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Practice Test 4 - NCLEX Rn

20 questions. Answer them in any order, then submit to see your score and every explanation.

  1. A 37-year-old client is on a telehealth visit for anxiety and is using earbuds. The client states they are driving and wants to continue the video visit hands-free. Which action should the nurse take FIRST to ensure client safety and privacy during the telehealth session?
  2. A 6-year-old child with a history of asthma is in the emergency department with respiratory distress. Current status: nasal flaring, intercostal retractions, and lethargy. Vital signs: heart rate 156/min, respiratory rate 44/min, blood pressure 92/54 mm Hg, oxygen saturation 89% on room air. The nurse notes the child is now quieter with diminished breath sounds. What is the nurse's PRIORITY action based on the child's current status?
  3. A 58-year-old client with a history of stroke is receiving enteral feedings via a nasogastric (NG) tube for dysphagia in a rehabilitation unit. During a scheduled feeding, the client coughs, reports nausea, and the nurse notes abdominal distention and no aspirate obtained from the tube; vital signs: BP 132/78, HR 98, RR 22, SpO2 91% on room air. What is the nurse's PRIORITY intervention for this client?
  4. A 73-year-old client is postoperative day 3 after left hip fracture repair. History includes dementia and prior DVT. Assessment: heart rate 96/min, blood pressure 142/80 mm Hg, respiratory rate 18/min, oxygen saturation 95% on room air; the client repeatedly removes SCDs and refuses to ambulate; enoxaparin prophylaxis is scheduled. Which intervention should the nurse implement to prevent DVT in this client?
  5. A 19-year-old client is 12 hours postpartum after a vaginal birth; the newborn is stable and rooming-in. The client asks how often to breastfeed and how to know the baby is latched correctly. What should the nurse include in teaching about newborn feeding?
  6. During a busy medical-surgical shift, an RN accidentally sustains a needle-stick to the left index finger while activating the safety device after drawing blood from a 58-year-old client with type 2 diabetes mellitus and chronic hepatitis C; current medications include metformin and lisinopril. The puncture site has a visible drop of blood; the nurse's vital signs are temperature 98.6°F (37°C), heart rate 92/min, respiratory rate 18/min, blood pressure 128/76 mm Hg. What is the nurse's FIRST action following exposure?
  7. A 62-year-old client is 3 days postoperative from abdominal surgery with a JP drain on a surgical unit. The nurse observes the insertion site is red and tender with a small amount of thick yellow drainage; vital signs: BP 126/74, HR 92, temp 38.0°C (100.4°F), WBC 14,200/mm³. The nurse should IMPLEMENT which intervention FIRST?
  8. A 29-year-old client is post-operative day 1 after appendectomy and is tolerating ice chips. The client reports hunger and has active bowel sounds; vital signs are stable. Which action should the nurse take FIRST to address the client's nutritional needs?
  9. A 30-year-old client is in an outpatient clinic one week after being diagnosed with type 1 diabetes. The client recently moved to the area and reports limited social support, stating, "I am terrified I will mess this up and something bad will happen." The client is fidgeting and speaking rapidly. Which therapeutic communication technique should the nurse use FIRST?
  10. A nurse is reviewing new provider orders for a 66-year-old with chronic obstructive pulmonary disease exacerbation. Current assessment: RR 28, SpO2 88% on 2 L/min nasal cannula, drowsy but arousable. ABG: pH 7.28 (reference 7.35–7.45), PaCO2 62 mmHg (reference 35–45), HCO3− 29 mEq/L (reference 22–26). The nurse should QUESTION which order?
  11. A 22-year-old primigravida at 18 weeks of gestation asks what symptoms are normal in pregnancy versus warning signs. She reports mild nausea in the morning and occasional dizziness when standing quickly. The nurse should provide which education regarding warning signs during pregnancy?
  12. A 72-year-old long-term care resident with a history of type 2 diabetes and limited mobility after a stroke requires extensive assistance to turn in bed. Assessment shows right-sided weakness (muscle strength 2/5), cannot reposition independently, reports sacral discomfort rated 3/10, and has non-blanchable erythema over the sacrum. Which positioning technique should the nurse use to prevent complications?
  13. A 72-year-old client (male) with advanced dementia is hospitalized with aspiration pneumonia; his advance directive indicates no feeding tube, but two family members disagree and argue at the bedside. The RN collaborates with the provider and case manager and wants to respect client autonomy and reduce harm. What is the nurse's ethical obligation in this scenario?
  14. A 50-year-old client is post-operative and on a ventilator with a high set respiratory rate; the client is awake and appears anxious; vital signs: heart rate 108/min, blood pressure 136/78 mm Hg, oxygen saturation 99%. ABG results: pH 7.57, PaCO2 23 mm Hg, HCO3 21 mEq/L, PaO2 115 mm Hg. Based on the ABG, which treatment should the nurse QUESTION?
  15. A 75-year-old client with chronic heart failure is in a long-term care facility and has increasing dyspnea and swelling. Assessment: oxygen saturation 90% on room air, respiratory rate 24/min, heart rate 96/min, blood pressure 138/80 mm Hg, 3+ pitting edema, and reports sleeping in a recliner for the past week. The nurse notes the client is confused compared with baseline and is using accessory muscles to breathe. Which assessment finding requires the nurse to act FIRST?
  16. A 44-year-old client is hospitalized for a gastrointestinal bleed and has a history of heavy alcohol use (8–10 drinks/day); last drink was 24 hours ago. The client is increasingly confused with visual hallucinations, severe tremors, and diaphoresis; vital signs: temperature 38.6°C (101.5°F), heart rate 138/min, blood pressure 190/110 mm Hg, respiratory rate 28/min; mental status: disoriented to place and time; labs: potassium 3.1 mEq/L (normal 3.5–5.0 mEq/L). The nurse should PRIORITIZE which action for the client experiencing withdrawal?
  17. A 58-year-old client is postoperative day 1 after abdominal hysterectomy and is receiving enoxaparin for DVT prophylaxis. History includes peptic ulcer disease. Assessment: heart rate 88/min, blood pressure 118/70 mm Hg, respiratory rate 16/min, oxygen saturation 98% on room air; client reports new black, tarry stools and dizziness when standing. The nurse should QUESTION which order related to DVT prophylaxis?
  18. A 45-year-old client on a psychiatric unit takes lithium for bipolar disorder. The client was started on hydrochlorothiazide 3 days ago for hypertension and now reports nausea, diarrhea, and hand tremors; the nurse notes unsteady gait and slurred speech. Which medication should the nurse QUESTION for a client with these symptoms?
  19. In an outpatient clinic, a nurse is preparing to irrigate a draining wound for a client with methicillin-resistant Staphylococcus aureus (MRSA) requiring contact precautions. The nurse will wear a gown, gloves, a mask, and a face shield because splashing is likely. What is the correct sequence for donning PPE before beginning the procedure?
  20. A 35-year-old client with a known peanut allergy develops throat tightness, hoarseness, and facial swelling 10 minutes after eating a cookie. Respiratory rate is 32/min, heart rate is 132/min, blood pressure is 86/50 mm Hg, oxygen saturation is 90% on room air, and stridor is present. Which action should the nurse take FIRST?

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