NCLEX-RN Nursing — All Questions

A nurse is caring for a client at risk for pressure injuries. Which intervention is most effective for prevention?

• a.Keep the head of the bed elevated at 90 degrees continuously
• b.Use a doughnut-shaped cushion for sitting
• c.Reposition the client at least every two hours✓
• d.Massage bony prominences vigorously

Repositioning at least every two hours relieves pressure over bony prominences and prevents skin breakdown. Massaging bony areas and doughnut cushions can cause tissue damage.

A client has a new order for a clear liquid diet. Which item is appropriate?

• a.Melted vanilla ice cream
• b.Orange juice with pulp
• c.Cream of chicken soup
• d.Apple juice and gelatin✓

Clear liquids are transparent and leave little residue, such as apple juice and plain gelatin. Pulp, cream soups, and ice cream are not clear liquids.

A nurse is assisting a client with dysphagia to eat. Which action promotes safe swallowing?

• a.Position the client upright and encourage chin-tuck swallowing✓
• b.Encourage rapid eating so the meal is finished while food is warm
• c.Have the client lie flat while eating to relax the throat
• d.Offer thin liquids through a straw so that swallowing takes less effort

Sitting upright with a chin-tuck reduces aspiration risk in dysphagia. Lying flat, thin liquids, and rushing increase aspiration risk.

A nurse is providing oral care to an unconscious client. Which action is most important for safety?

• a.Use large amounts of water to rinse the mouth well
• b.Position the client side-lying to prevent aspiration✓
• c.Place the client supine with the head flat to see better
• d.Insert gloved fingers between the teeth to hold it open

A side-lying position allows secretions to drain and prevents aspiration during oral care in an unconscious client. Minimal fluid and safe technique protect the airway.

A nurse is caring for a client with a nasogastric tube for feeding. What action best confirms placement before feeding?

• a.Verify placement per facility protocol, often with pH testing or radiographic confirmation✓
• b.Ask the client whether the tube feels correctly placed before starting
• c.Auscultate over the stomach while injecting air through the tube with a syringe
• d.Place the end of the tube in a cup of water and watch for bubbles before feeding

Current standards rely on pH testing of aspirate and radiographic confirmation to verify tube placement. The auscultation and water-bubble methods are unreliable.

A client reports constipation. Which intervention should the nurse implement first?

• a.Restrict the client's oral intake to rest the bowel
• b.Administer a cleansing enema before trying other measures
• c.Increase fluid and fiber intake and encourage activity✓
• d.Request a prescription for a daily stimulant laxative first

Nonpharmacologic measures such as increasing fluids, fiber, and activity are first-line for constipation. Enemas and laxatives are used when conservative measures fail.

A nurse is measuring a client's urine output through an indwelling catheter. Which finding should be reported to the provider?

• a.Clear yellow urine totaling 60 mL over the past hour in a stable client
• b.Urine output of less than 30 mL per hour for two consecutive hours✓
• c.Slightly increased urine output an hour after a scheduled diuretic dose
• d.Pale straw-colored urine draining steadily into the closed drainage bag

Urine output below 30 mL per hour may indicate inadequate renal perfusion or obstruction and should be reported. Clear, adequate output is a normal finding.

A nurse is assisting a client to use crutches on level ground. Where should the top of the crutch rest?

• a.Directly under the axilla to bear the weight
• b.Level with the waist so the arms stay straight
• c.About two finger-widths below the axilla✓
• d.Against the mid-chest to steady the client

Crutch tops should rest about two finger-widths below the axilla to avoid pressure on the brachial nerves, with weight borne on the hands. Resting on the axillae can cause nerve damage.

A nurse is caring for a client on bed rest. Which intervention prevents venous thromboembolism?

• a.Placing pillows under the knees continuously to keep the legs supported
• b.Encouraging leg exercises and applying sequential compression devices✓
• c.Massaging the calves firmly to relieve stiffness and improve leg comfort
• d.Keeping the client's legs crossed at the ankles because it feels comfortable

Leg exercises and sequential compression devices promote venous return and prevent clot formation. Crossing the legs, calf massage, and continuous knee flexion impede circulation.

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

• a.Use the same section of the cloth for each stroke
• b.Apply powder around the catheter insertion site to keep it dry
• c.Clean from the urethra outward, away from the anus✓
• d.Clean from the anus toward the urethra with one stroke

Perineal care is performed from the cleanest area, the urethra, toward the anus to prevent introducing bacteria. A clean cloth section is used for each stroke.

A client is being repositioned to prevent complications of immobility. Which position best relieves pressure on the sacrum while maintaining alignment?

• a.Prone position for extended periods
• b.Supine with the head of the bed at 90 degrees
• c.The 30-degree lateral (side-lying) position✓
• d.High Fowler's position continuously

The 30-degree lateral position offloads the sacrum and trochanter while maintaining alignment. High Fowler's and prolonged supine positions increase shear and sacral pressure.

A nurse is caring for a client with a stage 2 pressure injury. Which description matches this stage?

• a.Intact, unbroken skin showing localized nonblanchable redness over a bony prominence
• b.Partial-thickness loss of the dermis presenting as a shallow open ulcer✓
• c.Skin loss covered entirely by eschar, so that the depth cannot be judged
• d.Full-thickness loss with exposed bone, tendon, or supporting muscle

A stage 2 pressure injury is partial-thickness skin loss involving the dermis, appearing as a shallow open ulcer or blister. Nonblanchable redness is stage 1 and exposed bone is stage 4.

A client who is NPO reports a dry mouth. Which comfort measure is appropriate?

• a.Offer frequent oral care and moisten the lips✓
• b.Encourage the client to drink small sips of juice
• c.Provide a large glass of water
• d.Give the client hard candy to suck

For an NPO client, oral care and lip moisture relieve dryness without violating the NPO status. Providing water, candy, or juice would break the NPO order.

A nurse is applying antiembolism stockings. Which action is correct?

• a.Apply the stockings while the client is lying down before rising✓
• b.Leave a few wrinkles in the stocking to allow for flexibility
• c.Apply the stockings after the client has been up walking in the hall
• d.Roll the top of the stocking down to create a snug, secure fit

Antiembolism stockings are applied before the client rises, while lying down, to prevent pooling of blood. Rolling the top or leaving wrinkles can create a tourniquet effect.

A nurse is assisting an 82-year-old client who has mild left-sided weakness after a stroke with a bed bath. The client washes his own face and chest but works slowly and pauses to rest. Which action by the nurse best supports the client's performance of this activity of daily living?

• a.Postpone the bath until the client can wash every area by himself
• b.Complete the entire bath quickly so the client is able to rest sooner
• c.Have the client repeat each area until he can do it without resting
• d.Let the client wash the areas he can reach and finish the others for him✓

Letting the client do what he is able to do and completing the rest preserves strength, mobility, and self-esteem, which is the goal of ADL assistance. Taking the whole bath over because it is faster is the most tempting alternative, but doing for a client what he can do for himself accelerates the decline in function that the nurse is trying to prevent.

A nurse is teaching a client who has weakness of the right leg how to walk with a single-point cane on level ground. What instruction should the nurse give about the cane?

• a.Hold it in the right hand and move it forward with the right leg
• b.Hold it in the left hand and move it forward with the left leg
• c.Hold it in the left hand and move it forward with the right leg✓
• d.Hold it in the right hand and move it forward with the left leg

The cane is held in the hand opposite the weaker leg and advanced at the same time as that weaker leg, so the cane and the weak limb share the load and the base of support widens. Holding the cane on the same side as the weak leg puts the support under the side that is already failing and narrows the stance.

A client who had a right total knee arthroplasty is learning to go down a flight of stairs using a cane and the handrail. Which sequence should the nurse teach the client to use?

• a.Cane first, then the left leg, then the right leg
• b.Left leg first, then the right leg, then the cane
• c.Right leg first, then the cane, then the left leg
• d.The cane first, then the right leg, then the left leg✓

Going down, the cane is set on the lower step first, the weaker (operative right) leg follows, and the stronger leg comes down last, which is the basis of the phrase 'up with the good, down with the bad.' Leading down with the stronger leg leaves the weak knee to absorb the full body weight on the descent.

A nurse is helping a client who has left hemiplegia after a stroke put on a front-opening shirt. Which action should the nurse take?

• a.Place the right arm into its sleeve before the left arm
• b.Pull the shirt over the head before placing either arm
• c.Place the left arm into the sleeve before the right✓
• d.Place both arms into their sleeves at the same time

The weaker limb goes into the garment first, while the sleeve is still loose and the stronger arm is free to guide it, which protects the affected shoulder and hand from strain. Dressing the strong arm first leaves the client trying to force the flaccid arm through a sleeve that is already anchored by the rest of the shirt; when undressing, the order reverses and the strong side comes out first.

Before giving an intermittent feeding, a nurse notes that the marking on the client's nasogastric feeding tube now sits 6 cm farther out of the nares than the length documented after the confirming x-ray. Which action should the nurse take?

• a.Hold the feeding and arrange for radiographic confirmation of the tube✓
• b.Start the feeding slowly and watch the client for coughing or gagging
• c.Inject 30 mL of air and listen over the stomach, then start the feeding
• d.Advance the tube 6 cm to the documented mark and start the feeding

A change in the external tube length means the tip may no longer be in the stomach, so the feeding is held and placement is re-established radiographically before anything is instilled. Auscultating an injected air bolus is the most tempting shortcut and is still taught in some texts, but air can be heard over the epigastrium even when the tube sits in the airway, so it is not an acceptable verification method.

A nurse has just finished administering a 300 mL intermittent gastric tube feeding to a client who is on bed rest. Which action should the nurse take next?

• a.Keep the head of the bed at 30 to 45 degrees for at least an hour✓
• b.Lower the head of the bed to 15 degrees once the feeding ends
• c.Lay the client flat for an hour so the formula empties evenly
• d.Turn the client fully prone for the next hour to aid digestion

Keeping the head of the bed at 30 to 45 degrees during the feeding and for at least an hour afterward uses gravity to keep formula in the stomach and is the core aspiration precaution for enteral feeding. Lowering the head of the bed right after a bolus, for any stated reason, puts gastric contents at the level of the esophagus while the stomach is still full.

A client dies unexpectedly two hours after admission, and the death is referred to the medical examiner. An endotracheal tube and two intravenous catheters are still in place. Which action should the nurse take?

• a.Clip the intravenous lines at the skin and cap the airway
• b.Take out the endotracheal tube and the intravenous lines
• c.Remove the lines and chart the location of each insertion site
• d.Leave the endotracheal tube and the intravenous lines in place✓

In a medical examiner or coroner case the therapeutic devices are part of the evidence, because their position tells the death investigator whether they were placed correctly; removing or altering them before the investigator documents them is considered alteration of evidence. Charting the sites carefully does not substitute for leaving the devices where the investigator can see them.

A nurse is preparing to irrigate an adult client's ear canal to remove impacted cerumen. Which action most directly prevents the client from becoming dizzy during the procedure?

• a.Warm the irrigating solution to body temperature✓
• b.Chill the irrigating solution to numb the ear canal first
• c.Direct the stream straight onto the tympanic membrane
• d.Deliver the whole solution in one rapid high-pressure push

Solution that is cooler or warmer than body temperature sets up convection currents in the semicircular canals and provokes the caloric response, producing vertigo, nystagmus, and nausea; warming the solution to roughly 37 degrees Celsius prevents this. Aiming the stream at the tympanic membrane or using high pressure is unsafe because it risks perforation, not because it causes dizziness.

A client arrives in the emergency department five minutes after an alkaline drain cleaner splashed into the right eye. The eye is tearing and the client is squinting. Which action should the nurse take first?

• a.Measure visual acuity in both eyes before any fluid is instilled
• b.Cover the eye with a dry sterile pad and wait for the provider
• c.Instill an antibiotic ointment and then flush the eye with saline
• d.Flush the eye with saline, directing flow from the inner corner outward✓

An alkali burn keeps saponifying tissue until it is diluted, so immediate copious irrigation comes before every other step, including visual acuity, and the flow runs from the inner canthus outward so contaminated fluid does not cross to the unaffected eye. Checking acuity first feels thorough but costs minutes of continuing corneal injury.

A client has continuous bladder irrigation after a transurethral resection of the prostate. During a 12-hour shift the nurse hangs three 2,000 mL bags of irrigating solution; at the end of the shift 400 mL is still in the hanging bag. The drainage bag output for the shift totals 6,150 mL. What is the client's urine output for the shift?

• a.150 mL
• b.550 mL✓
• c.5,600 mL
• d.6,150 mL

Everything instilled into the bladder drains back out, so urine equals total drainage minus irrigant actually infused. Irrigant infused = 3 bags x 2,000 mL = 6,000 mL hung, minus 400 mL still hanging = 5,600 mL. Urine = 6,150 mL - 5,600 mL = 550 mL. Checking it the other way: two bags ran in completely (4,000 mL) and 1,600 mL of the third ran in (2,000 - 400), giving the same 5,600 mL infused and the same 550 mL of urine. Subtracting all 6,000 mL hung, rather than the 5,600 mL infused, yields 150 mL and understates the output.

A nurse assesses a pressure injury over a client's ischial tuberosity. It is an open full-thickness ulcer with visible yellow subcutaneous fat and rolled wound edges; no fascia, muscle, tendon, or bone is visible or palpable, and the base is not obscured. How should the nurse stage this injury?

• a.Stage 2 pressure injury
• b.Stage 4 pressure injury
• c.Unstageable pressure injury
• d.Stage 3 pressure injury✓

Stage 3 is full-thickness skin loss in which adipose is visible and rolled edges (epibole) and granulation tissue are often present, while fascia, muscle, tendon, ligament, cartilage, and bone are not exposed. Stage 4 is the tempting alternative but requires those deeper structures to be visible or directly palpable, and visible fat rules out stage 2, in which adipose is not visible.

A nurse finds a 4 cm area of intact skin over a client's heel that is a persistent deep maroon color and does not blanch under pressure. The area feels boggy and warmer than the surrounding skin. How should the nurse document this finding?

• a.Stage 1 pressure injury
• b.Deep tissue pressure injury✓
• c.Stage 2 pressure injury
• d.Unstageable pressure injury

Persistent non-blanchable deep red, maroon, or purple discoloration of intact skin, often with a boggy texture and temperature change, is a deep tissue pressure injury caused by pressure and shear at the bone-muscle interface. Stage 1 is the closest look-alike, but its definition explicitly excludes purple or maroon discoloration, and unstageable requires an open full-thickness wound whose base is hidden by slough or eschar.

A client's stage 4 sacral pressure injury has filled in with granulation tissue over six weeks and is now shallow, with no bone or tendon palpable. How should the nurse document the injury at this point?

• a.As a healing stage 3 pressure injury
• b.As a resolved stage 4 pressure injury
• c.As a healing stage 4 pressure injury✓
• d.As a healing stage 2 pressure injury

The stage records the deepest tissue that was lost, and the staging system implies no progression in either direction, so an injury is not reverse staged or down staged as it fills in; it stays a stage 4 and is described as healing. Calling it a stage 3 or stage 2 is the common error, and it is wrong physiologically as well: full-thickness loss is replaced by scar tissue, not by the muscle and fat that were destroyed.

On the second postoperative day a nurse changes the pouch of a client who has a new descending colostomy. The stoma is dusky purple and dry rather than moist. Which action should the nurse take?

• a.Massage the stoma gently to improve its blood flow
• b.Record the appearance as expected for a new stoma
• c.Apply a warm compress and reassess in four hours
• d.Report the appearance of the stoma to the provider promptly✓

A viable stoma is moist and pink to dark red; a bluish, purple, black, or pale stoma signals impaired perfusion and must be reported without delay because the segment can become ischemic. Documenting it as normal is the trap here, since some swelling and oozing genuinely are expected on postoperative day two, but a colour change is not.

A nurse empties the drainage bag of a 70 kg adult client's indwelling urinary catheter at 0600 and again at 1400, measuring 208 mL for those eight hours. The urine is dark amber. Which action should the nurse take?

• a.Notify the provider; output averages about 26 mL per hour✓
• b.Notify the provider; output averages about 13 mL per hour
• c.Continue routine monitoring; output averages 42 mL per hour
• d.Continue routine monitoring; output averages 26 mL per hour

208 mL divided by 8 hours = 26 mL/hr; multiplying back, 26 x 8 = 208 mL, which confirms it. That is below the 30 mL/hr threshold for notifying the provider, and it is also below 0.5 mL/kg/hr, which for a 70 kg client is 35 mL/hr, so both benchmarks agree that this output must be escalated rather than simply monitored. Dividing 208 by 5 instead of 8 gives the incorrect 42 mL/hr.

Six hours after a short-arm fiberglass cast is applied for a radius fracture, a client reports deep forearm pain that is worse than before and is not relieved by the prescribed opioid. Passive extension of the fingers reproduces severe pain. Which action should the nurse take first?

• a.Give the next scheduled opioid dose early, then reassess
• b.Contact the provider at once about splitting the cast✓
• c.Raise the arm well above heart level and reassess later
• d.Apply ice over the cast and have the client make a fist

Pain out of proportion to the injury and pain on passive stretch of the digits are the earliest signs of acute compartment syndrome, and the restrictive cast must be bivalved or split, which requires the provider now; pulselessness, pallor, and paralysis are late findings and waiting for them costs the limb. Elevating above heart level is the tempting comfort measure but reduces arterial inflow, so the limb is kept at heart level.

A nurse finds that the weights of a client's balanced skeletal traction are resting on the floor because the client has slid toward the foot of the bed. Which action should the nurse take?

• a.Add a weight to restore the pull the traction has now lost
• b.Shorten the rope so the weights clear the floor by an inch
• c.Reposition the client up in bed so the weights hang free✓
• d.Remove the weights until the client is repositioned in bed

Traction pulls only while the weights hang freely, so the nurse restores the pull by moving the client back up in bed, keeping the prescribed weight and rope untouched. Lifting or removing weights from a client with a fracture releases the reduction and causes muscle spasm, and it is done only on the provider's order or in an emergency.

A nurse is giving a complete bed bath to a client in a semiprivate room while the client's roommate has visitors. Which action best protects the client's dignity and privacy?

• a.Work as fast as possible so that the exposure time is shortened
• b.Draw the curtain and uncover only the area being washed✓
• c.Leave the privacy curtain open so the client can see the doorway
• d.Draw the privacy curtain and remove the gown for the whole bath

Screening the client and keeping a bath blanket over everything except the part actively being washed protects modesty throughout the procedure. Pulling the curtain but stripping the client for the whole bath is the closest wrong answer because it does half the job: the curtain alone does not prevent unnecessary exposure to the nurse or to anyone who steps through it.

A nurse cares for a client with advanced dementia who can no longer report pain in words. During repositioning the client grimaces, moans, and pushes the nurse's hands away. Which action should the nurse take?

• a.Score the pain with a validated behavioral scale✓
• b.Chart that pain cannot be rated because of the dementia
• c.Judge the pain from the heart rate and the blood pressure
• d.Ask the client to point to a number on a 0 to 10 scale

A client's own report is the standard whenever one can be given, but for a client who cannot self-report the nurse substitutes an observational tool such as PAINAD, which scores exactly these behaviors. Vital signs are the tempting objective measure and are unreliable for pain, and a 0-to-10 numeric scale demands an abstraction this client can no longer perform.

A client is one day after an open cholecystectomy and rates incisional pain 4 out of 10 an hour after an oral analgesic. The client asks for something other than more medicine. Which nursing action is appropriate?

• a.Reposition the client and begin guided imagery with slow breathing✓
• b.Postpone the next pain assessment until the next medication is due
• c.Hold the remaining analgesic orders while the imagery is being used
• d.Explain that comfort measures help only pain that is rated 2 or less

Repositioning, guided imagery, music, distraction, and heat or cold are used alongside analgesics; consistent with gate control theory, competing input and relaxation reduce how much pain reaches awareness. Withholding the ordered analgesics is the tempting distractor because the client asked for a nondrug option, but the client asked to add one, not to lose access to the prescribed regimen.

A client with stage 4 chronic kidney disease has been taught to limit dietary potassium. Which lunch selection indicates that the teaching was effective?

• a.Turkey on white bread, a fresh banana, and orange juice
• b.Turkey on white bread, canned pears, and grape juice✓
• c.Turkey on white bread, a baked potato, and tomato juice
• d.Turkey on white bread, dried apricots, and prune juice

Pears and grape juice are on the lower-potassium list for chronic kidney disease, so this tray shows the teaching took hold. Bananas, oranges and orange juice, potatoes, tomatoes and tomato juice, and dried fruit such as apricots and prunes are all named as high-potassium foods to limit, and dried fruit is especially concentrated because the water has been removed.

An older adult client reports lying awake for hours after getting into bed and feeling exhausted the next day. Which statement by the client indicates that teaching about sleep habits was effective?

• a.I will have a glass of wine at bedtime to help me drop off
• b.If I am still awake after about 20 minutes, I will get up and read✓
• c.I will take a two-hour nap each afternoon to catch up on rest
• d.I will stay in bed until I fall asleep, however long that takes

Getting out of bed after about 20 minutes of wakefulness and doing something quiet keeps the bed associated with sleep instead of with frustration, which is the point of reserving the bed for sleep. Lying there waiting does the opposite, daytime naps reduce the drive to sleep at night, and alcohol is not a sleep aid and is specifically cautioned against for older adults who may also be taking sleep medication.

During an eight-hour shift a client takes 6 oz of apple juice, 4 oz of coffee, 8 oz of clear broth, and 12 oz of ice chips. The facility records 1 oz as 30 mL and records ice chips as half of their volume. How much intake should the nurse document for the shift?

• a.900 mL
• b.540 mL
• c.720 mL✓
• d.600 mL

Liquids: 6 + 4 + 8 = 18 oz, and 18 x 30 = 540 mL. Ice chips: 12 oz x 30 = 360 mL of ice, recorded at half, which is 180 mL. Total = 540 + 180 = 720 mL. Checking a second way, the ice counts as the equivalent of 6 oz, so the shift total is 18 + 6 = 24 oz, and 24 x 30 = 720 mL. Counting the ice chips at their full 360 mL gives 900 mL, and leaving the coffee out of the tally gives 600 mL.

A nurse totals a client's 24-hour record. Intake: a continuous tube feeding running at 55 mL/hr for all 24 hours, four 30 mL water flushes, and 1,000 mL of intravenous fluid. Output: 1,850 mL of urine, 200 mL of emesis, and 125 mL from a closed wound drain. What is the client's 24-hour fluid balance?

• a.Positive 265 mL✓
• b.Positive 390 mL
• c.Positive 465 mL
• d.Positive 145 mL

Intake: 55 x 24 = 1,320 mL of formula, plus 4 x 30 = 120 mL of flushes, plus 1,000 mL intravenous = 2,440 mL. Output: 1,850 + 200 + 125 = 2,175 mL. Balance = 2,440 - 2,175 = positive 265 mL. Recomputed independently: 55 x 20 = 1,100 and 55 x 4 = 220, so the feeding is 1,320 mL; 1,320 + 120 + 1,000 = 2,440; 1,850 + 200 = 2,050 and 2,050 + 125 = 2,175; 2,440 - 2,175 = 265 mL. Leaving the emesis out of output gives 465 mL, leaving the flushes out of intake gives 145 mL, and leaving the drain out gives 390 mL.

A client who takes sertraline for depression tells the clinic nurse about starting St. John's wort bought at a health food store. Which response by the nurse is accurate?

• a.Combining it with sertraline can push serotonin up to a harmful level✓
• b.It interacts only with warfarin, so sertraline is not a concern here
• c.Combining it with sertraline makes the antidepressant work faster
• d.Herbal products are regulated as drugs, so this pair is safe to use

St. John's wort combined with a serotonergic antidepressant can cause a potentially life-threatening rise in serotonin, so this combination is reported to the prescriber rather than continued. It is not a warfarin-only problem either: the herb also speeds the metabolism of oral contraceptives, cyclosporine, digoxin, indinavir, and irinotecan, weakening all of them.