60 Medical-Surgical Practice Questions & Answers

1. 1. A client with chronic kidney disease has a serum potassium of 6.9 mEq/L with peaked T waves on the ECG. Which intervention should the nurse anticipate FIRST?

   • A.IV calcium gluconate✓ Answer
   • B.Encourage a high-potassium diet
   • C.IV potassium chloride
   • D.Oral sodium polystyrene sulfonate (Kayexalate)

   With ECG changes from hyperkalemia, IV calcium gluconate is given first because it stabilizes the cardiac membrane and prevents lethal dysrhythmias; it does not lower potassium. Insulin/D50 and Kayexalate then reduce the level. Giving KCl or high-potassium foods would worsen the emergency.

   Source: Physiological Adaptation: hyperkalemia with ECG changes — current U.S./ACLS electrolyte emergency managementReport a problem with this question

2. 2. A client taking digoxin has a serum potassium of 2.9 mEq/L. What is the priority nursing concern?

   • A.Increased risk of digoxin toxicity and dysrhythmias✓ Answer
   • B.Fluid volume overload
   • C.Increased risk of seizures
   • D.Hyperactive deep tendon reflexes

   Hypokalemia potentiates digoxin binding at the myocardial cell, greatly increasing the risk of digoxin toxicity and life-threatening dysrhythmias. Low potassium causes flattened T waves, U waves, and decreased (not hyperactive) reflexes.

   Source: Pharmacology/Physiological Adaptation: hypokalemia–digoxin interaction, K+ 3.5–5.0 mEq/LReport a problem with this question

3. 3. A client with COPD has an ABG of pH 7.28, PaCO2 58 mmHg, HCO3 25 mEq/L. How should the nurse interpret this result?

   • A.Uncompensated metabolic acidosis
   • B.Compensated respiratory alkalosis
   • C.Uncompensated metabolic alkalosis
   • D.Uncompensated respiratory acidosis✓ Answer

   Using ROME (Respiratory Opposite): pH is low (acidotic) and CO2 is high — they move in opposite directions, indicating respiratory acidosis. HCO3 is normal, so there is no metabolic compensation; the result is uncompensated respiratory acidosis, typical of CO2 retention in COPD.

   Source: Reduction of Risk Potential: ABG interpretation (ROME), respiratory acidosisReport a problem with this question

4. 4. A client in diabetic ketoacidosis has an ABG of pH 7.24, PaCO2 30 mmHg, HCO3 15 mEq/L. Which interpretation is correct?

   • A.Respiratory acidosis, uncompensated
   • B.Metabolic alkalosis with respiratory compensation
   • C.Respiratory alkalosis, uncompensated
   • D.Metabolic acidosis with partial respiratory compensation✓ Answer

   By ROME (Metabolic Equal), low pH with low HCO3 move in the same direction — metabolic acidosis. The low CO2 shows the lungs are blowing off acid (Kussmaul respirations) to compensate, but pH is still abnormal, so it is metabolic acidosis with partial respiratory compensation.

   Source: Physiological Adaptation: ABG interpretation, DKA metabolic acidosis with Kussmaul compensationReport a problem with this question

5. 5. A nurse observes continuous vigorous bubbling in the water-seal chamber of a client's chest drainage system. What is the priority action?

   • A.Clamp the chest tube immediately
   • B.Milk the tubing toward the client
   • C.Assess the tubing and connections for an air leak✓ Answer
   • D.Document it as expected functioning

   Continuous bubbling in the water-seal chamber signals an air leak in the system. The nurse first checks the tubing and connections from the client toward the drainage unit. Clamping a chest tube can cause a tension pneumothorax and is contraindicated. Tidaling (rising/falling with respiration) is the expected finding.

   Source: Physiological Adaptation: chest tube management — air leak vs tidaling; never clampReport a problem with this question

6. 6. A client's chest tube becomes disconnected from the drainage system. Until a new system is set up, what should the nurse do?

   • A.Submerge the tube's end in a bottle of sterile water✓ Answer
   • B.Reconnect immediately without cleaning and tape over it
   • C.Lay the client flat and elevate the tube above the chest
   • D.Clamp the chest tube near the insertion site

   Submerging the tube's end in sterile water re-establishes a water seal, allowing air to escape the pleural space while preventing atmospheric air from entering. Clamping risks tension pneumothorax; the drainage unit must stay below chest level, not the tube be elevated.

   Source: Physiological Adaptation: chest tube disconnection — re-establish water seal, keep unit below chestReport a problem with this question

7. 7. Before administering the morning digoxin, the nurse assesses an apical heart rate of 52 beats/min. What is the appropriate action?

   • A.Administer the dose as ordered
   • B.Give the dose and recheck the pulse in 1 hour
   • C.Administer half the ordered dose
   • D.Hold the dose and notify the provider✓ Answer

   Digoxin slows the heart rate; the nurse must hold the drug and notify the provider when the apical rate is below 60 beats/min in an adult, because giving it could cause dangerous bradycardia. The nurse never independently alters the ordered dose.

   Source: Pharmacology: digoxin — hold if apical HR <60 bpmReport a problem with this question

8. 8. A client on warfarin has an INR of 6.5 and gum bleeding. Which medication should the nurse anticipate administering?

   • A.Protamine sulfate
   • B.Calcium gluconate
   • C.Vitamin K (phytonadione)✓ Answer
   • D.Naloxone

   Vitamin K is the antidote for warfarin because warfarin works by inhibiting vitamin K–dependent clotting factors; an INR of 6.5 with active bleeding is well above the therapeutic 2–3 range. Protamine reverses heparin, and naloxone reverses opioids.

   Source: Pharmacology: warfarin antidote vitamin K; therapeutic INR 2–3Report a problem with this question

9. 9. A client receiving a continuous IV heparin infusion is monitored primarily with which laboratory value?

   • A.Platelet count only
   • B.aPTT✓ Answer
   • C.Serum sodium
   • D.INR

   Heparin therapy is monitored by the aPTT, kept at roughly 1.5–2 times the control value. INR monitors warfarin. Platelets are watched for heparin-induced thrombocytopenia but are not the primary therapeutic gauge, and the antidote for heparin is protamine sulfate.

   Source: Pharmacology: heparin monitored by aPTT 1.5–2x controlReport a problem with this question

10. 10. Fifteen minutes into a blood transfusion, a client reports chills, low back pain, and has a fever. What is the nurse's FIRST action?

    • A.Stop the transfusion and keep the vein open with normal saline✓ Answer
    • B.Administer acetaminophen and continue the transfusion
    • C.Notify the provider before stopping the infusion
    • D.Slow the transfusion rate and continue monitoring

    These are signs of a hemolytic transfusion reaction. The first action is to stop the transfusion immediately and keep the vein open with normal saline through new tubing, preventing further infusion of incompatible blood; the provider and blood bank are notified next.

    Source: Pharmacology/Parenteral: transfusion reaction — stop, NS, notifyReport a problem with this question

11. 11. A client with a T4 spinal cord injury suddenly develops a pounding headache, blood pressure 210/110 mmHg, and flushing above the injury. What should the nurse do FIRST?

    • A.Lay the client flat and elevate the legs
    • B.Raise the head of the bed to a sitting position✓ Answer
    • C.Administer an antihypertensive and recheck in 30 minutes
    • D.Perform a bladder scan and wait for results

    These are signs of autonomic dysreflexia, a medical emergency. The nurse first raises the head of the bed to lower blood pressure via orthostatic effect, then quickly removes the trigger — usually a distended bladder or bowel. Lying flat would worsen the dangerous hypertension.

    Source: Physiological Adaptation: autonomic dysreflexia — elevate HOB first, remove triggerReport a problem with this question

12. 12. A client is admitted in diabetic ketoacidosis with blood glucose 620 mg/dL and signs of dehydration. Which intervention is the priority?

    • A.Give subcutaneous regular insulin
    • B.Restrict all fluids until glucose normalizes
    • C.Administer IV sodium bicarbonate
    • D.Begin IV 0.9% normal saline infusion✓ Answer

    In DKA the priority is IV fluid resuscitation with 0.9% normal saline to restore intravascular volume and perfusion; profound osmotic diuresis has caused dehydration. Insulin is given IV (not subcutaneously) after fluids are started, and bicarbonate is reserved for severe acidosis.

    Source: Physiological Adaptation: DKA management — fluids first, then IV insulinReport a problem with this question

13. 13. A client with a head injury shows a rising blood pressure with widening pulse pressure, bradycardia, and irregular respirations. These findings indicate:

    • A.Hypovolemic shock
    • B.An expected response to injury
    • C.Sepsis
    • D.Increased intracranial pressure (Cushing's triad)✓ Answer

    Cushing's triad — hypertension with widening pulse pressure, bradycardia, and irregular respirations — is a late, ominous sign of dangerously increased intracranial pressure. It requires immediate action, as it reflects brainstem compression. Shock instead produces hypotension and tachycardia.

    Source: Physiological Adaptation: increased ICP — Cushing's triadReport a problem with this question

14. 14. A charge nurse is assigning tasks. Which task is appropriate to delegate to unlicensed assistive personnel (UAP)?

    • A.Teaching a newly diagnosed diabetic about insulin
    • B.Evaluating a client's response to pain medication
    • C.Measuring vital signs on a stable postoperative client✓ Answer
    • D.Assessing a client's surgical wound for infection

    UAP may perform standard, predictable tasks such as vital signs on a stable client. UAP cannot assess, teach, evaluate, or administer medications — those require the nursing judgment of a licensed nurse. This reflects the five rights of delegation and scope-of-practice rules.

    Source: Management of Care: delegation — UAP scope, five rights of delegationReport a problem with this question

15. 15. Which nursing task is within the scope of a licensed practical/vocational nurse (LPN/LVN) rather than requiring the registered nurse?

    • A.Developing the client's plan of care
    • B.Administering the first dose of IV chemotherapy
    • C.Reinforcing established teaching and monitoring a stable client✓ Answer
    • D.Performing the initial admission assessment

    An LPN/LVN can reinforce teaching already begun by the RN and monitor stable clients. The initial assessment, care planning, initial teaching, and IV push of high-alert drugs like chemotherapy require the RN's independent judgment and remain outside LPN scope.

    Source: Management of Care: LPN/LVN vs RN scope of practiceReport a problem with this question

16. 16. A nurse receives report on four clients. Which client should the nurse assess FIRST?

    • A.A client with stable chronic pain rated 4/10
    • B.A client requesting discharge teaching
    • C.A client with new-onset stridor and restlessness✓ Answer
    • D.A postoperative client due for a routine dressing change

    Using the ABC framework, airway is the highest priority. New-onset stridor with restlessness signals impending airway obstruction and possible hypoxia — an actual, unstable, life-threatening problem. The other clients are stable or have routine, non-urgent needs.

    Source: Management of Care: prioritization — ABC, unstable/actual over stableReport a problem with this question

17. 17. A client is admitted with active pulmonary tuberculosis. Which type of isolation precaution is required?

    • A.Droplet precautions with a surgical mask
    • B.Contact precautions with gown and gloves
    • C.Airborne precautions with an N95 respirator and negative-pressure room✓ Answer
    • D.Standard precautions only

    Tuberculosis spreads by tiny airborne droplet nuclei that remain suspended, so airborne precautions are required: a fitted N95 respirator and a negative-pressure (airborne infection isolation) room. A surgical mask does not filter these particles. Measles and varicella also need airborne precautions.

    Source: Safety & Infection Control: airborne precautions — TB, N95, negative pressureReport a problem with this question

18. 18. A client with Clostridioides difficile (C. diff) infection requires which specific hand-hygiene measure?

    • A.Use alcohol-based hand rub only
    • B.Wash hands with soap and water✓ Answer
    • C.No special hand hygiene beyond gloves
    • D.Use alcohol rub, then don a surgical mask

    C. diff forms spores that are not killed by alcohol-based hand rubs, so hands must be washed with soap and water to physically remove them. C. diff requires contact precautions with gown and gloves; airborne masking is not indicated.

    Source: Safety & Infection Control: C. diff — soap and water, contact precautionsReport a problem with this question

19. 19. A client with bacterial meningitis is admitted. In addition to standard precautions, which precaution should the nurse initiate?

    • A.No transmission-based precautions are needed
    • B.Droplet precautions with a surgical mask✓ Answer
    • C.Airborne precautions with an N95 respirator
    • D.Contact precautions with soap-and-water hand washing

    Neisseria meningitidis meningitis spreads by large respiratory droplets over short distances, requiring droplet precautions with a surgical mask (and eye protection for close contact). Airborne precautions are for TB, measles, and varicella, not meningococcal disease.

    Source: Safety & Infection Control: droplet precautions — meningococcal meningitisReport a problem with this question

20. 20. A client receiving chemotherapy has an absolute neutrophil count (ANC) of 480/mm3. Which intervention is the priority?

    • A.Implement neutropenic precautions to protect from infection✓ Answer
    • B.Place the client in a negative-pressure room
    • C.Initiate bleeding precautions as the primary measure
    • D.Restrict the client's oral fluid intake

    An ANC below 500/mm3 indicates severe neutropenia, leaving the client highly vulnerable to infection. Neutropenic (protective) precautions — meticulous hand hygiene, no fresh flowers or raw produce, avoiding sick visitors — are the priority. Negative pressure protects others, not a neutropenic client.

    Source: Safety & Infection Control: neutropenic precautions, ANC <500/mm3Report a problem with this question

21. 21. A nurse is teaching a client about NPH insulin taken at 0700. When should the nurse warn the client is at greatest risk for hypoglycemia?

    • A.At bedtime, well after the peak
    • B.Only if a meal is doubled
    • C.Immediately after injection
    • D.In the late afternoon, around the insulin's peak✓ Answer

    NPH is an intermediate-acting insulin that peaks roughly 4–12 hours after administration, so a 0700 dose peaks in the afternoon — the time of greatest hypoglycemia risk. Teaching clients to match food intake to the insulin's peak prevents hypoglycemic reactions.

    Source: Pharmacology: NPH insulin peak 4–12 h, hypoglycemia timingReport a problem with this question

22. 22. Six hours after casting a fractured tibia, a client reports severe, unrelieved pain and numbness in the toes. What is the priority nursing action?

    • A.Elevate the leg above heart level and apply ice
    • B.Reassure the client that pain is expected after casting
    • C.Notify the provider immediately about possible compartment syndrome✓ Answer
    • D.Administer additional opioid analgesic and reassess in 1 hour

    Severe pain unrelieved by opioids plus paresthesia (numbness) are early signs of compartment syndrome — the 5 P's. Rising pressure can cause irreversible tissue and nerve damage within hours, so the provider must be notified immediately; the cast may need to be split. Elevating above heart level can reduce arterial flow and worsen it.

    Source: Reduction of Risk Potential: compartment syndrome — 5 P's, notify providerReport a problem with this question

23. 23. On the second postoperative day after a total hip replacement, a client suddenly develops dyspnea, pleuritic chest pain, and tachycardia. The nurse should suspect:

    • A.Paralytic ileus
    • B.Pulmonary embolism✓ Answer
    • C.Wound dehiscence
    • D.Atelectasis

    Sudden dyspnea, pleuritic chest pain, and tachycardia after orthopedic surgery strongly suggest pulmonary embolism from a lower-extremity deep vein thrombosis. It is a life-threatening emergency requiring oxygen and immediate provider notification. Atelectasis and ileus do not cause this abrupt triad.

    Source: Reduction of Risk Potential: postoperative PE from VTEReport a problem with this question

24. 24. Which intervention best prevents postoperative atelectasis in a client recovering from abdominal surgery?

    • A.Administer a cough suppressant around the clock
    • B.Encourage use of the incentive spirometer every 1–2 hours while awake✓ Answer
    • C.Keep the client on strict bed rest for 48 hours
    • D.Restrict fluids to reduce pulmonary secretions

    The incentive spirometer promotes deep breathing and sustained lung inflation, re-expanding collapsed alveoli and preventing atelectasis — a common complication after abdominal surgery due to shallow breathing from pain. Early ambulation and coughing also help; bed rest and cough suppression worsen the risk.

    Source: Reduction of Risk Potential: incentive spirometry prevents atelectasisReport a problem with this question

25. 25. Immediately after a cardiac catheterization via the right femoral artery, which assessment is the priority?

    • A.Have the client flex the affected leg frequently
    • B.Check distal pulses and the insertion site for bleeding✓ Answer
    • C.Elevate the head of the bed to 90 degrees
    • D.Encourage the client to ambulate to prevent stiffness

    After femoral cardiac catheterization the priority is checking distal pulses, color, temperature, and the site for bleeding or hematoma, because arterial access risks hemorrhage and impaired perfusion. The client must keep the affected leg straight and remain on bed rest for several hours, not ambulate or flex the leg.

    Source: Reduction of Risk Potential: post cardiac catheterization careReport a problem with this question

26. 26. A client is scheduled for a CT scan with iodinated contrast dye. Which finding must the nurse report to the provider before the procedure?

    • A.A reported allergy to penicillin
    • B.A blood pressure of 128/76 mmHg
    • C.A hemoglobin of 13.5 g/dL
    • D.An elevated serum creatinine and current metformin use✓ Answer

    Iodinated contrast is nephrotoxic; an elevated creatinine signals impaired renal function, and metformin combined with contrast raises the risk of lactic acidosis if renal function worsens, so metformin is typically held. A penicillin allergy is unrelated to iodine contrast reactions.

    Source: Reduction of Risk Potential: contrast dye — check creatinine, hold metforminReport a problem with this question

27. 27. After a paracentesis in which 4 liters of ascitic fluid were removed, which assessment finding requires immediate nursing attention?

    • A.A decrease in abdominal girth
    • B.Hypotension and tachycardia✓ Answer
    • C.Mild soreness at the puncture site
    • D.Increased ease of breathing

    Removing a large volume of ascitic fluid can cause fluid to shift back into the peritoneal space, leading to intravascular hypovolemia — signaled by hypotension and tachycardia. This requires immediate attention. Decreased girth and easier breathing are expected, desirable outcomes.

    Source: Reduction of Risk Potential: post-paracentesis hypovolemiaReport a problem with this question

28. 28. A client arrives reporting crushing substernal chest pain radiating to the left arm. After ensuring airway and applying oxygen, which medication does the nurse anticipate administering FIRST?

    • A.Chewable aspirin✓ Answer
    • B.Subcutaneous heparin
    • C.Oral metoprolol
    • D.IV furosemide

    For suspected acute myocardial infarction, chewable aspirin is given early because its antiplatelet action limits clot growth in the coronary artery and reduces mortality. Nitroglycerin and morphine also feature in early care, but aspirin is a first-line, mortality-reducing intervention. Furosemide is not indicated for uncomplicated MI.

    Source: Pharmacology/Physiological Adaptation: acute MI — early aspirinReport a problem with this question

29. 29. A client with acute decompensated heart failure has crackles, dyspnea, and pink frothy sputum. Which nursing action is the priority?

    • A.Lay the client supine and elevate both legs
    • B.Restrict the client to bed rest in a flat position
    • C.Place the client in high Fowler's position and apply oxygen✓ Answer
    • D.Encourage increased oral fluid intake

    Pink frothy sputum with crackles indicates acute pulmonary edema. High Fowler's position decreases venous return and improves lung expansion, while oxygen relieves hypoxemia — both reduce the work of breathing immediately. Lying flat or elevating legs increases venous return and worsens pulmonary congestion; fluids are restricted.

    Source: Physiological Adaptation: acute pulmonary edema positioning and oxygenReport a problem with this question

30. 30. A client on lithium reports coarse hand tremors, vomiting, and confusion; the level is 1.8 mEq/L. What should the nurse do?

    • A.Restrict the client's fluid intake
    • B.Encourage a low-sodium diet to lower the level
    • C.Administer the next scheduled dose as ordered
    • D.Hold the next dose and notify the provider of toxicity✓ Answer

    A lithium level of 1.8 mEq/L is toxic (therapeutic range 0.6–1.2), and coarse tremors, GI upset, and confusion are classic signs. The nurse holds the dose and notifies the provider. Low sodium and fluid restriction cause lithium retention and worsen toxicity, so adequate sodium and hydration are important.

    Source: Pharmacology: lithium toxicity >1.5 mEq/L, therapeutic 0.6–1.2Report a problem with this question

31. 31. Which client report is an early sign of digoxin toxicity the nurse should recognize?

    • A.Bright red rash on the trunk
    • B.Hyperactivity and insomnia
    • C.Nausea, anorexia, and yellow-green visual halos✓ Answer
    • D.Increased appetite and weight gain

    Early digoxin toxicity classically presents with anorexia, nausea, vomiting, and visual disturbances such as yellow-green halos, along with bradycardia and dysrhythmias. Recognizing these prompts checking the digoxin level (therapeutic 0.5–2 ng/mL) and potassium, since hypokalemia potentiates toxicity.

    Source: Pharmacology: digoxin toxicity signs, therapeutic 0.5–2 ng/mLReport a problem with this question

32. 32. A client started on an ACE inhibitor (lisinopril) for hypertension should be monitored for which characteristic adverse effect?

    • A.Bradycardia and constipation
    • B.Weight gain and hyperglycemia
    • C.A persistent dry cough and elevated potassium✓ Answer
    • D.Hypokalemia and muscle cramps

    ACE inhibitors block breakdown of bradykinin, producing a characteristic persistent dry cough, and reduce aldosterone, causing potassium retention (hyperkalemia). Angioedema is a rare but dangerous effect. They do not cause hypokalemia; that is more typical of loop or thiazide diuretics.

    Source: Pharmacology: ACE inhibitor — cough, hyperkalemia, angioedemaReport a problem with this question

33. 33. While infusing IV vancomycin, the nurse notes flushing and redness over the client's face and neck. What is the appropriate action?

    • A.Continue at the same rate; it is expected and harmless
    • B.Increase the infusion rate to finish quickly
    • C.Slow the infusion rate; this is likely infusion-related flushing✓ Answer
    • D.Stop the drug permanently and label a true drug allergy

    Flushing and redness of the face, neck, and upper torso during vancomycin infusion indicate infusion-related (vancomycin flushing) reaction caused by rapid infusion triggering histamine release. Slowing the rate usually resolves it; it is not a true allergy. Continuing at the same or faster rate would worsen the reaction.

    Source: Pharmacology: vancomycin infusion (flushing) reaction — slow rateReport a problem with this question

34. 34. A client receiving gentamicin (an aminoglycoside) should be monitored primarily for which toxicities?

    • A.Pulmonary fibrosis and gingival hyperplasia
    • B.Cardiotoxicity and hyperglycemia
    • C.Nephrotoxicity and ototoxicity✓ Answer
    • D.Hepatotoxicity and photosensitivity

    Aminoglycosides such as gentamicin are classically nephrotoxic and ototoxic, so the nurse monitors BUN/creatinine, urine output, peak and trough drug levels, and reports tinnitus, hearing changes, or vertigo. Recognizing these early helps prevent permanent kidney or hearing damage.

    Source: Pharmacology: aminoglycoside nephrotoxicity and ototoxicityReport a problem with this question

35. 35. A client with cirrhosis is increasingly confused and disoriented. The nurse anticipates administering which medication?

    • A.A high-protein supplement
    • B.Furosemide
    • C.Lactulose✓ Answer
    • D.Vitamin K

    Confusion in cirrhosis suggests hepatic encephalopathy from rising blood ammonia. Lactulose lowers ammonia by acidifying the bowel to trap ammonium and by increasing its elimination in stool, improving mental status. High-protein intake is limited because protein metabolism generates more ammonia.

    Source: Physiological Adaptation: hepatic encephalopathy — lactulose lowers ammoniaReport a problem with this question

36. 36. A client with acute pancreatitis reports severe epigastric pain. Which nursing intervention is most appropriate initially?

    • A.Encourage large oral fluid boluses
    • B.Provide a high-fat meal to reduce acidity
    • C.Maintain NPO status to rest the pancreas✓ Answer
    • D.Position the client flat and supine

    Keeping the client NPO rests the pancreas by avoiding stimulation of pancreatic enzyme secretion, which reduces autodigestion and pain. Fatty food strongly stimulates the pancreas and would worsen it. Clients often prefer a side-lying, knees-flexed position for comfort.

    Source: Physiological Adaptation: acute pancreatitis — NPO to rest pancreasReport a problem with this question

37. 37. A client with a history of peptic ulcer disease has black, tarry stools and reports dizziness. What is the priority nursing action?

    • A.Reassure the client that dark stools are from iron in food
    • B.Assess vital signs and prepare for possible GI hemorrhage✓ Answer
    • C.Administer an oral laxative for constipation
    • D.Encourage a high-fiber breakfast

    Black, tarry stools (melena) indicate upper GI bleeding, and dizziness suggests developing hypovolemia. The priority is to assess vital signs for signs of shock and prepare for hemorrhage management (IV access, fluids, labs, possible transfusion). Assuming a benign cause could delay life-saving care.

    Source: Physiological Adaptation: GI bleed — melena, assess for hemorrhage/shockReport a problem with this question

38. 38. A client with chronic kidney disease is prescribed a phosphate binder. The nurse teaches the client to take it:

    • A.With meals✓ Answer
    • B.Two hours after every meal
    • C.On an empty stomach at bedtime
    • D.Only when serum calcium is high

    Phosphate binders must be taken with meals so they bind dietary phosphorus in the GI tract and prevent its absorption, controlling the hyperphosphatemia of chronic kidney disease. Taken on an empty stomach, there is no dietary phosphate to bind, so they are ineffective.

    Source: Pharmacology/Basic Care: phosphate binders taken with meals in CKDReport a problem with this question

39. 39. Two days after a total thyroidectomy, a client develops tingling around the mouth and a positive Chvostek's sign. This indicates:

    • A.Hypernatremia
    • B.Hyperglycemia
    • C.Hyperkalemia
    • D.Hypocalcemia from parathyroid injury✓ Answer

    The parathyroid glands lie behind the thyroid and can be damaged during thyroidectomy, causing hypocalcemia. Perioral tingling and a positive Chvostek's (facial twitch) or Trousseau's sign reflect the neuromuscular irritability of low calcium and require prompt intervention with calcium.

    Source: Physiological Adaptation: hypocalcemia — Chvostek/Trousseau, post-thyroidectomyReport a problem with this question

40. 40. A client's serum sodium is 118 mEq/L. Which assessment finding is the priority for the nurse to monitor?

    • A.Seizures and altered level of consciousness✓ Answer
    • B.Increased urine output
    • C.Dry, flushed skin
    • D.Constipation

    Severe hyponatremia (118 mEq/L) causes water to shift into brain cells, producing cerebral edema. The priority is monitoring for neurologic deterioration — confusion, seizures, and decreased level of consciousness — which can be life-threatening and requires seizure precautions and careful sodium correction.

    Source: Physiological Adaptation: hyponatremia neurologic effects, Na+ 135–145Report a problem with this question

41. 41. A client with Graves' disease is in suspected thyroid storm. Which set of findings supports this?

    • A.Cold intolerance and weight gain
    • B.Bradycardia, hypothermia, and lethargy
    • C.Hypertension with slow, deep respirations
    • D.High fever, severe tachycardia, and agitation✓ Answer

    Thyroid storm is a life-threatening surge of thyroid hormone producing high fever, severe tachycardia or dysrhythmias, hypertension, and agitation or delirium. It is a medical emergency requiring cooling, beta-blockers, and antithyroid therapy. Bradycardia, hypothermia, and lethargy instead suggest hypothyroid (myxedema) states.

    Source: Physiological Adaptation: thyroid storm findingsReport a problem with this question

42. 42. A client with Guillain-Barré syndrome has ascending muscle weakness now reaching the chest. Which assessment is the priority?

    • A.Respiratory rate and depth / vital capacity✓ Answer
    • B.Skin turgor
    • C.Deep tendon reflexes in the arms
    • D.Bowel sounds

    In Guillain-Barré, ascending paralysis can reach the diaphragm and intercostal muscles, causing respiratory failure. Monitoring respiratory rate, depth, and vital capacity is the priority (airway/breathing) so ventilatory support can be started before decompensation. The other assessments are lower priority.

    Source: Physiological Adaptation/Management of Care: Guillain-Barré respiratory monitoring (ABC)Report a problem with this question

43. 43. A client is admitted with an acute ischemic stroke and difficulty swallowing. Which intervention best reduces the risk of aspiration?

    • A.Encourage rapid eating to limit fatigue
    • B.Have the client lie flat during meals
    • C.Keep the client NPO until a swallow evaluation is completed✓ Answer
    • D.Offer thin liquids frequently to keep the throat moist

    After a stroke, dysphagia greatly increases aspiration risk, so the client is kept NPO until a formal swallow evaluation confirms safety. Thin liquids are the hardest to control and most likely aspirated, lying flat and rapid eating also increase risk. Safe positioning is upright with the chin tucked.

    Source: Reduction of Risk Potential: post-stroke dysphagia — NPO until swallow evalReport a problem with this question

44. 44. The nurse assesses a pressure injury that shows full-thickness skin loss with visible subcutaneous fat but no exposed bone, tendon, or muscle. This is classified as:

    • A.Stage 2
    • B.Stage 3✓ Answer
    • C.Unstageable
    • D.Stage 1

    A Stage 3 pressure injury involves full-thickness skin loss with visible subcutaneous fat, possibly with slough, undermining, or tunneling, but without exposed bone, tendon, or muscle. Stage 1 is intact skin with non-blanchable redness; Stage 2 is partial-thickness loss; exposed bone/muscle would be Stage 4.

    Source: Basic Care & Comfort: pressure injury staging (NPUAP/NPIAP), Stage 3Report a problem with this question

45. 45. A client is receiving continuous tube feedings through a nasogastric tube. Which intervention best prevents aspiration?

    • A.Dilute the formula with extra water
    • B.Hold feedings if bowel sounds are present
    • C.Keep the client flat to prevent reflux
    • D.Keep the head of the bed elevated 30–45 degrees✓ Answer

    Keeping the head of the bed elevated 30–45 degrees uses gravity to reduce gastric reflux and aspiration during tube feeding. Lying flat increases reflux risk. Bowel sounds indicate motility and are reassuring, not a reason to hold feeds, and routine dilution is unnecessary.

    Source: Basic Care & Comfort: tube feeding aspiration precautions — HOB 30–45°Report a problem with this question

46. 46. A client newly diagnosed with cancer says, 'I don't think I can handle this.' Which is the most therapeutic response?

    • A.'Don't worry, treatments today are very effective.'
    • B.'Many people have it much worse than you do.'
    • C.'This must feel overwhelming. Tell me what worries you most.'✓ Answer
    • D.'You need to stay positive for your family.'

    The therapeutic response acknowledges the client's feelings and uses an open-ended invitation to explore concerns, which is client-centered and empathic. The other options offer false reassurance, dismiss feelings, or impose the nurse's judgment — all block communication.

    Source: Psychosocial Integrity: therapeutic communication — open-ended, empathicReport a problem with this question

47. 47. A client hospitalized after abruptly stopping heavy alcohol use becomes tremulous, tachycardic, and diaphoretic 48 hours later. Which medication class does the nurse anticipate?

    • A.Benzodiazepines✓ Answer
    • B.Stimulants
    • C.Opioids
    • D.Antipsychotics as first-line

    Alcohol withdrawal — tremors, tachycardia, diaphoresis, and risk of seizures and delirium tremens — is treated with benzodiazepines, which are cross-tolerant with alcohol at the GABA receptor and prevent seizures. Severity is tracked with the CIWA scale. Opioids and stimulants are inappropriate and dangerous here.

    Source: Psychosocial Integrity: alcohol withdrawal — benzodiazepines, CIWAReport a problem with this question

48. 48. An older postoperative client is suddenly confused, disoriented, and agitated in the evening but was alert this morning. What does the nurse recognize this most likely represents?

    • A.Dementia, which is chronic and progressive
    • B.Delirium, which is acute and often reversible✓ Answer
    • C.Normal aging changes
    • D.Expected postoperative behavior needing no evaluation

    An acute, fluctuating change in cognition with disorientation and agitation that develops over hours indicates delirium, which is often reversible and has an underlying cause such as infection, hypoxia, medications, or electrolyte imbalance. Dementia develops gradually over months to years. Delirium requires prompt investigation of the cause.

    Source: Psychosocial Integrity: delirium vs dementia — acute fluctuating onsetReport a problem with this question

49. 49. A client with COPD has a chronically elevated CO2. Which oxygen delivery approach is most appropriate?

    • A.Low-flow oxygen titrated to the prescribed target saturation✓ Answer
    • B.High-flow 100% oxygen by non-rebreather routinely
    • C.Oxygen only when the client is asleep
    • D.Withhold oxygen entirely to preserve respiratory drive

    Clients with chronic CO2 retention are given low-flow oxygen carefully titrated to a prescribed target saturation (often around 88–92%) to correct hypoxemia without abolishing respiratory drive. Routine high-flow oxygen can suppress ventilation, but oxygen is never fully withheld from a hypoxemic client, as hypoxia is more immediately deadly.

    Source: Physiological Adaptation: COPD oxygen therapy — titrated low-flowReport a problem with this question

50. 50. A nurse must obtain informed consent documentation for surgery. Which statement reflects the nurse's correct role?

    • A.The nurse witnesses the signature and confirms understanding; the surgeon explains the procedure✓ Answer
    • B.The nurse explains the surgical risks, benefits, and alternatives
    • C.Consent is unnecessary if a family member agrees
    • D.The nurse may sign on the client's behalf if the client is nervous

    Informed consent for a procedure is the responsibility of the provider performing it, who explains the risks, benefits, and alternatives. The nurse's role is to witness the signature, verify the client is informed and consenting voluntarily, and notify the provider if the client has unanswered questions. The nurse never signs for the client.

    Source: Management of Care: informed consent — roles of provider and nurseReport a problem with this question

51. 51. A client with hypertension is prescribed metoprolol, a beta-blocker. Which teaching point is most important?

    • A.Do not stop the drug abruptly and check pulse before taking it✓ Answer
    • B.Stop the drug as soon as blood pressure is normal
    • C.Double the dose if a dose is missed
    • D.Expect the heart rate to increase on this medication

    Beta-blockers slow the heart rate and lower blood pressure, so the client should check the pulse before each dose and hold it if too low. Abrupt discontinuation can cause rebound hypertension, tachycardia, or angina, so the drug must be tapered. Doubling missed doses risks bradycardia and hypotension.

    Source: Pharmacology: beta-blocker teaching — pulse check, no abrupt stopReport a problem with this question

52. 52. A client with heart failure is placed on a sodium-restricted diet. Which meal choice indicates the client understands the teaching?

    • A.Fresh baked chicken with steamed vegetables✓ Answer
    • B.Canned soup with crackers
    • C.A frozen dinner with processed cheese
    • D.Cured ham with a dill pickle

    Fresh baked chicken with steamed vegetables is naturally low in sodium, supporting fluid balance in heart failure by reducing sodium-driven water retention. Canned soups, cured/processed meats, pickles, and frozen or processed meals are very high in sodium and would worsen fluid overload.

    Source: Basic Care & Comfort/Health Promotion: low-sodium diet in heart failureReport a problem with this question

53. 53. A nurse is teaching an older adult about expected age-related changes. Which statement by the client indicates correct understanding?

    • A.'I may need more time to respond, but confusion is not a normal part of aging.'✓ Answer
    • B.'Becoming confused and disoriented is a normal part of getting older.'
    • C.'I should expect chest pain to be a normal sign of aging.'
    • D.'Losing control of my bladder is unavoidable as I age.'

    Normal aging may slow reaction and processing time, but acute confusion, chest pain, and incontinence are NOT normal and signal a problem needing evaluation. Recognizing this prevents older adults from dismissing treatable conditions such as delirium, cardiac disease, or infection as 'just aging.'

    Source: Health Promotion & Maintenance: expected aging vs abnormal findingsReport a problem with this question

54. 54. A nurse is teaching a client to use a cane on the affected (weak) leg side or the unaffected side, and how to advance it. Which instruction is correct?

    • A.Hold the cane on the stronger side and advance it with the stronger leg
    • B.Carry the cane and use it only on stairs
    • C.Hold the cane on the stronger side and advance it with the weaker leg✓ Answer
    • D.Hold the cane on the weaker side and move it with the stronger leg

    A cane is held on the stronger (unaffected) side and advanced together with the weaker leg, so the cane and weak leg share the load and provide a wide, stable base of support. Holding it on the weak side would not offload the affected limb effectively and increases fall risk.

    Source: Basic Care & Comfort: cane use — hold on stronger side, advance with weaker legReport a problem with this question

55. 55. A client with acute respiratory distress syndrome (ARDS) is on mechanical ventilation. Which finding indicates the priority problem the nurse must address?

    • A.A slightly elevated temperature of 37.9°C
    • B.Mild anxiety about the ventilator
    • C.Worsening hypoxemia despite increasing oxygen✓ Answer
    • D.A cough productive of clear sputum

    The hallmark of ARDS is refractory hypoxemia — low oxygen that persists despite increasing supplemental oxygen — because widespread alveolar-capillary damage impairs gas exchange. Worsening hypoxemia is the priority (airway/breathing) and may require higher PEEP or ventilator changes. The other findings are lower priority.

    Source: Physiological Adaptation: ARDS — refractory hypoxemiaReport a problem with this question

56. 56. A client with sepsis has a lactate of 4.2 mmol/L, blood pressure 84/48 mmHg, and heart rate 122 beats/min. Which intervention should the nurse anticipate implementing FIRST?

    • A.Restrict fluids to prevent overload
    • B.Administer an oral antipyretic and reassess in 4 hours
    • C.Delay antibiotics until all culture results return
    • D.Rapid IV isotonic fluid bolus and obtain blood cultures before antibiotics✓ Answer

    This client is in septic shock (hypotension, tachycardia, elevated lactate reflecting hypoperfusion). Early management is a rapid isotonic fluid bolus to restore perfusion, with blood cultures drawn before starting broad-spectrum antibiotics promptly. Restricting fluids or delaying antibiotics until all cultures return worsens outcomes.

    Source: Physiological Adaptation: sepsis/septic shock — early fluids, cultures then antibioticsReport a problem with this question

57. 57. A client with type 1 diabetes is found diaphoretic, shaky, and confused with a fingerstick glucose of 48 mg/dL, but able to swallow. What is the priority action?

    • A.Encourage the client to eat a high-fat meal
    • B.Give 15 g of a fast-acting oral carbohydrate, then recheck in 15 minutes✓ Answer
    • C.Administer the client's scheduled dose of insulin
    • D.Withhold all food and observe for one hour

    For symptomatic hypoglycemia in a conscious client who can swallow, the rule of 15 applies: give 15 grams of fast-acting carbohydrate (such as juice or glucose tablets), then recheck glucose in 15 minutes and repeat if still low. Giving insulin would deepen the hypoglycemia and could be fatal; fat slows glucose absorption.

    Source: Physiological Adaptation/Pharmacology: hypoglycemia — rule of 15Report a problem with this question

58. 58. A client scheduled for surgery says, 'I've changed my mind, I don't want the operation.' What is the nurse's best action?

    • A.Ask the family to convince the client to proceed
    • B.Tell the client it is too late to cancel now
    • C.Reassure the client and send them to the operating room as planned
    • D.Notify the surgeon and document the client's statement; do not proceed✓ Answer

    A competent client has the right to withdraw consent at any time, including immediately before surgery. The nurse must stop the process, notify the surgeon, and document the client's statement. Proceeding without valid consent would constitute battery and violate the client's autonomy.

    Source: Management of Care: informed consent/autonomy — right to withdraw consentReport a problem with this question

59. 59. A nurse discovers that a medication error occurred and the client received twice the ordered dose. After assessing and stabilizing the client, what is the next appropriate step?

    • A.Document nothing to avoid legal liability
    • B.Report the error only if the client is harmed
    • C.Notify the provider and complete an incident/occurrence report✓ Answer
    • D.Ask a colleague to change the medication record

    After ensuring client safety, the nurse must notify the provider and complete an incident/occurrence report so the event can be reviewed and future errors prevented. Errors are reported regardless of whether harm occurred. Concealing, falsifying, or altering records is unethical and illegal.

    Source: Safety & Infection Control/Management of Care: medication error reportingReport a problem with this question

60. 60. A confused client repeatedly tries to climb out of bed. Which action should the nurse take FIRST?

    • A.Move the client to a distant room away from the nurses' station
    • B.Apply wrist and vest restraints immediately
    • C.Implement the least restrictive measures such as a bed alarm and frequent checks✓ Answer
    • D.Sedate the client with an as-needed antipsychotic

    Restraints require the least-restrictive approach; the nurse first tries alternatives such as a bed alarm, frequent monitoring, moving the client closer to the nurses' station, and addressing the cause of confusion. Physical restraints and chemical sedation are last resorts requiring a provider order and carry serious risks.

    Source: Safety & Infection Control: restraints — least restrictive firstReport a problem with this question

Practice questions based on the NCSBN NCLEX-RN test plan. Not affiliated with NCSBN and not medical advice — always follow your program and current clinical guidelines. About the NCLEX →