CSLB General Building (B) — All Questions
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A charge nurse is assigning tasks at the start of a shift. Which task is appropriate to delegate to unlicensed assistive personnel (UAP)?
- a.Taking vital signs on a stable postoperative client✓
- b.Performing the initial assessment of a newly admitted client
- c.Adjusting the flow rate of a continuous IV infusion
- d.Teaching a client how to use an incentive spirometer
UAP may perform routine, standardized tasks such as vital signs on stable clients. Assessment, IV titration, and client teaching require the judgment of a licensed nurse and cannot be delegated.
A nurse must see four clients. Which client should the nurse assess FIRST?
- a.A client scheduled for discharge who needs teaching
- b.A client reporting new-onset shortness of breath and chest tightness✓
- c.A client requesting pain medication for a headache
- d.A client asking for help ambulating to the bathroom
Airway and breathing problems take priority. New shortness of breath with chest tightness may signal a life-threatening event and must be evaluated before less urgent needs.
Which nursing task is appropriate to delegate to a licensed practical/vocational nurse (LPN/LVN)?
- a.Developing the initial plan of care
- b.Providing discharge teaching about a new diagnosis
- c.Administering an oral medication to a stable client✓
- d.Performing triage in the emergency department
LPNs/LVNs may administer many routine medications and reinforce teaching for stable clients. Care planning, initial teaching, and triage require the broader scope of the registered nurse.
The nurse is caring for four clients. Applying the ABC framework, which finding requires the most immediate action?
- a.Blood pressure of 148/88 mm Hg
- b.Temperature of 100.8 F (38.2 C)
- c.Reports of mild incisional pain
- d.Oxygen saturation of 86% on room air✓
An oxygen saturation of 86% reflects a breathing and oxygenation emergency and takes priority over an elevated blood pressure, a low-grade fever, or mild pain.
A nurse delegates client hygiene to a UAP. Which statement reflects the nurse's continued accountability?
- a.The nurse remains accountable for the overall client outcome and must follow up✓
- b.The UAP is fully responsible for the outcome once the task is assigned
- c.Accountability transfers to the provider who wrote the orders
- d.No follow-up is required if the UAP is experienced
Delegation transfers the task, not the accountability. The RN retains responsibility for the outcome and must supervise and evaluate the delegated care.
Which situation is the highest priority for the nurse to report to the oncoming shift during handoff?
- a.A client whose dressing was changed two hours ago
- b.A client with a newly inserted chest tube and unstable vital signs✓
- c.A client who ate 100% of the evening meal
- d.A client who ambulated in the hallway without difficulty
Handoff should emphasize the least stable, highest-risk client. A new chest tube with unstable vital signs requires close monitoring and clear communication to ensure continuity of care.
A nurse observes a coworker preparing to administer a medication without checking the client's identification band. What is the nurse's best initial action?
- a.Report the coworker to the state board of nursing
- b.Document the observation in the client's chart
- c.Remind the coworker to verify two client identifiers before administration✓
- d.Say nothing because no harm has occurred yet
The immediate priority is client safety. Reminding the coworker to verify two identifiers prevents a potential error. Formal reporting is reserved for repeated or unresolved unsafe practice.
The nurse is planning care for a group of clients. Which client is most appropriate to assign to a newly graduated RN?
- a.A client requiring titration of a vasoactive drip
- b.A client actively receiving blood who is having a reaction
- c.A client being emergently transferred to the ICU
- d.A stable client needing routine postoperative care on day two✓
A new graduate should be assigned stable, predictable clients. Complex, rapidly changing situations such as drip titration, transfusion reactions, and ICU transfers require experienced staff.
A client refuses a prescribed treatment. Which action by the nurse best respects client autonomy?
- a.Documenting the refusal and notifying the provider✓
- b.Administering the treatment because the provider ordered it
- c.Telling the client they will be discharged if they refuse
- d.Waiting until a family member can convince the client
Competent clients have the right to refuse treatment. The nurse documents the informed refusal and notifies the provider, respecting autonomy while ensuring continuity of care.
Which of the following is the nurse's primary responsibility when a client signs a surgical consent form?
- a.Explaining the surgical risks and alternatives to the client
- b.Verifying that the client's consent is voluntary and witnessing the signature✓
- c.Deciding whether the client should proceed with surgery
- d.Guaranteeing that the surgery will be successful
The provider is responsible for explaining risks, benefits, and alternatives. The nurse verifies that consent is voluntary and informed and witnesses the signature.
A nurse is prioritizing care using Maslow's hierarchy of needs. Which client need should be met first?
- a.A client's need for reassurance about surgery
- b.A client's request to see the hospital chaplain
- c.A client's difficulty maintaining a patent airway✓
- d.A client's concern about the cost of care
Physiological needs such as a patent airway are the base of Maslow's hierarchy and take priority over safety, love and belonging, esteem, and self-actualization needs.
The nurse receives report on four clients. Which client should the nurse plan to reassess first after receiving report?
- a.A client with chronic stable heart failure awaiting discharge
- b.A client with a healing surgical wound scheduled for a dressing change
- c.A client requesting a snack before bedtime
- d.A client who received IV morphine 15 minutes ago and is now very drowsy✓
A client who is increasingly drowsy after IV opioids may be developing respiratory depression and must be reassessed first to prevent harm.
Which task can the RN appropriately delegate to a UAP for a client on strict intake and output monitoring?
- a.Emptying the urinary drainage bag and recording the amount✓
- b.Interpreting the significance of a low urine output
- c.Deciding whether to notify the provider about the output
- d.Adjusting the client's fluid restriction
Measuring and recording output is a routine task suitable for UAP. Interpreting values, clinical decision-making, and modifying the plan of care remain RN responsibilities.
A nurse is coordinating a client's discharge. Which action best demonstrates effective case management?
- a.Delaying discharge until every family question is answered in person
- b.Arranging home health services and follow-up appointments before discharge✓
- c.Providing only verbal instructions to save time
- d.Leaving medication reconciliation to the community pharmacy
Effective case management coordinates resources across the continuum of care. Arranging home health and follow-up appointments promotes continuity and reduces readmission risk.
The nurse identifies a near-miss medication error that did not reach the client. What is the appropriate action?
- a.Ignore it because the client was not harmed
- b.Record it in the client's medical record as an error
- c.Complete an incident and occurrence report to support system improvement✓
- d.Report it directly to the state licensing board
Near-miss and error events are documented on an incident report for quality improvement. The report is not filed in the medical record, and licensing boards address serious professional issues only.
A nurse is supervising a UAP. Which observed action requires the nurse to intervene?
- a.The UAP raises the side rails after repositioning a client
- b.The UAP offers a bedpan to a client on bed rest
- c.The UAP reports a blood pressure to the nurse
- d.The UAP applies a vest restraint without a current provider order✓
Restraints require a current provider order and specific criteria. Applying a restraint without an order is unsafe and unlawful, so the nurse must intervene immediately.
Which principle should guide the nurse when assigning client care during a staffing shortage?
- a.Match client acuity and complexity to staff competency✓
- b.Assign the most clients to the least experienced staff
- c.Give all unstable clients to a single nurse to concentrate care
- d.Distribute clients randomly to save time
Safe assignment matches client acuity to the skill and scope of the staff member. Overloading unstable clients on one nurse or assigning complex clients to novices threatens safety.
A nurse witnesses a colleague documenting care that was not actually provided. Which ethical principle is most directly violated?
- a.Autonomy
- b.Veracity✓
- c.Beneficence
- d.Justice
Veracity is the duty to tell the truth. Falsifying documentation violates veracity and is both an ethical breach and a legal risk.
A nurse is caring for a client on contact precautions for Clostridioides difficile. Which action is correct?
- a.Use alcohol-based hand rub after removing gloves
- b.Wear an N95 respirator when entering the room
- c.Wash hands with soap and water after client contact✓
- d.Place the client in a negative-pressure room
C. difficile spores are not reliably killed by alcohol-based rubs, so hand hygiene with soap and water is required. Contact precautions, not airborne precautions, are indicated.
Which client requires airborne precautions?
- a.A client with a draining wound infection
- b.A client with influenza
- c.A client with scabies
- d.A client with active pulmonary tuberculosis✓
Pulmonary tuberculosis is spread by airborne droplet nuclei and requires a negative-pressure room and an N95 respirator. Wound infections and scabies need contact precautions, and influenza needs droplet precautions.
When donning personal protective equipment (PPE), which sequence is correct?
- a.Gown, mask, goggles, gloves✓
- b.Gloves, gown, mask, goggles
- c.Mask, gloves, gown, goggles
- d.Goggles, gloves, gown, mask
The correct donning sequence is gown, then mask or respirator, then goggles or face shield, then gloves. The correct order reduces contamination risk to the wearer.
A nurse is assessing fall risk. Which client is at highest risk for falling?
- a.A 30-year-old ambulating independently
- b.An 82-year-old taking a sedative who is confused✓
- c.A 45-year-old on bed rest with side rails up
- d.A 25-year-old awaiting discharge
Advanced age, a sedating medication, and confusion together create a high fall risk. Interventions such as frequent rounding and bed alarms should be prioritized for this client.
Which action best prevents catheter-associated urinary tract infection (CAUTI)?
- a.Keeping the drainage bag above the level of the bladder
- b.Routinely irrigating the catheter every shift
- c.Removing the indwelling catheter as soon as it is no longer needed✓
- d.Disconnecting the tubing to obtain urine samples
Early removal of an unnecessary catheter is the most effective way to prevent CAUTI. The bag should stay below the bladder, the system should remain closed, and routine irrigation is not recommended.
A nurse discovers a small fire in a client's trash can. Using the RACE protocol, what is the first action?
- a.Activate the fire alarm
- b.Confine the fire by closing doors
- c.Extinguish the fire with an extinguisher
- d.Rescue any clients in immediate danger✓
RACE stands for Rescue, Alarm, Confine, and Extinguish. The first priority is to rescue anyone in immediate danger before activating the alarm and containing the fire.
A client is receiving oxygen at 4 L/min by nasal cannula. Which instruction promotes safety?
- a.Post no-smoking signs and keep open flames away from the oxygen✓
- b.Allow smoking if the client stays six feet from the tank
- c.Use petroleum-based lubricant on the client's dry lips
- d.Increase the flow rate whenever the client feels anxious
Oxygen supports combustion, so no smoking or open flames are permitted near it, and only water-based lubricants should be used. Flow rate changes require a provider order.
The nurse is preparing to move a heavy client up in bed. Which technique protects the nurse from injury?
- a.Bend at the waist and lift with the back
- b.Use a friction-reducing device and additional staff✓
- c.Twist at the trunk to reposition the client quickly
- d.Keep the feet close together for a narrow base
Safe patient handling uses mechanical aids and adequate help, a wide base of support, and the leg muscles rather than the back. Twisting and bending at the waist cause injury.
A nurse is verifying a client before a blood transfusion. Which action is essential to prevent a transfusion error?
- a.Begin the transfusion rapidly to reduce spoilage
- b.Use a standard IV line shared with dextrose solution
- c.Verify the client and blood product with a second qualified nurse✓
- d.Skip baseline vital signs to save time
Two qualified staff must independently verify the client identity and the blood product to prevent an ABO incompatibility reaction. Blood is infused with normal saline only, and baseline vital signs are required.
Which environmental modification best prevents falls for a confused older adult at home?
- a.Using throw rugs to mark walking paths
- b.Keeping the client in a dimly lit room to promote rest
- c.Placing frequently used items on high shelves
- d.Removing clutter and ensuring adequate lighting✓
Removing clutter and improving lighting reduces trip and fall hazards. Throw rugs, poor lighting, and out-of-reach items increase fall risk.
A nurse receives a client with a suspected external chemical exposure. What is the priority action?
- a.Decontaminate the client before further care✓
- b.Bring the client into the main unit for assessment
- c.Administer pain medication first
- d.Obtain a detailed medical history before any intervention
Decontamination prevents ongoing harm to the client and protects staff and other clients from secondary contamination. It precedes routine assessment and treatment.
The nurse is teaching a client about safe medication storage at home. Which statement indicates a need for further teaching?
- a.I will keep my medications in their original labeled containers
- b.I will keep expired medications in case I need them later✓
- c.I will store all medicines in a locked cabinet away from children
- d.I will not share my prescriptions with family members
Expired medications should be discarded because potency and safety cannot be assured. Keeping them for later use is unsafe and indicates a need for further teaching.
A nurse is caring for a client with a seizure disorder. Which item should be available at the bedside?
- a.A padded tongue blade to insert during a seizure
- b.Wrist restraints to prevent movement
- c.Functioning suction and oxygen equipment✓
- d.A bright overhead light kept on at all times
Suction and oxygen should be ready to maintain the airway during and after a seizure. Nothing should be inserted into the mouth, and restraints and constant stimulation are not appropriate.
Which client should be placed in a private room with droplet precautions?
- a.A client with methicillin-resistant Staphylococcus aureus in a wound
- b.A client with measles
- c.A client with a Clostridioides difficile infection
- d.A client with meningococcal meningitis✓
Meningococcal meningitis is transmitted by respiratory droplets and requires droplet precautions. MRSA wounds and C. difficile need contact precautions, and measles requires airborne precautions.
A nurse identifies a client with a latex allergy. Which action is appropriate?
- a.Ensure latex-free supplies and place an allergy alert on the chart✓
- b.Use only sterile latex gloves for procedures
- c.Keep latex products nearby in case they are needed
- d.Assume powdered latex gloves are safe to use
Clients with a latex allergy require latex-free supplies and clear allergy alerts to prevent an anaphylactic reaction. Powdered latex gloves increase airborne allergen exposure and are unsafe.
The nurse is applying restraints to an agitated client per provider order. Which action is correct?
- a.Tie the restraint to the movable side rail
- b.Secure the restraint with a quick-release knot to the bed frame✓
- c.Check circulation once every four hours
- d.Leave the client alone to reduce stimulation
Restraints are tied with a quick-release knot to a fixed part of the bed frame, never the side rails. Circulation, skin, and needs must be checked frequently, typically every 15 to 30 minutes.
A nurse is teaching an adult about routine health screening. Which recommendation is appropriate for colorectal cancer screening in average-risk adults?
- a.Begin screening only after age 70
- b.Screening is unnecessary without symptoms
- c.Begin screening at age 45✓
- d.Begin screening at age 25
Current guidelines recommend that average-risk adults begin colorectal cancer screening at age 45. Waiting for symptoms delays detection of early, treatable disease.
A pregnant client at 12 weeks' gestation asks about weight gain. Which teaching is appropriate for a client of normal pre-pregnancy weight?
- a.Weight gain should be avoided during pregnancy
- b.A gain of 50 to 60 pounds is expected
- c.Weight should be gained only in the first trimester
- d.A total gain of 25 to 35 pounds is recommended✓
A woman with a normal pre-pregnancy body mass index is advised to gain about 25 to 35 pounds. Adequate, gradual gain supports fetal growth without excess maternal risk.
The nurse is teaching parents about infant nutrition. When is it generally appropriate to introduce solid foods?
- a.Around 6 months of age✓
- b.At 2 months of age
- c.At 12 months of age
- d.As soon as the newborn shows hunger cues
Solid foods are typically introduced around 6 months, when the infant can sit with support and has lost the tongue-thrust reflex. Earlier introduction increases the risk of choking and allergies.
A nurse is providing immunization teaching. Which vaccine is a live attenuated vaccine that is contraindicated during pregnancy?
- a.Inactivated influenza vaccine
- b.Measles, mumps, and rubella (MMR) vaccine✓
- c.Tetanus, diphtheria, and pertussis (Tdap) vaccine
- d.Hepatitis B vaccine
MMR is a live attenuated vaccine and is contraindicated during pregnancy. Inactivated influenza and Tdap are recommended in pregnancy to protect the mother and infant.
The nurse is assessing developmental milestones. Which gross motor skill is expected of a typical 12-month-old?
- a.Walking up stairs independently
- b.Riding a tricycle
- c.Pulling to stand and cruising along furniture✓
- d.Skipping on alternating feet
By about 12 months, infants typically pull to stand and cruise while holding furniture, and many take their first independent steps. Stair climbing, tricycle riding, and skipping are later skills.
A nurse teaches a postmenopausal client about osteoporosis prevention. Which action best supports bone health?
- a.Avoiding all weight-bearing activity
- b.Limiting sun exposure completely
- c.Increasing caffeine and carbonated soda intake
- d.Performing regular weight-bearing exercise and ensuring adequate calcium and vitamin D✓
Weight-bearing exercise plus adequate calcium and vitamin D strengthens bone. Inactivity and excess caffeine or soda contribute to bone loss.
A nurse is counseling an adult on tobacco cessation. Which statement reflects effective health promotion?
- a.Setting a quit date and using support resources improves success✓
- b.You must quit immediately or it is not worth trying
- c.Nicotine replacement never helps people quit
- d.Cutting back is impossible, so do not attempt it
Setting a specific quit date combined with behavioral support and, when appropriate, nicotine replacement improves cessation success. Supportive, nonjudgmental counseling promotes readiness to change.
The nurse teaches a new mother about breastfeeding. Which sign indicates the infant is adequately hydrated?
- a.Fewer than two wet diapers per day
- b.Six or more wet diapers per day✓
- c.Dark, concentrated urine
- d.A sunken anterior fontanel
Six or more wet diapers a day indicate adequate intake and hydration in a breastfeeding infant. Few wet diapers, concentrated urine, and a sunken fontanel suggest dehydration.
A nurse provides teaching about a heart-healthy diet. Which choice best fits this diet?
- a.Fried chicken with buttered mashed potatoes
- b.A cheeseburger with bacon and fries
- c.Baked salmon with steamed vegetables✓
- d.A processed deli meat sandwich with chips
Baked fish rich in omega-3 fatty acids with vegetables supports cardiovascular health. Fried, high-saturated-fat, and processed high-sodium foods increase cardiac risk.
The nurse is teaching an older adult about safe physical activity. Which recommendation is appropriate for most healthy older adults?
- a.Avoid all exercise to prevent injury
- b.Only exercise if pain is present
- c.Perform only high-intensity workouts
- d.Aim for about 150 minutes of moderate activity weekly plus balance exercises✓
Most healthy older adults benefit from about 150 minutes of moderate aerobic activity weekly plus muscle-strengthening and balance exercises to reduce falls and chronic disease risk.
A nurse assesses a 4-year-old's language development. Which finding is expected?
- a.Speaks in sentences of three to four words and is understood by strangers✓
- b.Speaks in single words only
- c.Uses no recognizable words
- d.Reads simple sentences fluently
A typical 4-year-old speaks in short sentences that strangers can generally understand. Single-word speech is expected earlier, and fluent reading comes later.
A nurse is teaching about skin cancer prevention. Which statement indicates correct understanding?
- a.Sunscreen is only needed on very hot days
- b.I will apply broad-spectrum sunscreen and reapply every two hours outdoors✓
- c.A base tan protects me from sun damage
- d.I only need sunscreen at the beach
Broad-spectrum sunscreen reapplied every two hours, plus protective clothing and shade, reduces skin cancer risk. Ultraviolet exposure occurs on cloudy and cool days, and a tan is a sign of skin damage.
The nurse discusses recommended cervical cancer screening. Which schedule is generally appropriate for an average-risk woman aged 30?
- a.No screening is needed at any age
- b.Daily self-testing at home
- c.A Papanicolaou (Pap) test every three years, or co-testing options per guidelines✓
- d.Screening only after menopause
Average-risk women aged 30 may have a Pap test every three years or human papillomavirus co-testing at extended intervals. Screening should not be delayed until menopause.
A nurse counsels an adult on alcohol use. Which statement reflects moderate drinking guidelines for health promotion?
- a.Any amount of alcohol is required for heart health
- b.Binge drinking on weekends is safe if avoided on weekdays
- c.There is no upper limit to safe alcohol intake
- d.Moderate intake means up to one drink per day for women and two for men✓
Moderate drinking is defined as up to one drink per day for women and two for men. Binge drinking is harmful, and lower intake is generally healthier.
A client newly diagnosed with cancer says, 'I just can't believe this is happening to me.' Which response is most therapeutic?
- a.This must be very difficult for you. Tell me what you are feeling✓
- b.At least it was caught early, so try to stay positive
- c.You should focus on your treatment plan now
- d.Many people do well with this diagnosis
Acknowledging the client's emotion and inviting them to share feelings uses empathy and open-ended communication. False reassurance and changing the focus block therapeutic dialogue.
A nurse is caring for a client with major depressive disorder who states, 'Life isn't worth living anymore.' What is the nurse's priority action?
- a.Reassure the client that things will improve
- b.Directly ask the client if they are thinking of suicide✓
- c.Change the subject to reduce the client's distress
- d.Document the statement and continue routine care
Safety is the priority. Directly asking about suicidal ideation assesses risk and does not increase the likelihood of self-harm; it opens the door to protective intervention.
A client experiencing a panic attack is hyperventilating and pacing. Which nursing action is most appropriate?
- a.Leave the client alone to calm down
- b.Provide detailed teaching about anxiety physiology
- c.Stay with the client and speak calmly using short, simple statements✓
- d.Encourage the client to describe every worry in detail
During a panic attack the nurse should stay with the client, remain calm, and use brief, clear communication. Complex teaching and detailed discussion overwhelm the client until the acute anxiety subsides.
A client with anorexia nervosa is admitted for treatment. Which finding is the priority concern?
- a.The client's distorted body image
- b.The client's refusal to discuss feelings
- c.The client's preoccupation with calories
- d.Bradycardia and electrolyte imbalance✓
Physiological instability such as bradycardia and electrolyte imbalance can be life-threatening in anorexia nervosa and takes priority over the important psychological issues.
A nurse uses therapeutic communication with a grieving client. Which technique best encourages the client to continue talking?
- a.Using silence and attentive presence✓
- b.Offering personal opinions about the loss
- c.Asking rapid closed-ended questions
- d.Reassuring the client that grief will pass quickly
Silence and attentive presence give the grieving client time to process and express feelings. Opinions, closed questions, and false reassurance interrupt therapeutic communication.
A client with schizophrenia says, 'The voices are telling me I am worthless.' Which response is most therapeutic?
- a.The voices are not real, so ignore them
- b.I do not hear the voices, but I understand they seem real and upsetting to you✓
- c.What exactly are the voices telling you to do?
- d.You should not listen to those voices
The nurse presents reality without arguing and acknowledges the client's experience and distress. Denying the client's perception or dismissing it damages trust.
A nurse is caring for a client in the manic phase of bipolar disorder. Which intervention supports the client's needs?
- a.Encourage participation in a competitive group activity
- b.Serve large meals at a communal table
- c.Provide a calm, low-stimulation environment and finger foods✓
- d.Schedule several stimulating activities back to back
During mania, clients are easily overstimulated and may not sit to eat. A low-stimulation environment and portable, high-calorie finger foods support rest and nutrition.
A client discloses a history of intimate partner violence. What is the nurse's priority action?
- a.Advise the client to leave the relationship immediately
- b.Contact the partner to discuss the situation
- c.Tell the client the abuse is not their fault and end the conversation
- d.Assess the client's immediate safety and provide resources✓
Assessing immediate safety and offering resources respects autonomy while protecting the client. Directing the client to leave or contacting the partner can increase danger.
A nurse is supporting a client through the stages of grief. A client who says, 'If I had only gone to the doctor sooner' is likely in which stage?
- a.Bargaining✓
- b.Denial
- c.Acceptance
- d.Anger
Statements involving 'if only' and attempts to undo the loss reflect the bargaining stage of grief. Recognizing the stage helps the nurse respond supportively.
A client with alcohol use disorder is 12 hours into withdrawal. Which finding requires immediate attention?
- a.Mild hand tremors
- b.Seizure activity✓
- c.Requests for a cigarette
- d.Increased appetite
Seizures during alcohol withdrawal are a medical emergency and require immediate intervention. Mild tremors are common early findings but are less urgent.
A nurse is caring for a client experiencing acute confusion (delirium). Which intervention is most appropriate?
- a.Keep the room dark and quiet at all times
- b.Restrain the client to prevent wandering
- c.Frequently reorient the client and provide familiar objects✓
- d.Rotate caregivers frequently to provide variety
Frequent reorientation, familiar objects, and consistent caregivers reduce confusion in delirium. Restraints and frequent caregiver changes can worsen agitation.
A client is angry and shouting at the nurse about a delayed procedure. Which response best de-escalates the situation?
- a.You need to lower your voice right now
- b.There is nothing I can do about the schedule
- c.If you keep yelling, I will have to leave
- d.I can see you are frustrated. Let's talk about what is upsetting you✓
Acknowledging the client's feelings and inviting discussion de-escalates anger and builds rapport. Commanding or threatening the client escalates the conflict.
A nurse is assessing a client for postpartum depression. Which finding warrants further evaluation?
- a.Persistent sadness and disinterest in the infant after three weeks✓
- b.Occasional tearfulness that resolves within two weeks
- c.Fatigue related to nighttime feedings
- d.Excitement about caring for the newborn
Persistent sadness and lack of interest in the infant beyond two weeks suggest postpartum depression rather than transient baby blues, and require further evaluation and support.
A nurse cares for a dying client's family. Which action best supports the family during end-of-life care?
- a.Limiting visiting hours to reduce fatigue
- b.Providing privacy and encouraging expression of feelings✓
- c.Avoiding discussion of the client's condition
- d.Encouraging the family to stay positive at all times
Providing privacy and encouraging the family to express feelings supports coping during end-of-life care. Restricting presence and avoiding honest discussion isolate the family.
A nurse is caring for a client at risk for pressure injuries. Which intervention is most effective for prevention?
- a.Massage bony prominences vigorously
- b.Keep the head of the bed elevated at 90 degrees continuously
- c.Reposition the client at least every two hours✓
- d.Use a doughnut-shaped cushion for sitting
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.Orange juice with pulp
- b.Cream of chicken soup
- c.Vanilla ice cream
- 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.Have the client lie flat while eating
- c.Offer thin liquids with a straw
- d.Encourage rapid eating to finish the meal
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.Place the client supine with the head flat
- b.Position the client side-lying to prevent aspiration✓
- c.Use large amounts of water to rinse thoroughly
- d.Insert fingers between the teeth to open the mouth
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.Auscultate air injected into the tube
- b.Place the tube end in water to check for bubbling
- c.Verify placement per facility protocol, often with pH testing or radiographic confirmation✓
- d.Ask the client if the tube feels correctly placed
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.Administer an enema immediately
- b.Request a prescription for a stimulant laxative
- c.Restrict the client's oral intake
- d.Increase fluid and fiber intake and encourage activity✓
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.Urine output of less than 30 mL per hour for two consecutive hours✓
- b.Clear yellow urine of 60 mL over the past hour
- c.Slightly increased output after a diuretic
- d.Pale straw-colored urine
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 for support
- b.About two finger-widths below the axilla✓
- c.At the level of the waist
- d.Against the mid-chest
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.Keeping the client's legs crossed for comfort
- b.Massaging the calves to relieve stiffness
- c.Encouraging leg exercises and applying sequential compression devices✓
- d.Placing pillows under the knees continuously
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.Clean from the anus toward the urethra
- b.Use the same cloth section for each stroke
- c.Apply powder around the catheter insertion site
- d.Clean from the urethra outward, away from the anus✓
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.The 30-degree lateral (side-lying) position✓
- b.Supine with the head of the bed at 90 degrees
- c.Prone position for extended periods
- 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 skin with nonblanchable redness
- b.Partial-thickness loss of the dermis presenting as a shallow open ulcer✓
- c.Full-thickness loss with exposed bone
- d.Skin loss covered entirely by eschar
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.Provide a large glass of water
- b.Give the client hard candy to suck
- c.Offer frequent oral care and moisten the lips✓
- d.Encourage the client to drink small sips of juice
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 after the client has been up walking
- b.Roll the top of the stocking down for a snug fit
- c.Leave wrinkles in the stocking for flexibility
- d.Apply the stockings while the client is lying down before rising✓
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 client is prescribed warfarin. Which laboratory value is used to monitor its therapeutic effect?
- a.Prothrombin time and international normalized ratio (INR)✓
- b.Activated partial thromboplastin time (aPTT)
- c.Platelet count only
- d.Serum potassium
Warfarin is monitored using the prothrombin time and INR. The aPTT is used to monitor heparin, not warfarin.
A client receiving IV heparin has an aPTT far above the therapeutic range and is bleeding. Which medication is the antidote?
- a.Vitamin K
- b.Protamine sulfate✓
- c.Calcium gluconate
- d.Naloxone
Protamine sulfate reverses heparin. Vitamin K reverses warfarin, and naloxone reverses opioids.
A nurse is administering digoxin. Which finding requires the nurse to hold the dose and notify the provider?
- a.Blood pressure of 118/72 mm Hg
- b.Respiratory rate of 16 breaths per minute
- c.Apical heart rate of 52 beats per minute✓
- d.Temperature of 98.6 F (37 C)
Digoxin should be held for an apical heart rate below 60 beats per minute in adults because it can further slow the heart and may signal toxicity. The other vital signs are within normal limits.
A client is starting an angiotensin-converting enzyme (ACE) inhibitor. Which side effect should the nurse teach the client to report?
- a.Improved appetite
- b.Increased salivation
- c.Darkened urine that clears quickly
- d.A persistent dry cough✓
ACE inhibitors commonly cause a persistent dry cough due to bradykinin accumulation. Clients should report it, and angioedema, though rare, is an emergency.
A nurse prepares to administer an aminoglycoside antibiotic. Which parameters are most important to monitor?
- a.Renal function and drug peak and trough levels✓
- b.Blood glucose and hemoglobin A1c
- c.Serum calcium and phosphate
- d.Thyroid hormone levels
Aminoglycosides are nephrotoxic and ototoxic, so renal function and peak and trough serum levels must be monitored to ensure safety and efficacy.
A client is prescribed 250 mg of a medication. The pharmacy supplies 125 mg tablets. How many tablets should the nurse administer?
- a.Half a tablet
- b.Two tablets✓
- c.Four tablets
- d.One tablet
Using desired over available, 250 mg divided by 125 mg per tablet equals two tablets. Accurate dose calculation prevents a medication error.
A nurse teaches a client taking an oral corticosteroid long term. Which instruction is correct?
- a.Stop the medication abruptly when symptoms improve
- b.Take the medication on an empty stomach
- c.Do not stop the medication suddenly; taper as directed✓
- d.Avoid monitoring blood glucose
Long-term corticosteroids must be tapered to avoid adrenal insufficiency. They should be taken with food, and blood glucose should be monitored because they raise glucose.
A client is receiving IV furosemide. Which electrolyte imbalance should the nurse monitor for?
- a.Hyperkalemia
- b.Hypernatremia
- c.Hypercalcemia
- d.Hypokalemia✓
Loop diuretics such as furosemide promote potassium excretion and can cause hypokalemia. The nurse monitors potassium and watches for muscle weakness and cardiac dysrhythmias.
A client taking a monoamine oxidase inhibitor (MAOI) for depression requires dietary teaching. Which food should be avoided?
- a.Aged cheese and cured meats✓
- b.Fresh apples
- c.White rice
- d.Steamed carrots
Tyramine-rich foods such as aged cheese and cured meats can trigger a hypertensive crisis in clients taking MAOIs and must be avoided.
A nurse administers insulin lispro, a rapid-acting insulin. When should the nurse ensure the client is ready to eat?
- a.Two hours after the injection
- b.Within about 15 minutes of the injection✓
- c.Only at bedtime
- d.Meal timing does not matter
Rapid-acting insulin such as lispro begins working within about 15 minutes, so food should be available promptly to prevent hypoglycemia.
A client is prescribed morphine for pain. Which assessment is most important before and after administration?
- a.Bowel sounds only
- b.Skin turgor
- c.Respiratory rate and level of sedation✓
- d.Deep tendon reflexes
Opioids such as morphine can cause respiratory depression and sedation, so respiratory rate and sedation level must be assessed before and after administration.
A client taking phenytoin for seizures needs teaching. Which instruction is appropriate?
- a.Skip doses if you feel well
- b.Stop the drug if a rash appears without contacting the provider
- c.Expect the urine to turn blue
- d.Maintain good oral hygiene because of gum overgrowth risk✓
Phenytoin commonly causes gingival hyperplasia, so meticulous oral hygiene is important. Doses should not be skipped, and any rash should be reported because it may signal a serious reaction.
A nurse is administering a beta-blocker such as metoprolol. Which parameter should be checked before administration?
- a.Apical heart rate and blood pressure✓
- b.Urine specific gravity
- c.Serum bilirubin
- d.White blood cell count
Beta-blockers lower heart rate and blood pressure, so both should be assessed before administration and the dose held for significant bradycardia or hypotension per parameters.
A client on lithium for bipolar disorder reports vomiting, coarse tremors, and confusion. What does the nurse suspect?
- a.A therapeutic drug response
- b.Lithium toxicity✓
- c.A common cold
- d.Normal side effects that require no action
Vomiting, coarse tremors, and confusion are signs of lithium toxicity. The narrow therapeutic range makes level monitoring and adequate hydration essential.
A client is prescribed an oral tetracycline antibiotic. Which instruction is correct?
- a.Take it with milk or antacids to reduce stomach upset
- b.Take it only with grapefruit juice
- c.Avoid dairy products and antacids near the time of the dose✓
- d.Double the dose if a dose is missed
Calcium in dairy and antacids binds tetracycline and reduces its absorption, so they should be separated from the dose. Doses should not be doubled if missed.
A nurse is preparing to administer a medication and notes the client has a documented allergy to it. What is the nurse's action?
- a.Give a smaller dose to test tolerance
- b.Administer with an antihistamine to prevent a reaction
- c.Give the medication and monitor closely
- d.Hold the medication and notify the prescriber✓
A documented allergy is a contraindication. The nurse holds the drug and notifies the prescriber to clarify or change the order, preventing a potentially life-threatening reaction.
A client is receiving an IV infusion of potassium chloride. Which action is essential for safety?
- a.Infuse diluted potassium slowly using an infusion pump✓
- b.Administer potassium by rapid IV push
- c.Give potassium undiluted for faster effect
- d.Stop cardiac monitoring during the infusion
IV potassium must always be diluted and infused slowly with a pump; it is never given by IV push because rapid administration can cause fatal cardiac arrest. Cardiac monitoring is important.
A client taking an opioid reports no bowel movement for three days. Which intervention should the nurse anticipate?
- a.Withholding all fluids
- b.Initiating a bowel regimen with a stool softener and increased fluids✓
- c.Discontinuing the opioid without consulting the provider
- d.Restricting dietary fiber
Opioids commonly cause constipation, so a prophylactic bowel regimen with stool softeners, fluids, and fiber is appropriate. Fluids and fiber should be increased, not restricted.
A nurse reviews a client's laboratory results. Which serum potassium value is within the normal range?
- a.6.5 mEq/L
- b.2.8 mEq/L
- c.4.0 mEq/L✓
- d.7.2 mEq/L
The normal serum potassium range is approximately 3.5 to 5.0 mEq/L, so 4.0 mEq/L is normal. Values of 6.5 and 7.2 indicate hyperkalemia, and 2.8 indicates hypokalemia.
A client with heart failure gains 3 pounds in two days and has new crackles in the lungs. Which condition does the nurse suspect?
- a.Dehydration
- b.Hypokalemia
- c.Metabolic alkalosis
- d.Fluid volume overload✓
Rapid weight gain and pulmonary crackles indicate fluid volume overload, common in a heart failure exacerbation. Prompt recognition allows diuretic and fluid management.
A nurse is caring for a client with diabetic ketoacidosis. Which arterial blood gas finding is expected?
- a.Metabolic acidosis✓
- b.Respiratory alkalosis
- c.Metabolic alkalosis
- d.Respiratory acidosis
Diabetic ketoacidosis produces excess ketoacids, causing metabolic acidosis with a low pH and low bicarbonate. Kussmaul respirations develop as compensation.
A client with chronic obstructive pulmonary disease has an oxygen saturation of 90%. Which oxygen delivery approach is appropriate?
- a.Administer high-flow oxygen at 10 L/min immediately
- b.Provide low-flow oxygen and titrate to the target saturation✓
- c.Withhold all oxygen to preserve respiratory drive
- d.Place the client on a nonrebreather mask routinely
Clients with COPD are given controlled low-flow oxygen titrated to a target saturation, often around 88 to 92 percent, to avoid suppressing respiratory drive while treating hypoxemia.
A nurse assesses a client with hypocalcemia. Which finding is expected?
- a.Decreased deep tendon reflexes
- b.Constipation and lethargy
- c.Positive Trousseau and Chvostek signs✓
- d.Warm, flushed skin
Hypocalcemia increases neuromuscular excitability, producing positive Trousseau and Chvostek signs, muscle cramps, and tingling. Hypercalcemia causes the opposite findings.
A client presents with slurred speech, facial droop, and right-sided weakness. What is the nurse's priority action?
- a.Administer aspirin immediately
- b.Encourage the client to rest and reassess in an hour
- c.Give the client oral fluids
- d.Activate the stroke protocol and note the time of symptom onset✓
These signs suggest an acute stroke. Rapid activation of the stroke protocol and documenting the symptom onset time are critical because treatment such as thrombolytics is time-dependent.
A nurse is caring for a client after a myocardial infarction. Which laboratory marker is most specific for cardiac muscle damage?
- a.Troponin✓
- b.Total white blood cell count
- c.Serum sodium
- d.Blood urea nitrogen
Troponin is the most specific and sensitive biomarker for myocardial injury and rises within hours of an infarction, guiding diagnosis and treatment.
A client has a nasogastric tube to continuous suction and develops muscle weakness. Which disturbance is most likely?
- a.Metabolic acidosis with hyperkalemia
- b.Metabolic alkalosis with hypokalemia✓
- c.Respiratory acidosis with hypernatremia
- d.Respiratory alkalosis with hypercalcemia
Loss of gastric acid and potassium through continuous suction leads to metabolic alkalosis and hypokalemia, which can cause muscle weakness and dysrhythmias.
A nurse reviews an arterial blood gas: pH 7.30, PaCO2 55 mm Hg, HCO3 24 mEq/L. How should the nurse interpret this?
- a.Metabolic acidosis
- b.Respiratory alkalosis
- c.Respiratory acidosis✓
- d.Metabolic alkalosis
A low pH with an elevated PaCO2 and a normal bicarbonate indicates uncompensated respiratory acidosis, often from hypoventilation.
A client with cirrhosis develops confusion and asterixis. Which laboratory value best explains these findings?
- a.Decreased serum glucose
- b.Elevated serum calcium
- c.Decreased white blood cell count
- d.Elevated serum ammonia✓
Impaired liver function raises serum ammonia, causing hepatic encephalopathy with confusion and asterixis. Treatment such as lactulose lowers ammonia levels.
A nurse cares for a client with acute kidney injury and a serum potassium of 6.8 mEq/L. Which finding is the priority concern?
- a.Peaked T waves on the electrocardiogram✓
- b.Mild peripheral edema
- c.Decreased urine output
- d.Fatigue
Hyperkalemia can cause life-threatening cardiac dysrhythmias; peaked T waves signal cardiac effects and require immediate intervention. The other findings are important but less urgent.
A client is admitted with dehydration. Which assessment finding supports this diagnosis?
- a.Bounding pulse and elevated blood pressure
- b.Poor skin turgor and elevated urine specific gravity✓
- c.Moist mucous membranes
- d.Jugular vein distention
Dehydration produces poor skin turgor, dry mucous membranes, and concentrated urine with a high specific gravity. Jugular distention and bounding pulses suggest fluid overload.
A nurse assesses a client with hypothyroidism. Which finding is expected?
- a.Weight loss and heat intolerance
- b.Tachycardia and exophthalmos
- c.Fatigue, cold intolerance, and bradycardia✓
- d.Diarrhea and tremors
Hypothyroidism slows metabolism, causing fatigue, cold intolerance, weight gain, and bradycardia. Weight loss, heat intolerance, and tachycardia occur in hyperthyroidism.
A client with type 1 diabetes is diaphoretic, shaky, and confused with a blood glucose of 54 mg/dL. What is the priority intervention?
- a.Administer long-acting insulin
- b.Encourage the client to exercise
- c.Withhold all food until the provider is notified
- d.Give 15 grams of a fast-acting carbohydrate✓
These are signs of hypoglycemia. For a conscious client, giving about 15 grams of fast-acting carbohydrate raises the glucose quickly; the level is then rechecked.
A nurse is monitoring a client after a total hip replacement. Which finding suggests a possible pulmonary embolism?
- a.Sudden dyspnea, chest pain, and tachycardia✓
- b.Gradual improvement in mobility
- c.Mild incisional soreness
- d.Decreased appetite
Sudden dyspnea, pleuritic chest pain, and tachycardia after orthopedic surgery suggest a pulmonary embolism, a medical emergency requiring immediate action.
A client's laboratory results show a hemoglobin of 7.2 g/dL. Which assessment finding is most consistent with this value?
- a.Bradycardia and hypertension
- b.Fatigue, pallor, and tachycardia✓
- c.Warm, ruddy skin
- d.Increased energy and alertness
A hemoglobin of 7.2 g/dL indicates anemia, producing fatigue, pallor, and compensatory tachycardia due to reduced oxygen-carrying capacity.
A nurse cares for a client with increased intracranial pressure. Which finding is an early sign?
- a.Fixed and dilated pupils
- b.Cushing's triad
- c.A change in level of consciousness✓
- d.Deep coma
A change in level of consciousness is the earliest and most sensitive sign of increased intracranial pressure. Fixed pupils and Cushing's triad are late, ominous findings.
A client with Addison's disease is at risk for adrenal crisis. Which finding requires immediate intervention?
- a.Mild fatigue
- b.Slightly bronzed skin
- c.Salt craving
- d.Severe hypotension and hyperkalemia✓
Adrenal crisis causes profound hypotension, hyperkalemia, and hyponatremia and is life-threatening, requiring immediate fluids and hydrocortisone. Bronzing and salt craving are chronic features.
A nurse reviews arterial blood gases: pH 7.50, PaCO2 30 mm Hg, HCO3 24 mEq/L. Which condition does this represent?
- a.Respiratory alkalosis✓
- b.Respiratory acidosis
- c.Metabolic acidosis
- d.Metabolic alkalosis
An elevated pH with a low PaCO2 and a normal bicarbonate indicates respiratory alkalosis, often caused by hyperventilation.
A client with gastroenteritis has had severe diarrhea for two days. Which electrolyte imbalance is most likely?
- a.Hyperkalemia
- b.Hypokalemia✓
- c.Hypercalcemia
- d.Hypernatremia
Prolonged diarrhea causes significant potassium loss through the stool, leading to hypokalemia, which can produce weakness and cardiac dysrhythmias.
A nurse assesses a client in the compensatory stage of hypovolemic shock. Which finding is expected?
- a.Bradycardia and warm skin
- b.Elevated blood pressure and flushed skin
- c.Increased heart rate and cool, clammy skin✓
- d.Slow, deep respirations
In compensated shock, the body increases the heart rate and constricts peripheral vessels, producing tachycardia and cool, clammy skin as it attempts to maintain perfusion.
A client with pneumonia has a fever and thick secretions. Which intervention best promotes airway clearance?
- a.Restrict oral fluids
- b.Keep the client flat in bed
- c.Suppress the cough with medication
- d.Encourage fluids and provide chest physiotherapy as ordered✓
Adequate hydration thins secretions and chest physiotherapy mobilizes them, promoting airway clearance. Restricting fluids and suppressing a productive cough would worsen secretion retention.
A nurse cares for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding is expected?
- a.Hyponatremia and fluid retention✓
- b.Hypernatremia and increased urine output
- c.Dehydration and excessive thirst
- d.High serum osmolality
SIADH causes excessive water retention, leading to dilutional hyponatremia, low serum osmolality, and concentrated urine. Fluid restriction is a key treatment.
A client with a history of gout has an elevated serum uric acid level. Which dietary teaching is appropriate?
- a.Increase intake of organ meats and shellfish
- b.Limit purine-rich foods and increase fluid intake✓
- c.Avoid all dairy products
- d.Restrict water to reduce swelling
Limiting purine-rich foods such as organ meats and shellfish and increasing fluids helps lower uric acid and prevent gout attacks. Adequate hydration promotes uric acid excretion.
A nurse reviews a client's coagulation results. Which value indicates the client is at increased risk for bleeding?
- a.INR of 1.0
- b.Platelet count of 250,000/microliter
- c.INR of 5.0✓
- d.Hemoglobin of 14 g/dL
An INR of 5.0 is well above the therapeutic range and indicates a high bleeding risk. An INR of 1.0 and a normal platelet count reflect normal clotting ability.
A client with liver failure has a prolonged prothrombin time. Which nursing action is appropriate?
- a.Encourage vigorous tooth brushing
- b.Administer intramuscular injections freely
- c.Ignore minor bruising as unimportant
- d.Implement bleeding precautions and use a soft toothbrush✓
A prolonged prothrombin time indicates impaired clotting, so bleeding precautions such as a soft toothbrush and avoiding unnecessary injections reduce the risk of hemorrhage.