deep breathing exercises can help reduce hyperventilation and anxiety
during a panic attack.

Question 1239: Endocrine

A nurse is caring for a patient with Addison's disease. Which assessment finding would the nurse
expect?

 A) Hypertension
  B) Weight gain
 C) Hyperkalemia
 D) Hyperglycemia

Correct Answer: C
Rationale: Addison's disease is associated with hyperkalemia due to the adrenal glands' inability
to produce adequate aldosterone.

Question 1240: Surgical

A nurse is caring for a patient after a laparoscopic cholecystectomy. Which nursing intervention
is a priority?

 A) Encourage ambulation to prevent complications.

 B) Monitor the incision site for drainage.
 C) Assess bowel sounds.
 D) Administer analgesics for pain management.

Correct Answer: A
Rationale: Early ambulation is crucial after surgery to prevent complications such as deep vein
thrombosis and pulmonary embolism.

Question 1241: Cardiovascular

A patient with congestive heart failure (CHF) is receiving furosemide (Lasix). Which electrolyte
imbalance should the nurse monitor for?

 A) Hypernatremia
 B) Hyperkalemia
 C) Hypokalemia
 D) Hypercalcemia

Correct Answer: C
Rationale: Furosemide is a loop diuretic that can lead to hypokalemia due to increased
potassium excretion.

Question 1242: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
experiencing shortness of breath. Which position should the nurse place the patient in for optimal
comfort?

 A) Supine
 B) Trendelenburg
 C) Sitting upright or in a tripod position
 D) Lying on the left side

Correct Answer: C
Rationale: Sitting upright or in a tripod position helps maximize lung expansion and comfort for
patients with COPD.

Question 1243: Pediatric

A nurse is caring for a 5-year-old child with a high fever. Which assessment finding would be
the priority for the nurse to monitor?

 A) Respiratory rate
 B) Skin color
 C) Level of consciousness
 D) Heart rate

Correct Answer: C
Rationale: Monitoring the level of consciousness is critical, as altered consciousness may
indicate a serious infection or complication.

Question 1244: Neurological

A nurse is assessing a patient for signs of stroke. Which acronym should the nurse use to quickly
assess the patient's symptoms?

 A) CAB
 B) FAST
 C) ABC
 D) STOP

Correct Answer: B
Rationale: The acronym FAST (Face, Arms, Speech, Time) is used to identify the signs of
stroke quickly.
Question 1245: Infection Control

A nurse is providing care for a patient with a respiratory infection. What is the best way to
prevent the spread of infection in this scenario?

 A) Wear gloves when touching the patient.

 B) Use an N95 mask during care.
 C) Wash hands frequently and use hand sanitizer.
 D) Limit visitors to the room.

Correct Answer: C
Rationale: Frequent handwashing and the use of hand sanitizer are the most effective ways to
prevent the spread of infection.

Question 1246: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia who is experiencing auditory
hallucinations. Which intervention should the nurse prioritize?

 A) Provide reality orientation.

 B) Encourage the patient to discuss the hallucinations.
 C) Offer distraction techniques.
 D) Administer antipsychotic medications.

Correct Answer: A
Rationale: Providing reality orientation helps the patient differentiate between hallucinations
and reality, which is essential in managing symptoms.

Question 1247: Endocrine

A patient with diabetes is receiving insulin therapy. Which statement by the patient indicates a
need for further education?

 A) "I should rotate my injection sites."

 B) "I can skip a meal if I feel fine."
 C) "I need to check my blood sugar regularly."
 D) "I will store my insulin in the refrigerator."

Correct Answer: B
Rationale: Skipping meals can lead to hypoglycemia, especially if the patient is on insulin
therapy.
Question 1248: Gastrointestinal

A nurse is caring for a patient who has undergone an upper gastrointestinal (GI) series. Which
assessment finding would require immediate reporting?

 A) Mild abdominal discomfort

 B) Nausea and vomiting
 C) Inability to pass gas
 D) Dark stools

Correct Answer: D
Rationale: Dark stools can indicate bleeding in the upper GI tract and should be reported
immediately.

Question 1249: Cardiovascular

A patient who has been diagnosed with hypertension is prescribed lisinopril. Which instruction
should the nurse provide regarding this medication?

 A) "You may experience a dry cough."

 B) "Take this medication with food."
 C) "Avoid potassium-rich foods."
 D) "This medication may cause drowsiness."

Correct Answer: A
Rationale: A common side effect of lisinopril is a persistent dry cough.

Question 1250: Surgical

A nurse is providing discharge teaching for a patient after an appendectomy. Which statement
indicates the patient understands the discharge instructions?

 A) "I should avoid lifting anything heavier than 10 pounds for a few weeks."
 B) "It's fine to take a bath as soon as I get home."
 C) "If I have a fever, I should call my doctor immediately."
 D) "I can resume normal activities right away."

Correct Answer: C
Rationale: Patients should call their healthcare provider if they experience a fever, which could
indicate infection.
Question 1251: Pediatric

A nurse is assessing a child with suspected dehydration. Which sign is most indicative of
dehydration?

 A) Increased urine output

 B) Moist mucous membranes
 C) Decreased skin turgor
 D) Normal vital signs

Correct Answer: C
Rationale: Decreased skin turgor is a classic sign of dehydration.

Question 1252: Pharmacology

A patient is prescribed digoxin (Lanoxin) for heart failure. What should the nurse assess before
administering this medication?

 A) Blood pressure
 B) Heart rate
 C) Respiratory rate
 D) Serum potassium levels

Correct Answer: B
Rationale: The nurse should assess the heart rate because digoxin can cause bradycardia. The
heart rate should be above 60 beats per minute before administration.

Question 1253: Respiratory

A patient with asthma is using a bronchodilator. Which side effect should the nurse monitor for?

 A) Bradycardia
 B) Hypotension
 C) Increased heart rate
 D) Decreased respiratory rate

Correct Answer: C
Rationale: Bronchodilators can cause tachycardia as a side effect.
Question 1254: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis. Which isolation precaution should be
implemented?

 A) Standard precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Contact precautions

Correct Answer: C
Rationale: Tuberculosis requires airborne precautions due to the risk of airborne transmission.

Question 1255: Endocrine

A patient is experiencing a thyroid storm. Which symptom should the nurse anticipate?

 A) Weight gain
 B) Bradycardia
 C) Hyperthermia
 D) Cold intolerance

Correct Answer: C
Rationale: Hyperthermia is a significant symptom of a thyroid storm, indicating a life-
threatening condition.

Question 1256: Neurological

A nurse is caring for a patient with a head injury. Which assessment finding would require
immediate action?

 A) Slurred speech
 B) Unilateral pupil dilation
 C) Mild confusion
 D) Occasional headache

Correct Answer: B
Rationale: Unilateral pupil dilation may indicate increased intracranial pressure or brain
herniation and requires immediate medical intervention.
Question 1257: Gastrointestinal

A nurse is caring for a patient with chronic pancreatitis. Which dietary recommendation should
the nurse provide?

 A) High-fat diet
 B) High-protein diet
 C) Low-carbohydrate diet
 D) Low-fat diet

Correct Answer: D
Rationale: A low-fat diet is recommended for patients with chronic pancreatitis to minimize
pancreatic stimulation.

Question 1258: Mental Health

A nurse is working with a patient diagnosed with bipolar disorder who is in a manic phase.
Which intervention is most appropriate?

 A) Allow the patient to set their own limits.

 B) Encourage the patient to engage in group activities.
 C) Provide a structured environment with limits.
 D) Focus on the patient's feelings.

Correct Answer: C
Rationale: A structured environment with clear limits is essential to ensure safety and manage
behavior during a manic episode.

Question 1259: Pharmacology

A patient is prescribed prednisone. Which instruction should the nurse provide regarding this
medication?

 A) "Take this medication on an empty stomach."

 B) "You may experience weight loss."
 C) "Do not stop taking this medication abruptly."
 D) "It is safe to take this medication with NSAIDs."

Correct Answer: C
Rationale: Patients should not stop taking prednisone abruptly due to the risk of adrenal crisis.
Question 1260: Cardiovascular

A nurse is monitoring a patient receiving a blood transfusion. Which finding would indicate a
transfusion reaction?

 A) Elevated blood pressure

 B) Chills and fever
 C) Increased heart rate
 D) All of the above

Correct Answer: D
Rationale: All of these findings can indicate a transfusion reaction and should be addressed
immediately.

Question 1261: Musculoskeletal

A patient is recovering from a hip replacement. What is the priority nursing intervention?

 A) Administer pain medication.

 B) Encourage deep breathing exercises.
 C) Monitor for signs of infection.
 D) Assist with ambulation.

Correct Answer: D
Rationale: Assisting with ambulation is crucial for recovery after hip replacement surgery to
promote circulation and prevent complications.

Question 1262: Endocrine

A patient diagnosed with type 1 diabetes is experiencing signs of hypoglycemia. Which

symptom should the nurse monitor for?

 A) Polyuria
 B) Confusion
 C) Weight gain
 D) Hyperglycemia

Correct Answer: B
Rationale: Confusion is a common symptom of hypoglycemia due to the brain's reliance on
glucose for energy.
Question 1263: Respiratory

A patient with pneumonia is being treated with antibiotics. Which nursing intervention is most
appropriate?

 A) Encourage fluid intake.

 B) Restrict activity.
 C) Monitor for fever only.
 D) Provide a high-fat diet.

Correct Answer: A
Rationale: Encouraging fluid intake helps thin secretions and promotes better lung function.

Question 1264: Neurological

A nurse is caring for a patient with Parkinson's disease. Which intervention would be most
beneficial in promoting safety?

 A) Use of restraints
 B) Provide a clutter-free environment
 C) Encourage the patient to walk without assistance
 D) Maintain a low-calorie diet

Correct Answer: B
Rationale: A clutter-free environment reduces the risk of falls for patients with Parkinson’s
disease.

Question 1265: Cardiovascular

A nurse is assessing a patient with heart failure. Which assessment finding indicates worsening
heart failure?

 A) Weight loss
 B) Peripheral edema
 C) Increased energy level
 D) Improved exercise tolerance

Correct Answer: B
Rationale: Peripheral edema is a sign of fluid retention and worsening heart failure.
Question 1266: Gastrointestinal

A nurse is caring for a patient with a nasogastric (NG) tube. What is the priority nursing action?

 A) Check tube placement before feeding.

 B) Administer medications via the tube.
 C) Change the tube every week.
 D) Remove the tube after use.

Correct Answer: A
Rationale: Ensuring proper tube placement is critical before any feeding or medication
administration to prevent aspiration.

Question 1267: Infection Control

A patient with a wound infection is receiving antibiotic therapy. Which laboratory test should the
nurse monitor to evaluate the effectiveness of treatment?

 A) Hemoglobin
 B) WBC count
 C) Platelet count
 D) Blood glucose level

Correct Answer: B
Rationale: Monitoring the white blood cell (WBC) count helps assess the body's response to
infection and the effectiveness of antibiotics.

Question 1268: Pediatric

A nurse is teaching a parent about caring for a child with asthma. Which statement by the parent
indicates a need for further teaching?

 A) "I should keep my child's rescue inhaler with me at all times."

 B) "My child can take their medications only when they feel sick."
 C) "I will avoid exposing my child to smoke."
 D) "I need to monitor my child's peak flow readings."

Correct Answer: B
Rationale: Asthma medications should be taken as prescribed, not just when feeling sick.
Question 1269: Mental Health

A nurse is caring for a patient with depression. Which intervention should be included in the care
plan?

 A) Encourage social isolation.

 B) Provide consistent and structured routines.
 C) Limit physical activity to conserve energy.
 D) Discourage the patient from discussing feelings.

Correct Answer: B
Rationale: Providing a consistent and structured routine can help improve mood and provide
stability for patients with depression.

Question 1270: Pharmacology

A nurse is administering metoprolol to a patient with hypertension. What is the priority nursing
assessment before administration?

 A) Assess for peripheral edema.

 B) Monitor heart rate and blood pressure.
 C) Evaluate renal function.
 D) Check for respiratory rate.

Correct Answer: B
Rationale: Monitoring heart rate and blood pressure is crucial because metoprolol can cause
bradycardia and hypotension.

Question 1271: Respiratory

A patient with chronic bronchitis is prescribed a mucolytic agent. What is the expected outcome
of this medication?

 A) Decreased heart rate

 B) Reduced airway inflammation
 C) Thinning and loosening of mucus secretions
 D) Increased respiratory rate

Correct Answer: C
Rationale: Mucolytic agents work to thin and loosen mucus, making it easier to expectorate.
Question 1272: Endocrine

A patient is diagnosed with Addison's disease. Which medication is the patient likely to be
prescribed?

 A) Levothyroxine
 B) Prednisone
 C) Insulin
 D) Metformin

Correct Answer: B
Rationale: Prednisone is a corticosteroid that helps manage the adrenal insufficiency seen in
Addison's disease.

Question 1273: Neurological

A patient is admitted with a suspected stroke. Which test should the nurse anticipate being
ordered immediately?

 A) MRI of the brain

 B) CT scan of the head
 C) EEG
 D) Lumbar puncture

Correct Answer: B
Rationale: A CT scan of the head is typically ordered first to determine if there is bleeding or an
ischemic stroke.

Question 1274: Surgical

A nurse is caring for a patient post-laparoscopic cholecystectomy. Which discharge instruction

should the nurse provide?

 A) "You can resume normal activities immediately."

 B) "Avoid lifting anything heavier than 15 pounds for a few weeks."
 C) "You should not eat solid foods for one week."
 D) "You will need to come back for a wound dressing change."

Correct Answer: B
Rationale: Patients are typically advised to avoid heavy lifting for several weeks to promote
healing.
Question 1275: Pediatric

A nurse is assessing a 4-year-old child with a respiratory infection. Which assessment finding is
most concerning?

 A) Low-grade fever
 B) Stridor on inspiration
 C) Mild cough
 D) Increased respiratory rate

Correct Answer: B
Rationale: Stridor indicates a narrowing of the airway and is a sign of potential respiratory
distress that requires immediate attention.

Question 1276: Infection Control

A nurse is caring for a patient with clostridium difficile infection (CDI). What is the most
important infection control measure?

 A) Standard precautions
 B) Handwashing with soap and water
 C) Wearing gloves only
 D) Using alcohol-based hand sanitizer

Correct Answer: B
Rationale: Handwashing with soap and water is critical to effectively remove spores from the
hands.

Question 1277: Endocrine

A patient with diabetes mellitus is prescribed glipizide. What is the primary action of this
medication?

 A) Decreases hepatic glucose production

 B) Increases insulin secretion from the pancreas
 C) Enhances cellular sensitivity to insulin
 D) Delays carbohydrate absorption

Correct Answer: B
Rationale: Glipizide is a sulfonylurea that stimulates the pancreas to release more insulin.
Question 1278: Cardiovascular

A patient is prescribed warfarin (Coumadin). Which laboratory test should the nurse monitor?

 A) aPTT
 B) PT/INR
 C) CBC
 D) D-dimer

Correct Answer: B
Rationale: The prothrombin time (PT) and international normalized ratio (INR) are monitored to
ensure the patient is within the therapeutic range for anticoagulation.

Question 1279: Gastrointestinal

A patient with liver cirrhosis is at risk for developing which complication?

 A) Hyperglycemia
 B) Hepatic encephalopathy
 C) Hypokalemia
 D) Pulmonary embolism

Correct Answer: B
Rationale: Hepatic encephalopathy can occur due to the buildup of toxins, particularly
ammonia, in patients with liver dysfunction.

Question 1280: Neurological

A nurse is assessing a patient who has just received a seizure medication. Which symptom
indicates a possible adverse effect of the medication?

 A) Increased appetite
 B) Rash
 C) Drowsiness
 D) Improved mood

Correct Answer: B
Rationale: A rash can indicate an allergic reaction or serious side effect of some seizure
medications, such as Steven-Johnson syndrome.
Question 1281: Musculoskeletal

A patient is being discharged after a total knee replacement. Which instruction should the nurse
include in the discharge teaching?

 A) Limit range of motion exercises for the first week.

 B) Apply ice to the knee for the first 24 hours.
 C) Avoid using any assistive devices when ambulating.
 D) Elevate the leg only while sleeping.

Correct Answer: B
Rationale: Applying ice to the knee for the first 24 hours helps reduce swelling and pain.

Question 1282: Endocrine

A patient with diabetes is prescribed insulin glargine. What is an important teaching point for the
nurse to provide?

 A) Take this medication with food.

 B) This insulin should be taken once daily at the same time.
 C) Rotate injection sites every day.
 D) This insulin can be mixed with other insulins.

Correct Answer: B
Rationale: Insulin glargine is a long-acting insulin that is usually administered once daily at the
same time.

Question 1283: Cardiovascular

A nurse is assessing a patient with heart failure. Which finding is most indicative of fluid
overload?

 A) Hypotension
 B) Bradycardia
 C) Pulmonary crackles
 D) Dry mucous membranes

Correct Answer: C
Rationale: Pulmonary crackles are a classic sign of fluid accumulation in the lungs due to heart
failure.
Question 1284: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is using a metered-dose inhaler
(MDI) for the first time. What should the nurse teach the patient?

 A) Take a deep breath before inhaling.

 B) Hold the inhaler upside down for better delivery.
 C) Exhale completely before using the inhaler.
 D) Use the inhaler every hour for maximum effect.

Correct Answer: C
Rationale: Exhaling completely before using the inhaler helps to maximize the amount of
medication delivered to the lungs.

Question 1285: Gastrointestinal

A patient with peptic ulcer disease is prescribed ranitidine. What is the primary action of this
medication?

 A) Increases gastric acid production

 B) Neutralizes stomach acid
 C) Inhibits gastric acid secretion
 D) Protects the gastric mucosa

Correct Answer: C
Rationale: Ranitidine is an H2 receptor antagonist that inhibits gastric acid secretion.

Question 1286: Mental Health

A patient diagnosed with schizophrenia is prescribed risperidone. Which side effect should the
nurse monitor for?

 A) Weight loss
 B) Extrapyramidal symptoms
 C) Hypotension
 D) Bradycardia

Correct Answer: B
Rationale: Extrapyramidal symptoms (EPS) are common side effects of antipsychotic
medications like risperidone.
Question 1287: Neurological

A nurse is caring for a patient with a spinal cord injury. Which nursing diagnosis is the priority
for this patient?

 A) Impaired physical mobility

 B) Risk for impaired skin integrity
 C) Risk for injury
 D) Ineffective coping

Correct Answer: B
Rationale: Risk for impaired skin integrity is a priority concern due to decreased mobility and
sensation.

Question 1288: Surgical

A nurse is preparing a patient for a colonoscopy. Which bowel preparation should the nurse
instruct the patient to complete?

 A) Low-fiber diet for three days prior

 B) Clear liquid diet for 24 hours
 C) High-fiber diet the day before
 D) Regular diet without restrictions

Correct Answer: B
Rationale: A clear liquid diet for 24 hours helps ensure the bowel is clean for the procedure.

Question 1289: Infection Control

A nurse is providing care for a patient with tuberculosis (TB). Which precaution should the nurse
take?

 A) Wear gloves only.

 B) Use a standard surgical mask.
 C) Place the patient in a negative pressure room.
 D) No special precautions are needed.

Correct Answer: C
Rationale: A negative pressure room helps prevent the spread of TB bacteria in the air.
Question 1290: Pediatric

A nurse is assessing a 2-year-old child for signs of dehydration. Which sign is most concerning?

 A) Dry skin
 B) Decreased urine output
 C) Sunken eyes
 D) Irritability

Correct Answer: C
Rationale: Sunken eyes are a significant indicator of severe dehydration in children.

Question 1291: Pharmacology

A patient is prescribed lisinopril. What is the primary therapeutic effect of this medication?

 A) Increases heart rate

 B) Reduces blood pressure
 C) Decreases blood glucose
 D) Increases blood volume

Correct Answer: B
Rationale: Lisinopril is an ACE inhibitor that primarily works to reduce blood pressure.

Question 1292: Cardiovascular

A nurse is caring for a patient who just had a myocardial infarction. Which medication should
the nurse expect to be prescribed?

 A) Calcium channel blocker

 B) Beta-blocker
 C) Antihistamine
 D) Antidepressant

Correct Answer: B
Rationale: Beta-blockers are commonly prescribed after a myocardial infarction to reduce the
heart's workload.
Question 1293: Gastrointestinal

A patient with cirrhosis is experiencing ascites. Which nursing intervention is most appropriate?

 A) Administer diuretics as prescribed.

 B) Encourage high-sodium foods.
 C) Increase fluid intake.
 D) Limit protein intake.

Correct Answer: A
Rationale: Administering diuretics helps manage fluid retention associated with ascites.

Question 1294: Mental Health

A nurse is caring for a patient with major depressive disorder who is beginning selective
serotonin reuptake inhibitors (SSRIs). What is an important teaching point?

 A) "You will feel better immediately."

 B) "It may take several weeks to feel the effects."
 C) "You should stop taking this medication if you feel anxious."
 D) "You can stop this medication whenever you want."

Correct Answer: B
Rationale: It may take several weeks for SSRIs to show therapeutic effects.

Question 1295: Neurological

A nurse is assessing a patient with suspected meningitis. Which finding would be most
concerning?

 A) Stiff neck
 B) Sensitivity to light
 C) Nausea and vomiting
 D) Bradycardia

Correct Answer: D
Rationale: Bradycardia in a patient with suspected meningitis could indicate increased
intracranial pressure.

Question 1296: Respiratory

A patient with asthma is prescribed a corticosteroid inhaler. What is the purpose of this
medication?

 A) Immediate bronchodilation
 B) Long-term control of inflammation
 C) Relief of acute symptoms
 D) Increased mucus production

Correct Answer: B
Rationale: Corticosteroid inhalers are used for long-term control of airway inflammation in
asthma management.

Question 1297: Surgical

A nurse is caring for a patient after a thyroidectomy. Which assessment finding would be most
concerning?

 A) Mild hoarseness
 B) Difficulty swallowing
 C) Tetany and numbness in extremities
 D) Low-grade fever

Correct Answer: C
Rationale: Tetany and numbness can indicate hypoparathyroidism and hypocalcemia, which are
serious complications after a thyroidectomy.

Question 1298: Infection Control

A nurse is providing education to a group of nursing students about the transmission of

infections. Which statement is true regarding airborne precautions?

 A) They are not required for tuberculosis.

 B) They require the use of a standard surgical mask.
 C) Patients should be placed in private rooms with negative air pressure.
 D) Hand hygiene is not essential when caring for these patients.

Correct Answer: C
Rationale: Airborne precautions require private rooms with negative pressure to prevent the
spread of infections.
Question 1299: Endocrine

A nurse is teaching a patient with hyperthyroidism about symptoms to report. Which symptom
should the nurse emphasize?

 A) Weight gain
 B) Increased heart rate
 C) Fatigue
 D) Cold intolerance

Correct Answer: B
Rationale: Increased heart rate can indicate worsening hyperthyroidism and should be reported
to a healthcare provider.

Question 1300: Cardiovascular

A patient with hypertension is prescribed a thiazide diuretic. Which lab value should the nurse
monitor closely?

 A) Potassium levels
 B) Calcium levels
 C) Sodium levels
 D) Magnesium levels

Correct Answer: A
Rationale: Thiazide diuretics can cause hypokalemia, so potassium levels should be monitored
regularly.

Question 1301: Pharmacology

A nurse is administering warfarin to a patient. Which lab value should the nurse monitor to
assess the effectiveness of this medication?

 A) Hemoglobin
 B) International normalized ratio (INR)
 C) Partial thromboplastin time (PTT)
 D) Platelet count

Correct Answer: B
Rationale: The INR is used to monitor the effectiveness of warfarin therapy.
Question 1302: Gastrointestinal

A nurse is caring for a patient with liver cirrhosis who has developed hepatic encephalopathy.
Which symptom should the nurse monitor for?

 A) Increased appetite
 B) Confusion and altered mental status
 C) Bradycardia
 D) Increased energy levels

Correct Answer: B
Rationale: Confusion and altered mental status are common symptoms of hepatic
encephalopathy due to increased ammonia levels.

Question 1303: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
experiencing shortness of breath. Which position is most appropriate to promote optimal lung
expansion?

 A) Supine
 B) Prone
 C) High Fowler's
 D) Lithotomy

Correct Answer: C
Rationale: The High Fowler's position promotes optimal lung expansion and eases breathing.

Question 1304: Mental Health

A nurse is caring for a patient diagnosed with bipolar disorder. Which behavior should the nurse
monitor as a sign of mania?

 A) Decreased need for sleep

 B) Increased interest in activities
 C) Withdrawal from social interactions
 D) Pessimistic outlook

Correct Answer: A
Rationale: A decreased need for sleep is a common sign of mania in bipolar disorder.
Question 1305: Cardiovascular

A patient is receiving a transfusion of packed red blood cells. Which assessment finding should
the nurse monitor closely for a potential transfusion reaction?

 A) Elevated blood pressure

 B) Increased temperature
 C) Urine output of 60 mL/hour
 D) Decreased respiratory rate

Correct Answer: B
Rationale: An increased temperature can indicate a febrile transfusion reaction.

Question 1306: Endocrine

A patient diagnosed with hyperthyroidism is being treated with radioactive iodine. What is an
important nursing intervention?

 A) Monitor for signs of hypothyroidism.

 B) Encourage a high-iodine diet.
 C) Administer thyroid hormone supplements.
 D) Place the patient in isolation.

Correct Answer: A
Rationale: Patients treated with radioactive iodine may develop hypothyroidism, so monitoring
for this condition is important.

Question 1307: Pediatric

A nurse is caring for a 5-year-old child with asthma. Which symptom should the nurse prioritize
as a sign of an asthma exacerbation?

 A) Coughing
 B) Wheezing
 C) Mild chest tightness
 D) Difficulty speaking in full sentences

Correct Answer: D
Rationale: Difficulty speaking in full sentences indicates significant airway obstruction and
should be prioritized.
Question 1308: Neurological

A nurse is assessing a patient who has had a stroke. Which sign would indicate that the patient
may be experiencing dysphagia?

 A) Complaints of double vision

 B) Coughing when drinking liquids
 C) Weakness on one side of the body
 D) Inability to raise both arms

Correct Answer: B
Rationale: Coughing when drinking liquids is a sign of dysphagia and potential aspiration risk.

Question 1309: Surgical

A patient is scheduled for an appendectomy. What preoperative teaching should the nurse
provide regarding postoperative care?

 A) You will be able to eat solid foods immediately after surgery.

 B) You will have a dressing on your abdomen that will remain for a week.
 C) You may experience pain at the incision site that can be managed with medication.
 D) You should avoid ambulating for at least 48 hours after surgery.

Correct Answer: C
Rationale: Pain at the incision site is expected after surgery, and the nurse should provide
information on pain management.

Question 1310: Infection Control

A nurse is caring for a patient with a MRSA infection. Which type of precautions should the
nurse implement?

 A) Contact precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Standard precautions only

Correct Answer: A
Rationale: Contact precautions are necessary to prevent the spread of MRSA.
Question 1311: Gastrointestinal

A nurse is caring for a patient with diverticulitis. Which dietary recommendation should the
nurse provide?

 A) High-fiber diet
 B) Low-residue diet
 C) Low-fiber diet
 D) Clear liquid diet

Correct Answer: B
Rationale: A low-residue diet is recommended during an acute diverticulitis flare-up to
minimize bowel activity.

Question 1312: Cardiovascular

A nurse is monitoring a patient who has just started taking a beta-blocker. Which side effect
should the nurse monitor for?

 A) Hypertension
 B) Tachycardia
 C) Bradycardia
 D) Hyperglycemia

Correct Answer: C
Rationale: Bradycardia is a common side effect of beta-blockers.

Question 1313: Neurological

A nurse is assessing a patient with Parkinson's disease. Which symptom should the nurse expect
to find?

 A) Hyperactivity
 B) Bradykinesia
 C) Increased appetite
 D) Insomnia

Correct Answer: B
Rationale: Bradykinesia, or slowness of movement, is a hallmark symptom of Parkinson's
disease.
Question 1314: Respiratory

A patient with pneumonia is being treated with antibiotics. Which lab value should the nurse
monitor to assess for treatment effectiveness?

 A) White blood cell count

 B) Blood glucose level
 C) BUN and creatinine
 D) Electrolytes

Correct Answer: A
Rationale: A decreasing white blood cell count indicates a response to antibiotic therapy in
pneumonia.

Question 1315: Endocrine

A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. Which
intervention should the nurse implement first?

 A) Administer glucagon.
 B) Provide a snack with protein and carbohydrates.
 C) Give oral glucose tablets.
 D) Call the physician.

Correct Answer: C
Rationale: Providing oral glucose tablets is the first intervention for conscious patients
experiencing hypoglycemia.

Question 1316: Surgical

A nurse is caring for a patient after a laparoscopic cholecystectomy. Which discharge instruction
should the nurse include?

 A) Avoid all fats in your diet for one month.

 B) You can resume normal activities immediately.
 C) Expect some shoulder pain due to gas used during surgery.
 D) Limit fluid intake for the first 24 hours.

Correct Answer: C
Rationale: Shoulder pain can occur due to carbon dioxide used during the procedure and is a
common postoperative complaint.
Question 1317: Pediatric

A nurse is assessing a child with suspected appendicitis. Which finding is most indicative of this
condition?

 A) Fever and chills

 B) Abdominal pain in the right lower quadrant
 C) Diarrhea
 D) Vomiting and nausea

Correct Answer: B
Rationale: Abdominal pain in the right lower quadrant is a classic sign of appendicitis.

Question 1318: Mental Health

A nurse is developing a care plan for a patient with generalized anxiety disorder. Which
intervention is a priority?

 A) Encourage daily exercise.

 B) Teach relaxation techniques.
 C) Schedule regular follow-up appointments.
 D) Initiate cognitive-behavioral therapy.

Correct Answer: B
Rationale: Teaching relaxation techniques is essential for helping patients manage anxiety
symptoms effectively.

Question 1319: Infection Control

A nurse is caring for a patient with a urinary tract infection (UTI). Which action is most effective
in preventing future UTIs?

 A) Increasing fluid intake

 B) Using bubble bath
 C) Doubling up on antibiotics
 D) Avoiding caffeine

Correct Answer: A
Rationale: Increasing fluid intake helps flush bacteria out of the urinary tract, reducing the risk
of UTIs.
Question 1320: Cardiovascular

A patient is receiving a transfusion of packed red blood cells. Which assessment finding is most
concerning?

 A) Temperature increase of 1°F

 B) Mild itching at the IV site
 C) Blood pressure drop of 20 mm Hg
 D) Slight back pain

Correct Answer: C
Rationale: A drop in blood pressure of 20 mm Hg could indicate a transfusion reaction and
should be reported immediately.

Question 1321: Pharmacology

A nurse is teaching a patient about taking metformin for type 2 diabetes. Which statement by the
patient indicates a need for further teaching?

 A) "I will take this medication with meals."

 B) "I should monitor my blood sugar levels regularly."
 C) "I can skip doses if I’m feeling well."
 D) "I will notify my doctor if I experience any unusual symptoms."

Correct Answer: C
Rationale: Patients should not skip doses of metformin, as consistent administration is crucial
for controlling blood sugar levels.

Question 1322: Respiratory

A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) who has
developed a respiratory infection. Which assessment finding indicates the patient may be in
respiratory distress?

 A) O2 saturation of 95%
 B) Ability to speak in full sentences
 C) Use of accessory muscles for breathing
 D) Mild cough with clear sputum
Correct Answer: C
Rationale: The use of accessory muscles for breathing indicates respiratory distress and
increased work of breathing.

Question 1323: Neurological

A nurse is caring for a patient who has experienced a seizure. Which action should the nurse take
first after the seizure has ended?

 A) Administer oxygen
 B) Turn the patient onto their side
 C) Assess the patient's level of consciousness
 D) Document the seizure activity

Correct Answer: B
Rationale: Turning the patient onto their side helps maintain an open airway and prevents
aspiration.

Question 1324: Cardiovascular

A patient is being discharged after a myocardial infarction (MI). Which instruction should the
nurse prioritize for the patient?

 A) Engage in heavy lifting within one week.

 B) Avoid all physical activity for one month.
 C) Attend cardiac rehabilitation sessions.
 D) Follow a high-fat diet to increase calorie intake.

Correct Answer: C
Rationale: Attending cardiac rehabilitation is crucial for recovery after an MI and helps the
patient learn how to manage their health.

Question 1325: Mental Health

A nurse is caring for a patient diagnosed with major depressive disorder. Which intervention is
most appropriate to promote the patient’s safety?

 A) Encourage the patient to express their feelings.

 B) Provide the patient with a list of coping strategies.
 C) Conduct a suicide risk assessment.
  D) Increase the patient's physical activity.

Correct Answer: C
Rationale: Conducting a suicide risk assessment is essential to ensure the patient’s safety.

Question 1326: Pediatric

A nurse is assessing a child with croup. Which finding is most characteristic of this condition?

 A) High fever
 B) Barking cough
 C) Wheezing
 D) Nasal congestion

Correct Answer: B
Rationale: A barking cough is a classic sign of croup, which is caused by inflammation of the
larynx.

Question 1327: Gastrointestinal

A patient with chronic pancreatitis is being educated about dietary modifications. Which
statement indicates the need for further teaching?

 A) "I will eat a low-fat diet."

 B) "I can continue to drink alcohol in moderation."
 C) "I should avoid foods that are spicy or fried."
 D) "I will eat small, frequent meals throughout the day."

Correct Answer: B
Rationale: Alcohol should be completely avoided in patients with chronic pancreatitis.

Question 1328: Infection Control

A nurse is preparing to perform a dressing change on a patient with a surgical wound. Which
action is most appropriate for maintaining aseptic technique?

 A) Use sterile gloves only when handling the dressing.

 B) Place all supplies on the bedside table before donning gloves.
 C) Avoid touching the inside of the dressing package.
 D) Use the same pair of gloves for multiple tasks during the procedure.
Correct Answer: C
Rationale: Avoiding contact with the inside of the dressing package maintains aseptic technique.

Question 1329: Endocrine

A nurse is monitoring a patient with Addison’s disease. Which finding should the nurse
anticipate?

 A) Hypoglycemia
 B) Hypernatremia
 C) Weight gain
 D) Hypertension

Correct Answer: A
Rationale: Patients with Addison's disease often experience hypoglycemia due to insufficient
cortisol production.

Question 1330: Surgical

A nurse is providing post-operative education to a patient who has undergone a total hip
replacement. Which statement indicates the need for further teaching?

 A) "I can cross my legs when sitting in a chair."

 B) "I should avoid bending my hips greater than 90 degrees."
 C) "I will use a raised toilet seat to prevent hip flexion."
 D) "I can participate in physical therapy to regain strength."

Correct Answer: A
Rationale: Crossing the legs can lead to dislocation of the new hip joint and should be avoided.

Question 1331: Respiratory

A patient diagnosed with asthma is using a peak flow meter. Which reading indicates that the
patient's asthma is under control?

 A) 50% of personal best

 B) 80% of personal best
 C) 30% of personal best
 D) 70% of personal best
Correct Answer: B
Rationale: A reading of 80% or above indicates that asthma is under good control.

Question 1332: Cardiovascular

A nurse is monitoring a patient who has received a dose of digoxin. Which assessment finding
would warrant immediate intervention?

 A) Heart rate of 68 beats per minute

 B) Blood pressure of 110/70 mm Hg
 C) Serum potassium level of 3.0 mEq/L
 D) ECG showing sinus rhythm

Correct Answer: C
Rationale: A low serum potassium level can increase the risk of digoxin toxicity, requiring
immediate intervention.

Question 1333: Mental Health

A nurse is caring for a patient with obsessive-compulsive disorder (OCD). Which intervention is
most appropriate?

 A) Encourage the patient to avoid rituals.

 B) Allow the patient to engage in compulsive behaviors to reduce anxiety.
 C) Provide positive reinforcement for completing tasks without rituals.
 D) Suggest that the patient can control their thoughts.

Correct Answer: C
Rationale: Providing positive reinforcement for completing tasks without engaging in
compulsions can help manage OCD symptoms.

Question 1334: Pediatric

A nurse is caring for a 10-year-old child with a fracture. Which nursing intervention is most
appropriate for managing the child's pain?

 A) Allow the child to choose between a cold or hot pack.

 B) Administer the prescribed analgesics.
 C) Suggest that the child try to ignore the pain.
 D) Encourage the child to play games to distract from the pain.
Correct Answer: B
Rationale: Administering prescribed analgesics is the most effective way to manage the child's
pain.

Question 1335: Gastrointestinal

A nurse is assessing a patient who has just undergone a colonoscopy. Which finding is
concerning and should be reported?

 A) Mild abdominal cramping

 B) Passage of gas
 C) Bright red blood in the stool
 D) Slight dizziness

Correct Answer: C
Rationale: Bright red blood in the stool can indicate a potential complication and should be
reported immediately.

Question 1336: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis (TB). Which precaution should the
nurse take when providing care?

 A) Wear a gown and gloves only.

 B) Use a mask when within 3 feet of the patient.
 C) Implement airborne precautions.
 D) Limit visitors to one per day.

Correct Answer: C
Rationale: Airborne precautions are necessary to prevent the spread of tuberculosis.

Question 1337: Neurological

A nurse is monitoring a patient after a craniotomy. Which assessment finding is most

concerning?

 A) Slight headache
 B) Disorientation to time
 C) Sudden onset of a severe headache
 D) Reports of dizziness
Correct Answer: C
Rationale: A sudden onset of a severe headache may indicate complications such as a hematoma
or increased intracranial pressure.

Question 1338: Endocrine

A patient with diabetes is scheduled for a surgical procedure. What should the nurse advise the
patient regarding insulin administration?

 A) Skip the morning dose of insulin.

 B) Administer a full dose of insulin regardless of fasting.
 C) Discuss with the physician regarding insulin adjustment.
 D) Continue taking oral hypoglycemic agents up to the time of surgery.

Correct Answer: C
Rationale: It’s important for the patient to discuss insulin adjustments with the physician prior to
surgery.

Question 1339: Surgical

A nurse is caring for a patient post-laparoscopic surgery. Which finding should the nurse expect
as a normal post-operative assessment?

 A) Fever over 101°F

 B) Rigid abdomen
 C) Slight shoulder pain
 D) Severe pain at the incision site

Correct Answer: C
Rationale: Slight shoulder pain can occur due to irritation from carbon dioxide used during the
procedure.

Question 1340: Mental Health

A nurse is working with a patient diagnosed with schizophrenia. Which intervention is most
appropriate to promote effective communication?

 A) Use abstract concepts when discussing feelings.

 B) Maintain eye contact and use open-ended questions.
 C) Avoid discussing reality with the patient.
  D) Speak loudly to get the patient's attention.

Correct Answer: B
Rationale: Maintaining eye contact and using open-ended questions can help facilitate
communication with patients who have schizophrenia.

Question 1321: Pharmacology

A nurse is teaching a patient about taking metformin for type 2 diabetes. Which statement by the
patient indicates a need for further teaching?

 A) "I will take this medication with meals."

 B) "I should monitor my blood sugar levels regularly."
 C) "I can skip doses if I’m feeling well."
 D) "I will notify my doctor if I experience any unusual symptoms."

Correct Answer: C
Rationale: Patients should not skip doses of metformin, as consistent administration is crucial
for controlling blood sugar levels.

Question 1322: Respiratory

A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) who has
developed a respiratory infection. Which assessment finding indicates the patient may be in
respiratory distress?

 A) O2 saturation of 95%
 B) Ability to speak in full sentences
 C) Use of accessory muscles for breathing
 D) Mild cough with clear sputum

Correct Answer: C
Rationale: The use of accessory muscles for breathing indicates respiratory distress and
increased work of breathing.

Question 1323: Neurological

A nurse is caring for a patient who has experienced a seizure. Which action should the nurse take
first after the seizure has ended?
  A) Administer oxygen
 B) Turn the patient onto their side
 C) Assess the patient's level of consciousness
 D) Document the seizure activity

Correct Answer: B
Rationale: Turning the patient onto their side helps maintain an open airway and prevents
aspiration.

Question 1324: Cardiovascular

A patient is being discharged after a myocardial infarction (MI). Which instruction should the
nurse prioritize for the patient?

 A) Engage in heavy lifting within one week.

 B) Avoid all physical activity for one month.
 C) Attend cardiac rehabilitation sessions.
 D) Follow a high-fat diet to increase calorie intake.

Correct Answer: C
Rationale: Attending cardiac rehabilitation is crucial for recovery after an MI and helps the
patient learn how to manage their health.

Question 1325: Mental Health

A nurse is caring for a patient diagnosed with major depressive disorder. Which intervention is
most appropriate to promote the patient’s safety?

 A) Encourage the patient to express their feelings.

 B) Provide the patient with a list of coping strategies.
 C) Conduct a suicide risk assessment.
 D) Increase the patient's physical activity.

Correct Answer: C
Rationale: Conducting a suicide risk assessment is essential to ensure the patient’s safety.

Question 1326: Pediatric

A nurse is assessing a child with croup. Which finding is most characteristic of this condition?
  A) High fever
 B) Barking cough
 C) Wheezing
 D) Nasal congestion

Correct Answer: B
Rationale: A barking cough is a classic sign of croup, which is caused by inflammation of the
larynx.

Question 1327: Gastrointestinal

A patient with chronic pancreatitis is being educated about dietary modifications. Which
statement indicates the need for further teaching?

 A) "I will eat a low-fat diet."

 B) "I can continue to drink alcohol in moderation."
 C) "I should avoid foods that are spicy or fried."
 D) "I will eat small, frequent meals throughout the day."

Correct Answer: B
Rationale: Alcohol should be completely avoided in patients with chronic pancreatitis.

Question 1328: Infection Control

A nurse is preparing to perform a dressing change on a patient with a surgical wound. Which
action is most appropriate for maintaining aseptic technique?

 A) Use sterile gloves only when handling the dressing.

 B) Place all supplies on the bedside table before donning gloves.
 C) Avoid touching the inside of the dressing package.
 D) Use the same pair of gloves for multiple tasks during the procedure.

Correct Answer: C
Rationale: Avoiding contact with the inside of the dressing package maintains aseptic technique.

Question 1329: Endocrine

A nurse is monitoring a patient with Addison’s disease. Which finding should the nurse
anticipate?
  A) Hypoglycemia
 B) Hypernatremia
 C) Weight gain
 D) Hypertension

Correct Answer: A
Rationale: Patients with Addison's disease often experience hypoglycemia due to insufficient
cortisol production.

Question 1330: Surgical

A nurse is providing post-operative education to a patient who has undergone a total hip
replacement. Which statement indicates the need for further teaching?

 A) "I can cross my legs when sitting in a chair."

 B) "I should avoid bending my hips greater than 90 degrees."
 C) "I will use a raised toilet seat to prevent hip flexion."
 D) "I can participate in physical therapy to regain strength."

Correct Answer: A
Rationale: Crossing the legs can lead to dislocation of the new hip joint and should be avoided.

Question 1331: Respiratory

A patient diagnosed with asthma is using a peak flow meter. Which reading indicates that the
patient's asthma is under control?

 A) 50% of personal best

 B) 80% of personal best
 C) 30% of personal best
 D) 70% of personal best

Correct Answer: B
Rationale: A reading of 80% or above indicates that asthma is under good control.

Question 1332: Cardiovascular

A nurse is monitoring a patient who has received a dose of digoxin. Which assessment finding
would warrant immediate intervention?
  A) Heart rate of 68 beats per minute
 B) Blood pressure of 110/70 mm Hg
 C) Serum potassium level of 3.0 mEq/L
 D) ECG showing sinus rhythm

Correct Answer: C
Rationale: A low serum potassium level can increase the risk of digoxin toxicity, requiring
immediate intervention.

Question 1333: Mental Health

A nurse is caring for a patient with obsessive-compulsive disorder (OCD). Which intervention is
most appropriate?

 A) Encourage the patient to avoid rituals.

 B) Allow the patient to engage in compulsive behaviors to reduce anxiety.
 C) Provide positive reinforcement for completing tasks without rituals.
 D) Suggest that the patient can control their thoughts.

Correct Answer: C
Rationale: Providing positive reinforcement for completing tasks without engaging in
compulsions can help manage OCD symptoms.

Question 1334: Pediatric

A nurse is caring for a 10-year-old child with a fracture. Which nursing intervention is most
appropriate for managing the child's pain?

 A) Allow the child to choose between a cold or hot pack.

 B) Administer the prescribed analgesics.
 C) Suggest that the child try to ignore the pain.
 D) Encourage the child to play games to distract from the pain.

Correct Answer: B
Rationale: Administering prescribed analgesics is the most effective way to manage the child's
pain.

Question 1335: Gastrointestinal

A nurse is assessing a patient who has just undergone a colonoscopy. Which finding is
concerning and should be reported?

 A) Mild abdominal cramping

 B) Passage of gas
 C) Bright red blood in the stool
 D) Slight dizziness

Correct Answer: C
Rationale: Bright red blood in the stool can indicate a potential complication and should be
reported immediately.

Question 1336: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis (TB). Which precaution should the
nurse take when providing care?

 A) Wear a gown and gloves only.

 B) Use a mask when within 3 feet of the patient.
 C) Implement airborne precautions.
 D) Limit visitors to one per day.

Correct Answer: C
Rationale: Airborne precautions are necessary to prevent the spread of tuberculosis.

Question 1337: Neurological

A nurse is monitoring a patient after a craniotomy. Which assessment finding is most

concerning?

 A) Slight headache
 B) Disorientation to time
 C) Sudden onset of a severe headache
 D) Reports of dizziness

Correct Answer: C
Rationale: A sudden onset of a severe headache may indicate complications such as a hematoma
or increased intracranial pressure.

Question 1338: Endocrine

A patient with diabetes is scheduled for a surgical procedure. What should the nurse advise the
patient regarding insulin administration?

 A) Skip the morning dose of insulin.

 B) Administer a full dose of insulin regardless of fasting.
 C) Discuss with the physician regarding insulin adjustment.
 D) Continue taking oral hypoglycemic agents up to the time of surgery.

Correct Answer: C
Rationale: It’s important for the patient to discuss insulin adjustments with the physician prior to
surgery.

Question 1339: Surgical

A nurse is caring for a patient post-laparoscopic surgery. Which finding should the nurse expect
as a normal post-operative assessment?

 A) Fever over 101°F

 B) Rigid abdomen
 C) Slight shoulder pain
 D) Severe pain at the incision site

Correct Answer: C
Rationale: Slight shoulder pain can occur due to irritation from carbon dioxide used during the
procedure.

Question 1340: Mental Health

A nurse is working with a patient diagnosed with schizophrenia. Which intervention is most
appropriate to promote effective communication?

 A) Use abstract concepts when discussing feelings.

 B) Maintain eye contact and use open-ended questions.
 C) Avoid discussing reality with the patient.
 D) Speak loudly to get the patient's attention.

Correct Answer: B
Rationale: Maintaining eye contact and using open-ended questions can help facilitate
communication with patients who have schizophrenia.
Question 1341: Respiratory

A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) who is
experiencing dyspnea. Which finding is most concerning?

 A) Increased respiratory rate

 B) Use of accessory muscles
 C) O2 saturation of 90%
 D) Silent chest on auscultation

Correct Answer: D
Rationale: A silent chest indicates severe airway obstruction and is a medical emergency.

Question 1342: Cardiovascular

A patient with heart failure is prescribed a loop diuretic. Which electrolyte imbalance should the
nurse monitor closely?

 A) Hypercalcemia
 B) Hyperkalemia
 C) Hyponatremia
 D) Hypokalemia

Correct Answer: D
Rationale: Loop diuretics can cause hypokalemia by promoting the excretion of potassium.

Question 1343: Gastrointestinal

A nurse is caring for a patient with cirrhosis. Which assessment finding would indicate the
development of hepatic encephalopathy?

 A) Jaundice
 B) Ascites
 C) Confusion and disorientation
 D) Abdominal pain

Correct Answer: C
Rationale: Confusion and disorientation are signs of hepatic encephalopathy due to increased
ammonia levels.
Question 1344: Pediatric

A nurse is caring for a 6-year-old child who is hospitalized for asthma exacerbation. Which
intervention is most important?

 A) Encourage the child to play games.

 B) Assess the child's peak flow meter reading.
 C) Administer prescribed bronchodilator.
 D) Educate the family about asthma triggers.

Correct Answer: C
Rationale: Administering the bronchodilator is critical for managing the acute asthma
exacerbation.

Question 1345: Endocrine

A nurse is monitoring a patient with diabetes mellitus who is receiving insulin. Which finding
may indicate hypoglycemia?

 A) Increased thirst
 B) Dizziness and shakiness
 C) Blurred vision
 D) Frequent urination

Correct Answer: B
Rationale: Dizziness and shakiness are common symptoms of hypoglycemia.

Question 1346: Infection Control

A nurse is caring for a patient with a wound infection. Which of the following actions is most
effective in preventing the spread of infection?

 A) Wearing gloves only when handling the wound.

 B) Performing hand hygiene before and after patient contact.
 C) Using an antimicrobial agent on the skin before touching the wound.
 D) Restricting visitors to the patient.

Correct Answer: B
Rationale: Performing hand hygiene is the most effective way to prevent the spread of infection.
Question 1347: Neurological

A nurse is caring for a patient post-stroke who has right-sided weakness. Which approach will
best assist the patient in performing activities of daily living?

 A) Encourage the use of the left hand for all tasks.

 B) Provide adaptive devices for the right side.
 C) Assist the patient with all personal care tasks.
 D) Allow the patient to do everything independently.

Correct Answer: B
Rationale: Providing adaptive devices can help the patient maximize independence while
accommodating their weakness.

Question 1348: Surgical

A nurse is providing preoperative education to a patient scheduled for a total knee replacement.
Which information is most important to include?

 A) Expect to stay in bed for 48 hours after surgery.

 B) You will be up and walking the same day of surgery.
 C) Pain management will not be necessary post-operatively.
 D) You can eat a large meal right before surgery.

Correct Answer: B
Rationale: Early ambulation is important for recovery and is typically encouraged the same day
of surgery.

Question 1349: Pediatric

A nurse is assessing a 4-year-old child with suspected appendicitis. Which assessment finding is
most characteristic of this condition?

 A) Abdominal distention
 B) Fever and vomiting
 C) Periumbilical pain that migrates to the right lower quadrant
 D) Diarrhea

Correct Answer: C
Rationale: Pain that starts around the umbilicus and migrates to the right lower quadrant is a
classic sign of appendicitis.
Question 1350: Mental Health

A nurse is caring for a patient with anxiety disorder. Which intervention is most effective in
promoting relaxation?

 A) Teaching deep breathing exercises.

 B) Encouraging the patient to engage in vigorous activity.
 C) Suggesting that the patient avoid social interactions.
 D) Providing a written plan for the day.

Correct Answer: A
Rationale: Teaching deep breathing exercises is an effective way to promote relaxation and
reduce anxiety.

Question 1351: Respiratory

A nurse is assessing a patient with pneumonia. Which finding is most indicative of a pleural
effusion?

 A) Dry cough
 B) Decreased breath sounds on the affected side
 C) Increased tactile fremitus
 D) Fever

Correct Answer: B
Rationale: Decreased breath sounds on the affected side may indicate the presence of pleural
effusion.

Question 1352: Cardiovascular

A nurse is caring for a patient with a history of hypertension who is newly prescribed an ACE
inhibitor. Which side effect should the nurse educate the patient about?

 A) Weight gain
 B) Dry cough
 C) Increased heart rate
 D) Diarrhea

Correct Answer: B
Rationale: A common side effect of ACE inhibitors is a dry cough.
Question 1353: Gastrointestinal

A nurse is assessing a patient with cholecystitis. Which symptom is most characteristic of this
condition?

 A) Steatorrhea
 B) Right upper quadrant pain after fatty meals
 C) Jaundice
 D) Ascites

Correct Answer: B
Rationale: Right upper quadrant pain after fatty meals is a classic symptom of cholecystitis.

Question 1354: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). What
type of precautions should the nurse implement?

 A) Contact precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Standard precautions only

Correct Answer: A
Rationale: Contact precautions are necessary to prevent the spread of MRSA.

Question 1355: Endocrine

A nurse is monitoring a patient with hyperthyroidism. Which finding should the nurse expect?

 A) Weight gain
 B) Bradycardia
 C) Increased appetite
 D) Cold intolerance

Correct Answer: C
Rationale: Increased appetite is a common finding in patients with hyperthyroidism due to
increased metabolism.
Question 1356: Surgical

A nurse is caring for a patient after abdominal surgery. Which assessment finding should prompt
the nurse to notify the healthcare provider?

 A) Abdominal tenderness
 B) Wound drainage that is serous
 C) Heart rate of 110 beats per minute
 D) Patient reports moderate pain

Correct Answer: C
Rationale: A heart rate of 110 beats per minute may indicate complications such as hemorrhage
or infection.

Question 1357: Neurological

A nurse is assessing a patient who has had a stroke affecting the right side of the body. Which
assessment finding is expected?

 A) Right-sided weakness
 B) Left-sided neglect
 C) Aphasia
 D) Dysphagia

Correct Answer: B
Rationale: A stroke affecting the right side of the brain can lead to left-sided neglect due to the
brain's cross-wiring.

Question 1358: Mental Health

A nurse is caring for a patient who is suicidal. Which intervention is the highest priority?

 A) Establish a therapeutic relationship.

 B) Remove harmful objects from the patient’s room.
 C) Provide patient education on coping strategies.
 D) Encourage the patient to talk about their feelings.

Correct Answer: B
Rationale: Removing harmful objects is crucial to ensure the patient’s safety.
Question 1359: Respiratory

A nurse is caring for a patient with asthma who is prescribed a rescue inhaler. When should the
nurse instruct the patient to use this medication?

 A) Before exercising to prevent symptoms

 B) When experiencing wheezing or shortness of breath
 C) After using a corticosteroid inhaler
 D) At bedtime for prevention

Correct Answer: B
Rationale: The rescue inhaler is used during acute asthma symptoms like wheezing or shortness
of breath.

Question 1360: Pediatric

A nurse is teaching a parent about managing a child with attention-deficit/hyperactivity disorder

(ADHD). Which statement indicates a need for further education?

 A) "I will provide a structured routine for my child."

 B) "It's best to allow my child to watch TV whenever they want."
 C) "I will use positive reinforcement for good behavior."
 D) "I should limit distractions in my child's environment."

Correct Answer: B
Rationale: Allowing unrestricted TV time can increase distractions and is not beneficial for a
child with ADHD.

Question 1361: Gastrointestinal

A patient with ulcerative colitis is experiencing a flare-up. Which dietary modification should the
nurse recommend?

 A) High-fiber diet
 B) Low-residue diet
 C) Gluten-free diet
 D) High-protein diet

Correct Answer: B
Rationale: A low-residue diet can help reduce bowel movements and limit irritation during a
flare-up.
Question 1362: Endocrine

A patient with diabetes is receiving insulin therapy. Which symptom may indicate
hypoglycemia?

 A) Excessive thirst
 B) Confusion and irritability
 C) Increased urination
 D) Weight gain

Correct Answer: B
Rationale: Confusion and irritability are common symptoms of hypoglycemia.

Question 1363: Neurological

A nurse is assessing a patient with multiple sclerosis. Which symptom would the nurse expect to
find?

 A) Fluctuating blood pressure

 B) Sudden onset of severe headache
 C) Visual disturbances
 D) Bradycardia

Correct Answer: C
Rationale: Visual disturbances are common in multiple sclerosis due to optic nerve
involvement.

Question 1364: Respiratory

A nurse is monitoring a patient receiving oxygen therapy. Which finding indicates the patient
may be experiencing oxygen toxicity?

 A) Dry mouth
 B) Productive cough
 C) Substernal discomfort
 D) Decreased oxygen saturation

Correct Answer: C
Rationale: Substernal discomfort can indicate oxygen toxicity, particularly at high
concentrations.
Question 1365: Cardiovascular

A nurse is caring for a patient with heart failure who is receiving digoxin. Which symptom may
indicate digoxin toxicity?

 A) Nausea and vomiting

 B) Bradycardia
 C) Visual disturbances
 D) All of the above

Correct Answer: D
Rationale: Nausea, vomiting, bradycardia, and visual disturbances are all symptoms of digoxin
toxicity.

Question 1366: Infection Control

A nurse is caring for a patient with tuberculosis. What type of precautions should the nurse
implement?

 A) Contact precautions
 B) Droplet precautions
 C) Airborne precautions
 D) Standard precautions

Correct Answer: C
Rationale: Airborne precautions are necessary for tuberculosis to prevent transmission.

Question 1367: Pediatric

A nurse is teaching a parent about the signs of dehydration in children. Which statement by the
parent indicates a need for further education?

 A) "My child may have dry mouth and lips."

 B) "I should look for decreased urine output."
 C) "Fever is not a sign of dehydration."
 D) "My child may be more irritable than usual."

Correct Answer: C
Rationale: Fever can be a sign of dehydration and should not be disregarded.
Question 1368: Mental Health

A nurse is caring for a patient with generalized anxiety disorder. Which intervention is most
appropriate?

 A) Encourage the patient to avoid stressful situations.

 B) Teach relaxation techniques and coping strategies.
 C) Suggest medication as the first line of treatment.
 D) Dismiss the patient’s worries to help them feel better.

Correct Answer: B
Rationale: Teaching relaxation techniques and coping strategies can help manage anxiety
symptoms.

Question 1369: Surgical

A nurse is caring for a patient who has just undergone a laparoscopic cholecystectomy. Which
assessment finding should be reported to the healthcare provider?

 A) Moderate abdominal pain

 B) Presence of shoulder pain
 C) Fever of 100.4°F (38°C)
 D) Abdominal distension

Correct Answer: D
Rationale: Abdominal distension may indicate a complication such as bowel obstruction or
perforation.

Question 1370: Respiratory

A patient with chronic bronchitis is receiving a bronchodilator. Which assessment finding

indicates the medication is effective?

 A) Decreased respiratory rate

 B) Improved oxygen saturation
 C) Increased respiratory effort
 D) Increased wheezing
Correct Answer: B
Rationale: Improved oxygen saturation indicates that the bronchodilator is effectively improving
airway patency.

Question 1371: Gastrointestinal

A nurse is caring for a patient with pancreatitis. Which finding should the nurse monitor closely?

 A) Increased appetite
 B) Hyperglycemia
 C) Decreased liver function
 D) Constipation

Correct Answer: B
Rationale: Hyperglycemia can occur due to pancreatic damage affecting insulin production.

Question 1372: Endocrine

A nurse is caring for a patient with hypothyroidism. Which symptom would the nurse expect to
observe?

 A) Weight loss
 B) Increased heart rate
 C) Cold intolerance
 D) Insomnia

Correct Answer: C
Rationale: Cold intolerance is a common symptom of hypothyroidism due to decreased
metabolic rate.

Question 1373: Infection Control

A nurse is caring for a patient with Clostridium difficile infection. Which precautions should the
nurse implement?

 A) Droplet precautions
 B) Airborne precautions
 C) Contact precautions
 D) Standard precautions
Correct Answer: C
Rationale: Contact precautions are required to prevent the spread of C. difficile.

Question 1374: Neurological

A nurse is assessing a patient with Parkinson's disease. Which symptom is characteristic of this
condition?

 A) Rapid speech
 B) Tremors at rest
 C) High energy levels
 D) Frequent falls due to instability

Correct Answer: B
Rationale: Tremors at rest are a classic symptom of Parkinson's disease.

Question 1375: Mental Health

A nurse is teaching a patient with bipolar disorder about mood stabilization. Which statement
indicates a need for further education?

 A) "I should take my medication regularly."

 B) "I can stop my medication when I feel better."
 C) "I will keep a mood diary."
 D) "I need to avoid alcohol and drugs."

Correct Answer: B
Rationale: Patients should not stop their medication without consulting their healthcare
provider, even when feeling better.

Question 1376: Pediatric

A nurse is assessing a child with cystic fibrosis. Which symptom would be expected?

 A) Frequent, loose stools

 B) Dry, non-productive cough
 C) Foul-smelling, greasy stools
 D) Weight gain
Correct Answer: C
Rationale: Foul-smelling, greasy stools are a hallmark symptom of cystic fibrosis due to
malabsorption.

Question 1377: Surgical

A patient is recovering from surgery and has a Jackson-Pratt (JP) drain in place. Which
assessment finding indicates a potential complication?

 A) Drainage of 50 mL of serous fluid in 24 hours

 B) Drainage with a bright red color
 C) JP drain is patent with no kinks
 D) Patient reports minimal discomfort

Correct Answer: B
Rationale: Bright red drainage may indicate active bleeding and should be reported.

Question 1378: Respiratory

A nurse is assessing a patient with pulmonary embolism. Which symptom is most concerning?

 A) Sudden onset of chest pain

 B) Mild shortness of breath
 C) Coughing up blood
 D) Decreased oxygen saturation

Correct Answer: C
Rationale: Coughing up blood (hemoptysis) is a serious symptom and may indicate significant
pulmonary compromise.

Question 1379: Infection Control

A nurse is caring for a patient with a respiratory infection. Which intervention is most effective
in preventing the spread of infection?

 A) Wearing gloves at all times

 B) Practicing proper hand hygiene
 C) Using a surgical mask on the patient
 D) Isolating the patient in a private room
Correct Answer: B
Rationale: Proper hand hygiene is the most effective method to prevent the spread of infection.

Question 1380: Endocrine

A nurse is caring for a patient with Addison's disease. Which finding should the nurse anticipate?

 A) Weight gain
 B) Hypernatremia
 C) Hyperpigmentation of the skin
 D) Increased energy levels

Correct Answer: C
Rationale: Hyperpigmentation of the skin is a characteristic sign of Addison's disease due to
increased ACTH levels.

Question 1381: Cardiovascular

A patient is admitted with congestive heart failure. Which finding would the nurse expect during
assessment?

 A) Bradycardia
 B) Decreased blood pressure
 C) Increased jugular venous distention
 D) Cold extremities

Correct Answer: C
Rationale: Increased jugular venous distention is a common sign of right-sided heart failure.

Question 1382: Renal

A nurse is monitoring a patient with acute kidney injury. Which laboratory finding should the
nurse expect?

 A) Decreased creatinine levels

 B) Decreased BUN levels
 C) Elevated potassium levels
 D) Elevated sodium levels
Correct Answer: C
Rationale: Elevated potassium levels (hyperkalemia) are common in acute kidney injury due to
impaired renal function.

Question 1383: Gastrointestinal

A patient with a peptic ulcer is prescribed omeprazole. What is the expected action of this
medication?

 A) Increases gastric acid production

 B) Neutralizes stomach acid
 C) Inhibits gastric acid secretion
 D) Promotes mucosal healing

Correct Answer: C
Rationale: Omeprazole is a proton pump inhibitor that inhibits gastric acid secretion.

Question 1384: Neurological

A nurse is caring for a patient with a spinal cord injury at T6. Which assessment finding should
the nurse monitor for?

 A) Respiratory distress
 B) Bradycardia and hypotension
 C) Elevated temperature
 D) Urinary retention

Correct Answer: B
Rationale: Bradycardia and hypotension can occur due to autonomic dysreflexia in patients with
spinal cord injuries.

Question 1385: Endocrine

A patient with type 1 diabetes is experiencing a hypoglycemic episode. What should the nurse
administer?

 A) Insulin
 B) Glucagon
 C) Oral hypoglycemic agent
 D) Water
Correct Answer: B
Rationale: Glucagon can quickly raise blood sugar levels in a hypoglycemic episode.

Question 1386: Pediatric

A nurse is assessing a toddler with a viral infection. Which finding is most indicative of
dehydration?

 A) Dry skin
 B) Increased urine output
 C) Clear mucous membranes
 D) Weight gain

Correct Answer: A
Rationale: Dry skin is a sign of dehydration in toddlers, along with decreased urine output.

Question 1387: Infection Control

A patient with a confirmed diagnosis of influenza is in the hospital. What type of precautions
should the nurse use?

 A) Contact precautions
 B) Airborne precautions
 C) Droplet precautions
 D) Standard precautions

Correct Answer: C
Rationale: Droplet precautions should be implemented to prevent the spread of influenza.

Question 1388: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. What
is a priority nursing assessment?

 A) Monitor for increased respiratory rate

 B) Assess for signs of hypercapnia
 C) Encourage the use of pursed-lip breathing
 D) Check the patient’s oxygen saturation levels
Correct Answer: D
Rationale: Monitoring oxygen saturation levels is crucial to ensure adequate oxygenation
without causing hypercapnia.

Question 1389: Gastrointestinal

A nurse is caring for a patient after a colostomy. Which statement by the patient indicates a need
for further teaching?

 A) "I can eat whatever I want now."

 B) "I should avoid high-fiber foods initially."
 C) "I need to check my stoma for color changes."
 D) "I should empty the pouch when it's one-third full."

Correct Answer: A
Rationale: Patients need to be educated about dietary modifications post-colostomy to avoid gas
and blockage.

Question 1390: Mental Health

A nurse is caring for a patient with major depressive disorder. Which behavior would indicate
improvement in the patient's condition?

 A) Increased withdrawal from activities

 B) Improved appetite and weight gain
 C) Persistent feelings of hopelessness
 D) Continued lack of interest in personal hygiene

Correct Answer: B
Rationale: Improved appetite and weight gain indicate positive changes in the patient’s
condition.

Question 1391: Surgical

A patient is being discharged after abdominal surgery. Which instruction should the nurse
include in the discharge teaching?

 A) "You can lift heavy objects after one week."

 B) "Limit your fluid intake to prevent swelling."
 C) "Notify your provider if you experience increased pain or swelling."
  D) "It's normal to have a fever of 100°F after surgery."

Correct Answer: C
Rationale: Increased pain or swelling should be reported to the healthcare provider, as it may
indicate a complication.

Question 1392: Cardiovascular

A nurse is teaching a patient about the DASH diet to manage hypertension. Which food choice
aligns with the DASH diet?

 A) Fried chicken
 B) Whole grain bread
 C) Potato chips
 D) Processed cheese

Correct Answer: B
Rationale: The DASH diet emphasizes whole grains, fruits, vegetables, and low-fat dairy.

Question 1393: Neurological

A nurse is caring for a patient who had a stroke. Which assessment finding indicates a potential
for aspiration?

 A) Difficulty swallowing
 B) Clear speech
 C) Ability to cough effectively
 D) Normal gag reflex

Correct Answer: A
Rationale: Difficulty swallowing (dysphagia) increases the risk of aspiration in stroke patients.

Question 1394: Pediatric

A nurse is caring for a child with asthma. Which intervention should the nurse prioritize?

 A) Administer bronchodilators as needed

 B) Schedule routine pulmonary function tests
 C) Encourage fluid intake
 D) Monitor growth patterns
Correct Answer: A
Rationale: Administering bronchodilators during an asthma attack is crucial for immediate relief
of symptoms.

Question 1395: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). Which
precaution should the nurse take?

 A) Standard precautions only

 B) Droplet precautions
 C) Airborne precautions
 D) Contact precautions

Correct Answer: D
Rationale: Contact precautions are required for patients with MRSA to prevent transmission.

Question 1396: Gastrointestinal

A patient with liver cirrhosis is at risk for developing hepatic encephalopathy. Which assessment
finding may indicate this complication?

 A) Jaundice
 B) Confusion and lethargy
 C) Peripheral edema
 D) Elevated bilirubin levels

Correct Answer: B
Rationale: Confusion and lethargy are common signs of hepatic encephalopathy due to the
accumulation of toxins.

Question 1397: Endocrine

A patient with hyperthyroidism is prescribed propylthiouracil (PTU). What is the primary action
of this medication?

 A) Increases thyroid hormone production

 B) Decreases thyroid hormone production
 C) Blocks the uptake of iodine
 D) Relieves symptoms of hyperthyroidism
Correct Answer: B
Rationale: Propylthiouracil decreases thyroid hormone production in patients with
hyperthyroidism.

Question 1398: Cardiovascular

A nurse is monitoring a patient on anticoagulant therapy. Which laboratory value is most

important to monitor?

 A) Platelet count
 B) Hemoglobin level
 C) Prothrombin time (PT)/International Normalized Ratio (INR)
 D) Complete blood count (CBC)

Correct Answer: C
Rationale: Monitoring PT/INR is essential to ensure the effectiveness of anticoagulant therapy.

Question 1399: Mental Health

A nurse is assessing a patient with post-traumatic stress disorder (PTSD). Which symptom is
most characteristic of this condition?

 A) Delusions
 B) Re-experiencing traumatic events
 C) Impulsive behavior
 D) Social withdrawal

Correct Answer: B
Rationale: Re-experiencing traumatic events (flashbacks) is a hallmark symptom of PTSD.

Question 1400: Renal

A nurse is assessing a patient with nephrotic syndrome. Which laboratory finding would the
nurse expect?

 A) Decreased serum albumin

 B) Elevated serum calcium
 C) Low urine protein levels
 D) Increased hematocrit
Correct Answer: A
Rationale: Decreased serum albumin is characteristic of nephrotic syndrome due to protein loss
in urine.

Question 1401: Neurological

A nurse is assessing a patient with a possible stroke. Which acronym should the nurse use to
quickly assess the patient’s condition?

 A) FAST
 B) SLUMS
 C) RASS
 D) ABCDE

Correct Answer: A
Rationale: The acronym FAST (Face, Arms, Speech, Time) is used to assess signs of stroke
quickly.

Question 1402: Pediatric

A parent asks the nurse about the recommended immunization schedule for children. Which
immunization is typically given at 12 months of age?

 A) DTaP
 B) MMR
 C) Hepatitis B
 D) Varicella

Correct Answer: B
Rationale: The measles, mumps, and rubella (MMR) vaccine is typically administered at 12
months of age.

Question 1403: Gastrointestinal

A patient with gallbladder disease is experiencing acute pain. Which dietary recommendation
should the nurse provide?

 A) Low-fat diet
 B) High-protein diet
 C) High-carbohydrate diet
  D) No dietary restrictions

Correct Answer: A
Rationale: A low-fat diet is recommended to reduce gallbladder stimulation and alleviate pain.

Question 1404: Endocrine

A nurse is educating a patient with diabetes about foot care. Which statement indicates a need for
further teaching?

 A) "I should inspect my feet daily for cuts or blisters."

 B) "I can soak my feet in hot water to relax."
 C) "I should wear well-fitting shoes."
 D) "I need to keep my feet clean and dry."

Correct Answer: B
Rationale: Patients with diabetes should avoid soaking their feet in hot water to prevent injury
and skin breakdown.

Question 1405: Cardiovascular

A nurse is monitoring a patient for signs of heart failure. Which symptom should the nurse watch
for?

 A) Peripheral edema
 B) Hypotension
 C) Increased energy levels
 D) Decreased appetite

Correct Answer: A
Rationale: Peripheral edema is a common sign of heart failure due to fluid retention.

Question 1406: Infection Control

A nurse is caring for a patient with a urinary tract infection (UTI). What should the nurse include
in patient education?

 A) Drink cranberry juice regularly

 B) Avoid fluids to reduce urinary frequency
 C) Use douches for cleanliness
  D) Wear tight-fitting clothing

Correct Answer: A
Rationale: Drinking cranberry juice may help prevent UTIs by preventing bacteria from
adhering to the urinary tract.

Question 1407: Respiratory

A patient with asthma is prescribed a metered-dose inhaler (MDI). What should the nurse
instruct the patient to do before using the inhaler?

 A) Take a deep breath and hold it

 B) Shake the inhaler well
 C) Exhale completely before inhaling
 D) All of the above

Correct Answer: D
Rationale: All of these actions are important for effective use of the MDI.

Question 1408: Surgical

A nurse is assessing a postoperative patient for complications. Which sign would indicate a
potential infection?

 A) Warm, dry skin

 B) Fever and chills
 C) Normal white blood cell count
 D) Decreased pain at the surgical site

Correct Answer: B
Rationale: Fever and chills may indicate a postoperative infection.

Question 1409: Mental Health

A patient with schizophrenia is prescribed clozapine. What should the nurse monitor closely?

 A) Blood glucose levels

 B) White blood cell count
 C) Liver function tests
 D) Lipid levels
Correct Answer: B
Rationale: Clozapine can cause agranulocytosis, so regular monitoring of the white blood cell
count is essential.

Question 1410: Gastrointestinal

A nurse is caring for a patient with a nasogastric (NG) tube. Which finding should the nurse
report immediately?

 A) Tube placement is confirmed

 B) Patient has nausea and vomiting
 C) Residual volume of 200 mL
 D) NG tube is secured in place

Correct Answer: B
Rationale: Nausea and vomiting may indicate improper tube placement or intolerance to
feeding.

Question 1411: Renal

A patient with chronic kidney disease is experiencing pruritus. Which intervention should the
nurse consider?

 A) Increase fluid intake

 B) Apply lotion to the skin
 C) Decrease dietary protein
 D) Administer antihistamines

Correct Answer: B
Rationale: Applying lotion can help alleviate dry skin and pruritus associated with chronic
kidney disease.

Question 1412: Pediatric

A nurse is assessing a child with acute otitis media. Which symptom would the nurse expect?

 A) Clear nasal discharge

 B) Irritability and ear tugging
 C) Low-grade fever only
 D) Decreased appetite
Correct Answer: B
Rationale: Irritability and ear tugging are common symptoms of acute otitis media in children.

Question 1413: Infection Control

A nurse is caring for a patient with chickenpox. Which precaution should the nurse implement?

 A) Standard precautions only

 B) Droplet precautions
 C) Airborne precautions
 D) Contact precautions

Correct Answer: C
Rationale: Airborne precautions are required for chickenpox due to its highly contagious nature.

Question 1414: Neurological

A nurse is assessing a patient with Alzheimer’s disease. Which behavior would be most
concerning?

 A) Difficulty with short-term memory

 B) Disorientation to time and place
 C) Forgetting names of familiar people
 D) Sudden changes in personality

Correct Answer: D
Rationale: Sudden changes in personality can indicate a more serious underlying issue and
should be further evaluated.

Question 1415: Respiratory

A patient is being treated for chronic obstructive pulmonary disease (COPD). Which intervention
is most important for the nurse to implement?

 A) Encourage increased fluid intake

 B) Administer bronchodilators as prescribed
 C) Teach the patient to use diaphragmatic breathing
 D) Schedule regular pulmonary function tests
Correct Answer: B
Rationale: Administering bronchodilators is crucial for managing COPD and improving airway
patency.

Question 1416: Cardiovascular

A patient with hypertension is prescribed a beta-blocker. What should the nurse assess before
administering this medication?

 A) Blood pressure and heart rate

 B) Respiratory rate
 C) Serum potassium levels
 D) Weight

Correct Answer: A
Rationale: Assessing blood pressure and heart rate is essential before administering a beta-
blocker.

Question 1417: Endocrine

A patient with diabetes is experiencing polyuria. Which assessment should the nurse prioritize?

 A) Blood glucose level

 B) Blood pressure
 C) Weight
 D) Heart rate

Correct Answer: A
Rationale: Polyuria in diabetic patients is often due to elevated blood glucose levels, which
should be assessed.

Question 1418: Gastrointestinal

A patient with a history of diverticulitis is being discharged. Which dietary instruction should the
nurse provide?

 A) High-fiber diet
 B) Low-fiber diet
 C) High-protein diet
 D) Clear liquid diet
Correct Answer: A
Rationale: A high-fiber diet helps prevent future episodes of diverticulitis.

Question 1419: Surgical

A patient who underwent a total knee replacement is experiencing pain and swelling in the
affected leg. Which finding would indicate a possible complication?

 A) Moderate pain at the surgical site

 B) Warmth and redness in the leg
 C) Range of motion within normal limits
 D) No pain with ambulation

Correct Answer: B
Rationale: Warmth and redness may indicate a possible complication such as deep vein
thrombosis (DVT).

Question 1420: Mental Health

A nurse is teaching a patient about the side effects of fluoxetine (Prozac). Which statement
should the nurse emphasize?

 A) "You may feel more energetic after starting this medication."

 B) "You might experience weight gain."
 C) "Be aware of potential suicidal thoughts."
 D) "It may take effect immediately."

Correct Answer: C
Rationale: Patients taking antidepressants, including fluoxetine, should be monitored for
suicidal thoughts, especially during the initial treatment period.

Question 1421: Neurological

A nurse is assessing a patient with a traumatic brain injury. Which finding would indicate
increased intracranial pressure (ICP)?

 A) Decreased pulse rate

 B) Widening pulse pressure
 C) Decreased respiratory rate
 D) Increased temperature
Correct Answer: B
Rationale: Widening pulse pressure is a classic sign of increased intracranial pressure.

Question 1422: Pediatric

A nurse is caring for a 5-year-old child with asthma. What is the best way to explain the use of a
metered-dose inhaler (MDI) to the child?

 A) "It helps you breathe better."

 B) "It will make you feel happy."
 C) "It's a magic tool for your lungs."
 D) "It's like a whistle you blow into."

Correct Answer: A
Rationale: Using simple language that explains the function helps children understand the
purpose of the medication.

Question 1423: Gastrointestinal

A patient is receiving total parenteral nutrition (TPN). Which assessment finding would indicate
a potential complication?

 A) Elevated blood glucose levels

 B) Decreased blood pressure
 C) Increased urine output
 D) Normal temperature

Correct Answer: A
Rationale: Elevated blood glucose levels can occur with TPN due to high dextrose content.

Question 1424: Endocrine

A nurse is educating a patient with hypothyroidism about levothyroxine (Synthroid). Which

statement indicates the need for further teaching?

 A) "I should take this medication in the morning on an empty stomach."

 B) "I can stop taking it if I feel better."
 C) "I need regular blood tests to monitor my thyroid levels."
 D) "I should report any signs of chest pain."
Correct Answer: B
Rationale: Patients with hypothyroidism should not stop taking levothyroxine without
consulting their healthcare provider.

Question 1425: Cardiovascular

A patient with heart failure is prescribed furosemide (Lasix). What is the primary effect of this
medication?

 A) Decreases heart rate

 B) Increases urine output
 C) Reduces blood pressure
 D) Improves oxygenation

Correct Answer: B
Rationale: Furosemide is a loop diuretic that increases urine output, helping to reduce fluid
overload in heart failure.

Question 1426: Infection Control

A nurse is caring for a patient with Clostridium difficile (C. diff) infection. Which precaution
should the nurse implement?

 A) Standard precautions only

 B) Contact precautions
 C) Airborne precautions
 D) Droplet precautions

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of C. diff.

Question 1427: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is using a peak flow meter. Which
statement by the patient indicates understanding of its use?

 A) "I will use it only when I feel short of breath."

 B) "I should use it every day at the same time."
 C) "I will not record my readings."
 D) "I can use it anytime during the day."
Correct Answer: B
Rationale: Using a peak flow meter at the same time every day helps monitor respiratory
function consistently.

Question 1428: Surgical

A nurse is caring for a patient after laparoscopic cholecystectomy. Which discharge instruction is
most important?

 A) "You can resume normal activities immediately."

 B) "You should avoid fatty foods for a few weeks."
 C) "You will not need follow-up care."
 D) "You can remove the dressings after one day."

Correct Answer: B
Rationale: Avoiding fatty foods post-surgery can help prevent complications like diarrhea and
abdominal pain.

Question 1429: Mental Health

A patient diagnosed with major depressive disorder expresses feelings of hopelessness. What is
the most appropriate nursing intervention?

 A) "You need to think positively."

 B) "What you are feeling is normal."
 C) "Let’s talk about how you are feeling."
 D) "You should try to distract yourself."

Correct Answer: C
Rationale: Encouraging the patient to express their feelings helps establish rapport and provides
support.

Question 1430: Gastrointestinal

A patient with a history of peptic ulcer disease is being discharged. Which statement by the
patient indicates a need for further teaching?

 A) "I should take my medications with food."

 B) "I can drink alcohol in moderation."
 C) "I need to avoid spicy foods."
  D) "I should manage my stress."

Correct Answer: B
Rationale: Alcohol should generally be avoided as it can irritate the gastric mucosa.

Question 1431: Renal

A nurse is caring for a patient with acute kidney injury (AKI). Which laboratory finding should
the nurse expect?

 A) Decreased creatinine levels

 B) Increased blood urea nitrogen (BUN)
 C) Decreased potassium levels
 D) Normal glomerular filtration rate (GFR)

Correct Answer: B
Rationale: Increased BUN is commonly seen in patients with AKI due to impaired kidney
function.

Question 1432: Pediatric

A child with diabetes is experiencing hypoglycemia. What is the best initial action for the nurse
to take?

 A) Administer glucagon
 B) Provide a snack with protein
 C) Give the child orange juice
 D) Check the child’s blood glucose level

Correct Answer: C
Rationale: Providing a quick source of glucose, such as orange juice, is the best immediate
action for hypoglycemia.

Question 1433: Infection Control

A patient with tuberculosis (TB) is being discharged home. Which instruction should the nurse
provide to the patient?

 A) "You do not need to wear a mask at home."

 B) "You can return to work immediately."
  C) "You should take your medications as prescribed."
 D) "You should avoid all visitors."

Correct Answer: C
Rationale: Adherence to the prescribed medication regimen is essential to treat TB effectively.

Question 1434: Neurological

A nurse is caring for a patient with a seizure disorder. Which intervention should the nurse
prioritize during a seizure?

 A) Restrain the patient to prevent injury

 B) Place a padded tongue blade in the patient’s mouth
 C) Position the patient on their side
 D) Leave the patient alone until the seizure is over

Correct Answer: C
Rationale: Positioning the patient on their side helps maintain an open airway and prevents
aspiration.

Question 1435: Respiratory

A patient with pneumonia is receiving antibiotics. What is the priority nursing intervention?

 A) Assess for fever every hour

 B) Monitor lung sounds regularly
 C) Encourage fluid intake
 D) Administer antipyretics

Correct Answer: B
Rationale: Regular monitoring of lung sounds is crucial to evaluate the effectiveness of
treatment and detect any deterioration.

Question 1436: Endocrine

A nurse is educating a patient with hyperthyroidism about the use of radioactive iodine. What
should the nurse include in the teaching?

 A) "You will need to take this medication daily for life."

 B) "You may experience a sore throat after treatment."
  C) "You will feel an immediate improvement in your symptoms."
 D) "This treatment will cause weight gain."

Correct Answer: B
Rationale: A sore throat may occur as a side effect due to thyroid tissue destruction.

Question 1437: Surgical

A nurse is assessing a patient after a mastectomy. Which assessment finding should the nurse
report immediately?

 A) Slight swelling of the surgical site

 B) Pain at the incision site
 C) Fever greater than 100.5°F (38°C)
 D) Drainage from the incision site

Correct Answer: C
Rationale: A fever greater than 100.5°F may indicate infection and requires immediate
reporting.

Question 1438: Cardiovascular

A patient with heart failure is being treated with digoxin. Which assessment finding would
indicate potential digoxin toxicity?

 A) Bradycardia
 B) Increased appetite
 C) Weight loss
 D) Normal heart rate

Correct Answer: A
Rationale: Bradycardia is a classic sign of digoxin toxicity.

Question 1439: Pediatric

A nurse is caring for a child with cystic fibrosis. Which intervention is most important to
promote the child’s health?

 A) Encourage high-fat meals

 B) Administer pancreatic enzymes with meals
  C) Limit physical activity
 D) Monitor for signs of infection

Correct Answer: B
Rationale: Administering pancreatic enzymes with meals is crucial for digestion in patients with
cystic fibrosis.

Question 1440: Mental Health

A nurse is caring for a patient with generalized anxiety disorder. Which intervention is most
effective in helping the patient cope with anxiety?

 A) Encourage avoidance of stressful situations

 B) Teach relaxation techniques
 C) Suggest distraction with activities
 D) Promote medication adherence

Correct Answer: B
Rationale: Teaching relaxation techniques directly addresses the patient's anxiety and provides
coping strategies.

Question 1441: Cardiovascular

A nurse is assessing a patient with hypertension. Which dietary recommendation should the
nurse provide?

 A) Increase sodium intake

 B) Follow a low-fat diet
 C) Consume a diet high in fruits and vegetables
 D) Limit fluid intake

Correct Answer: C
Rationale: A diet high in fruits and vegetables can help lower blood pressure and improve
overall cardiovascular health.

Question 1442: Endocrine

A patient with diabetes mellitus is learning about foot care. Which statement indicates a need for
further teaching?
  A) "I should inspect my feet daily."
 B) "I can go barefoot in my home."
 C) "I should wear well-fitting shoes."
 D) "I need to report any cuts or blisters."

Correct Answer: B
Rationale: Patients with diabetes should avoid going barefoot to prevent injuries and infections.

Question 1443: Gastrointestinal

A nurse is providing discharge instructions to a patient after an appendectomy. What is the most
important instruction?

 A) "You can resume normal activities in one week."

 B) "Watch for signs of infection such as redness or drainage."
 C) "You should avoid all physical activity for two weeks."
 D) "You can take pain medication as needed."

Correct Answer: B
Rationale: Monitoring for signs of infection is crucial after surgery to ensure proper healing.

Question 1444: Neurological

A nurse is caring for a patient with a stroke who has right-sided weakness. Which intervention
should the nurse prioritize?

 A) Encourage the patient to use the right hand for activities

 B) Assist the patient with activities of daily living
 C) Reassure the patient that recovery will happen quickly
 D) Encourage independence to boost self-esteem

Correct Answer: B
Rationale: Assisting with activities of daily living is essential for the safety and well-being of a
patient with weakness.

Question 1445: Infection Control

A nurse is teaching a patient about infection prevention after a total hip replacement. Which
statement indicates that the patient understands the instructions?
  A) "I can use any public restroom."
 B) "I should avoid crowds and sick people."
 C) "I can resume normal activities immediately."
 D) "I should not worry about hand hygiene."

Correct Answer: B
Rationale: Avoiding crowds and sick individuals helps reduce the risk of infection post-surgery.

Question 1446: Respiratory

A patient with asthma is prescribed a corticosteroid inhaler. Which statement by the patient
indicates understanding of its use?

 A) "I can use this inhaler whenever I feel short of breath."

 B) "This inhaler will help prevent asthma attacks."
 C) "I should use it only during an asthma attack."
 D) "This inhaler does not have any side effects."

Correct Answer: B
Rationale: Corticosteroid inhalers are typically used for long-term control and prevention of
asthma symptoms.

Question 1447: Renal

A nurse is monitoring a patient on hemodialysis. Which finding would indicate a potential

complication?

 A) Decreased blood pressure

 B) Increased appetite
 C) Clear urine output
 D) Increased weight

Correct Answer: D
Rationale: Increased weight can indicate fluid overload, which is a complication of dialysis.

Question 1448: Pediatric

A child with asthma is prescribed a leukotriene receptor antagonist. Which statement by the
parent indicates understanding?
  A) "I will use this medication only during asthma attacks."
 B) "This medication can help reduce my child's asthma symptoms."
 C) "I should give this medication when my child has a cold."
 D) "This medication is a rescue inhaler."

Correct Answer: B
Rationale: Leukotriene receptor antagonists are used for long-term management of asthma
symptoms.

Question 1449: Surgical

A nurse is caring for a patient post-surgery who reports pain at the surgical site. What should the
nurse do first?

 A) Administer prescribed pain medication

 B) Assess the surgical site for complications
 C) Reassure the patient that pain is normal
 D) Contact the healthcare provider

Correct Answer: B
Rationale: Assessing the surgical site for complications is the priority before administering
medication.

Question 1450: Mental Health

A patient diagnosed with schizophrenia is experiencing auditory hallucinations. Which nursing

intervention is most appropriate?

 A) Ignore the hallucinations and redirect the conversation

 B) Challenge the patient’s beliefs about the hallucinations
 C) Validate the patient’s experience and offer support
 D) Encourage the patient to express their fears

Correct Answer: C
Rationale: Validating the patient’s experience can help build trust and provide support.

Question 1451: Endocrine

A patient with adrenal insufficiency is being discharged with a prescription for hydrocortisone.
Which instruction should the nurse emphasize?
  A) "You can stop taking this medication when you feel better."
 B) "Take the medication with food to avoid stomach upset."
 C) "You need to take the medication only during times of stress."
 D) "Avoid any vaccinations while on this medication."

Correct Answer: B
Rationale: Taking hydrocortisone with food helps prevent gastrointestinal upset.

Question 1452: Infection Control

A nurse is teaching a patient with a urinary tract infection (UTI) about prevention. Which
statement indicates a need for further teaching?

 A) "I should drink plenty of fluids."

 B) "I can use scented products in the genital area."
 C) "I should wipe from front to back."
 D) "I should urinate after sexual intercourse."

Correct Answer: B
Rationale: Scented products can irritate the urethra and increase the risk of UTIs.

Question 1453: Gastrointestinal

A patient with cirrhosis is experiencing ascites. Which intervention should the nurse implement?

 A) Restrict fluid intake

 B) Encourage a high-sodium diet
 C) Administer diuretics as prescribed
 D) Encourage bed rest

Correct Answer: C
Rationale: Administering diuretics helps reduce fluid accumulation in patients with ascites.

Question 1454: Respiratory

A nurse is teaching a patient with chronic bronchitis about smoking cessation. What is the most
effective approach?

 A) Provide pamphlets on smoking cessation

 B) Refer the patient to a smoking cessation program
  C) Encourage the patient to quit cold turkey
 D) Suggest reducing smoking gradually

Correct Answer: B
Rationale: Referral to a smoking cessation program provides structured support and resources.

Question 1455: Cardiovascular

A patient with heart failure is prescribed a beta-blocker. What is the primary effect of this
medication?

 A) Decreases heart rate

 B) Increases myocardial contractility
 C) Causes vasodilation
 D) Reduces blood volume

Correct Answer: A
Rationale: Beta-blockers primarily decrease heart rate, which helps reduce cardiac workload.

Question 1456: Neurological

A patient with multiple sclerosis is experiencing fatigue. Which intervention should the nurse
recommend?

 A) Increase physical activity

 B) Schedule frequent rest periods
 C) Limit fluid intake
 D) Engage in strenuous exercise

Correct Answer: B
Rationale: Scheduling frequent rest periods helps manage fatigue in patients with multiple
sclerosis.

Question 1457: Pediatric

A nurse is caring for a child with cystic fibrosis. What is the priority nursing intervention?

 A) Monitor the child’s weight

 B) Administer pancreatic enzymes with meals
 C) Encourage physical activity
  D) Assess lung function

Correct Answer: B
Rationale: Administering pancreatic enzymes with meals is essential for digestion in cystic
fibrosis.

Question 1458: Mental Health

A patient with major depressive disorder is prescribed an antidepressant. Which statement by the
patient indicates a need for further teaching?

 A) "I will start to feel better in a few days."

 B) "I should continue taking this medication as prescribed."
 C) "I will notify my doctor if I have any suicidal thoughts."
 D) "I may experience side effects while taking this medication."

Correct Answer: A
Rationale: Antidepressants can take several weeks to reach their full effect; immediate
improvement is not expected.

Question 1459: Endocrine

A patient with hyperthyroidism is experiencing weight loss and increased appetite. What is the
priority nursing intervention?

 A) Encourage high-calorie foods

 B) Monitor weight daily
 C) Limit fluid intake
 D) Provide educational materials

Correct Answer: A
Rationale: Encouraging high-calorie foods helps address the weight loss associated with
hyperthyroidism.

Question 1460: Infection Control

A nurse is caring for a patient with a central line. What is the most important nursing
intervention to prevent infection?

 A) Change the dressing every week

  B) Use sterile technique during line access
 C) Flush the line daily with saline
 D) Monitor the patient for signs of infection

Correct Answer: B
Rationale: Using sterile technique during line access is crucial in preventing central line-
associated infections.

Question 1461: Cardiovascular

A patient is prescribed warfarin after a myocardial infarction. Which statement by the patient
indicates a need for further teaching?

 A) "I need to have my INR checked regularly."

 B) "I can take over-the-counter medications without checking."
 C) "I should avoid foods high in vitamin K."
 D) "I must report any unusual bleeding."

Correct Answer: B
Rationale: Patients on warfarin should always check with their healthcare provider before taking
any over-the-counter medications.

Question 1462: Gastrointestinal

A nurse is caring for a patient with a nasogastric (NG) tube. What is the priority nursing
intervention?

 A) Administer oral medications through the NG tube

 B) Check the placement of the NG tube before feeding
 C) Monitor the patient’s bowel sounds
 D) Change the NG tube every week

Correct Answer: B
Rationale: Checking the placement of the NG tube is essential to ensure the patient receives
nutrition safely.

Question 1463: Endocrine

A nurse is providing discharge education to a patient with type 2 diabetes. Which statement
indicates a need for further teaching?
  A) "I should monitor my blood sugar regularly."
 B) "I can eat whatever I want as long as I take my medication."
 C) "I need to incorporate physical activity into my daily routine."
 D) "I should follow a meal plan to manage my diabetes."

Correct Answer: B
Rationale: Patients with diabetes should have a balanced diet, not eat whatever they want
without consideration of their blood sugar.

Question 1464: Neurological

A nurse is assessing a patient who has had a stroke. Which finding would indicate that the patient
is experiencing a right-sided stroke?

 A) Left-sided weakness
 B) Difficulty speaking
 C) Impaired judgment
 D) Right-sided paralysis

Correct Answer: A
Rationale: A right-sided stroke typically affects the left side of the body due to contralateral
control.

Question 1465: Infection Control

A nurse is teaching a patient about the importance of hand hygiene. Which statement indicates a
need for further teaching?

 A) "I should wash my hands before eating."

 B) "I can use hand sanitizer after using the restroom."
 C) "I can skip handwashing if my hands look clean."
 D) "I should wash my hands after coughing or sneezing."

Correct Answer: C
Rationale: Handwashing should be performed regardless of how clean the hands look to prevent
infection.

Question 1466: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which
position should the nurse encourage the patient to assume?

 A) Supine
 B) Prone
 C) High Fowler's
 D) Lateral

Correct Answer: C
Rationale: The High Fowler's position promotes optimal lung expansion and can help relieve
dyspnea.

Question 1467: Pediatric

A nurse is assessing a 2-year-old child for developmental milestones. Which milestone should
the nurse expect the child to achieve?

 A) Speaking in full sentences

 B) Climbing stairs with alternating feet
 C) Building a tower of six blocks
 D) Drawing a circle

Correct Answer: C
Rationale: By age 2, children can typically build a tower of six blocks.

Question 1468: Surgical

A nurse is caring for a postoperative patient who is experiencing nausea and vomiting. Which
intervention is appropriate?

 A) Encourage the patient to eat solid food

 B) Position the patient flat in bed
 C) Administer antiemetic medication as prescribed
 D) Offer clear liquids immediately

Correct Answer: C
Rationale: Administering antiemetic medication can help relieve nausea and vomiting.

Question 1469: Mental Health

A nurse is assessing a patient with generalized anxiety disorder. Which finding would the nurse
expect?

 A) Increased energy
 B) Sleep disturbances
 C) Decreased heart rate
 D) Heightened sense of reality

Correct Answer: B
Rationale: Patients with generalized anxiety disorder often experience sleep disturbances.

Question 1470: Cardiovascular

A nurse is monitoring a patient who is receiving digoxin. Which finding would indicate potential
digoxin toxicity?

 A) Bradycardia
 B) Hypertension
 C) Increased appetite
 D) Weight gain

Correct Answer: A
Rationale: Bradycardia is a common sign of digoxin toxicity.

Question 1471: Endocrine

A patient with diabetes is prescribed insulin glargine. When should the nurse instruct the patient
to administer this medication?

 A) Before meals
 B) At bedtime
 C) After meals
 D) When blood glucose is high

Correct Answer: B
Rationale: Insulin glargine is a long-acting insulin typically administered once daily, often at
bedtime.

Question 1472: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which lifestyle modification should the nurse
recommend?

 A) Increase caffeine intake

 B) Avoid spicy foods
 C) Eat three large meals daily
 D) Limit hydration

Correct Answer: B
Rationale: Avoiding spicy foods can help minimize irritation and discomfort associated with
peptic ulcers.

Question 1473: Neurological

A nurse is caring for a patient diagnosed with Parkinson's disease. Which intervention is most
appropriate for promoting safety?

 A) Provide large print reading materials

 B) Encourage the patient to walk without assistance
 C) Implement a regular toileting schedule
 D) Place rugs in the patient's room for comfort

Correct Answer: C
Rationale: A regular toileting schedule can help prevent falls and accidents due to urgency or
incontinence.

Question 1474: Pediatric

A child with cystic fibrosis is experiencing difficulty breathing. What should the nurse prioritize
in the care plan?

 A) Administer antibiotics
 B) Encourage high-fat foods
 C) Promote chest physiotherapy
 D) Monitor blood glucose levels

Correct Answer: C
Rationale: Chest physiotherapy helps loosen mucus and improve lung function in cystic fibrosis
patients.
Question 1475: Infection Control

A patient with tuberculosis is being discharged. What is the most important instruction for the
nurse to provide?

 A) "You will need to take your medication for 1 month."

 B) "You should isolate yourself from family members."
 C) "You need to cover your mouth when you cough."
 D) "You can stop taking your medication when you feel better."

Correct Answer: C
Rationale: Covering the mouth when coughing helps prevent the spread of tuberculosis.

Question 1476: Respiratory

A nurse is caring for a patient with pneumonia. Which assessment finding would be expected?

 A) Decreased respiratory rate

 B) Increased oxygen saturation
 C) Crackles on auscultation
 D) Diminished lung sounds

Correct Answer: C
Rationale: Crackles are commonly heard in patients with pneumonia due to fluid in the lungs.

Question 1477: Cardiovascular

A patient is diagnosed with hypertension. Which lifestyle modification should the nurse
emphasize?

 A) Decrease physical activity

 B) Increase sodium intake
 C) Follow a low-fat diet
 D) Maintain a healthy weight

Correct Answer: D
Rationale: Maintaining a healthy weight is crucial for managing hypertension.

Question 1478: Endocrine

A patient with Addison's disease is experiencing an adrenal crisis. What is the priority nursing
intervention?

 A) Administer oral corticosteroids

 B) Administer intravenous fluids and hydrocortisone
 C) Monitor vital signs every hour
 D) Encourage the patient to rest

Correct Answer: B
Rationale: Administering intravenous fluids and hydrocortisone is critical in managing an
adrenal crisis.

Question 1479: Gastrointestinal

A nurse is teaching a patient about dietary changes to manage irritable bowel syndrome (IBS).
Which food should the patient be encouraged to include?

 A) High-fat foods
 B) Whole grains
 C) Spicy foods
 D) Dairy products

Correct Answer: B
Rationale: Whole grains can help regulate bowel movements and improve overall gut health.

Question 1480: Mental Health

A patient with obsessive-compulsive disorder (OCD) is undergoing cognitive-behavioral therapy

(CBT). Which statement indicates that the patient is benefiting from the therapy?

 A) "I still perform my rituals daily."

 B) "I am learning to manage my anxiety better."
 C) "I believe my thoughts are controlling me."
 D) "I can't stop thinking about my fears."

Correct Answer: B
Rationale: Learning to manage anxiety is a positive outcome of cognitive-behavioral therapy for
OCD.

Question 1481: Cardiovascular

A patient with heart failure is prescribed a low-sodium diet. Which food choice by the patient
indicates a need for further teaching?

 A) Fresh fruits
 B) Canned soup
 C) Grilled chicken
 D) Steamed vegetables

Correct Answer: B
Rationale: Canned soup often contains high levels of sodium, which should be avoided in a low-
sodium diet.

Question 1482: Gastrointestinal

A nurse is caring for a patient with a history of liver cirrhosis. Which finding should the nurse
anticipate during the assessment?

 A) Decreased abdominal girth

 B) Ascites
 C) Increased energy levels
 D) Weight gain

Correct Answer: B
Rationale: Ascites is a common finding in patients with liver cirrhosis due to fluid accumulation
in the abdominal cavity.

Question 1483: Respiratory

A patient with asthma is prescribed a rescue inhaler. What is the purpose of this medication?

 A) To prevent asthma attacks

 B) To provide long-term control of asthma symptoms
 C) To relieve acute asthma symptoms
 D) To decrease inflammation in the airways

Correct Answer: C
Rationale: Rescue inhalers are used for immediate relief of acute asthma symptoms.

Question 1484: Mental Health

A nurse is caring for a patient with depression. Which intervention is most appropriate?

 A) Encourage the patient to isolate themselves

 B) Promote physical activity and social interaction
 C) Minimize discussions about feelings
 D) Provide a strict daily schedule

Correct Answer: B
Rationale: Promoting physical activity and social interaction can help improve mood and reduce
depressive symptoms.

Question 1485: Endocrine

A nurse is monitoring a patient with diabetes who is receiving insulin therapy. Which symptom
indicates hypoglycemia?

 A) Increased thirst
 B) Sweating and tremors
 C) Blurred vision
 D) Frequent urination

Correct Answer: B
Rationale: Sweating and tremors are common symptoms of hypoglycemia.

Question 1486: Neurological

A nurse is assessing a patient after a seizure. Which assessment should the nurse perform first?

 A) Check the patient's pulse

 B) Assess for incontinence
 C) Perform a neurological assessment
 D) Determine the length of the seizure

Correct Answer: C
Rationale: A neurological assessment is crucial to determine the patient’s status post-seizure.

Question 1487: Pediatric

A child with chickenpox is being treated at home. Which instruction should the nurse provide to
the parents?
  A) "Keep the child away from all other children."
 B) "Apply a cool compress to relieve itching."
 C) "Encourage the child to scratch the lesions."
 D) "No need for follow-up appointments."

Correct Answer: B
Rationale: Applying a cool compress can help relieve itching associated with chickenpox.

Question 1488: Surgical

A patient is scheduled for surgery and asks the nurse about the purpose of preoperative teaching.
What is the best response?

 A) "It is only to keep you busy before surgery."

 B) "It will help you understand what to expect and reduce anxiety."
 C) "It is a requirement by the surgeon."
 D) "It won't really make a difference."

Correct Answer: B
Rationale: Preoperative teaching helps patients understand what to expect and can reduce
anxiety.

Question 1489: Infection Control

A nurse is caring for a patient with a wound infection. Which intervention is most important to
prevent the spread of infection?

 A) Limit visitors
 B) Use sterile gloves when changing dressings
 C) Encourage the patient to cough and deep breathe
 D) Provide antibiotics as prescribed

Correct Answer: B
Rationale: Using sterile gloves during dressing changes is crucial to prevent the spread of
infection.

Question 1490: Gastrointestinal

A nurse is caring for a patient receiving enteral feedings. Which action should the nurse take to
ensure the patient's safety?
  A) Administer feedings at a high rate
 B) Elevate the head of the bed during feedings
 C) Flush the feeding tube with hot water
 D) Discontinue feedings for diarrhea

Correct Answer: B
Rationale: Elevating the head of the bed during feedings helps prevent aspiration.

Question 1491: Cardiovascular

A nurse is caring for a patient with hypertension. Which lifestyle modification should the nurse
recommend?

 A) Increase physical activity

 B) Increase caffeine intake
 C) Decrease fluid intake
 D) Increase alcohol consumption

Correct Answer: A
Rationale: Increasing physical activity can help lower blood pressure.

Question 1492: Neurological

A nurse is assessing a patient with suspected meningitis. Which finding would the nurse expect?

 A) Increased appetite
 B) Nuchal rigidity
 C) Bradycardia
 D) Hypotension

Correct Answer: B
Rationale: Nuchal rigidity, or neck stiffness, is a classic sign of meningitis.

Question 1493: Respiratory

A patient with chronic bronchitis is experiencing increased sputum production. Which

intervention should the nurse implement?

 A) Encourage fluid intake

 B) Administer bronchodilators
  C) Place the patient in a supine position
 D) Withhold oral medications

Correct Answer: A
Rationale: Encouraging fluid intake helps thin the mucus and facilitates expectoration.

Question 1494: Endocrine

A nurse is teaching a patient with hyperthyroidism about their condition. Which statement by the
patient indicates a need for further teaching?

 A) "I may experience weight loss."

 B) "I will feel cold all the time."
 C) "I can have an increased heart rate."
 D) "I may feel anxious or irritable."

Correct Answer: B
Rationale: Patients with hyperthyroidism often experience heat intolerance rather than feeling
cold.

Question 1495: Surgical

A patient is recovering from laparoscopic surgery. Which assessment should the nurse prioritize?

 A) Pain level
 B) Bowel sounds
 C) Surgical site
 D) Urine output

Correct Answer: B
Rationale: Assessing bowel sounds is crucial after abdominal surgery to ensure the
gastrointestinal tract is functioning.

Question 1496: Pediatric

A nurse is caring for a child with asthma. Which intervention is most effective in managing the
child’s condition?

 A) Keeping the child indoors during pollen season

 B) Encouraging the child to engage in strenuous exercise
  C) Educating the child about avoiding triggers
 D) Limiting fluid intake to prevent coughing

Correct Answer: C
Rationale: Educating the child about avoiding asthma triggers is essential for effective asthma
management.

Question 1497: Mental Health

A nurse is caring for a patient with schizophrenia. Which intervention is most appropriate?

 A) Encourage social isolation

 B) Validate the patient’s feelings and experiences
 C) Limit communication with the patient
 D) Dismiss hallucinations as unimportant

Correct Answer: B
Rationale: Validating the patient’s feelings can help build trust and rapport.

Question 1498: Infection Control

A nurse is caring for a patient diagnosed with Clostridium difficile (C. diff) infection. What
precaution should the nurse take?

 A) Use alcohol-based hand sanitizer

 B) Implement contact precautions
 C) Use a mask and gloves
 D) Limit fluid intake

Correct Answer: B
Rationale: Implementing contact precautions is essential to prevent the spread of C. diff
infection.

Question 1499: Respiratory

A patient is admitted with shortness of breath and is diagnosed with pulmonary embolism.
Which intervention should the nurse prioritize?

 A) Administer oxygen as ordered

 B) Encourage the patient to rest
  C) Monitor vital signs every four hours
 D) Assess lung sounds every shift

Correct Answer: A
Rationale: Administering oxygen is critical for patients with pulmonary embolism to ensure
adequate oxygenation.

Question 1500: Gastrointestinal

A nurse is caring for a patient with chronic constipation. Which dietary recommendation should
the nurse provide?

 A) Increase intake of processed foods

 B) Decrease fiber intake
 C) Increase intake of fruits and vegetables
 D) Limit fluid intake

Correct Answer: C
Rationale: Increasing the intake of fruits and vegetables can help alleviate constipation.

Question 1501: Cardiovascular

A patient is being discharged after a myocardial infarction. Which instruction should the nurse
include in the discharge teaching?

 A) "You can resume your normal diet immediately."

 B) "You should avoid all physical activity for six weeks."
 C) "Report any chest pain or discomfort to your healthcare provider."
 D) "You can stop your medications once you feel better."

Correct Answer: C
Rationale: Reporting any chest pain or discomfort is crucial for early detection of complications.

Question 1502: Neurological

A nurse is caring for a patient with Parkinson’s disease. Which symptom should the nurse expect
to observe?

 A) Increased energy levels

 B) Fine motor skills improvement
  C) Bradykinesia
 D) Rapid speech

Correct Answer: C
Rationale: Bradykinesia, or slow movement, is a hallmark symptom of Parkinson's disease.

Question 1503: Mental Health

A patient with generalized anxiety disorder is experiencing excessive worry. Which intervention
should the nurse prioritize?

 A) Provide information about anxiety medications

 B) Teach relaxation techniques
 C) Encourage avoidance of stressors
 D) Suggest physical exercise only

Correct Answer: B
Rationale: Teaching relaxation techniques can help manage anxiety symptoms effectively.

Question 1504: Pediatric

A nurse is assessing a 2-year-old child. Which finding should the nurse report to the healthcare
provider?

 A) The child can build a tower of four blocks.

 B) The child uses two-word phrases.
 C) The child has a weight below the 5th percentile.
 D) The child can jump with both feet.

Correct Answer: C
Rationale: A weight below the 5th percentile may indicate inadequate growth and should be
reported.

Question 1505: Gastrointestinal

A patient undergoing an upper gastrointestinal (GI) series is being instructed before the
procedure. Which statement indicates that the patient understands the pre-procedure instructions?

 A) "I can eat a light meal before the procedure."

 B) "I should not eat or drink anything after midnight."
  C) "I will need to drink a lot of water after the test."
 D) "I can take my medications with food."

Correct Answer: B
Rationale: Patients typically must fast after midnight before an upper GI series.

Question 1506: Endocrine

A nurse is teaching a patient with Type 1 diabetes about insulin administration. Which statement
indicates that the patient understands the teaching?

 A) "I can give my insulin in any area of my body."

 B) "I should rotate injection sites to prevent lipodystrophy."
 C) "I should inject insulin into a muscle for quicker absorption."
 D) "I can reuse needles as long as they are cleaned."

Correct Answer: B
Rationale: Rotating injection sites is essential to prevent lipodystrophy.

Question 1507: Infection Control

A nurse is caring for a patient diagnosed with a multidrug-resistant infection. What is the priority
nursing action?

 A) Implement standard precautions

 B) Use contact precautions
 C) Limit patient visitors
 D) Provide patient education on hygiene

Correct Answer: B
Rationale: Contact precautions should be implemented to prevent the spread of the infection.

Question 1508: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
assessment finding would indicate a need for further intervention?

 A) Increased respiratory rate

 B) Use of accessory muscles
 C) O2 saturation of 95%
  D) Increased heart rate

Correct Answer: C
Rationale: An O2 saturation of 95% is acceptable for COPD patients, but further intervention
may be needed if the patient shows other distress signs.

Question 1509: Cardiovascular

A patient presents with hypertension and is prescribed a thiazide diuretic. Which teaching point
should the nurse emphasize?

 A) "You can take this medication with food."

 B) "Expect to gain weight while on this medication."
 C) "This medication will increase your potassium levels."
 D) "You should limit your fluid intake while taking this medication."

Correct Answer: A
Rationale: Taking thiazide diuretics with food can help reduce gastrointestinal upset.

Question 1510: Surgical

A nurse is caring for a postoperative patient. Which finding is a priority for the nurse to assess?

 A) Pain level
 B) Surgical site drainage
 C) Level of consciousness
 D) Patient's appetite

Correct Answer: C
Rationale: Assessing the level of consciousness is critical to determine the patient's neurological
status post-surgery.

Question 1511: Gastrointestinal

A patient with liver disease is being educated on dietary modifications. Which statement
indicates the need for further teaching?

 A) "I should limit my intake of protein."

 B) "I can eat nuts and beans as protein sources."
 C) "I need to reduce my sodium intake."
  D) "I should avoid alcohol completely."

Correct Answer: B
Rationale: Nuts and beans can be high in protein and should be consumed with caution in
patients with liver disease.

Question 1512: Mental Health

A patient with bipolar disorder is experiencing a manic episode. Which nursing intervention is
most appropriate?

 A) Encourage the patient to express their feelings

 B) Allow the patient to socialize freely with others
 C) Provide a structured environment
 D) Minimize the patient's activity

Correct Answer: C
Rationale: Providing a structured environment can help manage the patient’s behavior during a
manic episode.

Question 1513: Neurological

A nurse is assessing a patient with a stroke. Which assessment finding would indicate right-sided
brain damage?

 A) Difficulty speaking
 B) Impaired judgment
 C) Hemiplegia of the left side
 D) Visual field deficits

Correct Answer: C
Rationale: Hemiplegia of the left side indicates damage to the right side of the brain, as motor
function is contralateral.

Question 1514: Endocrine

A nurse is caring for a patient with adrenal insufficiency. Which medication should the nurse
expect to administer?

 A) Levothyroxine
  B) Cortisone
 C) Insulin
 D) Metformin

Correct Answer: B
Rationale: Cortisone is a glucocorticoid medication used to replace the deficient hormones in
adrenal insufficiency.

Question 1515: Pediatric

A nurse is providing discharge instructions to the parents of a child with asthma. Which
statement by the parents indicates a need for further teaching?

 A) "We should keep the child away from pets."

 B) "It's okay to use scented candles in the house."
 C) "We will keep the child's rescue inhaler nearby."
 D) "We should monitor for triggers."

Correct Answer: B
Rationale: Using scented candles can trigger asthma symptoms and should be avoided.

Question 1516: Infection Control

A patient with a respiratory infection is being placed on isolation precautions. Which type of
precaution should the nurse implement?

 A) Airborne precautions
 B) Droplet precautions
 C) Contact precautions
 D) Standard precautions

Correct Answer: B
Rationale: Droplet precautions are appropriate for respiratory infections transmitted through
large respiratory droplets.

Question 1517: Respiratory

A patient is diagnosed with pneumonia. Which finding would indicate the need for immediate
nursing intervention?
  A) A productive cough with green sputum
 B) O2 saturation of 88%
 C) Fever of 101°F
 D) Chest pain when coughing

Correct Answer: B
Rationale: An O2 saturation of 88% indicates hypoxemia and requires immediate intervention.

Question 1518: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which medication should the nurse expect to
administer?

 A) Antibiotics
 B) Antacids
 C) Laxatives
 D) NSAIDs

Correct Answer: B
Rationale: Antacids can help neutralize stomach acid and provide relief for peptic ulcers.

Question 1519: Endocrine

A patient with Type 2 diabetes is prescribed metformin. Which instruction should the nurse
include in the teaching plan?

 A) "Take this medication with meals."

 B) "This medication can be taken at any time."
 C) "Avoid all carbohydrates while on this medication."
 D) "You will need to take insulin with this medication."

Correct Answer: A
Rationale: Metformin should be taken with meals to reduce the risk of gastrointestinal side
effects.

Question 1520: Surgical

A nurse is assessing a patient who had a laparoscopic cholecystectomy. Which finding should
the nurse report immediately?
  A) Abdominal tenderness
 B) Nausea and vomiting
 C) Fever of 101.5°F
 D) Increased pain at the incision site

Correct Answer: C
Rationale: A fever of 101.5°F may indicate an infection and should be reported immediately.

Question 1521: Cardiac

A patient with heart failure is prescribed a diuretic. Which assessment finding should the nurse
monitor for as a potential side effect of this medication?

 A) Hyperkalemia
 B) Hypoglycemia
 C) Hypokalemia
 D) Hypertension

Correct Answer: C
Rationale: Diuretics can lead to hypokalemia due to increased potassium excretion.

Question 1522: Neurological

A nurse is caring for a patient who has just had a stroke and is now experiencing difficulty
swallowing. What is the priority nursing intervention?

 A) Encourage the patient to eat soft foods.

 B) Assess the patient's ability to swallow.
 C) Notify the healthcare provider of the swallowing difficulty.
 D) Provide a thickened liquid for the patient to drink.

Correct Answer: B
Rationale: Assessing the patient's ability to swallow is the priority to prevent aspiration.

Question 1523: Pharmacology

A patient is prescribed warfarin for anticoagulation therapy. Which laboratory test should the
nurse monitor to evaluate the effectiveness of this medication?

 A) Hemoglobin
  B) Prothrombin time (PT)/International Normalized Ratio (INR)
 C) Platelet count
 D) Activated partial thromboplastin time (aPTT)

Correct Answer: B
Rationale: The PT/INR is used to monitor the effectiveness and safety of warfarin therapy.

Question 1524: Mental Health

A nurse is assessing a patient with depression. Which finding would indicate a need for
immediate intervention?

 A) Expressing feelings of sadness

 B) Lack of energy and motivation
 C) Talking about suicidal thoughts
 D) Difficulty concentrating

Correct Answer: C
Rationale: Talking about suicidal thoughts indicates a potential risk for self-harm and requires
immediate intervention.

Question 1525: Respiratory

A patient with asthma is experiencing an acute exacerbation. Which intervention should the
nurse implement first?

 A) Administer a bronchodilator
 B) Encourage the patient to use pursed-lip breathing
 C) Administer oxygen therapy
 D) Notify the healthcare provider

Correct Answer: A
Rationale: Administering a bronchodilator is the first priority to relieve bronchospasm.

Question 1526: Gastrointestinal

A nurse is caring for a patient who has undergone a colostomy. Which statement by the patient
indicates a need for further education?

 A) "I will need to empty the bag when it's one-third full."
  B) "I can eat whatever I want after my surgery."
 C) "I should monitor my output for changes."
 D) "I will change the bag every few days."

Correct Answer: B
Rationale: Patients should be educated about dietary modifications to prevent complications
after colostomy.

Question 1527: Infection Control

A nurse is caring for a patient with a severe infection. Which action should the nurse take to
prevent the spread of infection?

 A) Place the patient in a semi-private room.

 B) Encourage frequent handwashing.
 C) Wear a mask when entering the room.
 D) Limit the use of personal protective equipment (PPE).

Correct Answer: B
Rationale: Frequent handwashing is one of the most effective ways to prevent the spread of
infection.

Question 1528: Endocrine

A nurse is monitoring a patient with hyperthyroidism. Which sign should the nurse expect to
observe?

 A) Weight gain
 B) Bradycardia
 C) Heat intolerance
 D) Cold intolerance

Correct Answer: C
Rationale: Heat intolerance is a common symptom of hyperthyroidism due to increased
metabolism.

Question 1529: Pediatric

A nurse is assessing a child with croup. Which assessment finding should the nurse expect?
  A) Bradycardia
 B) Barking cough
 C) Wheezing
 D) Hoarse voice

Correct Answer: B
Rationale: A barking cough is a characteristic symptom of croup.

Question 1530: Cardiac

A patient with hypertension is prescribed an ACE inhibitor. Which adverse effect should the
nurse educate the patient about?

 A) Weight gain
 B) Dry cough
 C) Constipation
 D) Drowsiness

Correct Answer: B
Rationale: A dry cough is a common side effect of ACE inhibitors.

Question 1531: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which lifestyle modification should the nurse
recommend?

 A) Increase caffeine intake

 B) Reduce stress levels
 C) Increase alcohol consumption
 D) Avoid regular meals

Correct Answer: B
Rationale: Reducing stress levels can help manage symptoms and prevent ulcer exacerbation.

Question 1532: Surgical

A nurse is assessing a postoperative patient. Which finding should be reported immediately?

 A) Pain at the surgical site

 B) Decreased bowel sounds
  C) Bright red drainage on the dressing
 D) Mild nausea

Correct Answer: C
Rationale: Bright red drainage may indicate active bleeding and should be reported
immediately.

Question 1533: Respiratory

A patient with chronic bronchitis is being educated about self-care. Which statement indicates a
need for further teaching?

 A) "I will avoid smoking."

 B) "I can use a humidifier to help with my breathing."
 C) "I can exercise as much as I want."
 D) "I should get my flu shot every year."

Correct Answer: C
Rationale: Patients with chronic bronchitis should engage in regular but monitored exercise,
avoiding overexertion.

Question 1534: Endocrine

A patient with Addison’s disease is at risk for adrenal crisis. What is the priority nursing
intervention?

 A) Monitor blood glucose levels

 B) Educate the patient on stress management
 C) Administer glucocorticoids as prescribed
 D) Assess for signs of dehydration

Correct Answer: C
Rationale: Administering glucocorticoids as prescribed is essential to prevent adrenal crisis.

Question 1535: Neurological

A nurse is assessing a patient with a recent diagnosis of multiple sclerosis (MS). Which symptom
is characteristic of MS?

 A) Severe headache
  B) Visual disturbances
 C) Fever and chills
 D) Nausea and vomiting

Correct Answer: B
Rationale: Visual disturbances are a common symptom of multiple sclerosis.

Question 1536: Infection Control

A patient diagnosed with tuberculosis (TB) is being discharged. Which instruction should the
nurse provide?

 A) "You can stop taking your medications once you feel better."
 B) "You need to wear a mask at home."
 C) "You should avoid close contact with others until you're cured."
 D) "You need to have regular follow-up appointments."

Correct Answer: D
Rationale: Regular follow-up appointments are essential for monitoring the treatment progress
and ensuring compliance.

Question 1537: Pediatric

A nurse is caring for a child diagnosed with cystic fibrosis. Which finding would indicate a need
for further evaluation?

 A) Frequent respiratory infections

 B) Poor growth and weight gain
 C) Salty-tasting skin
 D) Increased energy levels

Correct Answer: D
Rationale: Increased energy levels are not typical in children with cystic fibrosis, as they often
experience fatigue.

Question 1538: Gastrointestinal

A nurse is caring for a patient with a history of gallstones. Which dietary change should the
nurse recommend?
  A) Increase saturated fats
 B) Limit high-fiber foods
 C) Avoid fatty foods
 D) Eat more refined sugars

Correct Answer: C
Rationale: Avoiding fatty foods can help reduce the risk of gallbladder attacks.

Question 1539: Cardiac

A patient is prescribed a beta-blocker. Which assessment should the nurse prioritize?

 A) Respiratory rate
 B) Heart rate and blood pressure
 C) Bowel sounds
 D) Urine output

Correct Answer: B
Rationale: Monitoring heart rate and blood pressure is critical for patients on beta-blockers to
prevent bradycardia and hypotension.

Question 1540: Endocrine

A nurse is monitoring a patient receiving insulin. Which finding would indicate hypoglycemia?

 A) Increased thirst
 B) Sweating and shakiness
 C) Frequent urination
 D) Nausea

Correct Answer: B
Rationale: Sweating and shakiness are classic signs of hypoglycemia.

Question 1541: Cardiovascular

A nurse is caring for a patient who has just returned from a cardiac catheterization. What is the
priority nursing action?

 A) Monitor vital signs every 15 minutes.

 B) Assess the puncture site for bleeding.
  C) Encourage the patient to ambulate.
 D) Administer prescribed analgesics.

Correct Answer: B
Rationale: Assessing the puncture site for bleeding is the priority to ensure there are no
complications.

Question 1542: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of

breath. Which intervention should the nurse implement first?

 A) Administer prescribed bronchodilator.

 B) Place the patient in a high-Fowler’s position.
 C) Encourage deep breathing exercises.
 D) Provide supplemental oxygen.

Correct Answer: A
Rationale: Administering a bronchodilator is the priority to relieve bronchospasm and improve
airflow.

Question 1543: Neurological

A nurse is caring for a patient with a seizure disorder. What should the nurse include in the
patient’s discharge teaching?

 A) Avoid driving for at least six months after the last seizure.
 B) Discontinue medication if seizures are controlled.
 C) Use a safety belt while driving.
 D) Avoid all physical activity.

Correct Answer: A
Rationale: Patients should avoid driving for at least six months after the last seizure to ensure
safety.

Question 1544: Pharmacology

A nurse is teaching a patient about the use of an albuterol inhaler. What is the correct instruction
for the patient?
  A) Use the inhaler only when experiencing shortness of breath.
 B) Shake the inhaler before use.
 C) Hold your breath for 2 seconds after inhaling.
 D) Administer the inhaler before meals.

Correct Answer: B
Rationale: The inhaler should be shaken before use to ensure proper mixing of the medication.

Question 1545: Mental Health

A patient with bipolar disorder is in a manic phase. Which behavior would the nurse most likely
observe?

 A) Withdrawal from social activities.

 B) Excessive talking and energy.
 C) Sleep disturbances and fatigue.
 D) Pessimistic outlook on life.

Correct Answer: B
Rationale: During a manic phase, patients exhibit excessive talking, energy, and activity levels.

Question 1546: Gastrointestinal

A patient with cirrhosis is at risk for hepatic encephalopathy. Which sign should the nurse
monitor for?

 A) Confusion and lethargy.

 B) Elevated blood pressure.
 C) Increased appetite.
 D) Frequent urination.

Correct Answer: A
Rationale: Confusion and lethargy are signs of hepatic encephalopathy due to the accumulation
of toxins.

Question 1547: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). What
type of precautions should the nurse implement?
  A) Contact precautions.
 B) Airborne precautions.
 C) Droplet precautions.
 D) Standard precautions only.

Correct Answer: A
Rationale: Contact precautions are necessary to prevent the spread of MRSA.

Question 1548: Endocrine

A nurse is monitoring a patient with diabetes mellitus who is being treated with metformin.
Which lab value indicates a potential complication of therapy?

 A) Blood glucose level of 150 mg/dL.

 B) Hemoglobin A1c of 7.5%.
 C) Serum creatinine level of 2.5 mg/dL.
 D) Lipid panel showing elevated triglycerides.

Correct Answer: C
Rationale: A serum creatinine level of 2.5 mg/dL indicates potential renal impairment, which
can complicate metformin therapy.

Question 1549: Pediatric

A nurse is assessing a child with asthma. Which finding should the nurse report immediately?

 A) Increased respiratory rate.

 B) Use of accessory muscles for breathing.
 C) Coughing after exercise.
 D) Mild wheezing.

Correct Answer: B
Rationale: The use of accessory muscles for breathing indicates increased respiratory distress
and should be reported immediately.

Question 1550: Surgical

A patient is scheduled for a total hip replacement. Which preoperative instruction should the
nurse provide?
  A) Avoid all food and drink after midnight before surgery.
 B) You will need to stay in bed for at least 48 hours post-op.
 C) You can return to your normal activities immediately after surgery.
 D) You will need to perform deep breathing exercises before surgery.

Correct Answer: A
Rationale: Patients are typically instructed to avoid all food and drink after midnight before
surgery to prevent aspiration.

Question 1551: Cardiovascular

A nurse is assessing a patient with peripheral artery disease (PAD). Which symptom would the
nurse expect to find?

 A) Pulses are bounding.

 B) Cool, pale extremities.
 C) Warm, red skin.
 D) Increased hair growth on the legs.

Correct Answer: B
Rationale: Cool, pale extremities are indicative of reduced blood flow associated with PAD.

Question 1552: Respiratory

A nurse is teaching a patient with asthma about the use of a peak flow meter. What is the purpose
of this device?

 A) To measure oxygen saturation levels.

 B) To assess lung capacity.
 C) To monitor airflow obstruction.
 D) To determine respiratory rate.

Correct Answer: C
Rationale: A peak flow meter measures how well air moves out of the lungs, helping to assess
airflow obstruction.

Question 1553: Gastrointestinal

A nurse is caring for a patient with a nasogastric (NG) tube. What is the priority nursing action?
  A) Monitor for abdominal distention.
 B) Verify tube placement before feeding.
 C) Change the NG tube every week.
 D) Encourage oral intake of fluids.

Correct Answer: B
Rationale: Verifying tube placement before feeding is essential to prevent aspiration.

Question 1554: Infection Control

A nurse is preparing to administer an antibiotic to a patient with a known penicillin allergy. What
is the priority nursing action?

 A) Administer the antibiotic slowly.

 B) Obtain a sample for culture and sensitivity.
 C) Document the allergy in the patient's chart.
 D) Notify the healthcare provider before administration.

Correct Answer: D
Rationale: The nurse should notify the healthcare provider about the allergy to ensure the
appropriate medication is prescribed.

Question 1555: Neurological

A patient is diagnosed with a transient ischemic attack (TIA). Which education should the nurse
provide?

 A) "You will need surgery to prevent another stroke."

 B) "This condition requires long-term bed rest."
 C) "You should see a healthcare provider if symptoms recur."
 D) "You can return to normal activities immediately."

Correct Answer: C
Rationale: Patients should be educated to seek medical attention if TIA symptoms recur, as it
may indicate a more serious stroke.

Question 1556: Endocrine

A nurse is caring for a patient with hyperthyroidism. Which symptom would the nurse expect to
observe?
  A) Fatigue and weight gain.
 B) Increased appetite and weight loss.
 C) Cold intolerance.
 D) Constipation.

Correct Answer: B
Rationale: Increased appetite and weight loss are common symptoms of hyperthyroidism due to
an accelerated metabolism.

Question 1557: Pediatric

A nurse is assessing a child who has just been diagnosed with diabetes mellitus. Which statement
by the parent indicates a need for further education?

 A) "I need to check my child's blood sugar levels regularly."

 B) "I should let my child eat whatever they want as long as they take their insulin."
 C) "I will ensure my child has regular check-ups."
 D) "I will monitor for signs of hypoglycemia."

Correct Answer: B
Rationale: Parents should be educated about the importance of diet in managing diabetes, not
just insulin administration.

Question 1558: Pharmacology

A patient is prescribed digoxin. Which symptom should the nurse monitor for as a potential side
effect?

 A) Nausea and vomiting.

 B) Bradycardia.
 C) Diarrhea.
 D) Elevated blood pressure.

Correct Answer: A
Rationale: Nausea and vomiting can indicate digoxin toxicity, and the nurse should monitor for
these symptoms.

Question 1559: Surgical

A nurse is preparing a patient for surgery. Which medication should the nurse withhold until the
healthcare provider is notified?

 A) Antihypertensives.
 B) Antibiotics.
 C) Anticoagulants.
 D) Analgesics.

Correct Answer: C
Rationale: Anticoagulants should be withheld prior to surgery due to the risk of excessive
bleeding.

Question 1560: Mental Health

A patient in a psychiatric unit is experiencing severe anxiety. What is the most appropriate
nursing intervention?

 A) Encourage the patient to talk about their feelings.

 B) Offer to sit quietly with the patient.
 C) Suggest the patient engage in group therapy.
 D) Administer prescribed anti-anxiety medication.

Correct Answer: B
Rationale: Offering to sit quietly with the patient can help provide a calming presence without
overwhelming them.

Question 1561: Cardiovascular

A patient is being discharged after undergoing coronary artery bypass graft (CABG) surgery.
Which statement by the patient indicates a need for further teaching?

 A) "I will call my doctor if I notice any swelling in my legs."

 B) "I can return to work as soon as I feel better."
 C) "I should avoid lifting anything heavier than 10 pounds for the next few weeks."
 D) "I need to follow a low-sodium diet to help manage my blood pressure."

Correct Answer: B
Rationale: Patients should be educated about the timeline for returning to work, which typically
involves a gradual increase in activity.
Question 1562: Respiratory

A patient with chronic bronchitis is experiencing an acute exacerbation. Which assessment

finding would be expected?

 A) Decreased sputum production.

 B) Productive cough with thick, green sputum.
 C) Clear lung sounds upon auscultation.
 D) Increased respiratory rate with normal oxygen saturation.

Correct Answer: B
Rationale: A productive cough with thick, green sputum is a typical finding during an
exacerbation of chronic bronchitis.

Question 1563: Neurological

A nurse is assessing a patient who has just undergone a craniotomy. Which finding would be of
greatest concern?

 A) Complaints of headache.
 B) Clear drainage from the nose.
 C) Decreased level of consciousness.
 D) Slight fever.

Correct Answer: C
Rationale: A decreased level of consciousness could indicate increased intracranial pressure or
neurological deterioration, warranting immediate attention.

Question 1564: Pharmacology

A nurse is administering warfarin to a patient. Which laboratory value should the nurse monitor?

 A) Complete blood count (CBC).

 B) International normalized ratio (INR).
 C) Blood glucose level.
 D) Liver function tests.

Correct Answer: B
Rationale: The INR is monitored to assess the effectiveness of warfarin therapy and ensure it is
within the therapeutic range.
Question 1565: Infection Control

A nurse is caring for a patient with tuberculosis (TB). What type of isolation precautions should
the nurse implement?

 A) Contact precautions.
 B) Droplet precautions.
 C) Airborne precautions.
 D) Standard precautions only.

Correct Answer: C
Rationale: Airborne precautions are necessary to prevent the spread of TB, which is transmitted
through the air.

Question 1566: Endocrine

A nurse is teaching a patient with diabetes about insulin administration. Which statement
indicates a need for further teaching?

 A) "I should rotate injection sites to prevent lipodystrophy."

 B) "It's okay to inject insulin into the muscle for faster absorption."
 C) "I need to check my blood sugar before each injection."
 D) "I should store my insulin in the refrigerator."

Correct Answer: B
Rationale: Insulin should be injected subcutaneously, not intramuscularly, to prevent rapid
absorption and potential hypoglycemia.

Question 1567: Pediatric

A nurse is caring for a 6-year-old child with asthma. What is the best method to administer a
metered-dose inhaler (MDI) to the child?

 A) Have the child inhale the medication quickly.

 B) Use a spacer to enhance delivery of the medication.
 C) Administer the medication while the child is lying down.
 D) Ask the child to hold their breath for 10 seconds.

Correct Answer: B
Rationale: Using a spacer improves medication delivery and effectiveness for children using
MDIs.
Question 1568: Gastrointestinal

A patient with liver cirrhosis is experiencing ascites. Which nursing intervention is most
appropriate?

 A) Encourage high sodium intake.

 B) Monitor abdominal girth daily.
 C) Administer diuretics as prescribed.
 D) Limit fluid intake to 2000 mL per day.

Correct Answer: B
Rationale: Monitoring abdominal girth daily helps assess the severity of ascites and the
effectiveness of treatment.

Question 1569: Mental Health

A nurse is caring for a patient with major depressive disorder. Which statement made by the
patient indicates a potential risk for suicide?

 A) "I have been feeling sad lately."

 B) "I don't see any reason to go on."
 C) "I enjoy spending time with my friends."
 D) "I have been trying to eat healthy."

Correct Answer: B
Rationale: The statement reflects hopelessness and may indicate a higher risk for suicide,
requiring immediate assessment and intervention.

Question 1570: Surgical

A patient is being prepared for a laparoscopic cholecystectomy. Which preoperative intervention

should the nurse perform?

 A) Instruct the patient to remain NPO for 6 hours.

 B) Provide a full liquid diet the night before.
 C) Encourage the patient to take a warm bath.
 D) Administer antibiotics before surgery.
Correct Answer: A
Rationale: Patients should be instructed to remain NPO (nothing by mouth) for a specified time
before surgery to reduce the risk of aspiration.

Question 1571: Cardiovascular

A nurse is monitoring a patient with heart failure. Which finding indicates that the patient may
be experiencing worsening heart failure?

 A) Weight gain of 1 pound over 3 days.

 B) Decreased respiratory rate.
 C) Increased peripheral edema.
 D) Heart rate of 72 bpm.

Correct Answer: C
Rationale: Increased peripheral edema is a sign of worsening heart failure due to fluid overload.

Question 1572: Respiratory

A nurse is caring for a patient with pneumonia. What is the priority nursing diagnosis for this
patient?

 A) Ineffective airway clearance.

 B) Risk for infection.
 C) Impaired gas exchange.
 D) Activity intolerance.

Correct Answer: C
Rationale: Impaired gas exchange is a priority concern in patients with pneumonia due to
inflammation and fluid in the alveoli.

Question 1573: Neurological

A patient presents to the emergency department with symptoms of a stroke. What is the most
important intervention by the nurse?

 A) Administer aspirin immediately.

 B) Assess the patient’s neurological status.
 C) Obtain a detailed medical history.
 D) Prepare the patient for a CT scan.
Correct Answer: D
Rationale: Preparing the patient for a CT scan is crucial to determine the type of stroke and
initiate appropriate treatment.

Question 1574: Pharmacology

A nurse is caring for a patient taking lisinopril. Which side effect should the nurse monitor for?

 A) Bradycardia.
 B) Hyperkalemia.
 C) Weight loss.
 D) Hypertension.

Correct Answer: B
Rationale: Lisinopril can cause hyperkalemia, so monitoring potassium levels is important.

Question 1575: Infection Control

A nurse is caring for a patient with Clostridium difficile infection. Which precautions should the
nurse implement?

 A) Standard precautions.
 B) Contact precautions.
 C) Droplet precautions.
 D) Airborne precautions.

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of C. difficile, which is
transmitted via fecal-oral route.

Question 1576: Endocrine

A nurse is educating a patient with hyperthyroidism about potential symptoms. Which symptom
should the nurse include?

 A) Weight gain.
 B) Cold intolerance.
 C) Increased heart rate.
 D) Constipation.
Correct Answer: C
Rationale: Increased heart rate is a common symptom of hyperthyroidism due to the increased
metabolic rate.

Question 1577: Pediatric

A nurse is caring for a child with cystic fibrosis. Which statement indicates the need for further
teaching?

 A) "I should give my child pancreatic enzymes with meals."

 B) "I need to monitor my child's weight regularly."
 C) "My child can eat a low-salt diet."
 D) "I should encourage my child to stay active."

Correct Answer: C
Rationale: Children with cystic fibrosis typically require a higher salt intake due to loss of salt in
sweat.

Question 1578: Gastrointestinal

A patient is recovering from a colostomy. What is the best nursing intervention to promote
adaptation?

 A) Restrict oral intake until bowel sounds return.

 B) Provide education about stoma care.
 C) Encourage the patient to avoid all social activities.
 D) Monitor for signs of infection at the stoma site.

Correct Answer: B
Rationale: Providing education about stoma care helps promote adaptation and independence in
managing the colostomy.

Question 1579: Mental Health

A nurse is assessing a patient diagnosed with generalized anxiety disorder. Which symptom
would the nurse most likely observe?

 A) Hallucinations.
 B) Avoidance of social situations.
 C) Euphoria.
  D) Paranoia.

Correct Answer: B
Rationale: Avoidance of social situations is common in patients with generalized anxiety
disorder due to excessive worry.

Question 1580: Surgical

A patient is scheduled for a total hip replacement. Which assessment finding should the nurse
report to the surgeon?

 A) Mild fever.
 B) Increased heart rate.
 C) Positive Homan's sign.
 D) History of smoking.

Correct Answer: C
Rationale: A positive Homan's sign may indicate a deep vein thrombosis (DVT), which is a
concern prior to surgery.

Question 1581: Cardiovascular

A patient is diagnosed with hypertension. Which lifestyle modification should the nurse
recommend?

 A) Decrease physical activity.

 B) Increase sodium intake.
 C) Limit alcohol consumption.
 D) Maintain a sedentary lifestyle.

Correct Answer: C
Rationale: Limiting alcohol consumption can help reduce blood pressure and promote overall
cardiovascular health.

Question 1582: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. What
is the priority nursing assessment?

 A) Skin integrity.
  B) Respiratory rate.
 C) Oxygen saturation levels.
 D) Blood pressure.

Correct Answer: C
Rationale: Monitoring oxygen saturation levels is essential to ensure the patient is receiving
adequate oxygenation.

Question 1583: Neurological

A nurse is assessing a patient who has experienced a seizure. What is the priority nursing
intervention immediately after the seizure?

 A) Position the patient on their back.

 B) Administer a benzodiazepine.
 C) Document the duration of the seizure.
 D) Ensure the patient's airway is patent.

Correct Answer: D
Rationale: Ensuring the airway is patent is the priority after a seizure to prevent respiratory
compromise.

Question 1584: Pharmacology

A nurse is preparing to administer digoxin to a patient. What is the most important assessment
before administering this medication?

 A) Assess the patient's blood pressure.

 B) Assess the patient's apical pulse.
 C) Monitor the patient's weight.
 D) Check the patient's potassium level.

Correct Answer: B
Rationale: The apical pulse should be assessed because digoxin can cause bradycardia; it should
be administered only if the pulse is above 60 bpm.

Question 1585: Infection Control

A nurse is caring for a patient in isolation for vancomycin-resistant enterococcus (VRE). Which
precaution is most important for the nurse to follow?
  A) Wear a gown and gloves when entering the room.
 B) Perform hand hygiene before leaving the room.
 C) Wear a mask when caring for the patient.
 D) Place a sign on the door indicating isolation precautions.

Correct Answer: A
Rationale: Wearing a gown and gloves when entering the room is essential to prevent the
transmission of VRE.

Question 1586: Endocrine

A nurse is teaching a patient with type 1 diabetes about insulin administration. Which statement
by the patient indicates a need for further teaching?

 A) "I can inject my insulin into my thigh for a quicker effect."

 B) "I should use a different site for each injection."
 C) "I need to rotate my injection sites."
 D) "I will keep my insulin in the refrigerator until I use it."

Correct Answer: A
Rationale: Insulin should generally be injected into subcutaneous tissue, not muscle, to ensure
appropriate absorption.

Question 1587: Pediatric

A nurse is assessing a 2-year-old child. Which developmental milestone should the child have
achieved?

 A) Hopping on one foot.

 B) Building a tower of six blocks.
 C) Speaking in full sentences.
 D) Riding a tricycle.

Correct Answer: B
Rationale: By age 2, children can typically build a tower of six blocks, indicating appropriate
fine motor skills.

Question 1588: Gastrointestinal

A patient is diagnosed with peptic ulcer disease. Which lifestyle change should the nurse
recommend?

 A) Increase caffeine intake.

 B) Eat small, frequent meals.
 C) Avoid all physical activity.
 D) Increase intake of spicy foods.

Correct Answer: B
Rationale: Eating small, frequent meals can help reduce symptoms and promote healing in
patients with peptic ulcer disease.

Question 1589: Mental Health

A nurse is caring for a patient with schizophrenia who is exhibiting paranoid behavior. Which
intervention is most appropriate?

 A) Encourage the patient to express feelings of paranoia.

 B) Confront the patient's delusions.
 C) Use a calm and reassuring approach.
 D) Ignore the patient's fears to avoid reinforcement.

Correct Answer: C
Rationale: Using a calm and reassuring approach helps build trust and reduces anxiety in
patients with paranoid behaviors.

Question 1590: Surgical

A nurse is preparing a patient for a hysterectomy. Which preoperative education is most

important?

 A) Discuss the types of anesthesia that will be used.

 B) Explain the purpose of the surgery and expected outcomes.
 C) Instruct the patient to refrain from eating solid foods for 24 hours.
 D) Encourage the patient to schedule follow-up appointments.

Correct Answer: B
Rationale: Educating the patient about the purpose of the surgery and expected outcomes helps
reduce anxiety and prepares them for the procedure.
Question 1591: Cardiovascular

A nurse is caring for a patient with heart failure who reports increased shortness of breath.
Which action should the nurse take first?

 A) Administer the prescribed diuretic.

 B) Assess lung sounds.
 C) Place the patient in a high-Fowler’s position.
 D) Monitor the patient’s vital signs.

Correct Answer: C
Rationale: Placing the patient in a high-Fowler’s position can help alleviate shortness of breath
by improving lung expansion.

Question 1592: Respiratory

A patient with asthma is experiencing an acute exacerbation. What should the nurse prioritize in
the care of this patient?

 A) Administering oral corticosteroids.

 B) Encouraging slow, deep breathing exercises.
 C) Providing a bronchodilator as prescribed.
 D) Assessing peak flow meter readings.

Correct Answer: C
Rationale: Administering a bronchodilator is the priority intervention to relieve bronchospasm
and improve airflow.

Question 1593: Neurological

A nurse is caring for a patient who has just had a lumbar puncture. Which position should the
nurse place the patient in afterward?

 A) Supine.
 B) Prone.
 C) Left lateral.
 D) Right lateral.

Correct Answer: A
Rationale: The patient should be kept in a supine position to reduce the risk of a headache
following a lumbar puncture.
Question 1594: Pharmacology

A nurse is monitoring a patient receiving heparin therapy. Which lab value should the nurse
monitor to assess the effectiveness of the therapy?

 A) Hemoglobin and hematocrit.

 B) Prothrombin time (PT).
 C) Activated partial thromboplastin time (aPTT).
 D) International normalized ratio (INR).

Correct Answer: C
Rationale: The aPTT is monitored to assess the effectiveness and safety of heparin therapy.

Question 1595: Infection Control

A nurse is caring for a patient with a respiratory infection. What type of mask should the nurse
wear when entering the patient's room?

 A) Surgical mask.
 B) N95 respirator.
 C) Regular face mask.
 D) No mask is necessary.

Correct Answer: B
Rationale: An N95 respirator is required for airborne precautions, particularly for patients with
respiratory infections like tuberculosis.

Question 1596: Endocrine

A patient with hypothyroidism is being treated with levothyroxine. What is the most important
point for the nurse to include in the teaching plan?

 A) Take the medication with food to enhance absorption.

 B) Expect to feel immediate effects after starting the medication.
 C) Monitor for signs of hyperthyroidism.
 D) The medication should be taken at bedtime.

Correct Answer: C
Rationale: Patients should be educated to monitor for signs of hyperthyroidism as the dosage
may need adjustment.
Question 1597: Pediatric

A nurse is assessing a child for signs of dehydration. Which finding would be most concerning?

 A) Dry mucous membranes.

 B) Increased thirst.
 C) Decreased urine output.
 D) Sunken fontanelle (in infants).

Correct Answer: D
Rationale: A sunken fontanelle in infants is a significant indicator of dehydration and requires
immediate attention.

Question 1598: Gastrointestinal

A nurse is caring for a patient with diverticulitis. Which dietary recommendation should the
nurse provide?

 A) Increase fiber intake.

 B) Avoid all solid foods.
 C) Limit fluids to prevent diarrhea.
 D) Include clear liquids during flare-ups.

Correct Answer: D
Rationale: Clear liquids are recommended during flare-ups of diverticulitis to allow the bowel to
rest and heal.

Question 1599: Mental Health

A patient diagnosed with obsessive-compulsive disorder (OCD) is scheduled for cognitive-

behavioral therapy. Which statement by the nurse is most appropriate?

 A) "You should avoid talking about your obsessions."

 B) "This therapy will help you face your fears."
 C) "Medication is the only effective treatment for OCD."
 D) "You can manage your symptoms by ignoring them."

Correct Answer: B
Rationale: Cognitive-behavioral therapy aims to help patients face their fears and reduce
compulsive behaviors.
Question 1600: Surgical

A patient recovering from a cholecystectomy is complaining of shoulder pain. What should the
nurse explain as the cause of this pain?

 A) Gas trapped in the abdomen.

 B) Surgical incision site irritation.
 C) Referred pain from the gallbladder.
 D) Infection at the surgical site.

Correct Answer: A
Rationale: Shoulder pain after laparoscopic surgery is often due to carbon dioxide gas used
during the procedure, which can irritate the diaphragm.

Question 1601: Cardiovascular

A patient presents with chest pain and shortness of breath. The ECG shows ST-segment
elevation. What does this finding indicate?

 A) Unstable angina.
 B) Myocardial infarction.
 C) Atrial fibrillation.
 D) Ventricular tachycardia.

Correct Answer: B
Rationale: ST-segment elevation is indicative of a myocardial infarction (MI), requiring
immediate intervention.

Question 1602: Respiratory

A patient with asthma is prescribed a peak flow meter. What is the purpose of this device?

 A) To measure blood oxygen levels.

 B) To assess the need for bronchodilator therapy.
 C) To evaluate lung capacity.
 D) To monitor respiratory rate.

Correct Answer: B
Rationale: A peak flow meter is used to assess the patient’s ability to exhale air, helping to
determine the need for bronchodilator therapy.
Question 1603: Neurological

A patient is experiencing a transient ischemic attack (TIA). Which teaching point is most
important for the nurse to include?

 A) TIA does not require any lifestyle changes.

 B) A TIA increases the risk of a future stroke.
 C) Symptoms of a TIA are permanent.
 D) Medication compliance is optional.

Correct Answer: B
Rationale: A TIA is a warning sign of a potential future stroke, and lifestyle changes and
medication compliance are crucial to prevention.

Question 1604: Pharmacology

A patient is prescribed warfarin. Which laboratory test should the nurse monitor to ensure safe
therapeutic levels?

 A) Hemoglobin.
 B) Platelet count.
 C) Prothrombin time (PT) and International normalized ratio (INR).
 D) Activated partial thromboplastin time (aPTT).

Correct Answer: C
Rationale: PT and INR are monitored to assess the effectiveness and safety of warfarin therapy.

Question 1605: Infection Control

A nurse is caring for a patient with a known Clostridium difficile infection. What type of
isolation precautions should the nurse implement?

 A) Standard precautions only.

 B) Contact precautions.
 C) Airborne precautions.
 D) Droplet precautions.

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of C. difficile, which can be
transmitted through direct contact.
Question 1606: Endocrine

A patient with type 2 diabetes is started on metformin. Which teaching point should the nurse
emphasize?

 A) Take the medication on an empty stomach.

 B) Monitor blood glucose levels regularly.
 C) Avoid all carbohydrates.
 D) This medication is a cure for diabetes.

Correct Answer: B
Rationale: Regular monitoring of blood glucose levels is essential for managing diabetes and
evaluating the effectiveness of treatment.

Question 1607: Pediatric

A nurse is assessing a 6-month-old infant. Which finding would be expected for this age?

 A) Sitting without support.

 B) Crawling.
 C) Babbling.
 D) Walking.

Correct Answer: C
Rationale: Babbling is a developmental milestone typically reached by 6 months of age.

Question 1608: Gastrointestinal

A patient with inflammatory bowel disease (IBD) is experiencing a flare-up. What dietary
recommendation should the nurse provide?

 A) High fiber diet.

 B) Low residue diet.
 C) Full liquid diet.
 D) Gluten-free diet.

Correct Answer: B
Rationale: A low residue diet is often recommended during flare-ups of IBD to reduce bowel
irritation.
Question 1609: Mental Health

A patient diagnosed with major depressive disorder expresses feelings of hopelessness. What is
the nurse’s best response?

 A) "You shouldn't feel that way."

 B) "Tell me more about how you're feeling."
 C) "You’ll feel better soon."
 D) "It's just a phase you're going through."

Correct Answer: B
Rationale: Encouraging the patient to express their feelings helps validate their experience and
promotes therapeutic communication.

Question 1610: Surgical

A nurse is caring for a postoperative patient who has just received an epidural for pain
management. What is the priority nursing assessment?

 A) Level of consciousness.
 B) Urinary output.
 C) Respiratory status.
 D) Pain level.

Correct Answer: C
Rationale: Respiratory status is a priority assessment because epidural anesthesia can affect
respiratory function.

Question 1611: Cardiovascular

A nurse is assessing a patient with heart failure. Which finding is indicative of fluid overload?

 A) Decreased heart rate.

 B) Increased blood pressure.
 C) Dry mucous membranes.
 D) Weight loss.

Correct Answer: B
Rationale: Increased blood pressure can indicate fluid overload in patients with heart failure.
Question 1612: Respiratory

A patient with pneumonia is experiencing increased respiratory distress. What is the nurse’s
priority intervention?

 A) Administer antibiotics.
 B) Position the patient in high-Fowler's position.
 C) Increase oral fluid intake.
 D) Monitor oxygen saturation levels.

Correct Answer: B
Rationale: Positioning the patient in high-Fowler's position can help facilitate better lung
expansion and ease breathing.

Question 1613: Neurological

A patient who had a stroke is exhibiting signs of dysphagia. What should the nurse assess next?

 A) Speech clarity.
 B) Level of consciousness.
 C) Ability to perform activities of daily living.
 D) Swallowing ability.

Correct Answer: D
Rationale: Assessing swallowing ability is essential to prevent aspiration and ensure safe eating.

Question 1614: Pharmacology

A nurse is administering potassium chloride to a patient. Which assessment is most important

prior to administration?

 A) Blood glucose level.

 B) Serum potassium level.
 C) Heart rate.
 D) Respiratory rate.

Correct Answer: B
Rationale: Monitoring serum potassium levels is critical to avoid hyperkalemia, especially if the
patient has renal issues.
Question 1615: Infection Control

A nurse is caring for a patient with a respiratory infection. Which action should the nurse take to
prevent the spread of infection?

 A) Use gloves when entering the room.

 B) Encourage the patient to cough into their hand.
 C) Provide tissues and instruct the patient to cover their mouth when coughing.
 D) Limit visitors to the room.

Correct Answer: C
Rationale: Instructing the patient to cover their mouth when coughing helps reduce the
transmission of respiratory droplets.

Question 1616: Endocrine

A patient is newly diagnosed with hyperthyroidism. What symptom should the nurse educate the
patient to monitor for?

 A) Weight gain.
 B) Increased energy levels.
 C) Heat intolerance.
 D) Dry skin.

Correct Answer: C
Rationale: Heat intolerance is a common symptom of hyperthyroidism due to increased
metabolism.

Question 1617: Pediatric

A nurse is teaching the parents of a toddler about age-appropriate activities. Which activity
should the nurse recommend?

 A) Playing with small puzzles.

 B) Building with blocks.
 C) Playing video games.
 D) Riding a bicycle.
Correct Answer: B
Rationale: Building with blocks is an appropriate activity for toddlers that promotes fine motor
skills and creativity.

Question 1618: Gastrointestinal

A patient is scheduled for a colonoscopy. Which pre-procedure instruction is essential for the
nurse to provide?

 A) Eat a high-fiber diet the day before the procedure.

 B) Take all prescribed medications as usual.
 C) Drink plenty of fluids to stay hydrated.
 D) Follow a clear liquid diet and take a bowel prep as ordered.

Correct Answer: D
Rationale: Following a clear liquid diet and taking a bowel preparation is essential for adequate
visualization during the colonoscopy.

Question 1619: Mental Health

A nurse is caring for a patient with anxiety. Which intervention is most appropriate to help the
patient cope?

 A) Provide information about anxiety medications.

 B) Encourage deep breathing exercises.
 C) Suggest the patient avoid discussing their feelings.
 D) Tell the patient to stop worrying.

Correct Answer: B
Rationale: Deep breathing exercises can help the patient manage anxiety symptoms effectively.

Question 1620: Surgical

A patient has just undergone a mastectomy. Which discharge instruction should the nurse
emphasize?

 A) Limit mobility of the affected arm for two weeks.

 B) Avoid using deodorant on the affected side.
 C) Remove the drainage tube if it becomes full.
 D) Engage in vigorous physical activity to promote healing.
Correct Answer: B
Rationale: Patients should avoid using deodorant on the affected side to prevent irritation and
potential infection at the incision site.

Question 1601: Cardiovascular

A patient presents with chest pain and shortness of breath. The ECG shows ST-segment
elevation. What does this finding indicate?

 A) Unstable angina.
 B) Myocardial infarction.
 C) Atrial fibrillation.
 D) Ventricular tachycardia.

Correct Answer: B
Rationale: ST-segment elevation is indicative of a myocardial infarction (MI), requiring
immediate intervention.

Question 1602: Respiratory

A patient with asthma is prescribed a peak flow meter. What is the purpose of this device?

 A) To measure blood oxygen levels.

 B) To assess the need for bronchodilator therapy.
 C) To evaluate lung capacity.
 D) To monitor respiratory rate.

Correct Answer: B
Rationale: A peak flow meter is used to assess the patient’s ability to exhale air, helping to
determine the need for bronchodilator therapy.

Question 1603: Neurological

A patient is experiencing a transient ischemic attack (TIA). Which teaching point is most
important for the nurse to include?

 A) TIA does not require any lifestyle changes.

 B) A TIA increases the risk of a future stroke.
 C) Symptoms of a TIA are permanent.
 D) Medication compliance is optional.
Correct Answer: B
Rationale: A TIA is a warning sign of a potential future stroke, and lifestyle changes and
medication compliance are crucial to prevention.

Question 1604: Pharmacology

A patient is prescribed warfarin. Which laboratory test should the nurse monitor to ensure safe
therapeutic levels?

 A) Hemoglobin.
 B) Platelet count.
 C) Prothrombin time (PT) and International normalized ratio (INR).
 D) Activated partial thromboplastin time (aPTT).

Correct Answer: C
Rationale: PT and INR are monitored to assess the effectiveness and safety of warfarin therapy.

Question 1605: Infection Control

A nurse is caring for a patient with a known Clostridium difficile infection. What type of
isolation precautions should the nurse implement?

 A) Standard precautions only.

 B) Contact precautions.
 C) Airborne precautions.
 D) Droplet precautions.

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of C. difficile, which can be
transmitted through direct contact.

Question 1606: Endocrine

A patient with type 2 diabetes is started on metformin. Which teaching point should the nurse
emphasize?

 A) Take the medication on an empty stomach.

 B) Monitor blood glucose levels regularly.
 C) Avoid all carbohydrates.
 D) This medication is a cure for diabetes.
Correct Answer: B
Rationale: Regular monitoring of blood glucose levels is essential for managing diabetes and
evaluating the effectiveness of treatment.

Question 1607: Pediatric

A nurse is assessing a 6-month-old infant. Which finding would be expected for this age?

 A) Sitting without support.

 B) Crawling.
 C) Babbling.
 D) Walking.

Correct Answer: C
Rationale: Babbling is a developmental milestone typically reached by 6 months of age.

Question 1608: Gastrointestinal

A patient with inflammatory bowel disease (IBD) is experiencing a flare-up. What dietary
recommendation should the nurse provide?

 A) High fiber diet.

 B) Low residue diet.
 C) Full liquid diet.
 D) Gluten-free diet.

Correct Answer: B
Rationale: A low residue diet is often recommended during flare-ups of IBD to reduce bowel
irritation.

Question 1609: Mental Health

A patient diagnosed with major depressive disorder expresses feelings of hopelessness. What is
the nurse’s best response?

 A) "You shouldn't feel that way."

 B) "Tell me more about how you're feeling."
 C) "You’ll feel better soon."
 D) "It's just a phase you're going through."
Correct Answer: B
Rationale: Encouraging the patient to express their feelings helps validate their experience and
promotes therapeutic communication.

Question 1610: Surgical

A nurse is caring for a postoperative patient who has just received an epidural for pain
management. What is the priority nursing assessment?

 A) Level of consciousness.
 B) Urinary output.
 C) Respiratory status.
 D) Pain level.

Correct Answer: C
Rationale: Respiratory status is a priority assessment because epidural anesthesia can affect
respiratory function.

Question 1611: Cardiovascular

A nurse is assessing a patient with heart failure. Which finding is indicative of fluid overload?

 A) Decreased heart rate.

 B) Increased blood pressure.
 C) Dry mucous membranes.
 D) Weight loss.

Correct Answer: B
Rationale: Increased blood pressure can indicate fluid overload in patients with heart failure.

Question 1612: Respiratory

A patient with pneumonia is experiencing increased respiratory distress. What is the nurse’s
priority intervention?

 A) Administer antibiotics.
 B) Position the patient in high-Fowler's position.
 C) Increase oral fluid intake.
 D) Monitor oxygen saturation levels.
Correct Answer: B
Rationale: Positioning the patient in high-Fowler's position can help facilitate better lung
expansion and ease breathing.

Question 1613: Neurological

A patient who had a stroke is exhibiting signs of dysphagia. What should the nurse assess next?

 A) Speech clarity.
 B) Level of consciousness.
 C) Ability to perform activities of daily living.
 D) Swallowing ability.

Correct Answer: D
Rationale: Assessing swallowing ability is essential to prevent aspiration and ensure safe eating.

Question 1614: Pharmacology

A nurse is administering potassium chloride to a patient. Which assessment is most important

prior to administration?

 A) Blood glucose level.

 B) Serum potassium level.
 C) Heart rate.
 D) Respiratory rate.

Correct Answer: B
Rationale: Monitoring serum potassium levels is critical to avoid hyperkalemia, especially if the
patient has renal issues.

Question 1615: Infection Control

A nurse is caring for a patient with a respiratory infection. Which action should the nurse take to
prevent the spread of infection?

 A) Use gloves when entering the room.

 B) Encourage the patient to cough into their hand.
 C) Provide tissues and instruct the patient to cover their mouth when coughing.
 D) Limit visitors to the room.
Correct Answer: C
Rationale: Instructing the patient to cover their mouth when coughing helps reduce the
transmission of respiratory droplets.

Question 1616: Endocrine

A patient is newly diagnosed with hyperthyroidism. What symptom should the nurse educate the
patient to monitor for?

 A) Weight gain.
 B) Increased energy levels.
 C) Heat intolerance.
 D) Dry skin.

Correct Answer: C
Rationale: Heat intolerance is a common symptom of hyperthyroidism due to increased
metabolism.

Question 1617: Pediatric

A nurse is teaching the parents of a toddler about age-appropriate activities. Which activity
should the nurse recommend?

 A) Playing with small puzzles.

 B) Building with blocks.
 C) Playing video games.
 D) Riding a bicycle.

Correct Answer: B
Rationale: Building with blocks is an appropriate activity for toddlers that promotes fine motor
skills and creativity.

Question 1618: Gastrointestinal

A patient is scheduled for a colonoscopy. Which pre-procedure instruction is essential for the
nurse to provide?

 A) Eat a high-fiber diet the day before the procedure.

 B) Take all prescribed medications as usual.
 C) Drink plenty of fluids to stay hydrated.
  D) Follow a clear liquid diet and take a bowel prep as ordered.

Correct Answer: D
Rationale: Following a clear liquid diet and taking a bowel preparation is essential for adequate
visualization during the colonoscopy.

Question 1619: Mental Health

A nurse is caring for a patient with anxiety. Which intervention is most appropriate to help the
patient cope?

 A) Provide information about anxiety medications.

 B) Encourage deep breathing exercises.
 C) Suggest the patient avoid discussing their feelings.
 D) Tell the patient to stop worrying.

Correct Answer: B
Rationale: Deep breathing exercises can help the patient manage anxiety symptoms effectively.

Question 1620: Surgical

A patient has just undergone a mastectomy. Which discharge instruction should the nurse
emphasize?

 A) Limit mobility of the affected arm for two weeks.

 B) Avoid using deodorant on the affected side.
 C) Remove the drainage tube if it becomes full.
 D) Engage in vigorous physical activity to promote healing.

Correct Answer: B
Rationale: Patients should avoid using deodorant on the affected side to prevent irritation and
potential infection at the incision site.

Question 1621: Cardiovascular

A patient is diagnosed with heart failure and is prescribed digoxin. What should the nurse
monitor before administering this medication?

 A) Serum calcium levels.

 B) Blood glucose levels.
  C) Heart rate and rhythm.
 D) Blood pressure.

Correct Answer: C
Rationale: Digoxin can cause bradycardia; therefore, monitoring heart rate and rhythm is crucial
before administration.

Question 1622: Respiratory

A nurse is caring for a patient with COPD who is experiencing shortness of breath. Which
intervention should the nurse implement first?

 A) Administer bronchodilator medication.

 B) Position the patient in high-Fowler's position.
 C) Encourage the patient to use pursed-lip breathing.
 D) Check the patient's oxygen saturation levels.

Correct Answer: B
Rationale: Positioning the patient in high-Fowler's position promotes better lung expansion and
improves respiratory effort.

Question 1623: Neurological

A patient with a head injury is being monitored for signs of increased intracranial pressure (ICP).
Which finding would indicate a potential increase in ICP?

 A) Bradycardia.
 B) Increased responsiveness to stimuli.
 C) Unequal pupil size.
 D) Hyperactive reflexes.

Correct Answer: C
Rationale: Unequal pupil size can be a sign of increased ICP, indicating potential brain
herniation or pressure on cranial nerves.

Question 1624: Pharmacology

A patient is receiving a prescription for an antidepressant. Which statement by the patient

indicates a need for further teaching?
  A) "I will continue to take this medication even if I feel better."
 B) "I should avoid alcohol while on this medication."
 C) "I can stop taking the medication anytime I want."
 D) "It may take several weeks to feel the full effects of this medication."

Correct Answer: C
Rationale: Stopping antidepressants abruptly can lead to withdrawal symptoms and a relapse of
depression.

Question 1625: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis (TB). What type of precautions should
the nurse implement?

 A) Standard precautions.
 B) Droplet precautions.
 C) Airborne precautions.
 D) Contact precautions.

Correct Answer: C
Rationale: TB is transmitted through airborne particles, so airborne precautions must be
implemented.

Question 1626: Endocrine

A patient with diabetes is experiencing signs of hypoglycemia. Which of the following

symptoms should the nurse expect?

 A) Increased thirst.
 B) Drowsiness.
 C) Hyperactivity.
 D) Sweating and shakiness.

Correct Answer: D
Rationale: Symptoms of hypoglycemia often include sweating, shakiness, confusion, and
palpitations.

Question 1627: Pediatric

A nurse is assessing a 4-year-old child. Which developmental milestone should the nurse expect
at this age?

 A) Able to hop on one foot.

 B) Can draw a person with three parts.
 C) Can tie shoelaces independently.
 D) Can count to 20.

Correct Answer: B
Rationale: By age 4, children can typically draw a person with three parts, indicating cognitive
and motor development.

Question 1628: Gastrointestinal

A patient with liver cirrhosis is at risk for which complication?

 A) Hyperglycemia.
 B) Hypertension.
 C) Esophageal varices.
 D) Constipation.

Correct Answer: C
Rationale: Liver cirrhosis can lead to portal hypertension, resulting in esophageal varices.

Question 1629: Mental Health

A nurse is caring for a patient with obsessive-compulsive disorder (OCD). Which statement is
appropriate for the nurse to say?

 A) "You can overcome your compulsions by sheer willpower."

 B) "It's important to understand that your thoughts are not reality."
 C) "You should avoid talking about your feelings."
 D) "Ignoring your compulsions is the best strategy."

Correct Answer: B
Rationale: Helping the patient understand the nature of their thoughts can be part of cognitive-
behavioral therapy.

Question 1630: Surgical

A nurse is preparing a patient for abdominal surgery. Which preoperative instruction should be
included?

 A) Avoid all fluids after midnight.

 B) Shower with antibacterial soap the night before.
 C) Take all medications as usual.
 D) Wear makeup on the day of surgery.

Correct Answer: B
Rationale: Preoperative instructions often include using antibacterial soap to reduce the risk of
infection.

Question 1631: Cardiovascular

A patient is prescribed a thiazide diuretic. What should the nurse monitor regularly?

 A) Serum potassium levels.

 B) Serum calcium levels.
 C) Blood pressure.
 D) Glucose levels.

Correct Answer: A
Rationale: Thiazide diuretics can cause hypokalemia, so monitoring potassium levels is
important.

Question 1632: Respiratory

A patient with asthma is experiencing an acute exacerbation. Which medication should the nurse
anticipate administering first?

 A) Corticosteroids.
 B) Short-acting beta-agonist (SABA).
 C) Anticholinergic.
 D) Long-acting beta-agonist (LABA).

Correct Answer: B
Rationale: A short-acting beta-agonist (SABA) is the first-line treatment for immediate relief of
asthma symptoms.

Question 1633: Neurological

A patient presents with symptoms of a stroke. Which assessment finding is consistent with a
right-sided stroke?

 A) Right-sided weakness.
 B) Left-sided weakness.
 C) Difficulty speaking.
 D) Visual field loss in the right eye.

Correct Answer: B
Rationale: A right-sided stroke typically affects the left side of the body, leading to left-sided
weakness.

Question 1634: Pharmacology

A nurse is preparing to administer an antihypertensive medication. What should be the nurse’s

priority action?

 A) Assess blood pressure.

 B) Monitor for allergic reactions.
 C) Administer with food.
 D) Educate the patient about potential side effects.

Correct Answer: A
Rationale: Assessing blood pressure before administration ensures the medication is given
safely and appropriately.

Question 1635: Infection Control

A patient has a surgical wound that is infected. What is the most appropriate nursing
intervention?

 A) Apply warm compresses to the wound.

 B) Change the dressing only when it becomes saturated.
 C) Maintain sterile technique when changing the dressing.
 D) Document the wound appearance once a shift.

Correct Answer: C
Rationale: Maintaining sterile technique is essential to prevent further infection when caring for
a surgical wound.
Question 1636: Endocrine

A nurse is monitoring a patient with Addison's disease. Which finding should be reported
immediately?

 A) Weight loss.
 B) Hypotension.
 C) Hyperpigmentation of the skin.
 D) Fatigue.

Correct Answer: B
Rationale: Hypotension in a patient with Addison's disease could indicate adrenal crisis and
requires immediate intervention.

Question 1637: Pediatric

A nurse is caring for a child with a high fever. Which action should the nurse take first?

 A) Administer antipyretics.
 B) Apply a cool compress.
 C) Assess the child's hydration status.
 D) Check the child's heart rate.

Correct Answer: A
Rationale: Administering antipyretics is the first step in managing a fever and providing comfort
to the child.

Question 1638: Gastrointestinal

A patient is diagnosed with pancreatitis. Which dietary recommendation should the nurse
provide?

 A) High-fat diet.
 B) Low-protein diet.
 C) Clear liquid diet.
 D) Low-carbohydrate diet.

Correct Answer: C
Rationale: A clear liquid diet is often recommended during acute pancreatitis to reduce
pancreatic stimulation.
Question 1639: Mental Health

A patient is being treated for depression and is prescribed a selective serotonin reuptake inhibitor
(SSRI). Which statement indicates that the patient understands the medication?

 A) "I can stop taking it when I feel better."

 B) "It may take several weeks to feel the effects."
 C) "I need to take it on an empty stomach."
 D) "I can take it with alcohol."

Correct Answer: B
Rationale: SSRIs typically take several weeks to reach their full therapeutic effect.

Question 1640: Surgical

A patient is recovering from a knee arthroplasty. Which intervention is most important in the
immediate postoperative period?

 A) Encourage ambulation.
 B) Monitor vital signs.
 C) Assess the surgical site.
 D) Provide pain medication as needed.

Correct Answer: B
Rationale: Monitoring vital signs is critical in the immediate postoperative period to identify
any complications early.

Question 1641: Cardiovascular

A patient is receiving a blood transfusion and develops chills and fever. What is the priority
nursing action?

 A) Administer acetaminophen.
 B) Slow the transfusion rate.
 C) Stop the transfusion immediately.
 D) Document the findings.

Correct Answer: C
Rationale: Stopping the transfusion immediately is crucial to prevent further complications, as
these are signs of a possible transfusion reaction.
Question 1642: Respiratory

A patient with pneumonia is prescribed antibiotics. Which of the following findings indicates
that the treatment is effective?

 A) The patient's temperature is elevated.

 B) The patient reports increased fatigue.
 C) The patient's cough is productive with clear sputum.
 D) The patient's heart rate is elevated.

Correct Answer: C
Rationale: A productive cough with clear sputum suggests that the infection is resolving,
indicating the effectiveness of the antibiotics.

Question 1643: Neurological

A nurse is assessing a patient with suspected meningitis. Which sign should the nurse
specifically look for?

 A) Brudzinski's sign.
 B) Positive Babinski reflex.
 C) Trousseau's sign.
 D) Kernig's sign.

Correct Answer: A
Rationale: Brudzinski's sign is a classic indicator of meningitis, characterized by involuntary
lifting of the legs when the neck is flexed.

Question 1644: Pharmacology

A nurse is preparing to administer warfarin to a patient. Which laboratory test should the nurse
monitor to assess the effectiveness of this medication?

 A) Prothrombin time (PT)

 B) Partial thromboplastin time (PTT)
 C) Platelet count
 D) International normalized ratio (INR)

Correct Answer: D
Rationale: The INR is used to monitor the effectiveness of warfarin therapy.
Question 1645: Infection Control

A patient is being discharged with a diagnosis of Clostridioides difficile infection (CDI). What
instruction should the nurse include in the discharge teaching?

 A) Wash hands with soap and water after using the restroom.
 B) Use alcohol-based hand sanitizer for hand hygiene.
 C) Avoid all dairy products.
 D) Take the prescribed antibiotics until symptoms resolve.

Correct Answer: A
Rationale: Washing hands with soap and water is essential to effectively eliminate C. difficile
spores.

Question 1646: Endocrine

A nurse is caring for a patient with hyperthyroidism. Which symptom should the nurse expect to
assess?

 A) Weight gain.
 B) Cold intolerance.
 C) Bradycardia.
 D) Heat intolerance.

Correct Answer: D
Rationale: Patients with hyperthyroidism often experience heat intolerance due to an increased
metabolic rate.

Question 1647: Pediatric

A parent reports to the nurse that their child has developed a rash after taking an antibiotic. What
should the nurse assess for next?

 A) Signs of dehydration.
 B) Allergic reaction symptoms.
 C) Increased temperature.
 D) Changes in appetite.

Correct Answer: B
Rationale: Assessing for symptoms of an allergic reaction, such as hives or difficulty breathing,
is critical following a medication rash.
Question 1648: Gastrointestinal

A patient with a history of peptic ulcer disease is prescribed a proton pump inhibitor (PPI). What
is the primary action of this medication class?

 A) Increase gastric motility.

 B) Neutralize gastric acid.
 C) Inhibit gastric acid secretion.
 D) Protect the gastric mucosa.

Correct Answer: C
Rationale: PPIs inhibit gastric acid secretion, thereby reducing acidity and helping to heal
ulcers.

Question 1649: Mental Health

A nurse is conducting a therapeutic group session. Which behavior should the nurse monitor as a
potential sign of a group member's anxiety?

 A) Speaking clearly and calmly.

 B) Frequent eye contact.
 C) Fidgeting or restlessness.
 D) Asking questions about group topics.

Correct Answer: C
Rationale: Fidgeting or restlessness is often indicative of anxiety and discomfort in group
settings.

Question 1650: Surgical

A nurse is assessing a postoperative patient for signs of complications. Which assessment finding
would indicate potential internal bleeding?

 A) Increased urinary output.

 B) A firm and distended abdomen.
 C) Decreased blood pressure.
 D) Increased heart rate.
Correct Answer: B
Rationale: A firm and distended abdomen may suggest internal bleeding or accumulation of
fluid in the abdomen.

Question 1651: Cardiovascular

A patient diagnosed with hypertension is prescribed an ACE inhibitor. Which side effect should
the nurse educate the patient about?

 A) Weight gain.
 B) Dry cough.
 C) Rash.
 D) Drowsiness.

Correct Answer: B
Rationale: A dry cough is a common side effect of ACE inhibitors and should be communicated
to the patient.

Question 1652: Respiratory

A nurse is teaching a patient with asthma about the use of a peak flow meter. What is the correct
instruction for using this device?

 A) Use the peak flow meter only when feeling short of breath.
 B) Exhale forcefully into the meter to obtain a reading.
 C) Record the reading before using a bronchodilator.
 D) The highest reading should be taken three times, and the best of the three should be
recorded.

Correct Answer: D
Rationale: To get an accurate peak flow measurement, the patient should take three readings and
record the highest.

Question 1653: Neurological

A patient with a history of seizures is being discharged with a new prescription for phenytoin.
What should the nurse include in the discharge teaching?

 A) "It is safe to stop taking this medication when you feel better."
 B) "You should have regular dental check-ups."
  C) "This medication does not require monitoring."
 D) "You can drink alcohol while taking this medication."

Correct Answer: B
Rationale: Phenytoin can cause gum overgrowth; therefore, regular dental check-ups are
essential.

Question 1654: Pharmacology

A patient receiving antipsychotic medication is showing signs of extrapyramidal side effects

(EPS). Which of the following symptoms should the nurse monitor for?

 A) Confusion and disorientation.

 B) Tardive dyskinesia.
 C) Elevated blood sugar.
 D) Hypotension.

Correct Answer: B
Rationale: Tardive dyskinesia is a common extrapyramidal side effect of long-term
antipsychotic use.

Question 1655: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). Which
precaution should the nurse implement?

 A) Contact precautions.
 B) Airborne precautions.
 C) Droplet precautions.
 D) Standard precautions.

Correct Answer: A
Rationale: MRSA requires contact precautions to prevent the spread of the infection.

Question 1656: Endocrine

A patient with type 1 diabetes is about to undergo surgery. Which instruction should the nurse
provide regarding insulin administration?

 A) "You should skip your morning insulin dose."

  B) "Take your insulin as usual."
 C) "You may need to adjust your insulin dose."
 D) "Insulin should not be administered on the day of surgery."

Correct Answer: C
Rationale: Insulin doses may need adjustment on the day of surgery depending on the patient's
intake and blood glucose levels.

Question 1657: Pediatric

A nurse is teaching the parents of a toddler about safe toy selection. Which toy is appropriate for
a 3-year-old?

 A) Small building blocks.

 B) A puzzle with small pieces.
 C) A soft ball.
 D) A set of crayons.

Correct Answer: C
Rationale: A soft ball is appropriate for a toddler, as it is safe and encourages physical activity.

Question 1658: Gastrointestinal

A patient is scheduled for a colonoscopy. What preparation should the nurse instruct the patient
to follow?

 A) Eat a normal diet the day before the procedure.

 B) Take a laxative the night before.
 C) Drink only clear liquids the day before.
 D) Stop all medications one week prior.

Correct Answer: C
Rationale: Patients are typically instructed to consume only clear liquids the day before a
colonoscopy to ensure a clear view of the colon.

Question 1659: Mental Health

A nurse is caring for a patient diagnosed with generalized anxiety disorder. Which intervention is
most appropriate?
  A) Encourage avoidance of anxiety-provoking situations.
 B) Teach relaxation techniques.
 C) Limit communication about feelings.
 D) Recommend medication adherence without discussion.

Correct Answer: B
Rationale: Teaching relaxation techniques can help the patient manage anxiety symptoms
effectively.

Question 1660: Surgical

A nurse is monitoring a patient after a cholecystectomy. Which finding would indicate a

potential complication?

 A) Clear drainage from the surgical site.

 B) Fever of 100.4°F (38°C).
 C) Abdominal pain controlled with medication.
 D) Tachycardia and hypotension.

Correct Answer: D
Rationale: Tachycardia and hypotension could indicate a potential complication such as
hemorrhage or infection.

Question 1661: Pharmacology

A patient is prescribed metformin for type 2 diabetes. What is the primary action of this
medication?

 A) Increases insulin sensitivity.

 B) Stimulates insulin production from the pancreas.
 C) Reduces glucose absorption in the intestines.
 D) Causes the kidneys to excrete more glucose.

Correct Answer: A
Rationale: Metformin primarily increases insulin sensitivity and decreases hepatic glucose
production.

Question 1662: Cardiovascular

A nurse is assessing a patient with heart failure. Which finding is most indicative of worsening
heart failure?

 A) Weight loss.
 B) Decreased appetite.
 C) Peripheral edema.
 D) Increased exercise tolerance.

Correct Answer: C
Rationale: Peripheral edema is a common sign of worsening heart failure due to fluid overload.

Question 1663: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is experiencing shortness of

breath. Which position should the nurse encourage the patient to assume?

 A) Supine.
 B) Prone.
 C) High Fowler's.
 D) Trendelenburg.

Correct Answer: C
Rationale: High Fowler's position promotes lung expansion and eases breathing.

Question 1664: Neurological

A nurse is caring for a patient with a head injury. Which assessment finding is most concerning?

 A) Decreased level of consciousness.

 B) Clear nasal drainage.
 C) Bilateral pupil response to light.
 D) Headache relieved by analgesics.

Correct Answer: A
Rationale: A decreased level of consciousness may indicate increased intracranial pressure or
brain injury and requires immediate attention.

Question 1665: Infection Control

A nurse is teaching a patient with a urinary tract infection (UTI) about preventive measures.
Which statement indicates a need for further teaching?

 A) "I will drink plenty of fluids."

 B) "I should wipe from back to front after using the toilet."
 C) "I will urinate after sexual intercourse."
 D) "I will wear cotton underwear."

Correct Answer: B
Rationale: Patients should wipe from front to back to prevent the introduction of bacteria from
the rectal area to the urinary tract.

Question 1666: Endocrine

A patient with diabetes is experiencing hypoglycemia. Which symptom should the nurse expect
to assess?

 A) Flushed skin.
 B) Increased thirst.
 C) Confusion.
 D) Nausea and vomiting.

Correct Answer: C
Rationale: Confusion is a common symptom of hypoglycemia due to insufficient glucose
reaching the brain.

Question 1667: Pediatric

A nurse is assessing a child with asthma. Which finding indicates that the child's asthma is well-
controlled?

 A) The child has an occasional nighttime cough.

 B) The child can run without wheezing.
 C) The child uses their rescue inhaler every day.
 D) The child has frequent respiratory infections.

Correct Answer: B
Rationale: The ability to run without wheezing indicates good control of asthma symptoms.

Question 1668: Gastrointestinal

A patient undergoing a colonoscopy is concerned about the procedure. What should the nurse
explain?

 A) "You will be awake during the procedure and able to talk."

 B) "You may feel pressure but no pain."
 C) "You will receive general anesthesia for the procedure."
 D) "The procedure will take several hours."

Correct Answer: B
Rationale: Patients may feel pressure during the procedure, but they are typically sedated to
minimize discomfort.

Question 1669: Mental Health

A patient diagnosed with depression is prescribed selective serotonin reuptake inhibitors

(SSRIs). Which side effect should the nurse inform the patient about?

 A) Increased energy.
 B) Weight loss.
 C) Sexual dysfunction.
 D) Elevated mood.

Correct Answer: C
Rationale: Sexual dysfunction is a common side effect of SSRIs that patients should be made
aware of.

Question 1670: Surgical

A nurse is assessing a patient who had a hip replacement. Which finding would require
immediate intervention?

 A) Mild pain at the incision site.

 B) A temperature of 101°F (38.3°C).
 C) Severe swelling and redness in the affected leg.
 D) Limited range of motion in the hip.

Correct Answer: C
Rationale: Severe swelling and redness in the leg may indicate a deep vein thrombosis (DVT),
which requires immediate intervention.
Question 1671: Cardiovascular

A patient is prescribed a beta-blocker. What is the expected outcome of this medication?

 A) Increased heart rate.

 B) Decreased blood pressure.
 C) Increased cardiac output.
 D) Decreased cholesterol levels.

Correct Answer: B
Rationale: Beta-blockers are used to decrease blood pressure by reducing heart rate and
myocardial contractility.

Question 1672: Respiratory

A patient with pneumonia is being discharged. What is the most important teaching point the
nurse should include?

 A) "Avoid all physical activity for two weeks."

 B) "Complete the full course of antibiotics as prescribed."
 C) "You can stop taking the medication once you feel better."
 D) "Use an over-the-counter cough suppressant."

Correct Answer: B
Rationale: Completing the full course of antibiotics is essential to ensure the infection is
completely resolved.

Question 1673: Neurological

A patient is experiencing a stroke. Which intervention should the nurse implement first?

 A) Administer oxygen.
 B) Obtain a CT scan.
 C) Assess the patient's neurological status.
 D) Start intravenous fluids.

Correct Answer: C
Rationale: Assessing the patient's neurological status is critical for determining the severity of
the stroke and appropriate interventions.
Question 1674: Infection Control

A nurse is providing care to a patient with tuberculosis (TB). Which precaution should the nurse
implement?

 A) Standard precautions.
 B) Contact precautions.
 C) Droplet precautions.
 D) Airborne precautions.

Correct Answer: D
Rationale: TB is transmitted via airborne particles, so airborne precautions are necessary.

Question 1675: Endocrine

A patient with hyperthyroidism is experiencing increased heart rate and anxiety. Which
medication might the nurse expect to administer?

 A) Levothyroxine.
 B) Propylthiouracil.
 C) Insulin.
 D) Cortisol.

Correct Answer: B
Rationale: Propylthiouracil is an antithyroid medication used to reduce the production of thyroid
hormones in hyperthyroidism.

Question 1676: Pediatric

A nurse is teaching a parent about safety measures for a toddler. Which statement indicates a
need for further education?

 A) "I will keep small objects out of reach."

 B) "I can allow my child to play near the street as long as I am watching."
 C) "I will use safety gates at the top and bottom of stairs."
 D) "I will secure heavy furniture to the wall."

Correct Answer: B
Rationale: Toddlers should not be allowed to play near the street, even with supervision, due to
the high risk of accidents.
Question 1677: Gastrointestinal

A patient with a history of cirrhosis is experiencing ascites. What dietary change should the
nurse recommend?

 A) Increase protein intake.

 B) Decrease sodium intake.
 C) Increase fluid intake.
 D) Limit carbohydrate intake.

Correct Answer: B
Rationale: Decreasing sodium intake helps manage fluid retention and ascites in patients with
cirrhosis.

Question 1678: Mental Health

A nurse is caring for a patient with obsessive-compulsive disorder (OCD). Which intervention is
most appropriate?

 A) Encourage the patient to ignore compulsions.

 B) Provide structured routines for the patient.
 C) Minimize discussion about obsessive thoughts.
 D) Limit the patient's interactions with others.

Correct Answer: B
Rationale: Providing structured routines can help the patient feel more secure and reduce
anxiety related to OCD.

Question 1679: Surgical

A patient is recovering from laparoscopic surgery. Which assessment finding would be

concerning?

 A) Mild abdominal tenderness.

 B) Gas pain in the shoulder.
 C) Fever of 100°F (37.8°C).
 D) Severe abdominal pain.

Correct Answer: D
Rationale: Severe abdominal pain may indicate a complication such as perforation or internal
bleeding and requires immediate attention.
Question 1680: Cardiovascular

A nurse is assessing a patient with atrial fibrillation. Which complication should the nurse
monitor for?

 A) Hypotension.
 B) Stroke.
 C) Heart failure.
 D) Myocardial infarction.

Correct Answer: B
Rationale: Atrial fibrillation increases the risk of thrombus formation, which can lead to a
stroke.

Question 1681: Pharmacology

A patient is receiving furosemide (Lasix). What should the nurse monitor to assess for potential
adverse effects of this medication?

 A) Blood glucose levels.

 B) Serum potassium levels.
 C) White blood cell count.
 D) Liver function tests.

Correct Answer: B
Rationale: Furosemide can cause hypokalemia, so monitoring serum potassium levels is crucial.

Question 1682: Neurological

A nurse is caring for a patient who has just experienced a seizure. Which intervention is a
priority?

 A) Position the patient on their side.

 B) Administer oxygen.
 C) Call the physician.
 D) Document the seizure activity.

Correct Answer: A
Rationale: Positioning the patient on their side helps to maintain an open airway and prevent
aspiration.
Question 1683: Respiratory

A patient with asthma is prescribed a corticosteroid inhaler. What is the nurse's priority teaching
point for this medication?

 A) Use the inhaler only during an asthma attack.

 B) Rinse the mouth after using the inhaler.
 C) Store the inhaler in the refrigerator.
 D) Wait one hour after using the inhaler to eat.

Correct Answer: B
Rationale: Rinsing the mouth after using a corticosteroid inhaler helps prevent oral thrush and
other side effects.

Question 1684: Infection Control

A patient is being treated for methicillin-resistant Staphylococcus aureus (MRSA). What type of
precautions should the nurse implement?

 A) Standard precautions only.

 B) Airborne precautions.
 C) Contact precautions.
 D) Droplet precautions.

Correct Answer: C
Rationale: MRSA is transmitted through direct contact, so contact precautions are necessary.

Question 1685: Pediatric

A nurse is assessing a 3-year-old child. Which developmental milestone should the nurse expect
the child to achieve?

 A) Ability to ride a tricycle.

 B) Ability to tie shoelaces.
 C) Ability to use a spoon effectively.
 D) Ability to recite the alphabet.

Correct Answer: A
Rationale: By age 3, children typically can ride a tricycle and engage in other gross motor
activities.
Question 1686: Endocrine

A patient with diabetes is experiencing hyperglycemia. Which symptom is most characteristic of

this condition?

 A) Shakiness.
 B) Excessive urination.
 C) Cold sweats.
 D) Dizziness.

Correct Answer: B
Rationale: Excessive urination (polyuria) is a classic sign of hyperglycemia due to osmotic
diuresis.

Question 1687: Surgical

A nurse is caring for a patient who has undergone a total knee replacement. What is the most
important assessment during the immediate postoperative period?

 A) Pain level.
 B) Neurovascular status of the affected limb.
 C) Incision site appearance.
 D) Bowel sounds.

Correct Answer: B
Rationale: Monitoring neurovascular status is crucial to detect complications such as
compartment syndrome.

Question 1688: Mental Health

A patient with schizophrenia is prescribed clozapine. Which laboratory test should the nurse
monitor closely?

 A) Liver function tests.

 B) Complete blood count (CBC).
 C) Electrolytes.
 D) Thyroid function tests.
Correct Answer: B
Rationale: Clozapine can cause agranulocytosis, so monitoring the CBC for white blood cell
count is essential.

Question 1689: Gastrointestinal

A nurse is teaching a patient about a low-fiber diet before a colonoscopy. Which food should the
nurse instruct the patient to avoid?

 A) White rice.
 B) Applesauce.
 C) Whole grain bread.
 D) Plain yogurt.

Correct Answer: C
Rationale: Whole grain bread is high in fiber and should be avoided on a low-fiber diet.

Question 1690: Cardiovascular

A patient presents with chest pain and is suspected of having a myocardial infarction. Which
intervention should the nurse prioritize?

 A) Administer nitroglycerin.
 B) Obtain a 12-lead ECG.
 C) Draw cardiac enzymes.
 D) Start an IV line.

Correct Answer: B
Rationale: Obtaining a 12-lead ECG is critical to assess for ST elevation and determine the
appropriate treatment.

Question 1691: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is prescribed a bronchodilator.

What is the expected outcome of this medication?

 A) Decreased heart rate.

 B) Decreased respiratory rate.
 C) Increased airflow in the lungs.
 D) Decreased cough reflex.
Correct Answer: C
Rationale: Bronchodilators relax the bronchial smooth muscle, leading to increased airflow in
the lungs.

Question 1692: Pediatric

A nurse is caring for a child with chickenpox. What should the nurse implement to prevent the
spread of infection?

 A) Use contact precautions only.

 B) Use airborne precautions only.
 C) Use droplet precautions only.
 D) Use contact and airborne precautions.

Correct Answer: D
Rationale: Chickenpox is spread through airborne and contact routes, requiring both
precautions.

Question 1693: Neurological

A patient is admitted with a transient ischemic attack (TIA). What is the nurse's priority
intervention?

 A) Administer anticoagulants.
 B) Monitor vital signs closely.
 C) Provide education about lifestyle changes.
 D) Obtain a CT scan of the head.

Correct Answer: B
Rationale: Close monitoring of vital signs is essential to detect any progression to a full stroke.

Question 1694: Endocrine

A nurse is caring for a patient with Addison's disease. Which symptom should the nurse monitor
for?

 A) Weight gain.
 B) Hyperglycemia.
 C) Hyperkalemia.
 D) Hypertension.
Correct Answer: C
Rationale: Addison's disease can lead to hyperkalemia due to a deficiency in aldosterone.

Question 1695: Infection Control

A nurse is caring for a patient with a suspected influenza infection. Which precaution should the
nurse implement?

 A) Standard precautions.
 B) Airborne precautions.
 C) Contact precautions.
 D) Droplet precautions.

Correct Answer: D
Rationale: Influenza is spread through droplets, so droplet precautions are necessary.

Question 1696: Surgical

A nurse is monitoring a patient who has just had a laparoscopy. Which finding would be most
concerning?

 A) Shoulder pain.
 B) Moderate abdominal distension.
 C) Bright red drainage from the incision.
 D) Low-grade fever.

Correct Answer: C
Rationale: Bright red drainage could indicate a hemorrhage or complication and should be
reported immediately.

Question 1697: Mental Health

A patient diagnosed with major depressive disorder expresses feelings of hopelessness. What
should the nurse do first?

 A) Provide reassurance that things will get better.

 B) Assess for suicidal ideation.
 C) Encourage the patient to talk about their feelings.
 D) Suggest participation in group therapy.
Correct Answer: B
Rationale: Assessing for suicidal ideation is a priority when a patient expresses feelings of
hopelessness.

Question 1698: Gastrointestinal

A patient is recovering from a gastric bypass surgery. Which dietary instruction should the nurse
provide?

 A) Eat three large meals a day.

 B) Include high-fiber foods in the diet.
 C) Drink fluids during meals.
 D) Chew food thoroughly before swallowing.

Correct Answer: D
Rationale: Chewing food thoroughly helps prevent complications related to the smaller stomach
pouch.

Question 1699: Cardiovascular

A nurse is assessing a patient with heart failure. Which finding would indicate effective
treatment?

 A) Decreased blood pressure.

 B) Increased heart rate.
 C) Improved peripheral edema.
 D) Elevated respiratory rate.

Correct Answer: C
Rationale: Improved peripheral edema indicates that the treatment is effectively managing fluid
overload.

Question 1700: Respiratory

A patient with pneumonia is receiving antibiotic therapy. What is the most important assessment
for the nurse to perform?

 A) Monitor blood pressure.

 B) Assess lung sounds.
 C) Check serum electrolyte levels.
  D) Evaluate liver function.

Correct Answer: B
Rationale: Assessing lung sounds helps determine the effectiveness of antibiotic therapy and the
patient’s respiratory status.

Question 1701: Pharmacology

A nurse is preparing to administer digoxin to a patient. What is the nurse's priority assessment
before administering this medication?

 A) Assess for nausea.

 B) Check the patient’s pulse.
 C) Monitor blood pressure.
 D) Evaluate serum potassium levels.

Correct Answer: B
Rationale: Digoxin can cause bradycardia, so checking the patient’s pulse is essential before
administration.

Question 1702: Neurological

A patient with a stroke is experiencing dysphagia. What is the most appropriate nursing
intervention?

 A) Provide thin liquids for hydration.

 B) Assess swallowing ability before feeding.
 C) Encourage the patient to speak.
 D) Offer small bites of food.

Correct Answer: B
Rationale: Assessing the swallowing ability before feeding is crucial to prevent aspiration.

Question 1703: Endocrine

A patient with diabetes mellitus is prescribed metformin. Which teaching point should the nurse
include?

 A) "Take this medication with a meal."

 B) "This medication will cause weight gain."
  C) "Monitor your blood glucose for hypoglycemia."
 D) "This medication is a type of insulin."

Correct Answer: A
Rationale: Metformin should be taken with food to reduce gastrointestinal side effects.

Question 1704: Pediatric

A nurse is teaching a parent about the management of a child with asthma. Which statement by
the parent indicates a need for further teaching?

 A) "I will make sure my child takes their medication every day."
 B) "I should have a rescue inhaler available at all times."
 C) "My child can stop taking the medication when symptoms improve."
 D) "I need to avoid triggers for my child's asthma."

Correct Answer: C
Rationale: Asthma medications should not be stopped without a healthcare provider’s guidance,
even when symptoms improve.

Question 1705: Infection Control

A nurse is caring for a patient with C. difficile infection. Which precautions should the nurse
implement?

 A) Standard precautions.
 B) Airborne precautions.
 C) Contact precautions.
 D) Droplet precautions.

Correct Answer: C
Rationale: C. difficile is spread via the fecal-oral route, so contact precautions are necessary.

Question 1706: Gastrointestinal

A patient is recovering from a bowel resection. Which assessment finding would indicate a
potential complication?

 A) Bowel sounds present in all quadrants.

 B) Abdomen firm and distended.
  C) Passing flatus.
 D) Tolerating clear liquids.

Correct Answer: B
Rationale: A firm and distended abdomen may indicate complications such as obstruction or
ileus.

Question 1707: Cardiovascular

A patient presents with symptoms of heart failure. Which assessment finding would be most
concerning?

 A) Increased jugular venous distension.

 B) Bilateral crackles in lung fields.
 C) Weight gain of 2 pounds in one day.
 D) Mild peripheral edema.

Correct Answer: C
Rationale: A weight gain of 2 pounds in one day could indicate fluid retention and worsening
heart failure.

Question 1708: Respiratory

A patient is receiving oxygen therapy via nasal cannula. What should the nurse monitor to ensure
the patient’s safety?

 A) Presence of wheezing.
 B) Oxygen saturation levels.
 C) Respiratory rate.
 D) Blood pressure.

Correct Answer: B
Rationale: Monitoring oxygen saturation levels ensures that the patient is receiving adequate
oxygen.

Question 1709: Mental Health

A patient diagnosed with generalized anxiety disorder is prescribed an SSRI. Which statement
indicates the patient understands the treatment plan?
  A) "I can stop taking this medication when I feel better."
 B) "I will need to take this medication every day."
 C) "I should expect to feel better immediately."
 D) "This medication will help me sleep better."

Correct Answer: B
Rationale: SSRIs are typically taken daily to be effective and may take several weeks to show
effects.

Question 1710: Surgical

A nurse is caring for a patient after a laparoscopic cholecystectomy. Which finding should be
reported to the healthcare provider?

 A) Mild shoulder pain.

 B) Clear drainage from the incision.
 C) Fever of 101°F.
 D) Nausea and vomiting.

Correct Answer: C
Rationale: A fever of 101°F could indicate an infection and should be reported.

Question 1711: Pediatric

A nurse is assessing a child who is being treated for anaphylaxis. Which intervention should the
nurse prioritize?

 A) Administer antihistamines.
 B) Initiate intravenous fluid therapy.
 C) Administer epinephrine.
 D) Monitor vital signs.

Correct Answer: C
Rationale: Administering epinephrine is the priority intervention for treating anaphylaxis.

Question 1712: Cardiovascular

A patient with a history of hypertension is prescribed a beta-blocker. Which assessment finding

indicates the medication is effective?
  A) Increased heart rate.
 B) Decreased blood pressure.
 C) Weight loss.
 D) Decreased respiratory rate.

Correct Answer: B
Rationale: A decrease in blood pressure indicates the effectiveness of the beta-blocker.

Question 1713: Infection Control

A nurse is preparing to perform a dressing change for a patient with a surgical wound. Which
action should the nurse take first?

 A) Gather all necessary supplies.

 B) Assess the wound for signs of infection.
 C) Perform hand hygiene.
 D) Don sterile gloves.

Correct Answer: C
Rationale: Performing hand hygiene is the first step in any procedure to prevent infection.

Question 1714: Gastrointestinal

A patient with cirrhosis is at risk for hepatic encephalopathy. Which assessment finding should
the nurse monitor for?

 A) Confusion or altered mental status.

 B) Elevated liver enzymes.
 C) Jaundice.
 D) Weight gain.

Correct Answer: A
Rationale: Confusion or altered mental status can indicate hepatic encephalopathy due to the
accumulation of toxins.

Question 1715: Neurological

A patient is experiencing a tonic-clonic seizure. What is the nurse's priority intervention during
the seizure?
  A) Document the duration of the seizure.
 B) Protect the patient from injury.
 C) Administer rescue medication.
 D) Assess the patient's level of consciousness.

Correct Answer: B
Rationale: Protecting the patient from injury is the priority intervention during a seizure.

Question 1716: Endocrine

A nurse is caring for a patient with hypothyroidism. Which finding should the nurse expect
during the assessment?

 A) Weight loss.
 B) Heat intolerance.
 C) Bradycardia.
 D) Diarrhea.

Correct Answer: C
Rationale: Bradycardia is a common symptom of hypothyroidism due to a slowed metabolism.

Question 1717: Pediatric

A nurse is assessing a child for signs of dehydration. Which finding would indicate moderate
dehydration?

 A) Dry mucous membranes.

 B) Capillary refill time less than 2 seconds.
 C) Alert and active behavior.
 D) Increased urine output.

Correct Answer: A
Rationale: Dry mucous membranes are a sign of moderate dehydration.

Question 1718: Surgical

A patient has a drainage tube in place after abdominal surgery. What is the nurse's priority action
when assessing the drainage?

 A) Measure the amount of drainage.

  B) Check the color and consistency of the drainage.
 C) Ensure the drainage system is below the level of the abdomen.
 D) Assess the insertion site for redness or swelling.

Correct Answer: C
Rationale: Ensuring that the drainage system is below the level of the abdomen promotes
effective drainage.

Question 1719: Mental Health

A patient with depression expresses feelings of worthlessness. What is the nurse's best response?

 A) "You will feel better soon."

 B) "Many people feel this way sometimes."
 C) "Can you tell me more about how you’re feeling?"
 D) "You should try to think positively."

Correct Answer: C
Rationale: Encouraging the patient to express their feelings allows for therapeutic
communication and assessment of their mental state.

Question 1720: Respiratory

A patient with COPD is using a nebulizer. Which statement indicates that the patient understands
the treatment?

 A) "I will use the nebulizer every hour."

 B) "I should hold my breath during treatment."
 C) "I can stop using the nebulizer when I feel better."
 D) "I will rinse my mouth after using the nebulizer."

Correct Answer: D
Rationale: Rinsing the mouth after using a nebulizer can help prevent oral thrush and other side
effects.

Question 1721: Pharmacology

A nurse is teaching a patient about warfarin therapy. Which statement by the patient indicates a
need for further teaching?
  A) "I will need to have my INR checked regularly."
 B) "I can take aspirin for pain while on this medication."
 C) "I should avoid foods high in vitamin K."
 D) "I need to report any unusual bleeding."

Correct Answer: B
Rationale: Aspirin can increase the risk of bleeding when taken with warfarin, so it should be
avoided unless prescribed by a healthcare provider.

Question 1722: Pediatric

A nurse is assessing a 4-year-old child who has just returned from surgery. Which behavior
would the nurse expect to observe?

 A) Hyperactivity.
 B) Withdrawal from interactions.
 C) Expressive play with toys.
 D) Calm demeanor and quiet behavior.

Correct Answer: D
Rationale: A calm demeanor and quiet behavior are common post-surgery as children may feel
drowsy from anesthesia.

Question 1723: Neurological

A patient is admitted with a suspected stroke. Which assessment finding would the nurse expect
to see?

 A) Altered level of consciousness.

 B) Elevated blood pressure.
 C) Slurred speech.
 D) All of the above.

Correct Answer: D
Rationale: All these findings can be indicative of a stroke.

Question 1724: Cardiovascular

A patient with heart failure is being discharged with a prescription for a diuretic. What should
the nurse teach the patient about this medication?
  A) "You should expect to gain weight while on this medication."
 B) "It is important to maintain a consistent intake of potassium."
 C) "You can stop taking the medication if you feel better."
 D) "You should take this medication at bedtime."

Correct Answer: B
Rationale: Maintaining consistent potassium intake is essential as diuretics can cause potassium
depletion.

Question 1725: Infection Control

A nurse is caring for a patient on contact precautions due to a resistant infection. Which action is
appropriate for the nurse?

 A) Wearing gloves and a gown when entering the room.

 B) Placing the patient in a private room without special precautions.
 C) Limiting hand hygiene to when leaving the room.
 D) Using alcohol-based hand sanitizer only.

Correct Answer: A
Rationale: Wearing gloves and a gown is necessary for contact precautions to prevent the spread
of infection.

Question 1726: Gastrointestinal

A patient with chronic pancreatitis is being taught about dietary management. Which food choice
would be appropriate for the nurse to recommend?

 A) Fried chicken.
 B) Whole milk.
 C) Baked fish.
 D) Cheese pizza.

Correct Answer: C
Rationale: Baked fish is low in fat and appropriate for a patient with pancreatitis.

Question 1727: Respiratory

A patient with asthma is prescribed a corticosteroid inhaler. Which statement by the patient
indicates understanding of the medication?
  A) "I can use this inhaler as needed."
 B) "I will rinse my mouth after using it."
 C) "This inhaler is my rescue inhaler."
 D) "I do not need to worry about side effects."

Correct Answer: B
Rationale: Rinsing the mouth after using a corticosteroid inhaler can help prevent oral thrush.

Question 1728: Mental Health

A nurse is assessing a patient with depression. Which statement might indicate the patient is
experiencing suicidal thoughts?

 A) "I have been feeling really tired."

 B) "Nothing matters anymore."
 C) "I enjoy spending time with my family."
 D) "I am taking my medication regularly."

Correct Answer: B
Rationale: The statement "Nothing matters anymore" may indicate hopelessness, which can be
associated with suicidal ideation.

Question 1729: Surgical

A nurse is caring for a patient who has undergone a total hip replacement. What is the most
important intervention to prevent complications?

 A) Encourage the patient to ambulate frequently.

 B) Maintain strict bed rest for 48 hours.
 C) Monitor the patient’s pain level regularly.
 D) Provide a high-fiber diet.

Correct Answer: A
Rationale: Encouraging ambulation is essential to prevent complications such as deep vein
thrombosis and pulmonary embolism.

Question 1730: Endocrine

A patient with diabetes is being taught about foot care. Which instruction should the nurse
include?
  A) "Inspect your feet daily for any cuts or blisters."
 B) "You can use heating pads on your feet for warmth."
 C) "It’s okay to go barefoot at home."
 D) "Trim your toenails into a rounded shape."

Correct Answer: A
Rationale: Daily inspection of the feet is crucial for preventing complications in diabetic
patients.

Question 1731: Cardiovascular

A nurse is caring for a patient with hypertension. Which lifestyle change should the nurse
recommend?

 A) Increase sodium intake.

 B) Begin a regular exercise program.
 C) Decrease fluid intake.
 D) Avoid all forms of fat.

Correct Answer: B
Rationale: Regular exercise can help lower blood pressure and improve overall cardiovascular
health.

Question 1732: Infection Control

A nurse is preparing to administer a vaccine. Which action should the nurse take first?

 A) Obtain informed consent.

 B) Verify the expiration date of the vaccine.
 C) Assess the patient's vaccination history.
 D) Review the patient's allergies.

Correct Answer: A
Rationale: Obtaining informed consent is the first step before administering any vaccine.

Question 1733: Gastrointestinal

A nurse is monitoring a patient after an upper endoscopy. Which finding should the nurse report
immediately?
  A) Sore throat.
 B) Mild abdominal discomfort.
 C) Bright red blood in vomit.
 D) Low-grade fever.

Correct Answer: C
Rationale: Bright red blood in vomit indicates potential bleeding and requires immediate
attention.

Question 1734: Neurological

A patient presents with a sudden onset of facial drooping and inability to speak. What should the
nurse assess first?

 A) Respiratory rate.
 B) Blood pressure.
 C) Level of consciousness.
 D) Neurological reflexes.

Correct Answer: C
Rationale: Assessing the level of consciousness is crucial to evaluate the severity of the
potential stroke.

Question 1735: Pediatric

A nurse is teaching a parent about the importance of vaccinations. Which statement by the parent
indicates a need for further education?

 A) "Vaccinations help protect my child from serious diseases."

 B) "It's better for my child to get the disease than the vaccine."
 C) "Vaccines are safe and effective."
 D) "I need to keep a record of my child's vaccinations."

Correct Answer: B
Rationale: It is not safer for a child to get the disease than to be vaccinated; vaccines help
prevent serious illnesses.

Question 1736: Mental Health

A patient with anxiety is prescribed a benzodiazepine. What is the nurse’s priority action?
  A) Monitor the patient’s blood pressure.
 B) Teach the patient about potential dependence.
 C) Encourage the patient to engage in relaxation techniques.
 D) Assess the patient’s mental status.

Correct Answer: B
Rationale: Teaching the patient about the potential for dependence on benzodiazepines is
crucial.

Question 1737: Surgical

A nurse is preparing a patient for discharge following abdominal surgery. Which instruction
should be emphasized?

 A) "You can resume normal activities immediately."

 B) "You should report any signs of infection."
 C) "Avoid all physical activity for the next month."
 D) "You do not need to follow up with your doctor."

Correct Answer: B
Rationale: Reporting any signs of infection is critical after surgery.

Question 1738: Respiratory

A patient with COPD is experiencing dyspnea. What is the best position to help alleviate the
patient’s breathing difficulty?

 A) Supine position.
 B) Lithotomy position.
 C) High Fowler’s position.
 D) Prone position.

Correct Answer: C
Rationale: The High Fowler’s position helps to maximize lung expansion and ease breathing.

Question 1739: Endocrine

A patient with hyperthyroidism is experiencing heat intolerance and weight loss. What is the
priority nursing diagnosis?
  A) Risk for injury.
 B) Ineffective coping.
 C) Imbalanced nutrition: Less than body requirements.
 D) Activity intolerance.

Correct Answer: C
Rationale: Patients with hyperthyroidism often have increased metabolism, leading to weight
loss and imbalanced nutrition.

Question 1740: Infection Control

A nurse is caring for a patient with a surgical wound. What is the best practice for dressing
changes?

 A) Change the dressing when it becomes saturated.

 B) Use sterile technique when changing the dressing.
 C) Change the dressing every 48 hours regardless of the condition.
 D) Clean the wound with tap water.

Correct Answer: B
Rationale: Using sterile technique is crucial to prevent infection during dressing changes.

Question 1741: Pharmacology

A patient with chronic kidney disease is prescribed digoxin. What should the nurse assess before
administering this medication?

 A) Heart rate and rhythm.

 B) Blood glucose level.
 C) Serum potassium level.
 D) Weight.

Correct Answer: A
Rationale: Assessing heart rate and rhythm is essential before administering digoxin, as it can
cause bradycardia.

Question 1742: Maternity

A postpartum patient is concerned about breastfeeding and returning to work. What should the
nurse recommend?
  A) "You should stop breastfeeding before you return to work."
 B) "Consider pumping and storing your breast milk."
 C) "It's best to switch to formula."
 D) "You can breastfeed only in the morning."

Correct Answer: B
Rationale: Pumping and storing breast milk can help the mother continue breastfeeding while
returning to work.

Question 1743: Neurological

A patient with a spinal cord injury at the level of T6 is at risk for which complication?

 A) Deep vein thrombosis.

 B) Pressure ulcers.
 C) Autonomic dysreflexia.
 D) All of the above.

Correct Answer: D
Rationale: All of these complications are risks for patients with spinal cord injuries, particularly
at higher levels.

Question 1744: Cardiac

A patient with heart failure is prescribed furosemide. What is the most important assessment for
the nurse to perform?

 A) Lung sounds.
 B) Urine output.
 C) Weight.
 D) Blood pressure.

Correct Answer: C
Rationale: Monitoring weight is crucial to assess fluid status and effectiveness of the diuretic
therapy.

Question 1745: Gastrointestinal

A nurse is teaching a patient about a low-fiber diet. Which food choice indicates a need for
further teaching?
  A) White bread.
 B) Brown rice.
 C) Skinned potatoes.
 D) Canned fruits.

Correct Answer: B
Rationale: Brown rice is high in fiber and should be avoided on a low-fiber diet.

Question 1746: Infection Control

A nurse is caring for a patient diagnosed with Clostridium difficile. Which precaution should the
nurse implement?

 A) Airborne precautions.
 B) Contact precautions.
 C) Droplet precautions.
 D) Standard precautions only.

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of C. difficile.

Question 1747: Mental Health

A nurse is assessing a patient with bipolar disorder in a manic phase. Which behavior is most
characteristic of this phase?

 A) Extreme lethargy.
 B) Withdrawal from social interactions.
 C) Increased energy and decreased need for sleep.
 D) Indifference to personal hygiene.

Correct Answer: C
Rationale: Increased energy and decreased need for sleep are common during a manic episode.

Question 1748: Pediatric

A nurse is monitoring a child with asthma. What should the nurse assess for signs of an
impending asthma attack?

 A) Decreased appetite.
  B) Abdominal pain.
 C) Increased respiratory rate and wheezing.
 D) Fever.

Correct Answer: C
Rationale: Increased respiratory rate and wheezing are indicators of an impending asthma
attack.

Question 1749: Respiratory

A patient with COPD is prescribed a bronchodilator. Which statement by the patient indicates a
need for further teaching?

 A) "I can use this medication before exercising."

 B) "I should take this medication regularly even if I feel fine."
 C) "I can skip doses if I am feeling well."
 D) "This medication will help open my airways."

Correct Answer: C
Rationale: Patients should not skip doses of bronchodilators, even if they feel well, as they are
essential for managing COPD.

Question 1750: Endocrine

A nurse is teaching a patient with diabetes about foot care. Which statement indicates that further
teaching is needed?

 A) "I should inspect my feet daily for any injuries."

 B) "I can use lotion between my toes."
 C) "I should wear shoes at all times, even indoors."
 D) "I need to trim my toenails straight across."

Correct Answer: B
Rationale: Patients with diabetes should avoid putting lotion between their toes to prevent
fungal infections.

Question 1751: Cardiac

A patient with hypertension is prescribed lisinopril. What side effect should the nurse educate the
patient to report?
  A) Dry cough.
 B) Dizziness.
 C) Fatigue.
 D) Rash.

Correct Answer: A
Rationale: A dry cough is a common side effect of ACE inhibitors like lisinopril and should be
reported.

Question 1752: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which dietary recommendation should the
nurse provide?

 A) Avoid spicy foods.

 B) Increase caffeine intake.
 C) Consume three large meals daily.
 D) Eat high-fat foods.

Correct Answer: A
Rationale: Avoiding spicy foods can help prevent irritation of the ulcer.

Question 1753: Maternity

A nurse is assessing a newborn who was born at 36 weeks of gestation. What finding would the
nurse expect?

 A) Good muscle tone.

 B) Minimal lanugo.
 C) Poor sucking reflex.
 D) High birth weight.

Correct Answer: C
Rationale: Preterm infants often have a poor sucking reflex due to immature development.

Question 1754: Neurological

A patient is being evaluated for multiple sclerosis. Which symptom should the nurse expect?

 A) Sudden loss of vision.

  B) Intense headaches.
 C) Muscle weakness and fatigue.
 D) Nausea and vomiting.

Correct Answer: C
Rationale: Muscle weakness and fatigue are common symptoms of multiple sclerosis.

Question 1755: Infection Control

A nurse is caring for a patient with a respiratory infection. Which precaution should the nurse
implement?

 A) Droplet precautions.
 B) Contact precautions.
 C) Airborne precautions.
 D) Standard precautions only.

Correct Answer: A
Rationale: Droplet precautions are required for respiratory infections to prevent transmission.

Question 1756: Pediatric

A nurse is monitoring a child who has just received a vaccination. What is the most appropriate
action by the nurse?

 A) Document the vaccination immediately.

 B) Keep the child in the office for 15-30 minutes for observation.
 C) Send the child home immediately after the vaccination.
 D) Reassure the parent that no side effects will occur.

Correct Answer: B
Rationale: Monitoring the child for a short period after vaccination helps identify any immediate
allergic reactions.

Question 1757: Endocrine

A patient with diabetes is experiencing hypoglycemia. Which symptom should the nurse
anticipate?

 A) Increased thirst.
  B) Sweating and tremors.
 C) Frequent urination.
 D) Dry mouth.

Correct Answer: B
Rationale: Sweating and tremors are common symptoms of hypoglycemia.

Question 1758: Surgical

A nurse is preparing a patient for discharge after laparoscopic surgery. What should the nurse
instruct the patient to monitor for?

 A) Excessive bleeding from the incisions.

 B) Minimal pain at the incision site.
 C) Frequent urination.
 D) Increased appetite.

Correct Answer: A
Rationale: Monitoring for excessive bleeding is crucial following surgery.

Question 1759: Cardiac

A patient with heart failure is prescribed a low-sodium diet. What is the primary reason for this
dietary restriction?

 A) To increase blood volume.

 B) To prevent fluid retention.
 C) To decrease heart rate.
 D) To lower blood pressure.

Correct Answer: B
Rationale: A low-sodium diet helps prevent fluid retention, which is critical in managing heart
failure.

Question 1760: Respiratory

A nurse is assessing a patient with pneumonia. Which assessment finding is most concerning?

 A) Productive cough with green sputum.

 B) Elevated temperature.
  C) Decreased oxygen saturation levels.
 D) Chest pain with deep breathing.

Correct Answer: C
Rationale: Decreased oxygen saturation levels indicate impaired gas exchange and are
concerning in a patient with pneumonia.

Question 1761: Cardiovascular

A patient with a history of hypertension is prescribed a calcium channel blocker. What is the
expected effect of this medication?

 A) Increased heart rate.

 B) Decreased myocardial oxygen demand.
 C) Decreased respiratory rate.
 D) Increased blood pressure.

Correct Answer: B
Rationale: Calcium channel blockers decrease myocardial oxygen demand by reducing heart
contractility and dilating blood vessels.

Question 1762: Maternity

A nurse is caring for a postpartum patient who is experiencing excessive bleeding. Which action
should the nurse take first?

 A) Massage the fundus.

 B) Administer oxytocin.
 C) Assess the patient's vital signs.
 D) Notify the healthcare provider.

Correct Answer: A
Rationale: Massaging the fundus can help stimulate uterine contraction and reduce bleeding.

Question 1763: Pediatric

A parent asks the nurse how to help their child with ADHD focus better in school. What is the
best recommendation?

 A) "Give them caffeine before school."

  B) "Consider medication management."
 C) "Let them choose their classes."
 D) "Encourage them to study late at night."

Correct Answer: B
Rationale: Medication management is often a key component in effectively managing ADHD
symptoms.

Question 1764: Respiratory

A patient is prescribed a steroid inhaler for asthma. What should the nurse teach the patient about
this medication?

 A) "Use this inhaler only during an asthma attack."

 B) "Rinse your mouth after using the inhaler."
 C) "This medication is not for long-term use."
 D) "You can use it as needed for shortness of breath."

Correct Answer: B
Rationale: Rinsing the mouth after using a steroid inhaler helps prevent oral thrush.

Question 1765: Endocrine

A nurse is teaching a patient with diabetes about carbohydrate counting. What is the best food
choice for the patient?

 A) 1 slice of white bread (15g of carbs).

 B) 1 small apple (15g of carbs).
 C) 1 cup of cooked pasta (45g of carbs).
 D) 1 cup of cooked broccoli (6g of carbs).

Correct Answer: B
Rationale: A small apple is a healthy carbohydrate choice for a diabetic diet.

Question 1766: Neurological

A patient with a stroke is exhibiting aphasia. Which statement should the nurse make to facilitate
communication?

 A) "Can you tell me what you need?"

  B) "Try to write it down."
 C) "Speak louder."
 D) "Take your time."

Correct Answer: D
Rationale: Encouraging the patient to take their time can reduce frustration and facilitate better
communication.

Question 1767: Surgical

A nurse is caring for a patient who just underwent an appendectomy. Which finding should be
reported immediately?

 A) Abdominal tenderness.
 B) Low-grade fever.
 C) Distended abdomen.
 D) Nausea.

Correct Answer: C
Rationale: A distended abdomen could indicate an obstruction or complications and should be
reported immediately.

Question 1768: Infection Control

A nurse is teaching a patient about preventing the spread of influenza. Which statement indicates
the need for further teaching?

 A) "I should wash my hands frequently."

 B) "I can go back to work as soon as I feel better."
 C) "I should cover my mouth when I cough."
 D) "I need to get a flu shot every year."

Correct Answer: B
Rationale: Patients should not return to work until they have been symptom-free for at least 24
hours to prevent spreading the virus.

Question 1769: Gastrointestinal

A patient with a history of cirrhosis presents with ascites. What should the nurse assess for?
  A) Hyperkalemia.
 B) Abdominal girth.
 C) Weight loss.
 D) Jaundice.

Correct Answer: B
Rationale: Assessing abdominal girth helps monitor the extent of fluid accumulation.

Question 1770: Mental Health

A nurse is caring for a patient diagnosed with major depressive disorder. What is a priority
nursing intervention?

 A) Encourage socialization with others.

 B) Assess for suicidal thoughts.
 C) Promote healthy eating habits.
 D) Provide medication education.

Correct Answer: B
Rationale: Assessing for suicidal thoughts is critical in patients with depression to ensure their
safety.

Question 1771: Pharmacology

A patient taking warfarin should be monitored for which laboratory value?

 A) Platelet count.
 B) Prothrombin time (PT) and International Normalized Ratio (INR).
 C) Hemoglobin level.
 D) Liver function tests.

Correct Answer: B
Rationale: PT and INR are critical for monitoring the effectiveness and safety of warfarin
therapy.

Question 1772: Pediatric

A nurse is assessing a 2-year-old child for developmental milestones. Which skill should the
nurse expect the child to demonstrate?
  A) Hop on one foot.
 B) Use complete sentences.
 C) Build a tower of four blocks.
 D) Ride a tricycle.

Correct Answer: C
Rationale: A 2-year-old should be able to build a tower of four blocks, which is appropriate for
their developmental stage.

Question 1773: Cardiac

A patient with a history of myocardial infarction is prescribed a beta-blocker. What is the

primary action of this medication class?

 A) Increase heart rate.

 B) Decrease myocardial oxygen demand.
 C) Increase blood pressure.
 D) Improve blood flow.

Correct Answer: B
Rationale: Beta-blockers decrease myocardial oxygen demand by slowing heart rate and
reducing contractility.

Question 1774: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
position is best for promoting optimal breathing?

 A) Supine.
 B) High Fowler's.
 C) Prone.
 D) Lateral.

Correct Answer: B
Rationale: High Fowler's position helps promote lung expansion and improves respiratory
function.

Question 1775: Surgical

A patient is recovering from a total hip replacement. Which nursing intervention is essential for
preventing complications?

 A) Allowing the patient to cross their legs.

 B) Encouraging deep breathing and coughing.
 C) Limiting fluid intake.
 D) Keeping the affected leg flat.

Correct Answer: B
Rationale: Deep breathing and coughing help prevent pneumonia and other respiratory
complications post-surgery.

Question 1776: Infection Control

A nurse is caring for a patient with MRSA. Which type of precautions should be implemented?

 A) Airborne precautions.
 B) Standard precautions.
 C) Contact precautions.
 D) Droplet precautions.

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of MRSA.

Question 1777: Endocrine

A patient with hyperthyroidism is experiencing palpitations. What should the nurse assess for in
this patient?

 A) Weight gain.
 B) Cold intolerance.
 C) Increased appetite.
 D) Elevated blood pressure.

Correct Answer: D
Rationale: Elevated blood pressure is common in patients with hyperthyroidism due to increased
metabolic activity.

Question 1778: Neurological

A nurse is caring for a patient with Parkinson's disease. Which symptom should the nurse expect
to assess?

 A) Hyperactivity.
 B) Bradykinesia.
 C) Slurred speech.
 D) Memory loss.

Correct Answer: B
Rationale: Bradykinesia, or slowed movement, is a characteristic symptom of Parkinson's
disease.

Question 1779: Mental Health

A patient is diagnosed with generalized anxiety disorder. What is the priority nursing
intervention?

 A) Encourage the patient to avoid stressors.

 B) Teach relaxation techniques.
 C) Provide frequent reassurances.
 D) Offer cognitive-behavioral therapy.

Correct Answer: B
Rationale: Teaching relaxation techniques can help manage anxiety symptoms effectively.

Question 1780: Gastrointestinal

A nurse is caring for a patient with a peptic ulcer. Which dietary choice should the nurse
encourage?

 A) Spicy foods.
 B) High-fat foods.
 C) Bland foods.
 D) Alcoholic beverages.

Correct Answer: C
Rationale: Bland foods are less likely to irritate the gastric lining and can help alleviate ulcer
symptoms.

Question 1781: Cardiovascular

A patient presents to the emergency department with chest pain, diaphoresis, and shortness of
breath. Which priority action should the nurse take?

 A) Obtain a 12-lead ECG.

 B) Administer nitroglycerin.
 C) Assess vital signs.
 D) Obtain a medical history.

Correct Answer: A
Rationale: Obtaining a 12-lead ECG is crucial for diagnosing potential cardiac issues such as
myocardial infarction.

Question 1782: Maternity

During a prenatal visit, a nurse assesses a patient's fundal height. At 28 weeks gestation, where
should the fundus be located?

 A) At the umbilicus.
 B) 2 cm above the pubic symphysis.
 C) At the xiphoid process.
 D) 4 cm below the umbilicus.

Correct Answer: A
Rationale: The fundus is typically at the level of the umbilicus at 28 weeks gestation.

Question 1783: Pediatric

A 5-year-old child is diagnosed with asthma. What is an important aspect of the child's care
plan?

 A) Limit physical activity.

 B) Teach the child to identify triggers.
 C) Administer antibiotics.
 D) Schedule frequent hospital visits.

Correct Answer: B
Rationale: Teaching the child to identify and avoid triggers is essential in managing asthma.

Question 1784: Respiratory

A nurse is teaching a patient about the use of an incentive spirometer. What is the best
instruction to provide?

 A) "Use it only when you feel short of breath."

 B) "Take slow, deep breaths and hold for a few seconds."
 C) "Use it once every hour."
 D) "Exhale quickly into the device."

Correct Answer: B
Rationale: Taking slow, deep breaths and holding for a few seconds helps improve lung
expansion and function.

Question 1785: Endocrine

A nurse is teaching a patient about managing diabetes mellitus. Which statement indicates the
need for further teaching?

 A) "I will check my blood sugar levels regularly."

 B) "I can eat whatever I want as long as I take my insulin."
 C) "I will follow a balanced diet."
 D) "I need to exercise regularly."

Correct Answer: B
Rationale: Patients with diabetes must follow a controlled diet regardless of insulin
administration.

Question 1786: Neurological

A nurse is caring for a patient with a seizure disorder. Which action should the nurse take during
a seizure?

 A) Restrain the patient to prevent injury.

 B) Place a padded tongue blade in the mouth.
 C) Turn the patient to the side.
 D) Call for help immediately.

Correct Answer: C
Rationale: Turning the patient to the side helps maintain airway patency and prevent aspiration.

Question 1787: Surgical

A patient is recovering from abdominal surgery. Which finding should the nurse report to the
healthcare provider?

 A) Abdominal pain rated 4/10.

 B) Passing flatus.
 C) Bowel sounds present in all quadrants.
 D) Absent bowel sounds after 48 hours.

Correct Answer: D
Rationale: Absent bowel sounds after 48 hours may indicate an ileus or obstruction and should
be reported.

Question 1788: Infection Control

A patient with tuberculosis is being discharged home. What instruction should the nurse provide
to the family?

 A) "The patient should wear a mask at all times."

 B) "Keep the patient isolated from others."
 C) "The patient can return to work immediately."
 D) "Air out the patient's room frequently."

Correct Answer: D
Rationale: Airing out the room helps reduce the risk of transmission of tuberculosis.

Question 1789: Gastrointestinal

A nurse is assessing a patient with cirrhosis. Which assessment finding is most concerning?

 A) Jaundice.
 B) Ascites.
 C) Confusion.
 D) Fatigue.

Correct Answer: C
Rationale: Confusion may indicate hepatic encephalopathy, a serious complication of cirrhosis.

Question 1790: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia. Which intervention is most
appropriate?

 A) Encourage isolation from others.

 B) Challenge the patient's delusions.
 C) Establish a trusting relationship.
 D) Provide multiple stimuli to enhance engagement.

Correct Answer: C
Rationale: Establishing a trusting relationship is essential for effective communication and care.

Question 1791: Pharmacology

A patient taking digoxin is being monitored for toxicity. What is a common sign of digoxin
toxicity?

 A) Bradycardia.
 B) Hypertension.
 C) Hyperglycemia.
 D) Weight gain.

Correct Answer: A
Rationale: Bradycardia is a common sign of digoxin toxicity and requires careful monitoring.

Question 1792: Pediatric

A nurse is assessing a toddler's growth and development. Which finding would be considered
typical for this age group?

 A) Ability to write their name.

 B) Ability to jump with both feet.
 C) Ability to ride a bike.
 D) Ability to use simple sentences.

Correct Answer: D
Rationale: Using simple sentences is a typical language development milestone for toddlers.

Question 1793: Cardiac

A nurse is caring for a patient with heart failure. What is a priority nursing diagnosis for this
patient?

 A) Impaired skin integrity.

 B) Excess fluid volume.
 C) Risk for injury.
 D) Activity intolerance.

Correct Answer: B
Rationale: Excess fluid volume is a hallmark of heart failure and needs to be closely monitored
and managed.

Question 1794: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is experiencing wheezing and
dyspnea. What should the nurse do first?

 A) Administer bronchodilator therapy.

 B) Obtain a sputum sample.
 C) Encourage deep breathing exercises.
 D) Position the patient in a supine position.

Correct Answer: A
Rationale: Administering bronchodilator therapy is a priority to relieve bronchospasm and
improve airflow.

Question 1795: Surgical

A patient is 12 hours post-operative from a cholecystectomy. Which assessment finding requires

immediate intervention?

 A) Pain level of 6/10.

 B) Nausea and vomiting.
 C) Temperature of 101°F (38.3°C).
 D) Abdominal rigidity and distension.

Correct Answer: D
Rationale: Abdominal rigidity and distension may indicate a complication such as perforation or
obstruction and require immediate intervention.
Question 1796: Infection Control

A nurse is educating a patient about the importance of hand hygiene. Which statement by the
patient indicates a need for further education?

 A) "I should wash my hands after using the bathroom."

 B) "I can use hand sanitizer when my hands are visibly dirty."
 C) "I need to wash my hands before preparing food."
 D) "I should wash my hands after coughing or sneezing."

Correct Answer: B
Rationale: Hand sanitizer is not effective when hands are visibly dirty; soap and water should be
used in that case.

Question 1797: Endocrine

A patient with hypothyroidism is prescribed levothyroxine. What is the most important

instruction for the nurse to give?

 A) "Take this medication with food."

 B) "Take this medication at the same time each day."
 C) "This medication can cause weight gain."
 D) "You can stop this medication when you feel better."

Correct Answer: B
Rationale: Taking levothyroxine at the same time each day helps maintain stable hormone
levels.

Question 1798: Neurological

A patient with multiple sclerosis (MS) is experiencing fatigue. Which nursing intervention is
most appropriate?

 A) Encourage frequent rest periods.

 B) Promote daily exercise.
 C) Schedule activities in the morning.
 D) Recommend a high-protein diet.

Correct Answer: A
Rationale: Encouraging frequent rest periods helps manage fatigue, a common symptom of MS.
Question 1799: Mental Health

A patient diagnosed with anxiety disorder is prescribed benzodiazepines. What should the nurse
monitor for?

 A) Signs of hypoglycemia.
 B) Signs of respiratory depression.
 C) Signs of hyperactivity.
 D) Signs of hypertension.

Correct Answer: B
Rationale: Benzodiazepines can cause respiratory depression, so monitoring for this side effect
is essential.

Question 1800: Gastrointestinal

A nurse is providing dietary education for a patient with celiac disease. Which food should the
patient avoid?

 A) Rice.
 B) Oats.
 C) Quinoa.
 D) Wheat.

Correct Answer: D
Rationale: Patients with celiac disease must avoid wheat and other gluten-containing foods.

Question 1801: Cardiovascular

A patient is diagnosed with hypertension and is prescribed lisinopril. What is the most important
instruction the nurse should provide?

 A) "You can stop taking this medication once your blood pressure is normal."
 B) "Monitor your blood pressure weekly."
 C) "Avoid potassium-rich foods."
 D) "Take this medication on an empty stomach."

Correct Answer: C
Rationale: Lisinopril can increase potassium levels, so patients should avoid potassium-rich
foods.
Question 1802: Maternity

During a prenatal visit, the nurse teaches a patient about the signs of preterm labor. Which
statement by the patient indicates a need for further teaching?

 A) "I should call my doctor if I have contractions every 10 minutes."

 B) "If I have lower back pain that doesn't go away, I should be concerned."
 C) "I shouldn't worry unless my water breaks."
 D) "I should look for changes in vaginal discharge."

Correct Answer: C
Rationale: Patients should be aware of all signs of preterm labor, not just the rupture of
membranes.

Question 1803: Pediatric

A nurse is caring for a 6-month-old infant. Which developmental milestone should the nurse
expect?

 A) Walking independently.
 B) Saying "mama" and "dada."
 C) Rolling over in both directions.
 D) Playing with other children.

Correct Answer: C
Rationale: Rolling over in both directions is a typical milestone for a 6-month-old infant.

Question 1804: Respiratory

A nurse is caring for a patient with asthma who is experiencing an acute asthma attack. Which
intervention should be prioritized?

 A) Administering corticosteroids.
 B) Providing oxygen therapy.
 C) Giving a short-acting beta-agonist.
 D) Encouraging pursed-lip breathing.

Correct Answer: C
Rationale: Administering a short-acting beta-agonist is the priority intervention during an acute
asthma attack to relieve bronchospasm.
Question 1805: Endocrine

A nurse is teaching a patient with diabetes about self-monitoring blood glucose. Which statement
indicates that the teaching was effective?

 A) "I will check my blood sugar before meals and at bedtime."

 B) "I only need to check my blood sugar when I feel symptoms."
 C) "I can use any part of my finger to check my blood sugar."
 D) "I should not record my results."

Correct Answer: A
Rationale: Checking blood sugar before meals and at bedtime is essential for effective diabetes
management.

Question 1806: Neurological

A patient presents to the emergency department with symptoms of a stroke. Which assessment
finding is most indicative of a stroke?

 A) Slurred speech.
 B) Fever.
 C) Chest pain.
 D) Abdominal pain.

Correct Answer: A
Rationale: Slurred speech is a common symptom of stroke and requires immediate evaluation.

Question 1807: Surgical

A nurse is caring for a postoperative patient who has a Jackson-Pratt drain. Which finding should
the nurse monitor for?

 A) Increased pain at the incision site.

 B) Amount of drainage.
 C) Color of urine.
 D) Temperature of the extremities.

Correct Answer: B
Rationale: Monitoring the amount of drainage from the Jackson-Pratt drain is crucial for
assessing potential complications.
Question 1808: Infection Control

A nurse is educating a patient about preventing urinary tract infections (UTIs). Which statement
by the patient indicates effective teaching?

 A) "I should drink plenty of water each day."

 B) "I can use scented soaps for hygiene."
 C) "I will hold my urine when I feel the urge."
 D) "I should avoid cranberry juice."

Correct Answer: A
Rationale: Drinking plenty of water helps flush bacteria from the urinary tract, reducing the risk
of UTIs.

Question 1809: Gastrointestinal

A patient with gastroesophageal reflux disease (GERD) is being discharged. Which instruction
should the nurse provide?

 A) "Eat large meals before bedtime."

 B) "Elevate the head of your bed."
 C) "Avoid taking antacids regularly."
 D) "Limit your fluid intake."

Correct Answer: B
Rationale: Elevating the head of the bed helps reduce reflux symptoms during sleep.

Question 1810: Mental Health

A nurse is caring for a patient with depression. Which intervention is most appropriate?

 A) Encourage the patient to engage in physical activity.

 B) Suggest that the patient avoids social interactions.
 C) Discourage expressing feelings.
 D) Recommend sleeping more to feel better.

Correct Answer: A
Rationale: Encouraging physical activity can help alleviate symptoms of depression.

Question 1811: Pharmacology

A nurse is administering warfarin to a patient. Which laboratory test is essential to monitor?

 A) Hemoglobin.
 B) Platelet count.
 C) International normalized ratio (INR).
 D) Prothrombin time (PT).

Correct Answer: C
Rationale: Monitoring the INR is essential to ensure the patient is within the therapeutic range
for warfarin therapy.

Question 1812: Pediatric

A nurse is assessing a 2-year-old child. Which behavior would indicate appropriate

development?

 A) Stacking five blocks.

 B) Jumping in place.
 C) Naming colors.
 D) Using two-word sentences.

Correct Answer: D
Rationale: Using two-word sentences is a normal speech development milestone for a 2-year-
old.

Question 1813: Cardiac

A patient with heart failure is prescribed a low-sodium diet. Which food should the patient
avoid?

 A) Fresh fruits.
 B) Whole grains.
 C) Processed meats.
 D) Vegetables.

Correct Answer: C
Rationale: Processed meats are often high in sodium and should be avoided on a low-sodium
diet.

Question 1814: Respiratory

A nurse is caring for a patient with pneumonia. What should be included in the patient’s plan of
care?

 A) Encourage bed rest and limited activity.

 B) Increase fluid intake to thin secretions.
 C) Administer cough suppressants regularly.
 D) Limit incentive spirometer use.

Correct Answer: B
Rationale: Increasing fluid intake helps thin secretions, making it easier for the patient to
expectorate mucus.

Question 1815: Infection Control

A nurse is caring for a patient with a compromised immune system. What is the priority nursing
action?

 A) Encourage the patient to socialize with others.

 B) Monitor the patient’s vital signs every 8 hours.
 C) Implement strict hand hygiene protocols.
 D) Avoid using gloves during patient care.

Correct Answer: C
Rationale: Implementing strict hand hygiene is crucial to prevent infection in
immunocompromised patients.

Question 1816: Endocrine

A patient is diagnosed with hyperthyroidism. Which sign should the nurse expect to assess?

 A) Weight gain.
 B) Cold intolerance.
 C) Bradycardia.
 D) Tremors.

Correct Answer: D
Rationale: Tremors are a common sign of hyperthyroidism due to increased metabolism.

Question 1817: Neurological

A nurse is assessing a patient with a traumatic brain injury. Which finding indicates increased
intracranial pressure (ICP)?

 A) Decreased heart rate.

 B) Widened pulse pressure.
 C) Hypotension.
 D) Increased temperature.

Correct Answer: B
Rationale: Widened pulse pressure is a classic sign of increased ICP.

Question 1818: Mental Health

A nurse is caring for a patient diagnosed with bipolar disorder who is currently experiencing a
manic episode. Which nursing intervention is most appropriate?

 A) Encourage the patient to make decisions about their care.

 B) Limit stimuli in the environment.
 C) Allow the patient to choose their own meal times.
 D) Encourage participation in group therapy.

Correct Answer: B
Rationale: Limiting stimuli helps reduce agitation and support the patient's stability during a
manic episode.

Question 1819: Gastrointestinal

A nurse is providing dietary education to a patient with irritable bowel syndrome (IBS). Which
recommendation is appropriate?

 A) Increase intake of high-fiber foods.

 B) Limit fluid intake to reduce bloating.
 C) Avoid all dairy products completely.
 D) Eat large meals to feel full longer.

Correct Answer: A
Rationale: Increasing fiber can help regulate bowel movements and alleviate symptoms of IBS.

Question 1820: Surgical

A patient is recovering from a total hip replacement. What is the most important nursing
intervention to prevent complications?

 A) Encourage the patient to lie flat in bed.

 B) Teach the patient to perform ankle pumps.
 C) Limit the patient's fluid intake.
 D) Avoid turning the patient on the affected side.

Correct Answer: B
Rationale: Ankle pumps help prevent venous thromboembolism (VTE) after surgery.

Question 1821: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis (TB). What is the priority nursing
intervention?

 A) Administer antibiotics as prescribed.

 B) Place the patient in a private room with negative pressure.
 C) Encourage family members to visit.
 D) Monitor the patient for fever.

Correct Answer: B
Rationale: Placing the patient in a private room with negative pressure is essential to prevent the
spread of TB.

Question 1822: Endocrine

A patient with Addison’s disease is at risk for adrenal crisis. Which symptom should the nurse
monitor for?

 A) Hyperglycemia.
 B) Hypertension.
 C) Severe abdominal pain.
 D) Weight gain.

Correct Answer: C
Rationale: Severe abdominal pain can indicate an adrenal crisis, which requires immediate
attention.

Question 1823: Cardiac

A patient with heart failure is prescribed furosemide. What is the most important nursing action?

 A) Monitor the patient’s blood glucose levels.

 B) Assess for signs of electrolyte imbalance.
 C) Encourage high-sodium foods.
 D) Limit the patient’s fluid intake to 500 mL per day.

Correct Answer: B
Rationale: Furosemide can cause electrolyte imbalances, so monitoring is essential.

Question 1824: Neurological

A nurse is caring for a patient with a seizure disorder. Which statement by the patient indicates a
need for further teaching?

 A) "I should take my medication at the same time every day."

 B) "I can stop taking my medication if I feel fine."
 C) "I need to avoid alcohol."
 D) "I should wear a medical alert bracelet."

Correct Answer: B
Rationale: Patients should not stop taking their medication without consulting their healthcare
provider.

Question 1825: Pediatric

A nurse is assessing a toddler during a routine check-up. Which finding would be concerning?

 A) The child has a 3-word vocabulary.

 B) The child refuses to share toys.
 C) The child has a temper tantrum when told "no."
 D) The child cannot jump on one foot.

Correct Answer: D
Rationale: A toddler should be able to jump with both feet by age 2; inability to do so may
indicate a developmental delay.

Question 1826: Cardiac

A patient presents with chest pain and is diagnosed with unstable angina. What should the nurse
prioritize in the care plan?

 A) Administering pain medication.

 B) Initiating IV access and oxygen therapy.
 C) Encouraging ambulation.
 D) Monitoring for gastrointestinal symptoms.

Correct Answer: B
Rationale: Initiating IV access and oxygen therapy is critical for managing unstable angina and
preventing myocardial infarction.

Question 1827: Respiratory

A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which
finding would indicate respiratory distress?

 A) Decreased respiratory rate.

 B) Use of accessory muscles.
 C) Clear lung sounds.
 D) Regular rhythm.

Correct Answer: B
Rationale: Use of accessory muscles is a sign of respiratory distress in patients with COPD.

Question 1828: Gastrointestinal

A patient with liver cirrhosis is at risk for developing hepatic encephalopathy. Which assessment
finding should the nurse monitor?

 A) Increased appetite.
 B) Confusion or altered mental status.
 C) Weight gain.
 D) Elevated blood pressure.

Correct Answer: B
Rationale: Confusion or altered mental status is a key sign of hepatic encephalopathy due to
ammonia buildup.

Question 1829: Infection Control

A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA). Which
precaution should the nurse take?

 A) Standard precautions only.

 B) Airborne precautions.
 C) Droplet precautions.
 D) Contact precautions.

Correct Answer: D
Rationale: Contact precautions are necessary to prevent the spread of MRSA.

Question 1830: Neurological

A nurse is caring for a patient post-stroke. The patient has weakness on the right side and
difficulty speaking. Which part of the brain is likely affected?

 A) Right hemisphere.
 B) Left hemisphere.
 C) Cerebellum.
 D) Brainstem.

Correct Answer: B
Rationale: The left hemisphere controls speech and the right side of the body, so damage there
would lead to these symptoms.

Question 1831: Maternity

A nurse is educating a pregnant woman about the importance of prenatal vitamins. Which
statement indicates the patient understands the information?

 A) "I should only take vitamins during the first trimester."

 B) "Prenatal vitamins will help prevent anemia and support fetal development."
 C) "I can get all the nutrients I need from my diet alone."
 D) "Taking too many vitamins can harm my baby."

Correct Answer: B
Rationale: Prenatal vitamins are important for preventing anemia and supporting fetal growth
and development.

Question 1832: Pharmacology

A patient is prescribed metformin for type 2 diabetes. What is the nurse's priority teaching point?

 A) "You must take this medication with food."

 B) "Watch for signs of hyperglycemia."
 C) "This medication can cause weight gain."
 D) "You may need to take insulin with this medication."

Correct Answer: A
Rationale: Taking metformin with food helps reduce gastrointestinal side effects.

Question 1833: Pediatric

A nurse is assessing a 5-year-old child. Which behavior would indicate normal development?

 A) The child cannot dress independently.

 B) The child has imaginary friends.
 C) The child is unable to hop on one foot.
 D) The child refuses to share toys.

Correct Answer: B
Rationale: Having imaginary friends is a common and normal part of development for
preschool-aged children.

Question 1834: Endocrine

A patient with diabetes is experiencing hypoglycemia. Which symptom should the nurse expect
to assess?

 A) Increased thirst.
 B) Dry skin.
 C) Sweating and trembling.
 D) Blurred vision.

Correct Answer: C
Rationale: Sweating and trembling are common symptoms of hypoglycemia.

Question 1835: Surgical

A nurse is caring for a patient after a laparoscopic cholecystectomy. Which assessment finding
should the nurse report immediately?
  A) Mild abdominal pain.
 B) Shoulder pain.
 C) Bright red drainage from the incision.
 D) Nausea.

Correct Answer: C
Rationale: Bright red drainage may indicate a complication such as hemorrhage and should be
reported immediately.

Question 1836: Cardiac

A nurse is monitoring a patient with heart failure who has just received furosemide. Which
finding is a potential side effect of this medication?

 A) Decreased urination.
 B) Hyperkalemia.
 C) Hypokalemia.
 D) Bradycardia.

Correct Answer: C
Rationale: Furosemide can cause hypokalemia (low potassium levels), so monitoring potassium
levels is important.

Question 1837: Respiratory

A patient is diagnosed with pneumonia. What is the best position to facilitate breathing?

 A) Supine.
 B) Trendelenburg.
 C) High Fowler's.
 D) Lateral.

Correct Answer: C
Rationale: High Fowler's position helps maximize lung expansion and facilitates breathing.

Question 1838: Gastrointestinal

A patient with chronic pancreatitis is experiencing severe abdominal pain. Which intervention
should the nurse implement first?
  A) Administer prescribed analgesics.
 B) Assess the patient's vital signs.
 C) Obtain a history of dietary habits.
 D) Initiate a clear liquid diet.

Correct Answer: A
Rationale: Administering prescribed analgesics is the priority to manage the patient's severe
pain.

Question 1839: Infection Control

A patient with a history of recurrent urinary tract infections (UTIs) is being discharged. Which
instruction should the nurse provide to prevent future infections?

 A) "Avoid drinking cranberry juice."

 B) "Wipe from back to front after using the toilet."
 C) "Drink plenty of fluids, especially water."
 D) "Limit your fluid intake in the evening."

Correct Answer: C
Rationale: Drinking plenty of fluids helps flush bacteria from the urinary tract and can prevent
UTIs.

Question 1840: Neurological

A nurse is assessing a patient with a head injury. Which sign would indicate increased
intracranial pressure?

 A) Bradypnea.
 B) Slow pulse.
 C) Widened pulse pressure.
 D) Unilateral pupil dilation.

Correct Answer: C
Rationale: Widened pulse pressure is indicative of increased intracranial pressure.

Question 1841: Mental Health

A nurse is caring for a patient with schizophrenia. Which intervention is the most appropriate?
  A) Encourage the patient to avoid social interactions.
 B) Validate the patient’s feelings and experiences.
 C) Limit the patient’s ability to express thoughts.
 D) Discourage any discussions about delusions.

Correct Answer: B
Rationale: Validating the patient’s feelings can help build trust and rapport, which is essential in
mental health care.

Question 1842: Endocrine

A patient with diabetes is prescribed insulin. Which statement indicates a need for further
education?

 A) "I can store my insulin in the refrigerator."

 B) "I should inject insulin into the same area each time."
 C) "I need to rotate my injection sites."
 D) "I will check my blood sugar before each meal."

Correct Answer: B
Rationale: Patients should rotate their injection sites to prevent lipodystrophy.

Question 1843: Surgical

A nurse is providing discharge instructions to a patient after a hysterectomy. Which statement

indicates a need for further teaching?

 A) "I will avoid lifting heavy objects for several weeks."

 B) "I can resume sexual activity as soon as I feel ready."
 C) "I should expect some vaginal bleeding for a few weeks."
 D) "I will stop taking my pain medication once I feel better."

Correct Answer: D
Rationale: Patients should be instructed not to stop pain medication abruptly; they should
consult their healthcare provider about tapering.

Question 1844: Pediatric

A nurse is assessing a child with asthma. Which finding indicates that the child's asthma is well-
controlled?
  A) Occasional wheezing.
 B) Normal activity level without limitations.
 C) Need for rescue inhaler every day.
 D) Frequent coughing at night.

Correct Answer: B
Rationale: A normal activity level without limitations indicates good asthma control.

Question 1845: Respiratory

A nurse is providing education to a patient with asthma about the use of a peak flow meter.
Which statement indicates a correct understanding?

 A) "I should use the peak flow meter only when I feel sick."
 B) "I will blow into the meter hard and fast."
 C) "I should use the peak flow meter once a month."
 D) "My peak flow readings do not matter."

Correct Answer: B
Rationale: Blowing hard and fast into the peak flow meter provides an accurate reading of the
patient's lung function.

Question 1846: Cardiac

A patient with atrial fibrillation is prescribed warfarin. Which statement by the patient indicates a
need for further education?

 A) "I should have my INR checked regularly."

 B) "I can take aspirin with this medication for added protection."
 C) "I will avoid foods high in vitamin K."
 D) "I can stop taking this medication when I feel better."

Correct Answer: D
Rationale: Patients should not stop taking warfarin without consulting their healthcare provider,
as this increases the risk of thromboembolism.

Question 1847: Neurological

A nurse is assessing a patient with suspected meningitis. Which sign would the nurse expect to
find?
  A) Positive Babinski sign.
 B) Nuchal rigidity.
 C) Diminished reflexes.
 D) Unequal pupils.

Correct Answer: B
Rationale: Nuchal rigidity (stiff neck) is a classic sign of meningitis.

Question 1848: Endocrine

A nurse is caring for a patient with hyperthyroidism. Which assessment finding would the nurse
expect?

 A) Cold intolerance.
 B) Weight gain.
 C) Increased appetite.
 D) Bradycardia.

Correct Answer: C
Rationale: Patients with hyperthyroidism often experience increased appetite due to a higher
metabolic rate.

Question 1849: Pediatric

A nurse is caring for a 4-year-old child with a diagnosis of cystic fibrosis. Which statement by
the parent indicates a need for further teaching?

 A) "I will ensure my child gets plenty of fluids."

 B) "I should encourage a high-protein, high-calorie diet."
 C) "I can stop the chest physiotherapy when my child seems healthy."
 D) "My child will need to take enzyme supplements with meals."

Correct Answer: C
Rationale: Chest physiotherapy should be continued regularly to help manage cystic fibrosis,
even if the child appears healthy.

Question 1850: Infection Control

A patient with a urinary tract infection is prescribed antibiotics. Which nursing intervention is
most important?
  A) Encourage the patient to increase fluid intake.
 B) Administer the antibiotics at the same time each day.
 C) Monitor for signs of an allergic reaction.
 D) Educate the patient about potential side effects.

Correct Answer: C
Rationale: Monitoring for allergic reactions is critical after administering antibiotics.

Question 1851: Surgical

A patient is scheduled for a total knee replacement. Which preoperative intervention is most
important for the nurse to perform?

 A) Encourage the patient to engage in deep breathing exercises.

 B) Educate the patient about postoperative pain management.
 C) Ensure the patient has signed the consent form.
 D) Assess the patient’s nutritional status.

Correct Answer: C
Rationale: Ensuring that the patient has signed the consent form is crucial before any surgical
procedure.

Question 1852: Gastrointestinal

A patient with chronic pancreatitis is being educated about dietary modifications. Which food
should the nurse encourage the patient to limit?

 A) Fruits.
 B) Whole grains.
 C) Lean proteins.
 D) Fried foods.

Correct Answer: D
Rationale: Fried foods should be limited as they can exacerbate symptoms of pancreatitis due to
high fat content.

Question 1853: Mental Health

A nurse is caring for a patient diagnosed with major depressive disorder. Which statement
indicates a need for further teaching?
  A) "I will continue my medication even when I feel better."
 B) "I should talk to my therapist about my feelings."
 C) "I can stop my medication if I feel side effects."
 D) "Regular exercise may help improve my mood."

Correct Answer: C
Rationale: Patients should consult their healthcare provider before stopping medication due to
side effects.

Question 1854: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is using
a metered-dose inhaler (MDI). What should the nurse teach the patient?

 A) "You should shake the inhaler before each use."

 B) "You can use the inhaler as often as you like."
 C) "Inhale quickly and deeply when using the inhaler."
 D) "Hold your breath for 10 seconds after inhaling the medication."

Correct Answer: D
Rationale: Holding the breath for 10 seconds after inhalation allows for better medication
absorption.

Question 1855: Cardiac

A nurse is monitoring a patient with heart failure who is on a low-sodium diet. Which food
choice would be appropriate?

 A) Canned soup.
 B) Fresh fruit.
 C) Processed cheese.
 D) Pickles.

Correct Answer: B
Rationale: Fresh fruits are low in sodium and suitable for a heart failure diet.

Question 1856: Pharmacology

A nurse is teaching a patient about atorvastatin. Which statement indicates the patient
understands the teaching?
  A) "I can stop taking this medication if my cholesterol levels are normal."
 B) "I need to avoid grapefruit juice while taking this medication."
 C) "I should take this medication in the morning with breakfast."
 D) "This medication will immediately lower my cholesterol."

Correct Answer: B
Rationale: Grapefruit juice can interact with atorvastatin and increase the risk of side effects.

Question 1857: Infection Control

A patient is diagnosed with clostridium difficile (C. diff) infection. Which precaution should the
nurse implement?

 A) Airborne precautions.
 B) Contact precautions.
 C) Droplet precautions.
 D) Standard precautions only.

Correct Answer: B
Rationale: Contact precautions are necessary to prevent the spread of C. diff.

Question 1858: Neurological

A nurse is caring for a patient with Parkinson's disease. Which symptom should the nurse
expect?

 A) Bradykinesia.
 B) Hyperactivity.
 C) Weight gain.
 D) Visual hallucinations.

Correct Answer: A
Rationale: Bradykinesia (slowness of movement) is a common symptom of Parkinson's disease.

Question 1859: Endocrine

A patient is diagnosed with hyperaldosteronism. What assessment finding should the nurse
expect?

 A) Hypokalemia.
  B) Hyponatremia.
 C) Dehydration.
 D) Hypercalcemia.

Correct Answer: A
Rationale: Hyperaldosteronism causes the kidneys to retain sodium and excrete potassium,
leading to hypokalemia.

Question 1860: Maternity

A nurse is caring for a postpartum patient who is experiencing heavy vaginal bleeding. What is
the priority nursing action?

 A) Assess the patient's vital signs.

 B) Massage the fundus.
 C) Administer prescribed medication.
 D) Notify the healthcare provider.

Correct Answer: B
Rationale: Massaging the fundus can help stimulate uterine contraction and reduce bleeding.

Question 1861: Pediatric

A nurse is assessing a child with a suspected ear infection. Which symptom would the nurse
expect to find?

 A) High fever.
 B) Decreased appetite.
 C) Coughing.
 D) Swollen lymph nodes.

Correct Answer: B
Rationale: Decreased appetite is common in children with ear infections due to discomfort.

Question 1862: Surgical

A nurse is caring for a patient who has undergone abdominal surgery. Which assessment finding
should be reported immediately?

 A) Absent bowel sounds.

  B) Mild abdominal distension.
 C) Fever of 100.4°F (38°C).
 D) Hard, distended abdomen.

Correct Answer: D
Rationale: A hard, distended abdomen may indicate complications such as bowel obstruction or
perforation.

Question 1863: Respiratory

A patient with asthma is experiencing an exacerbation. What is the nurse's priority intervention?

 A) Administer bronchodilator medication.

 B) Encourage pursed-lip breathing.
 C) Assess the patient's oxygen saturation.
 D) Document the event in the patient’s chart.

Correct Answer: A
Rationale: Administering bronchodilator medication is the priority action to relieve
bronchospasm.

Question 1864: Infection Control

A nurse is caring for a patient with a central line. Which intervention is essential to prevent
infection?

 A) Change the dressing every other day.

 B) Use sterile technique when accessing the line.
 C) Flush the line with saline once a week.
 D) Limit the number of healthcare providers accessing the line.

Correct Answer: B
Rationale: Using sterile technique is crucial to prevent infection when accessing a central line.

Question 1865: Gastrointestinal

A patient with hepatitis is being educated about dietary modifications. Which food choice should
the nurse encourage?

 A) High-fat foods.
  B) Lean proteins.
 C) Sugary snacks.
 D) Processed foods.

Correct Answer: B
Rationale: Lean proteins support liver function and recovery in patients with hepatitis.

Question 1866: Cardiac

A patient with heart failure is prescribed furosemide (Lasix). Which assessment finding indicates
the medication is effective?

 A) Decreased urine output.

 B) Weight loss.
 C) Elevated blood pressure.
 D) Peripheral edema.

Correct Answer: B
Rationale: Weight loss indicates a reduction in fluid retention, which is a sign that furosemide is
effective.

Question 1867: Mental Health

A patient diagnosed with schizophrenia is experiencing auditory hallucinations. Which nursing

intervention is most appropriate?

 A) Tell the patient that the voices are not real.

 B) Encourage the patient to describe the voices.
 C) Distract the patient with a game or activity.
 D) Validate the patient’s feelings and listen actively.

Correct Answer: D
Rationale: Validating the patient’s feelings while listening actively helps build trust and rapport.

Question 1868: Gastrointestinal

A patient with peptic ulcer disease is prescribed omeprazole. What should the nurse include in
the patient’s teaching?

 A) "Take this medication with milk."

  B) "You can stop taking this medication once symptoms improve."
 C) "This medication decreases stomach acid production."
 D) "Avoid antacids while taking this medication."

Correct Answer: C
Rationale: Omeprazole decreases stomach acid production and helps heal the ulcer.

Question 1869: Pediatric

A nurse is assessing a 6-month-old infant during a well-child visit. Which developmental

milestone should the nurse expect?

 A) Sits without support.

 B) Says "mama" or "dada."
 C) Rolls over both ways.
 D) Walks with assistance.

Correct Answer: C
Rationale: By 6 months, infants typically can roll over both ways.

Question 1870: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy.
Which is the best intervention to prevent oxygen toxicity?

 A) Use a non-rebreather mask.

 B) Monitor oxygen saturation levels.
 C) Increase the flow rate as needed.
 D) Administer oxygen continuously.

Correct Answer: B
Rationale: Monitoring oxygen saturation levels helps ensure the patient is receiving an
appropriate amount of oxygen.

Question 1871: Surgical

A nurse is preparing a patient for surgery. Which preoperative teaching is most important?

 A) "You will have a lot of pain after surgery."

 B) "You will be put to sleep during the procedure."
  C) "You need to avoid eating or drinking before surgery."
 D) "You can expect to be in the hospital for several days."

Correct Answer: C
Rationale: NPO (nothing by mouth) status is critical before surgery to prevent aspiration.

Question 1872: Endocrine

A patient with type 1 diabetes is experiencing hypoglycemia. Which symptom should the nurse
assess for?

 A) Nausea.
 B) Polyuria.
 C) Confusion.
 D) Weight gain.

Correct Answer: C
Rationale: Confusion is a common symptom of hypoglycemia due to decreased glucose
availability to the brain.

Question 1873: Infection Control

A nurse is caring for a patient diagnosed with tuberculosis (TB). What type of isolation
precautions should the nurse implement?

 A) Droplet precautions.
 B) Contact precautions.
 C) Airborne precautions.
 D) Standard precautions only.

Correct Answer: C
Rationale: Airborne precautions are required for patients with tuberculosis to prevent
transmission.

Question 1874: Neurological

A nurse is assessing a patient after a stroke. Which symptom would indicate right-sided
hemisphere damage?

 A) Difficulty speaking.
  B) Impulsive behavior.
 C) Weakness on the left side.
 D) Visual field deficits.

Correct Answer: B
Rationale: Impulsive behavior is commonly associated with right-sided brain damage.

Question 1875: Pharmacology

A nurse is administering metformin to a patient with type 2 diabetes. Which statement by the
patient indicates a need for further teaching?

 A) "I should take this medication with meals."

 B) "I need to watch for signs of low blood sugar."
 C) "I will avoid alcohol while taking this medication."
 D) "I can stop taking this medication if I lose weight."

Correct Answer: D
Rationale: Patients should not stop taking metformin without consulting their healthcare
provider, even if they lose weight.

Question 1876: Maternity

A nurse is caring for a pregnant patient in the third trimester. Which symptom should the nurse
report to the healthcare provider immediately?

 A) Increased fatigue.
 B) Swelling in the legs.
 C) Severe headache.
 D) Mild back pain.

Correct Answer: C
Rationale: Severe headache can indicate a serious condition such as preeclampsia and should be
reported immediately.

Question 1877: Cardiac

A patient is experiencing chest pain and shortness of breath. Which intervention should the nurse
implement first?
  A) Administer nitroglycerin.
 B) Obtain an ECG.
 C) Assess vital signs.
 D) Call for help.

Correct Answer: D
Rationale: Calling for help is the priority action to ensure the patient receives immediate
medical attention.

Question 1878: Pediatric

A nurse is caring for a child with asthma who is experiencing an acute attack. What is the nurse's
priority action?

 A) Administer a bronchodilator.
 B) Encourage the child to relax.
 C) Monitor respiratory rate.
 D) Assess for cyanosis.

Correct Answer: A
Rationale: Administering a bronchodilator is the priority action to relieve bronchospasm during
an asthma attack.

Question 1879: Endocrine

A patient with diabetes is prescribed insulin. Which action should the nurse instruct the patient to
take when drawing up insulin?

 A) Shake the vial before drawing up the insulin.

 B) Draw up the clear insulin before the cloudy insulin.
 C) Use the same syringe for different types of insulin.
 D) Inject the insulin into the muscle for quicker absorption.

Correct Answer: B
Rationale: When mixing insulin, clear (regular) insulin should be drawn up before cloudy
(NPH) insulin.

Question 1880: Respiratory

A patient with pneumonia is receiving antibiotic therapy. Which finding indicates the treatment
is effective?

 A) Increased temperature.
 B) Decreased sputum production.
 C) Shortness of breath.
 D) Increased heart rate.

Correct Answer: B
Rationale: Decreased sputum production indicates that the infection is resolving.

Question 1881: Infection Control

A nurse is caring for a patient with a stage 2 pressure ulcer. What is the best intervention to
promote healing?

 A) Apply a dry dressing to the ulcer.

 B) Use a hydrocolloid dressing.
 C) Clean the ulcer with alcohol.
 D) Keep the ulcer dry at all times.

Correct Answer: B
Rationale: Hydrocolloid dressings promote a moist wound environment, which is beneficial for
healing.

Question 1882: Gastrointestinal

A patient with cirrhosis is at risk for developing hepatic encephalopathy. Which symptom should
the nurse monitor for?

 A) Increased appetite.
 B) Confusion and lethargy.
 C) High blood pressure.
 D) Decreased urine output.

Correct Answer: B
Rationale: Confusion and lethargy are common signs of hepatic encephalopathy due to the
accumulation of toxins.

Question 1883: Surgical

A nurse is caring for a patient who has undergone a laparoscopic cholecystectomy. What is the
most important assessment to perform postoperatively?

 A) Monitor for bowel sounds.

 B) Assess the surgical incision site.
 C) Evaluate pain level.
 D) Check for signs of infection.

Correct Answer: C
Rationale: Pain assessment is crucial for managing postoperative discomfort and identifying
complications.

Question 1884: Mental Health

A nurse is caring for a patient with depression who is prescribed fluoxetine. Which side effect
should the nurse educate the patient about?

 A) Weight loss.
 B) Sedation.
 C) Insomnia.
 D) Increased appetite.

Correct Answer: C
Rationale: Insomnia is a common side effect of fluoxetine, which should be discussed with the
patient.

Question 1885: Neurological

A nurse is assessing a patient with a suspected transient ischemic attack (TIA). Which symptom
would the nurse expect?

 A) Prolonged loss of consciousness.

 B) Sudden weakness in one arm.
 C) Severe headache.
 D) Confusion lasting more than 24 hours.

Correct Answer: B
Rationale: Sudden weakness in one arm is a common symptom of a TIA.

Question 1886: Cardiovascular

A patient is receiving warfarin therapy. Which laboratory test should the nurse monitor to ensure
therapeutic effectiveness?

 A) Platelet count.
 B) Prothrombin time (PT).
 C) Activated partial thromboplastin time (aPTT).
 D) International normalized ratio (INR).

Correct Answer: D
Rationale: The INR is used to monitor the effectiveness of warfarin therapy.

Question 1887: Maternity

A pregnant patient in the second trimester is reporting frequent headaches. What is the nurse's
best response?

 A) "This is normal during pregnancy."

 B) "Have you been drinking enough fluids?"
 C) "You should take over-the-counter pain medication."
 D) "Let me check your blood pressure."

Correct Answer: D
Rationale: Headaches can be a sign of elevated blood pressure during pregnancy; checking BP
is essential.

Question 1888: Respiratory

A nurse is caring for a patient with COPD who is using a metered-dose inhaler (MDI). What is
the correct technique for using an MDI?

 A) Inhale quickly and deeply while pressing the canister.

 B) Exhale fully before pressing the canister.
 C) Hold the breath for 10 seconds after inhalation.
 D) Shake the canister vigorously before use.

Correct Answer: C
Rationale: Holding the breath for 10 seconds allows for optimal medication absorption.

Question 1889: Pediatric

A nurse is assessing a child with a suspected diagnosis of croup. Which symptom would the
nurse expect to find?

 A) High fever.
 B) Barking cough.
 C) Wheezing.
 D) Respiratory distress.

Correct Answer: B
Rationale: A barking cough is characteristic of croup.

Question 1890: Neurological

A patient is admitted with a diagnosis of meningitis. Which assessment finding would the nurse
expect?

 A) Hypotension.
 B) Stiff neck.
 C) Bradycardia.
 D) High fever.

Correct Answer: B
Rationale: A stiff neck is a classic sign of meningitis.

Question 1891: Cardiac

A patient is diagnosed with congestive heart failure (CHF) and is prescribed digoxin. What
should the nurse monitor prior to administering this medication?

 A) Respiratory rate.
 B) Blood glucose level.
 C) Heart rate.
 D) Blood pressure.

Correct Answer: C
Rationale: Digoxin can cause bradycardia; the nurse should check the heart rate before
administration.

Question 1892: Infection Control

A nurse is caring for a patient with Clostridium difficile (C. diff) infection. What isolation
precautions should the nurse implement?

 A) Contact precautions.
 B) Droplet precautions.
 C) Airborne precautions.
 D) Standard precautions.

Correct Answer: A
Rationale: Contact precautions are necessary to prevent the spread of C. diff.

Question 1893: Pediatric

A parent asks the nurse how to prevent their child from developing allergies. What is the best
advice for the nurse to provide?

 A) "Introduce solid foods early."

 B) "Breastfeed exclusively for at least 6 months."
 C) "Avoid all pets in the home."
 D) "Limit outdoor play during pollen season."

Correct Answer: B
Rationale: Breastfeeding exclusively for at least 6 months can help reduce the risk of developing
allergies.

Question 1894: Gastrointestinal

A patient diagnosed with appendicitis is experiencing severe abdominal pain. Which assessment
finding is the most indicative of a perforated appendix?

 A) Mild fever.
 B) Sudden relief of pain.
 C) Nausea and vomiting.
 D) Elevated white blood cell count.

Correct Answer: B
Rationale: Sudden relief of pain can indicate perforation, followed by the onset of peritonitis.

Question 1895: Endocrine

A patient with type 2 diabetes is prescribed glipizide. What should the nurse instruct the patient
regarding this medication?

 A) "You should take this medication with meals."

 B) "This medication can cause weight gain."
 C) "You will need to check your blood sugar frequently."
 D) "You can stop taking this medication if you feel well."

Correct Answer: C
Rationale: Patients taking glipizide should monitor their blood sugar levels regularly to prevent
hypoglycemia.

Question 1896: Neurological

A nurse is assessing a patient with a stroke. Which assessment finding would indicate a right
hemisphere stroke?

 A) Aphasia.
 B) Hemiplegia on the right side.
 C) Impulsive behavior.
 D) Visual deficits.

Correct Answer: C
Rationale: Impulsive behavior is commonly seen with right hemisphere strokes.

Question 1897: Respiratory

A nurse is teaching a patient about using a peak flow meter for asthma management. Which
statement indicates that the patient understands how to use the device?

 A) "I will use it only during an asthma attack."

 B) "I should blow into it as hard as I can."
 C) "I need to measure my peak flow after taking my medication."
 D) "I will keep a record of my peak flow readings."

Correct Answer: D
Rationale: Keeping a record of peak flow readings helps monitor asthma control and triggers.

Question 1898: Pharmacology

A patient taking lisinopril reports a persistent cough. What is the nurse's best response?

 A) "This is a normal side effect; it will go away."

 B) "You should stop taking the medication immediately."
 C) "We need to report this to your healthcare provider."
 D) "Take an over-the-counter cough suppressant."

Correct Answer: C
Rationale: A persistent cough is a known side effect of ACE inhibitors like lisinopril and should
be reported to the healthcare provider.

Question 1899: Maternity

A nurse is caring for a postpartum patient. Which finding should be reported immediately to the
healthcare provider?

 A) Fundus located above the umbilicus.

 B) Lochia rubra with a foul odor.
 C) Mild perineal swelling.
 D) Breast engorgement.

Correct Answer: B
Rationale: Lochia rubra with a foul odor may indicate an infection and requires immediate
attention.

Question 1900: Cardiac

A patient is being discharged after a myocardial infarction. Which statement indicates that the
patient understands discharge instructions?

 A) "I can resume my normal activities right away."

 B) "I will call my doctor if I have chest pain."
 C) "I don’t need to change my diet."
 D) "I should avoid exercising for the next few months."

Correct Answer: B
Rationale: Calling the doctor for chest pain is crucial for managing post-MI complications.

Question 1901: Gastrointestinal

A nurse is caring for a patient with a nasogastric tube. Which assessment finding indicates a
potential complication?

 A) Abdominal distention.
 B) Clear gastric aspirate.
 C) Regular bowel sounds.
 D) Patient reports no nausea.

Correct Answer: A
Rationale: Abdominal distention may indicate that the tube is not functioning properly or that
there is an obstruction.

Question 1902: Infection Control

A patient diagnosed with MRSA is being placed in isolation. Which type of precautions should
the nurse implement?

 A) Airborne precautions.
 B) Droplet precautions.
 C) Contact precautions.
 D) Standard precautions.

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of MRSA.

Question 1903: Endocrine

A nurse is caring for a patient with diabetic ketoacidosis (DKA). Which laboratory finding
would the nurse expect?

 A) Low blood glucose levels.

 B) Decreased serum bicarbonate levels.
 C) Elevated potassium levels.
 D) Normal pH levels.

Correct Answer: B
Rationale: DKA is characterized by decreased bicarbonate levels due to metabolic acidosis.

Question 1904: Pediatric

A nurse is preparing to assess a toddler's developmental milestones. Which milestone should the
nurse expect to see in a 2-year-old?

 A) Hops on one foot.

 B) Speaks in full sentences.
 C) Builds a tower of six blocks.
 D) Can draw a circle.

Correct Answer: C
Rationale: A 2-year-old typically can build a tower of six blocks.

Question 1905: Neurological

A nurse is caring for a patient with Parkinson's disease. Which symptom should the nurse expect
to assess?

 A) Tremors at rest.
 B) Unilateral weakness.
 C) Confusion and disorientation.
 D) Hyperactivity.

Correct Answer: A
Rationale: Tremors at rest are a hallmark symptom of Parkinson's disease.

Question 1906: Surgical

A patient is scheduled for surgery. Which medication should the nurse withhold prior to surgery?

 A) Aspirin.
 B) Insulin.
 C) Metoprolol.
 D) Antihypertensives.

Correct Answer: A
Rationale: Aspirin should be withheld due to its anticoagulant effects and the risk of bleeding
during surgery.

Question 1907: Respiratory

A patient with asthma is experiencing wheezing and shortness of breath. Which medication
should the nurse expect to administer first?

 A) Long-acting beta-agonist.
 B) Inhaled corticosteroid.
 C) Short-acting beta-agonist.
 D) Anticholinergic.

Correct Answer: C
Rationale: A short-acting beta-agonist is used for quick relief of asthma symptoms.

Question 1908: Maternity

A nurse is providing discharge instructions to a postpartum patient. What should the nurse
emphasize as a warning sign that requires immediate medical attention?

 A) Mood swings.
 B) Heavy vaginal bleeding.
 C) Fatigue.
 D) Breast tenderness.

Correct Answer: B
Rationale: Heavy vaginal bleeding could indicate postpartum hemorrhage and requires
immediate evaluation.

Question 1909: Cardiac

A patient with hypertension is prescribed losartan. Which statement indicates that the patient
understands the teaching regarding this medication?

 A) "I can stop taking this medication if my blood pressure is normal."

 B) "I need to monitor my blood pressure regularly."
 C) "This medication is only taken when I have symptoms."
 D) "I can eat foods high in potassium without concern."

Correct Answer: B
Rationale: Monitoring blood pressure regularly helps ensure the effectiveness of
antihypertensive therapy.

Question 1910: Neurological

A nurse is caring for a patient with multiple sclerosis (MS). Which assessment finding would the
nurse expect to see?

 A) Sudden loss of consciousness.

 B) Visual disturbances.
 C) Bradykinesia.
 D) Flaccid paralysis.

Correct Answer: B
Rationale: Visual disturbances, such as blurred vision or diplopia, are common in MS.

Question 1911: Infection Control

A nurse is teaching a patient about the use of hand hygiene to prevent infection. Which statement
by the patient indicates a need for further teaching?

 A) "I can use hand sanitizer when my hands are not visibly soiled."
 B) "I should wash my hands for at least 20 seconds with soap and water."
 C) "I only need to wash my hands after using the restroom."
 D) "I should wash my hands before preparing food."

Correct Answer: C
Rationale: Hand hygiene should be practiced regularly, not just after using the restroom.

Question 1912: Gastrointestinal

A patient with a history of cirrhosis is admitted with ascites. What assessment finding would the
nurse expect to see?

 A) Weight loss.
 B) Abdominal distension.
 C) Decreased abdominal girth.
 D) Hyperactive bowel sounds.

Correct Answer: B
Rationale: Abdominal distension is a common symptom of ascites due to fluid accumulation.

Question 1913: Respiratory

A nurse is caring for a patient with pneumonia. Which finding would indicate that the patient is
responding to treatment?

 A) Elevated white blood cell count.

 B) Improvement in lung sounds.
 C) Increased respiratory rate.
 D) Persistent cough.

Correct Answer: B
Rationale: Improvement in lung sounds indicates that the treatment is effective and the patient's
condition is improving.

Question 1914: Endocrine

A patient with hypothyroidism is being treated with levothyroxine. Which laboratory value
should the nurse monitor to assess the effectiveness of this medication?

 A) T3 levels.
 B) T4 levels.
 C) Thyroid-stimulating hormone (TSH) levels.
 D) Serum glucose levels.

Correct Answer: C
Rationale: Monitoring TSH levels helps assess the effectiveness of levothyroxine therapy.

Question 1915: Maternity

A nurse is assessing a pregnant patient at 28 weeks' gestation. Which finding would indicate a
possible complication?

 A) Fetal heart rate of 140 bpm.

 B) Swelling of the feet and ankles.
 C) Fundal height of 30 cm.
 D) Protein in the urine.

Correct Answer: D
Rationale: Protein in the urine may indicate preeclampsia, which is a complication of
pregnancy.

Question 1916: Neurological

A nurse is caring for a patient with a seizure disorder. Which intervention should the nurse
implement to ensure safety during a seizure?

 A) Place the patient in a high-Fowler's position.

 B) Restrain the patient's arms and legs.
 C) Move any nearby objects out of the way.
 D) Hold the patient's tongue to prevent biting.

Correct Answer: C
Rationale: Moving nearby objects reduces the risk of injury during a seizure.

Question 1917: Cardiovascular

A patient with heart failure is prescribed a diuretic. What should the nurse monitor for as a
potential side effect of this medication?

 A) Weight gain.
 B) Hypokalemia.
 C) Hypertension.
 D) Dehydration.

Correct Answer: B
Rationale: Diuretics can cause potassium loss, leading to hypokalemia.

Question 1918: Surgical

A nurse is caring for a patient following a laparoscopic cholecystectomy. Which assessment

finding would be concerning?

 A) Moderate pain at the incision site.

 B) Clear, bile-colored drainage from the drain.
 C) Jaundice.
 D) Low-grade fever.

Correct Answer: C
Rationale: Jaundice may indicate a complication, such as a bile duct injury.

Question 1919: Infection Control

A nurse is teaching a patient about the importance of vaccinations. Which statement by the
patient indicates a correct understanding of vaccination benefits?

 A) "Vaccines can prevent all infections."

 B) "Vaccines only protect me from getting sick."
 C) "Vaccines can help protect those around me."
 D) "I do not need vaccines if I am healthy."

Correct Answer: C
Rationale: Vaccines help protect not only the individual but also those around them through
herd immunity.

Question 1920: Gastrointestinal

A patient is experiencing gastroesophageal reflux disease (GERD). Which lifestyle change

should the nurse recommend?

 A) Eating large meals.

 B) Lying down immediately after meals.
 C) Avoiding trigger foods.
 D) Drinking carbonated beverages.

Correct Answer: C
Rationale: Avoiding trigger foods can help reduce GERD symptoms.

Question 1921: Pediatric

A nurse is teaching a parent about administering an EpiPen for anaphylaxis. Which statement
indicates proper understanding?

 A) "I should inject it into the muscle of the thigh."

 B) "I can use it on any part of the body."
 C) "I should only use it if the child has difficulty breathing."
 D) "I can reuse it if I don't see an immediate response."

Correct Answer: A
Rationale: The EpiPen should be injected into the muscle of the thigh for effective absorption.

Question 1922: Neurological

A patient with a history of stroke is being discharged. Which statement by the patient indicates a
need for further teaching regarding stroke prevention?

 A) "I will continue to manage my hypertension."

 B) "I can resume smoking now that I feel better."
 C) "I will take my medications as prescribed."
 D) "I should eat a healthy diet low in saturated fats."

Correct Answer: B
Rationale: Continuing to smoke increases the risk of another stroke.

Question 1923: Maternity

A nurse is assessing a newborn. Which finding would be concerning and require further
evaluation?

 A) Head circumference of 33 cm.

 B) Grunting during expiration.
 C) Pink skin with acrocyanosis.
 D) Weight loss of 5% since birth.

Correct Answer: B
Rationale: Grunting during expiration may indicate respiratory distress and requires further
evaluation.

Question 1924: Endocrine

A patient with Addison's disease is experiencing an adrenal crisis. What is the priority nursing
intervention?

 A) Administer IV fluids.
 B) Monitor blood glucose levels.
 C) Administer glucocorticoids.
 D) Check vital signs every hour.

Correct Answer: C
Rationale: Administering glucocorticoids is crucial in managing an adrenal crisis.

Question 1925: Cardiac

A patient is being treated for angina. Which statement indicates the patient understands their
condition?

 A) "I should limit my physical activity to prevent angina."

 B) "Angina is a sign of a heart attack."
 C) "I can stop taking my medication when I feel better."
 D) "I should call for help if my angina lasts more than 15 minutes."

Correct Answer: D
Rationale: Angina lasting more than 15 minutes may indicate a myocardial infarction, requiring
immediate medical attention.

Question 1926: Pharmacology

A nurse is educating a patient about warfarin therapy. Which statement indicates a need for
further teaching?

 A) "I should avoid foods high in vitamin K."

 B) "I can take over-the-counter NSAIDs for pain."
 C) "I need to have my INR levels checked regularly."
 D) "I should report any signs of bleeding to my healthcare provider."

Correct Answer: B
Rationale: NSAIDs can increase the risk of bleeding when taken with warfarin.

Question 1927: Mental Health

A nurse is assessing a patient with major depressive disorder. Which symptom would most likely
be present?

 A) Increased energy levels.

 B) Euphoric mood.
 C) Anhedonia.
 D) Heightened self-esteem.

Correct Answer: C
Rationale: Anhedonia, or the loss of interest in activities once enjoyed, is a common symptom
of depression.

Question 1928: Pediatric

A nurse is caring for a 3-year-old child who has just had a tonsillectomy. What is the most
important assessment to perform postoperatively?

 A) Assess for difficulty swallowing.

 B) Monitor for signs of dehydration.
 C) Check for signs of bleeding.
 D) Evaluate pain level.

Correct Answer: C
Rationale: Monitoring for signs of bleeding is crucial after a tonsillectomy due to the risk of
hemorrhage.

Question 1929: Gastrointestinal

A patient with chronic pancreatitis is experiencing severe abdominal pain. Which position may
provide the patient with the most comfort?

 A) Supine.
 B) Left lateral.
 C) High-Fowler's.
 D) Knee-chest.

Correct Answer: D
Rationale: The knee-chest position can help relieve abdominal pain associated with pancreatitis.

Question 1930: Respiratory

A patient with asthma is experiencing an exacerbation. Which medication should the nurse
anticipate administering first?

 A) Corticosteroids.
 B) Long-acting beta agonists.
 C) Short-acting beta agonists.
 D) Anticholinergics.

Correct Answer: C
Rationale: Short-acting beta agonists (like albuterol) are used as rescue medications during an
asthma attack.

Question 1931: Neurological

A patient with a recent head injury is being assessed for signs of increased intracranial pressure
(ICP). Which finding would be most concerning?

 A) Slurred speech.
 B) Papilledema.
 C) Restlessness.
 D) Vomiting.

Correct Answer: B
Rationale: Papilledema is a significant indicator of increased ICP and requires immediate
attention.

Question 1932: Cardiac

A nurse is assessing a patient who has just undergone a coronary artery bypass graft (CABG).
Which finding would be a priority to report to the physician?

 A) Blood pressure of 110/70 mmHg.

 B) Heart rate of 92 bpm.
 C) Increased chest pain.
 D) Mild edema in the legs.

Correct Answer: C
Rationale: Increased chest pain may indicate a complication, such as graft failure or myocardial
ischemia.

Question 1933: Maternity

A nurse is teaching a pregnant patient about signs of preterm labor. Which statement by the
patient indicates a correct understanding?

 A) "I should ignore any back pain."

 B) "I will call my doctor if I have regular contractions."
 C) "It is normal to have a slight increase in vaginal discharge."
 D) "I should stay active to prevent preterm labor."

Correct Answer: B
Rationale: Regular contractions before 37 weeks' gestation are a sign of preterm labor and
require medical evaluation.
Question 1934: Endocrine

A patient with diabetes is being educated about blood glucose monitoring. Which statement by
the patient indicates a need for further teaching?

 A) "I will check my blood glucose levels before meals."

 B) "I should only check my blood glucose if I feel symptoms."
 C) "I need to keep a log of my blood glucose readings."
 D) "I will notify my healthcare provider if my readings are consistently high."

Correct Answer: B
Rationale: Patients should monitor their blood glucose levels regularly, not just when they feel
symptoms.

Question 1935: Infectious Disease

A patient diagnosed with tuberculosis (TB) is being discharged home. Which instruction should
the nurse include in the discharge teaching?

 A) "You can return to work immediately."

 B) "You should wear a mask when around others."
 C) "You do not need to take your medications."
 D) "You can stop taking your medications when you feel better."

Correct Answer: B
Rationale: Wearing a mask helps prevent the spread of TB until the patient is no longer
infectious.

Question 1936: Musculoskeletal

A patient with rheumatoid arthritis is experiencing a flare-up of symptoms. Which intervention

should the nurse recommend to help manage the pain?

 A) Resting the affected joints.

 B) Engaging in vigorous exercise.
 C) Applying heat to the joints.
 D) Increasing fluid intake.

Correct Answer: A
Rationale: Resting the affected joints can help reduce inflammation and manage pain.
Question 1937: Hematology

A nurse is monitoring a patient receiving heparin therapy. Which laboratory test should the nurse
monitor closely?

 A) Prothrombin time (PT).

 B) Partial thromboplastin time (aPTT).
 C) Hemoglobin and hematocrit levels.
 D) Platelet count.

Correct Answer: B
Rationale: The aPTT is monitored to assess the effectiveness of heparin therapy and to prevent
bleeding.

Question 1938: Gastrointestinal

A patient with liver cirrhosis is at risk for hepatic encephalopathy. Which symptom would the
nurse monitor for?

 A) Bradycardia.
 B) Confusion.
 C) Dehydration.
 D) Hyperactivity.

Correct Answer: B
Rationale: Confusion is a common symptom of hepatic encephalopathy due to the accumulation
of toxins.

Question 1939: Cardiovascular

A nurse is caring for a patient with heart failure. Which symptom would indicate worsening heart
failure?

 A) Increased energy levels.

 B) Decreased urination.
 C) Weight loss.
 D) Improved appetite.

Correct Answer: B
Rationale: Decreased urination can indicate fluid retention and worsening heart failure.
Question 1940: Neurological

A nurse is assessing a patient with Parkinson's disease. Which finding would be consistent with
this diagnosis?

 A) Tremors at rest.
 B) Hyperreflexia.
 C) Memory loss.
 D) Positive Babinski sign.

Correct Answer: A
Rationale: Tremors at rest are a characteristic symptom of Parkinson's disease.

Question 1941: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia. Which intervention is most
appropriate for the nurse to implement?

 A) Encourage social interaction with peers.

 B) Provide a structured environment.
 C) Allow the patient to make all decisions.
 D) Minimize contact with the healthcare team.

Correct Answer: B
Rationale: A structured environment helps provide stability and predictability for patients with
schizophrenia.

Question 1942: Endocrine

A patient with hyperthyroidism is prescribed methimazole. Which side effect should the nurse
educate the patient to report immediately?

 A) Weight gain.
 B) Rash.
 C) Fever and sore throat.
 D) Nausea.

Correct Answer: C
Rationale: Fever and sore throat may indicate agranulocytosis, a serious side effect of
methimazole.
Question 1943: Surgical

A nurse is caring for a postoperative patient who is receiving patient-controlled analgesia (PCA).
Which assessment finding would indicate the patient is experiencing a potential complication?

 A) Sedation score of 1.
 B) Respiratory rate of 8 breaths per minute.
 C) Pain score of 2 on a scale of 0-10.
 D) Blood pressure within normal limits.

Correct Answer: B
Rationale: A respiratory rate of 8 breaths per minute is indicative of respiratory depression, a
potential complication of PCA.

Question 1944: Respiratory

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which
intervention should the nurse include in the care plan?

 A) Encourage rapid, shallow breathing.

 B) Teach the patient to use pursed-lip breathing.
 C) Instruct the patient to lie flat in bed.
 D) Administer oxygen at high flow rates.

Correct Answer: B
Rationale: Pursed-lip breathing helps improve ventilation and decrease shortness of breath in
COPD patients.

Question 1945: Infection Control

A nurse is educating a patient on the use of antibiotics. Which statement indicates a need for
further teaching?

 A) "I will finish my entire course of antibiotics even if I feel better."

 B) "I can stop taking the medication if I feel sick again."
 C) "I should notify my doctor if I experience any side effects."
 D) "I should not share my antibiotics with anyone."

Correct Answer: B
Rationale: Stopping antibiotics prematurely can lead to antibiotic resistance and treatment
failure.
Question 1946: Pharmacology

A nurse is administering metoprolol to a patient with hypertension. Which assessment should the
nurse perform before administering this medication?

 A) Assess the patient’s temperature.

 B) Monitor the patient’s heart rate and blood pressure.
 C) Check for a history of seizures.
 D) Assess the patient’s level of consciousness.

Correct Answer: B
Rationale: Metoprolol can cause bradycardia and hypotension; therefore, it's important to
monitor heart rate and blood pressure before administration.

Question 1947: Gastrointestinal

A patient presents with abdominal pain and has been diagnosed with appendicitis. What is the
most appropriate nursing intervention?

 A) Apply a heating pad to the abdomen.

 B) Prepare the patient for surgery.
 C) Encourage oral intake.
 D) Administer antacids as ordered.

Correct Answer: B
Rationale: The primary intervention for appendicitis is surgical removal of the appendix,
especially if there's a risk of rupture.

Question 1948: Neurological

A patient with a stroke is showing signs of left-sided weakness. What should the nurse do first?

 A) Encourage the patient to use their left side.

 B) Assess the patient's airway and breathing.
 C) Call for a physical therapist.
 D) Document the findings in the medical record.

Correct Answer: B
Rationale: Ensuring the airway and breathing are stable is the priority in stroke care.
Question 1949: Endocrine

A nurse is educating a patient with type 1 diabetes about insulin therapy. Which statement by the
patient indicates understanding?

 A) "I will store my insulin in the freezer."

 B) "I can inject insulin into my abdomen or thigh."
 C) "I will use a 20-gauge needle for my injections."
 D) "I will take my insulin only when I feel high blood sugar."

Correct Answer: B
Rationale: Insulin can be injected into the abdomen or thigh; it should never be stored in the
freezer, and a finer needle is recommended.

Question 1950: Maternity

A pregnant woman in her third trimester is experiencing swelling in her legs and feet. What is
the most appropriate nursing intervention?

 A) Encourage her to lie down and elevate her legs.

 B) Advise her to avoid physical activity.
 C) Suggest she increase her salt intake.
 D) Recommend she sleep on her back.

Correct Answer: A
Rationale: Elevating the legs can help reduce swelling and improve circulation.

Question 1951: Respiratory

A patient is experiencing wheezing and shortness of breath due to asthma. What should the nurse
administer first?

 A) Corticosteroids.
 B) Short-acting beta-agonist (SABA).
 C) Anticholinergic medication.
 D) Long-acting beta-agonist (LABA).

Correct Answer: B
Rationale: A SABA is used as a rescue inhaler for immediate relief during an asthma
exacerbation.
Question 1952: Cardiac

A patient is diagnosed with heart failure and is prescribed furosemide. What should the nurse
monitor for as a potential side effect of this medication?

 A) Hyperkalemia.
 B) Hypertension.
 C) Hypokalemia.
 D) Bradycardia.

Correct Answer: C
Rationale: Furosemide is a loop diuretic that can lead to hypokalemia (low potassium levels).

Question 1953: Infection Control

A nurse is caring for a patient diagnosed with C. difficile. Which precautions should the nurse
implement?

 A) Contact precautions.
 B) Droplet precautions.
 C) Airborne precautions.
 D) Standard precautions.

Correct Answer: A
Rationale: C. difficile requires contact precautions to prevent the spread of the infection.

Question 1954: Mental Health

A nurse is assessing a patient with obsessive-compulsive disorder (OCD). Which symptom is

most characteristic of OCD?

 A) Hallucinations.
 B) Compulsive behaviors.
 C) Extreme mood swings.
 D) Memory loss.

Correct Answer: B
Rationale: Compulsive behaviors are a hallmark symptom of OCD.
Question 1955: Musculoskeletal

A nurse is caring for a patient with rheumatoid arthritis. Which dietary recommendation should
the nurse include?

 A) High-protein diet.
 B) Increased intake of omega-3 fatty acids.
 C) High-carbohydrate diet.
 D) Reduced fluid intake.

Correct Answer: B
Rationale: Omega-3 fatty acids have anti-inflammatory properties that can help manage
rheumatoid arthritis symptoms.

Question 1956: Pediatric

A nurse is assessing a 4-year-old child with suspected chickenpox. Which symptom would the
nurse expect to find?

 A) High fever.
 B) Koplik spots.
 C) Vesicular rash.
 D) Rigor.

Correct Answer: C
Rationale: A vesicular rash is characteristic of chickenpox.

Question 1957: Hematology

A patient is diagnosed with anemia and is receiving iron supplements. What should the nurse
include in the patient teaching?

 A) "Take the supplements with dairy products."

 B) "Expect your stool to be dark in color."
 C) "Iron supplements can cause hypoglycemia."
 D) "You should take the supplements only when feeling fatigued."

Correct Answer: B
Rationale: Dark stools are a common side effect of iron supplements and indicate that the
medication is working.
Question 1958: Surgical

A patient is scheduled for a laparoscopic cholecystectomy. What preoperative teaching should

the nurse provide?

 A) "You will have a large incision on your abdomen."

 B) "You may feel pain in your shoulder after surgery."
 C) "You will be required to stay in bed for a week."
 D) "You will be able to eat solid foods immediately after surgery."

Correct Answer: B
Rationale: Referred shoulder pain can occur after laparoscopic surgery due to irritation of the
diaphragm from carbon dioxide used during the procedure.

Question 1959: Cardiovascular

A patient with hypertension is prescribed lisinopril. What side effect should the nurse educate the
patient to report immediately?

 A) Dry cough.
 B) Dizziness.
 C) Elevated potassium levels.
 D) Swelling of the face or throat.

Correct Answer: D
Rationale: Angioedema, or swelling of the face or throat, is a serious side effect of lisinopril and
requires immediate medical attention.

Question 1960: Neurological

A nurse is caring for a patient who has had a seizure. Which intervention is most important
immediately after the seizure?

 A) Offer the patient water.

 B) Place the patient in a prone position.
 C) Assess the patient’s level of consciousness.
 D) Document the duration of the seizure.

Correct Answer: C
Rationale: Assessing the patient's level of consciousness is crucial to determine their postictal
state and any potential complications.
Question 1961: Endocrine

A patient with diabetes is experiencing hypoglycemia. Which symptom would the nurse expect
to find?

 A) Dry mouth.
 B) Increased thirst.
 C) Sweating and tremors.
 D) Nausea and vomiting.

Correct Answer: C
Rationale: Sweating and tremors are common symptoms of hypoglycemia.

Question 1962: Gastrointestinal

A nurse is caring for a patient with a nasogastric (NG) tube. Which nursing intervention is
essential to prevent complications?

 A) Flush the NG tube with water every 12 hours.

 B) Keep the head of the bed elevated at least 30 degrees.
 C) Change the NG tube every 24 hours.
 D) Administer medications through the NG tube without checking placement.

Correct Answer: B
Rationale: Keeping the head of the bed elevated helps prevent aspiration and promotes gastric
drainage.

Question 1963: Infectious Disease

A nurse is caring for a patient with viral hepatitis. Which lab result would indicate a worsening
condition?

 A) Decreased liver enzymes.

 B) Elevated bilirubin levels.
 C) Normal coagulation profile.
 D) Increased albumin levels.

Correct Answer: B
Rationale: Elevated bilirubin levels indicate worsening liver function and potential liver failure.
Question 1964: Mental Health

A patient diagnosed with bipolar disorder is in a manic phase. Which nursing intervention is
most appropriate?

 A) Encourage the patient to talk about their feelings.

 B) Set limits on inappropriate behavior.
 C) Allow the patient to make all decisions.
 D) Minimize contact with the patient.

Correct Answer: B
Rationale: Setting limits is important to ensure the safety of the patient and others during a
manic episode.

Question 1965: Obstetrics

A nurse is caring for a pregnant patient who reports decreased fetal movement. What is the
priority nursing action?

 A) Encourage the patient to eat something sweet.

 B) Perform a non-stress test (NST).
 C) Reassure the patient that decreased movement is normal.
 D) Advise the patient to rest for a few hours.

Correct Answer: B
Rationale: A non-stress test should be performed to assess fetal well-being and rule out any
complications.

Question 1966: Pediatric

A nurse is preparing to administer an intramuscular injection to a 3-year-old child. Which site is

preferred for this age group?

 A) Dorsogluteal site.
 B) Vastus lateralis site.
 C) Deltoid site.
 D) Ventrogluteal site.
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in young children due to its
size and ease of access.

Question 1967: Surgical

A nurse is providing discharge teaching to a patient after laparoscopic surgery. Which statement
indicates that the patient understands the teaching?

 A) "I can resume all activities immediately."

 B) "I will call the doctor if I have a fever or increased pain."
 C) "I should eat solid foods right away."
 D) "I will take my pain medication only when needed."

Correct Answer: B
Rationale: The patient should report any signs of infection or increased pain post-surgery.

Question 1968: Nutrition

A nurse is discussing dietary changes with a patient diagnosed with chronic kidney disease
(CKD). Which food should the nurse recommend avoiding?

 A) Apples.
 B) Bananas.
 C) Carrots.
 D) Rice.

Correct Answer: B
Rationale: Bananas are high in potassium, which should be limited in patients with CKD.

Question 1969: Pain Management

A patient postoperatively is requesting pain medication. The nurse reviews the medication orders
and sees a prescription for morphine. What is the most important assessment before
administering the medication?

 A) Assess the patient’s surgical site.

 B) Evaluate the patient’s pain level.
 C) Monitor the patient’s respiratory rate.
 D) Check the patient's temperature.
Correct Answer: C
Rationale: Morphine can cause respiratory depression; therefore, assessing the respiratory rate is
crucial before administration.

Question 1970: Respiratory

A patient with chronic obstructive pulmonary disease (COPD) is being discharged with a
prescription for home oxygen therapy. Which instruction should the nurse provide?

 A) "Use oxygen continuously during the day and night."

 B) "You can adjust the flow rate as needed."
 C) "Avoid using oxygen when sleeping."
 D) "Do not smoke while using oxygen."

Correct Answer: D
Rationale: Smoking while using oxygen can cause a fire hazard; patients must be educated to
avoid smoking entirely during oxygen therapy.

Question 1971: Infection Control

A patient with tuberculosis is being discharged home. What is the most important instruction the
nurse should provide?

 A) "You should wear a mask when around others."

 B) "Take your medication until your symptoms resolve."
 C) "Stay away from crowded places for at least 6 months."
 D) "You can stop treatment once your sputum is negative."

Correct Answer: A
Rationale: Patients with tuberculosis should wear a mask to prevent the spread of infection to
others, especially in the initial treatment phase.

Question 1972: Cardiac

A nurse is monitoring a patient receiving digoxin. Which sign indicates potential digoxin
toxicity?

 A) Weight loss.
 B) Bradycardia.
 C) Increased urine output.
  D) Warm, dry skin.

Correct Answer: B
Rationale: Bradycardia is a common sign of digoxin toxicity and requires further evaluation.

Question 1973: Neurological

A patient diagnosed with multiple sclerosis is experiencing muscle spasticity. Which medication
is most likely to be prescribed?

 A) Baclofen.
 B) Levodopa.
 C) Gabapentin.
 D) Amitriptyline.

Correct Answer: A
Rationale: Baclofen is a muscle relaxant commonly used to treat muscle spasticity in multiple
sclerosis.

Question 1974: Gastrointestinal

A nurse is caring for a patient with cirrhosis who develops ascites. Which nursing intervention is
a priority?

 A) Administer diuretics as prescribed.

 B) Monitor for jaundice.
 C) Encourage a low-protein diet.
 D) Assess the patient’s level of consciousness.

Correct Answer: A
Rationale: Administering diuretics can help reduce fluid accumulation and manage ascites.

Question 1975: Maternity

A nurse is assessing a postpartum patient who is breastfeeding. What is the best way to
encourage the mother to produce more milk?

 A) Encourage her to drink more fluids.

 B) Suggest she use a breast pump regularly.
 C) Advise her to supplement with formula.
  D) Instruct her to limit feeding sessions.

Correct Answer: B
Rationale: Using a breast pump can help stimulate milk production by increasing demand.

Question 1976: Endocrine

A patient with Addison’s disease is experiencing an adrenal crisis. What should the nurse
administer immediately?

 A) Oral glucocorticoids.
 B) IV fluids.
 C) IV hydrocortisone.
 D) Insulin.

Correct Answer: C
Rationale: IV hydrocortisone is required to treat adrenal crisis, which can be life-threatening.

Question 1977: Respiratory

A nurse is caring for a patient with pneumonia. Which assessment finding is most concerning?

 A) Productive cough.
 B) Increased respiratory rate.
 C) Diminished breath sounds on one side.
 D) Low-grade fever.

Correct Answer: C
Rationale: Diminished breath sounds on one side may indicate a pleural effusion or other
complication and should be further evaluated.

Question 1978: Pharmacology

A nurse is teaching a patient about warfarin therapy. Which statement indicates that the patient
needs further teaching?

 A) "I should avoid leafy green vegetables."

 B) "I will have my INR levels checked regularly."
 C) "I can take aspirin for pain."
 D) "I need to inform my doctor if I have any unusual bleeding."
Correct Answer: C
Rationale: Aspirin can increase the risk of bleeding when taken with warfarin and should
generally be avoided unless directed by a healthcare provider.

Question 1979: Mental Health

A patient diagnosed with major depressive disorder is prescribed an SSRI. Which symptom
should the nurse monitor for as a potential side effect?

 A) Increased energy.
 B) Hypotension.
 C) Sexual dysfunction.
 D) Increased appetite.

Correct Answer: C
Rationale: Sexual dysfunction is a common side effect of selective serotonin reuptake inhibitors
(SSRIs).

Question 1980: Pediatric

A nurse is caring for a child with asthma. Which of the following should the nurse include in the
teaching plan?

 A) "You can stop using your inhaler when you feel better."
 B) "It's important to recognize and avoid your triggers."
 C) "You should use your inhaler only during an asthma attack."
 D) "Taking steroids will prevent your asthma symptoms."

Correct Answer: B
Rationale: Identifying and avoiding triggers is essential in managing asthma effectively.

Question 1981: Hematology

A nurse is caring for a patient with thrombocytopenia. Which precaution is most important to
include in the patient’s care plan?

 A) Avoiding physical activity.

 B) Monitoring for signs of infection.
 C) Implementing bleeding precautions.
 D) Encouraging a high-fiber diet.
Correct Answer: C
Rationale: Implementing bleeding precautions is essential to prevent injury due to low platelet
levels.

Question 1982: Surgical

A patient is scheduled for a total hip replacement. Which postoperative position should the nurse
encourage to prevent complications?

 A) Supine with legs crossed.

 B) Lateral position on the unaffected side.
 C) Semi-Fowler's position.
 D) Prone position.

Correct Answer: B
Rationale: Positioning the patient on the unaffected side helps prevent hip dislocation and
promotes comfort.

Question 1983: Nutrition

A nurse is providing dietary instructions for a patient with hypertension. Which food choice
should the nurse encourage?

 A) Canned soups.
 B) Fresh fruits and vegetables.
 C) Processed meats.
 D) Whole milk.

Correct Answer: B
Rationale: Fresh fruits and vegetables are low in sodium and beneficial for managing
hypertension.

Question 1984: Infection Control

A nurse is caring for a patient with MRSA. Which precaution should the nurse implement?

 A) Airborne precautions.
 B) Contact precautions.
 C) Droplet precautions.
 D) Standard precautions.
Correct Answer: B
Rationale: MRSA requires contact precautions to prevent transmission to others.

Question 1985: Cardiac

A patient is prescribed atorvastatin for hyperlipidemia. Which lab result should the nurse
monitor?

 A) Blood glucose.
 B) Liver function tests.
 C) Thyroid function tests.
 D) Electrolytes.

Correct Answer: B
Rationale: Statins can affect liver function, so monitoring liver enzymes is important.

Question 1986: Gastrointestinal

A nurse is caring for a patient with a colostomy. Which statement by the patient indicates a need
for further teaching?

 A) "I should change my ostomy bag when it's one-third full."

 B) "I can eat any foods I like now."
 C) "I need to monitor for signs of skin irritation."
 D) "I should empty my ostomy bag regularly."

Correct Answer: B
Rationale: While many foods can be eaten, some may cause blockages or gas, so dietary
adjustments may be necessary.

Question 1987: Endocrine

A nurse is teaching a patient with diabetes about the importance of foot care. What should the
nurse emphasize?

 A) "Inspect your feet daily for cuts or blisters."

 B) "Wear tight-fitting shoes to avoid blisters."
 C) "Soak your feet in hot water daily."
 D) "Only see a podiatrist if you have an infection."
Correct Answer: A
Rationale: Daily inspection of the feet is crucial for early detection of problems in patients with
diabetes.

Question 1988: Mental Health

A nurse is caring for a patient diagnosed with schizophrenia. Which symptom would the nurse
expect to see?

 A) Depression.
 B) Hallucinations.
 C) Obsessive thoughts.
 D) Panic attacks.

Correct Answer: B
Rationale: Hallucinations are a common symptom of schizophrenia.

Question 1989: Maternity

A postpartum nurse is assessing a patient for signs of postpartum hemorrhage. Which finding is
most concerning?

 A) Saturation of a pad in less than 1 hour.

 B) Increased heart rate.
 C) Mild abdominal cramping.
 D) Fundus firm at the umbilicus.

Correct Answer: B
Rationale: An increased heart rate may indicate hypovolemia due to hemorrhage and should be
investigated further.

Question 1990: Neurological

A nurse is assessing a patient with a head injury. Which sign would indicate increased
intracranial pressure (ICP)?

 A) Bradycardia.
 B) Clear nasal drainage.
 C) Increased blood pressure.
 D) Pupil constriction.
Correct Answer: C
Rationale: Increased blood pressure is often a compensatory response to increased ICP.

Question 1991: Pharmacology

A nurse is preparing to administer a beta-blocker to a patient with hypertension. Which

assessment is a priority before administration?

A) Blood glucose level.

B) Blood pressure and heart rate.

C) Respiratory rate.

D) Temperature.

Correct Answer: B
Rationale: Assessing blood pressure and heart rate is crucial before administering a beta-blocker
to avoid bradycardia and hypotension.

Question 1992: Cardiovascular

A patient is diagnosed with heart failure. Which of the following symptoms would the nurse
expect to see?

A) Weight loss.

B) Bradycardia.

C) Peripheral edema.

D) Decreased urine output.

Correct Answer: C
Rationale: Peripheral edema is a common symptom of heart failure due to fluid retention.

Question 1993: Respiratory

A nurse is caring for a patient with a tracheostomy. What is the priority nursing intervention?
 A) Provide humidified oxygen.

B) Suction the tracheostomy as needed.

C) Change the tracheostomy tube every 30 days.

D) Encourage deep breathing exercises.

Correct Answer: B
Rationale: Suctioning the tracheostomy as needed is essential for maintaining a patent airway.

Question 1994: Nutrition

A nurse is educating a patient with chronic kidney disease about dietary restrictions. Which food
should the patient avoid?

A) Chicken.

B) Potatoes.

C) Apples.

D) Bread.

Correct Answer: B
Rationale: Potatoes are high in potassium, which should be limited in patients with chronic
kidney disease.

Question 1995: Pain Management

A patient is prescribed a PCA (patient-controlled analgesia) pump. Which statement by the

patient indicates a need for further teaching?

A) "I can press the button whenever I want."

B) "This will help me manage my pain."

C) "I should wait until my pain is severe before using it."

D) "I will let my nurse know if it’s not effective."

Correct Answer: C
Rationale: Patients should use the PCA pump at the onset of pain, not wait until it becomes
severe.

Question 1996: Pediatric

A nurse is assessing a child with suspected asthma. Which assessment finding would be most
indicative of an asthma exacerbation?

A) Decreased respiratory rate.

B) Clear lung sounds.

C) Prolonged expiration phase.

D) Bradypnea.

Correct Answer: C
Rationale: Prolonged expiration is characteristic of an asthma exacerbation due to airway
obstruction.

Question 1997: Endocrine

A patient with diabetes is experiencing hypoglycemia. What is the priority nursing action?

A) Administer insulin.

B) Provide a snack high in protein.

C) Administer oral glucose.

D) Call for assistance.

Correct Answer: C
Rationale: Administering oral glucose is the priority action to quickly raise blood sugar levels in
a hypoglycemic patient.

Question 1998: Mental Health

A nurse is caring for a patient with anxiety disorder. Which intervention is most appropriate?
 A) Encourage the patient to express feelings.

B) Limit social interactions.

C) Provide distractions to avoid anxiety.

D) Teach relaxation techniques.

Correct Answer: D
Rationale: Teaching relaxation techniques can help the patient manage anxiety effectively.

Question 1999: Infection Control

A patient with a history of MRSA is being admitted to the hospital. Which precaution should the
nurse implement?

A) Droplet precautions.

B) Airborne precautions.

C) Contact precautions.

D) Standard precautions.

Correct Answer: C
Rationale: Contact precautions are necessary to prevent the spread of MRSA.

Question 2000: Obstetrics

A nurse is teaching a pregnant woman about the signs of labor. Which sign indicates that labor
may be imminent?

A) Lightening.

B) Increased energy.

C) Braxton Hicks contractions.

D) Vaginal discharge changes.

Correct Answer: A
Rationale: Lightening, or the descent of the fetus into the pelvis, indicates that labor may be
imminent.

Question 2001: Neurological

A nurse is assessing a patient with a stroke. Which assessment finding would indicate right-sided
brain involvement?

A) Impaired speech.

B) Right-sided weakness.

C) Left-sided neglect.

D) Changes in vision.

Correct Answer: C
Rationale: Left-sided neglect indicates right-sided brain involvement due to the way the brain
processes sensory information.

Question 2002: Surgical

A patient is post-operative after an appendectomy. Which assessment finding should the nurse
report immediately?

A) Tenderness at the incision site.

B) Low-grade fever.

C) Absent bowel sounds.

D) Clear drainage from the incision.

Correct Answer: C
Rationale: Absent bowel sounds may indicate a bowel obstruction or ileus, which requires
immediate attention.

Question 2003: Cardiac

A nurse is caring for a patient who is experiencing chest pain. Which of the following
interventions should the nurse implement first?

A) Obtain an ECG.

B) Administer nitroglycerin.

C) Call the healthcare provider.

D) Assess vital signs.

Correct Answer: D
Rationale: Assessing vital signs is crucial to determine the severity of the patient's condition and
guide further interventions.

Question 2004: Gastrointestinal

A nurse is teaching a patient about managing gastroesophageal reflux disease (GERD). Which
statement indicates a need for further education?

A) "I should eat smaller, more frequent meals."

B) "I can lie down immediately after eating."

C) "I should avoid spicy foods."

D) "I can elevate the head of my bed."

Correct Answer: B
Rationale: Patients should avoid lying down immediately after eating to reduce the risk of
reflux.

Question 2005: Pediatric

A nurse is assessing a 6-month-old infant. Which developmental milestone should the nurse
expect the infant to achieve?

A) Sitting without support.

B) Crawling.

C) Babbling.
 D) Walking.

Correct Answer: C
Rationale: Babbling is a developmental milestone typically achieved by 6 months of age.

Question 2006: Hematology

A patient with anemia is prescribed iron supplements. What should the nurse instruct the patient
regarding the use of these supplements?

A) "Take the iron with dairy products to enhance absorption."

B) "Expect dark stools as a normal side effect."

C) "You may take the iron at any time of day."

D) "Take the iron with antacids for better absorption."

Correct Answer: B
Rationale: Dark stools are a common side effect of iron supplements, indicating the medication
is working.

Question 2007: Nutrition

A nurse is educating a patient with hypertension about dietary modifications. Which food should
the nurse advise the patient to limit?

A) Fresh fruits.

B) Whole grains.

C) Processed foods.

D) Lean meats.

Correct Answer: C
Rationale: Processed foods often contain high levels of sodium, which can contribute to
increased blood pressure.

Question 2008: Maternity

A nurse is assessing a pregnant patient in her third trimester. What is a normal finding during this
stage of pregnancy?

A) Frequent urination.

B) Decreased fetal movement.

C) Abdominal cramping.

D) Elevated blood pressure.

Correct Answer: A
Rationale: Frequent urination is common in the third trimester due to pressure on the bladder.

Question 2009: Infection Control

A nurse is preparing to care for a patient with a respiratory infection. What type of mask should
the nurse wear to protect against airborne pathogens?

A) Surgical mask.

B) N95 respirator.

C) Simple mask.

D) Face shield.

Correct Answer: B
Rationale: An N95 respirator is required for protection against airborne pathogens.

Question 2010: Mental Health

A nurse is developing a care plan for a patient with major depressive disorder. Which
intervention should be included to enhance the patient’s motivation?

A) Encourage isolation to avoid overstimulation.

B) Set small, achievable goals.

C) Limit interactions with family.

D) Focus on the patient’s past failures.

Correct Answer: B
Rationale: Setting small, achievable goals can help enhance motivation and provide a sense of
accomplishment.