Nclexpn
Practice Test 2 for Nclexpn: real questions and explanations from the Varsity Tutors practice-test pool.
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A 34-year-old female in an emergency department is treated for pneumonia and has a documented allergy to azithromycin (hives). The medication administration record shows an order for azithromycin 500 mg by mouth now. Which action is the PRIORITY for the nurse?
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A 34-year-old female in an emergency department is treated for pneumonia and has a documented allergy to azithromycin (hives). The medication administration record shows an order for azithromycin 500 mg by mouth now. Which action is the PRIORITY for the nurse?
Explanation: This question tests recognition of medication allergy documentation and the nurse's responsibility to prevent allergic reactions. The client has a documented allergy to azithromycin with a previous reaction of hives, and the same medication has been ordered. Holding the dose and notifying the registered nurse (B) is the priority to prevent re-exposure to a known allergen that previously caused an allergic reaction. Administering the medication (A) violates the principle of allergy avoidance and could cause a severe reaction. Asking if the client is willing to take it (C) is inappropriate as it puts the client at risk. Giving with food (D) doesn't prevent allergic reactions. The principle of medication safety is that documented allergies must be strictly observed, and the nurse has a duty to advocate for safe medication administration. A transferable strategy is to always verify allergies before administration and recognize that the nurse must refuse to give medications to which the client has documented allergies.
A 3-year-old child is evaluated for failure to thrive. Weight is 11.0 kg, and the caregiver reports the child fills up on milk and refuses solid foods; diet record shows 40 oz whole milk/day and minimal iron-rich foods. The child is pale and irritable. Which dietary modification is MOST appropriate for this client?
Explanation: This question tests understanding of nutrition and oral hydration. The primary concern is iron deficiency from excessive milk intake, indicated by low weight, pallor, and irritability. Limiting milk and offering iron-rich foods with scheduled meals is most appropriate to correct anemia and promote growth. Increasing milk worsens displacement; eliminating snacks ignores needs; tea inhibits iron absorption. A key decision-making principle is to limit milk to 24 oz/day in toddlers. Another principle is to structure meals for balanced intake. A transferable strategy is to introduce iron sources gradually.
An LPN in a hospital clinic experiences a blood splash to the mouth while removing a saturated dressing; the nurse was not wearing a mask. The client’s infection status is unknown, and the nurse has no oral sores. What is the nurse's PRIORITY action following the exposure?
Explanation: This question tests the response to biohazard and needle-stick exposure. The priority concern is infection prevention by decontaminating the oral mucous membrane. Spitting out fluid and rinsing the mouth thoroughly with water immediately is the best choice per protocols for splash exposures. Swallowing water (B) may ingest pathogens; brushing teeth (C) could abrade; delaying (D) increases risk. This follows the clinical judgment model by immediate action on exposure. The decision-making principle prioritizes rinsing over other responses. A transferable strategy is to rinse mouth exposures with water right away, avoid swallowing, and report for evaluation in similar incidents.
In a long-term care facility, an LPN gives SBAR report to the oncoming nurse about a 90-year-old client with a stage 2 sacral pressure injury. Over the last 24 hours, drainage increased and the surrounding skin is warm and red; VS now: T 100.9°F (38.3°C) (was 98.6°F), HR 102 (was 84). History includes limited mobility and urinary incontinence; the dressing was changed twice today and the client is on a high-protein diet. Which detail is MOST important to include in the Situation part of SBAR?
Explanation: This question tests effective communication and handoff using SBAR, specifically identifying the most critical information for the Situation component when reporting wound infection concerns. SBAR is crucial for ensuring safe client care by immediately alerting the receiving nurse to changes that indicate potential complications requiring prompt intervention. The correct answer (B) is most important for the Situation because it describes the current problem - signs of wound infection including increased drainage, warmth, redness, and new fever (100.9°F) - which represents a significant change from baseline requiring evaluation and treatment. Option A provides background dietary information; option C gives historical risk factors; and option D offers recommendations rather than describing the situation. The communication principle underpinning SBAR is that the Situation must clearly describe what has changed and why it requires attention now. A transferable strategy for prioritizing information in clinical handoffs is to focus on new or worsening signs and symptoms that represent a departure from the client's baseline, particularly when they suggest infection or other complications.
A 47-year-old client in a hospital is scheduled for an MRI with contrast and states, "I am claustrophobic and I might panic." The provider has already ordered the test, but the client is unsure about proceeding. Facility policy requires the client to agree voluntarily and the nurse to notify the provider of concerns; the LPN/VN may reinforce teaching and offer coping strategies. How should the nurse proceed with client teaching on informed consent?
Explanation: This question tests ethical practice within the scope of the LPN/VN, focusing on informed consent amid client fears. The legal standard requires voluntary agreement, with nurses reinforcing expectations and notifying of concerns. Option B is the most ethical as it reinforces details, discusses strategies, and notifies the provider, respecting autonomy. Option A coerces; C administers without order; D delegates consent. The framework identifies barriers, provides support, and escalates. Document interactions. A transferable strategy is to address anxieties proactively, ensuring ethical procedural readiness.
The nurse is monitoring a client's peripheral IV site. Which finding would indicate the development of phlebitis?
Explanation: Phlebitis is the inflammation of a vein. Classic signs include warmth, pain, tenderness, erythema (redness), and a palpable cord or red streak along the path of the vein. Coolness and pallor are signs of infiltration. Leaking fluid may indicate a loose connection or infiltration. Decreased skin turgor is not a localized sign related to phlebitis.
An LPN in an urgent care clinic is stuck by a used lancet while assisting with a finger-stick glucose check on a client whose infection status is unknown; the LPN has a documented complete hepatitis B vaccine series. Which action is the nurse’s PRIORITY after providing immediate wound care?
Explanation: This question tests the response to biohazard and needle-stick exposure following immediate wound care. The priority concern after initial decontamination is proper reporting for risk assessment and appropriate post-exposure management. Reporting the exposure immediately to supervisor/occupational health (A) is the best choice because it initiates the formal exposure protocol, ensures proper risk assessment, and determines need for prophylaxis based on source patient factors. Starting HIV PEP independently (B) bypasses proper medical evaluation and may be unnecessary, discarding the lancet in regular trash (C) violates sharps disposal protocols, and delaying reporting until shift end (D) postpones critical time-sensitive interventions. The clinical judgment model emphasizes following established protocols after immediate safety measures. The transferable strategy is: after immediate wound care, promptly report all exposures through proper channels to ensure timely risk assessment and intervention.
In an acute care hospital, a 74-year-old client with diabetic neuropathy is on a treatment plan for ambulation with a walker and one-person assist. The nurse notes the rubber tips on the back legs of the walker are worn smooth. Which finding indicates a potential safety hazard with the use of the walker?
Explanation: This question tests the safe use of equipment and assistive devices. The priority safety concern is the worn rubber tips on the walker, which reduce traction and increase slip risk on floors. The walker having worn rubber tips indicates a hazard because it compromises stability and heightens fall potential during ambulation. Preferring hallway ambulation (B), using the call light (C), and labeling (D) are appropriate and do not indicate hazards. The decision-making principle for walkers is to maintain intact, non-slip tips for grip. Safety guidelines recommend regular checks and replacement of worn parts on mobility aids. A transferable safety strategy is to perform routine equipment inspections in any scenario to identify and correct defects before use.
In a hospital medical-surgical unit, a 72-year-old client with a draining wound culture positive for methicillin-resistant Staphylococcus aureus (MRSA) has a temperature of 37.9°C (100.2°F) and WBC 13,200/mm³. The dressing is saturated with serosanguinous drainage. What is the priority action to prevent infection spread?
Explanation: This question tests the application of infection control precautions. The key factor in determining the appropriate precaution is the contact transmission mode of MRSA through direct contact with the draining wound. Implementing contact precautions with gown and gloves for room entry is the priority because it prevents the spread of resistant bacteria via hands or clothing. Airborne precautions are for airborne pathogens like TB, droplet precautions address respiratory droplets, and sterile gloves without a gown do not fully protect against contact transmission, making them incorrect. Infection control principles emphasize using barrier precautions to interrupt contact transmission of multidrug-resistant organisms. Guidelines from the CDC recommend dedicating equipment and thorough cleaning to prevent cross-contamination. A transferable strategy is to don PPE before entering rooms of clients with known resistant infections and perform hand hygiene after removal to protect other clients and staff.
A 32-year-old postpartum client with a history of anxiety becomes overwhelmed on a mother-baby unit, crying and stating, "I'm a terrible mom," while breathing rapidly. Mood is anxious, affect is tearful, communication is self-critical, and the client is pacing. Which strategy should the nurse use to address the client's anxiety?
Explanation: This question tests the application of behavioral management techniques within psychosocial integrity. The primary behavioral issue is the client's overwhelming anxiety and self-doubt, with anxious mood, tearful affect, self-critical communication, and pacing. Guiding the client to sit, practice slow breathing, and use grounding by identifying items seen and felt is the most effective strategy because it anchors the client in the present and reduces physiological arousal. Telling the client many feel this way and to focus on the baby (B) minimizes feelings; asking about childhood (C) is not immediate; requesting anxiolytics first (D) skips non-pharmacologic options. The decision-making principle in behavioral management for postpartum anxiety involves using sensory grounding to interrupt negative thought patterns. This promotes quick stabilization. A transferable strategy for managing similar behavioral issues is to combine breathing with sensory awareness for rapid anxiety reduction in high-stress moments.
In a long-term care facility, an 80-year-old resident with mild hearing loss is receiving end-of-life care for advanced heart failure. The resident’s adult daughter says quietly, "I feel guilty leaving at night—what if he dies when I'm not here?" The LPN/VN is present during visiting hours. How should the nurse respond to express empathy?
Explanation: This question tests therapeutic communication skills in nursing. The key technique being tested is reflective listening to express empathy. The correct answer, choice C, effectively uses this by mirroring the daughter's internal conflict, validating her feelings without judgment. On the other hand, choice A dismisses her guilt, choice B normalizes but shifts focus abruptly, and choice D avoids the emotion by redirecting thoughts. Therapeutic communication is crucial in end-of-life care as it supports family members emotionally and reduces feelings of isolation. It also facilitates better coping and decision-making during difficult times. A transferable strategy is to use reflective statements like 'It sounds like you're...' to acknowledge emotions and encourage further expression.
A client diagnosed with schizophrenia tells the PN, “The voices are telling me I am a bad person.” Which response by the PN is most therapeutic?
Explanation: This response validates the client's feeling of fear without validating the hallucination itself. It also gently presents reality by stating, 'I do not hear any voices.' This is a therapeutic technique that builds trust and avoids arguing with the client about their perceptual disturbance.
A 52-year-old client with chronic gastritis identifies as Vietnamese American and says he uses coin rubbing (cao gio) at home when he feels unwell. On assessment, the LPN notes linear red marks on the client’s back. The client states the marks are from coin rubbing and are not painful. Which action respects the client's cultural beliefs?
Explanation: This question tests cultural and spiritual competence in client care. Respecting cultural and spiritual beliefs in nursing practice differentiates traditional practices like coin rubbing from abuse in Vietnamese American clients. Option B respects by assessing, documenting, and reporting without assumptions, ensuring safety. Option A accuses without assessment; option C prohibits practices; option D ignores findings. Cultural competence avoids misinterpretation. A decision-making framework uses cultural knowledge in assessments. A transferable strategy is to educate teams on common practices to prevent biased reporting and support holistic care.
A 68-year-old client asks the PN if they need the shingles vaccine. The client has a history of chickenpox as a child. What is the most appropriate information for the PN to reinforce?
Explanation: Current guidelines recommend the recombinant zoster vaccine (Shingrix) for all adults 50 years and older to prevent shingles and its complications, regardless of whether they recall having had chickenpox.
A 24-year-old client who is 10 weeks pregnant reports smoking marijuana several times a week and says it helps with anxiety. Vital signs are within expected limits. The client has missed the last prenatal appointment due to transportation problems. Which intervention should the nurse prioritize for this client?
Explanation: This question tests high-risk behavior education on substance use and prenatal care adherence. The primary behavior risk is marijuana use for anxiety and missed appointments, which is a priority due to potential fetal neurodevelopmental effects and care gaps. The correct answer provides the most effective education by highlighting risks and facilitating access to support. Option B is incorrect as tapering timing is misguided; C is wrong as alcohol is harmful; D is excessive and not nurse-led. Effective client education in high-risk scenarios addresses social determinants like transportation. It also builds trust through empathetic listening. A strategy for prioritizing education topics is to tackle substance use immediately, then logistical barriers, aligned with pregnancy trimester needs.
A 45-year-old client receiving intravenous antibiotics reports sudden itching and throat tightness; within minutes the LPN notes wheezing, stridor, facial swelling, hives, blood pressure 78/40 mm Hg, heart rate 132/min, and oxygen saturation 86%. What is the nurse's FIRST action in this emergency?
Explanation: This question tests knowledge of emergency response and CPR participation in anaphylaxis during IV antibiotics. The priority framework is immediate safety, focusing on stopping the allergen and treating shock. Stopping the infusion and administering IM epinephrine per protocol while calling for help is the highest priority to reverse bronchospasm and hypotension. Notifying for antihistamine (B) delays, obtaining history (C) is post-stabilization, and applying blanket (D) ignores airway. The decision-making principle is recognizing anaphylaxis signs requiring epinephrine as first-line. Prompt action prevents progression to arrest. A transferable strategy is to always have epinephrine ready for suspected allergic reactions and activate help immediately.
A 55-year-old client is 6 hours post-operative from a total laryngectomy with a new tracheostomy on a medical-surgical unit. Vital signs: temperature 37.1°C (98.8°F), heart rate 96/min, respiratory rate 22/min, blood pressure 138/82 mm Hg, oxygen saturation 93% on humidified tracheostomy collar. The client has thick secretions. What is the PRIORITY nursing action for this client?
Explanation: This question tests clinical judgment in tracheostomy and airway care. The priority framework is client safety, focusing on preparedness for potential airway emergencies in the postoperative period. Verifying that the obturator and a spare tracheostomy tube are at the bedside is the highest priority to ensure immediate availability for reinsertion if accidental decannulation occurs, which is a risk in new tracheostomies. Changing ties (B) and applying a new dressing (C) are routine care but not immediate priorities; measuring the stoma (D) is observational and lower priority without signs of complication. In airway management, maintaining emergency equipment readiness is essential to prevent life-threatening delays. The decision-making principle is to anticipate complications like tube dislodgement in fresh tracheostomies and prioritize preventive measures. A transferable strategy for managing airway emergencies is to always have backup airway devices accessible and check them at the start of each shift.
A 24-year-old client arrives at a community mental health center walk-in clinic after losing their job yesterday and reports they "can't breathe" and "feel like I'm dying." The client is pacing, shaking, speaking rapidly, and repeatedly looking toward the exit; history includes occasional panic episodes during school exams but no prior hospitalizations. Which intervention should the nurse implement IMMEDIATELY to support the client in crisis?
Explanation: This question tests crisis intervention and de-escalation skills for managing acute panic symptoms. The priority framework focuses on immediate client safety and symptom reduction through environmental and behavioral interventions. Moving the client to a quieter area, speaking calmly, and coaching slow deep breathing with short, simple directions (C) is the most effective immediate intervention because it addresses environmental overstimulation, provides grounding through the nurse's calm presence, and offers a concrete technique to manage physiological symptoms. Asking for detailed symptom history (A) delays necessary intervention when the client is in acute distress; standing close and giving firm commands (B) may increase anxiety and feelings of being trapped; requesting medication (D) is not the first-line intervention for panic and delays immediate support. The principle of crisis intervention emphasizes rapid, focused interventions that address immediate distress while maintaining client autonomy. When managing panic episodes, use the acronym CALM: Create quiet environment, Approach with reassurance, Lead breathing exercises, and Maintain therapeutic presence.
A 77-year-old long-term care resident with obesity and limited mobility is prescribed sequential compression devices (SCDs) when in bed. The nurse finds the SCD pump turned on, but the sleeves are loosely wrapped and sliding down; the resident has 1+ edema and calf circumferences are equal at 35 cm bilaterally. Which action is MOST important for ensuring the effectiveness of the compression device?
Explanation: This question tests understanding of DVT prevention and ensuring proper SCD application in obese residents with limited mobility. The priority concern is that loosely fitted SCDs provide inadequate compression for DVT prevention. Rewrapping sleeves for snug fit and confirming pump function at ordered settings (Option A) ensures the device provides therapeutic compression. Option B (powder application with loose fit) maintains ineffective compression; Option C (switching to stockings) requires physician order and may be less effective for this patient; Option D (pillow under knees) could impede venous return and doesn't address the loose fit. The decision-making principle is that SCDs must maintain proper fit throughout use to provide effective intermittent pneumatic compression. A transferable strategy is to check SCD placement and fit at regular intervals, especially in patients with obesity where sleeves may slide more easily, and readjust as needed.
Setting: 20-bed Medical-Surgical Unit. Staffing: 1 RN (Charge Nurse), 2 LPN/VNs, 2 UAPs. Situation: The unit is at full capacity. One LPN/VN is caring for 10 clients. One of these clients, a 75-year-old with heart failure, has suddenly become short of breath and restless. Baseline (Client): BP 130/80 mmHg, HR 78 bpm, RR 16, SpO2 95% on room air. Current (Client): BP 155/92 mmHg, HR 102 bpm, RR 26, SpO2 89% on room air.
The nurse recognizes that because the client is now unstable, which task is no longer appropriate to delegate to a UAP?
Explanation: Once a client becomes unstable, the nurse must personally perform clinical data collection for that client rather than delegating it. Measuring SpO2 on an unstable client is not simply a data-recording task — it requires the nurse to be present, to interpret the reading in the context of the client's rapidly evolving condition, and to respond immediately to changes. A UAP can report a number, but cannot recognize the clinical significance of a declining trajectory or determine the appropriate next action. This is a critical distinction from routine vital sign measurement on stable clients, which UAPs routinely perform. Delivering a water pitcher (A) is a routine non-clinical supply task with no assessment component. Helping the client sit upright (B) is a physical assist task — positioning is within UAP scope, and the UAP can do this while the nurse is simultaneously conducting other aspects of the assessment. Assisting the roommate (D) involves a different, stable client and can continue as delegated.
A 6-year-old child with asthma lives with grandparents in a home where family members smoke indoors. The nurse observes a strong smoke odor, a cat that sleeps in the child’s bedroom, and stuffed animals covering the bed; the caregiver reports the child wakes up coughing at night. What is the PRIORITY safety concern for this client?
Explanation: This question tests home and environmental safety management for a child with asthma exposed to multiple triggers. The key safety concern is exposure to secondhand smoke, which is a potent asthma trigger that can cause immediate bronchospasm and respiratory distress. Exposure to secondhand smoke (A) is the priority safety concern because it poses the most immediate threat to the child's respiratory status and can trigger severe asthma exacerbations. Dehydration risk (B) is a potential complication but not the immediate threat; tripping over toys (C) is a safety concern but less critical than respiratory compromise; constipation (D) is not directly related to the environmental hazards present. The safety management principle is that removing or minimizing exposure to known respiratory irritants takes priority in managing asthma safety at home. A transferable strategy is to prioritize interventions that address immediate threats to breathing and oxygenation over other potential safety concerns.
A client with liver failure is ordered to receive fresh frozen plasma (FFP). The LPN/VN understands that FFP is most likely ordered for which therapeutic purpose in this client?
Explanation: Fresh frozen plasma contains all clotting factors and is indicated when a client has coagulopathy related to factor deficiency. In liver failure, the liver's ability to synthesize clotting factors (including factors I, II, V, VII, IX, and X) is impaired, resulting in elevated PT/INR and increased bleeding risk. FFP replaces these deficient factors. Packed red blood cells, not FFP, are used to raise hemoglobin and hematocrit. Platelet concentrates, not FFP, are indicated for thrombocytopenia. While FFP provides some volume expansion, this is not its primary indication in liver failure; albumin or crystalloids are preferred for volume replacement alone.
A 57-year-old client is newly prescribed Lisinopril 10 mg by mouth daily for hypertension. The client has a history of mild chronic kidney disease and reports dizziness when standing up, saying, “I might just stop taking it.” The LPN/VN is reinforcing medication teaching about expected effects and safety. Which side effect should the nurse emphasize when reinforcing medication education?
Explanation: This question tests understanding of medication education reinforcement for clients starting ACE inhibitors like lisinopril. The key medication concept being reinforced is common side effects, particularly those that may prompt discontinuation if not anticipated. The correct answer, a dry, persistent cough, accurately reflects the medication information because it is a well-known side effect of ACE inhibitors due to bradykinin accumulation, and clients should be advised to report it rather than stop the medication abruptly. Orange-colored urine is associated with medications like rifampin; hearing loss and tinnitus are ototoxic effects of drugs like aminoglycosides; black, tarry stools indicate gastrointestinal bleeding, which is more common with NSAIDs, making these distractors less optimal. A principle for effective medication education reinforcement is to differentiate between expected side effects and those requiring immediate medical attention. Another principle is to address client concerns empathetically to promote adherence. A strategy for ensuring client understanding and compliance is to provide written materials and follow up with questions to confirm comprehension of side effect management.
A 50-year-old client is admitted for alcohol withdrawal and asks the nurse not to tell their employer, who is calling the unit, that the client is hospitalized. The caller says they are the client's supervisor and need to know the diagnosis to arrange coverage. Facility policy prohibits confirming a patient's presence without authorization. Which action should the nurse take to maintain client confidentiality?
Explanation: This question tests ethical practice within the scope of the LPN/VN, emphasizing confidentiality from unauthorized employers. The legal standard is facility policy and HIPAA, forbidding confirmation of presence or details without authorization. Option B is the most ethical as it avoids disclosure and offers message-taking, protecting privacy. Option A confirms admission; C shares vaguely; D transfers inappropriately. The framework identifies unauthorized callers, uses neutral responses, and documents. Escalate if persistent. A transferable strategy is to safeguard employment-related privacy, reinforcing ethical trust in healthcare.
An older adult client with delirium is agitated, pulling at an IV line, and unable to rest. Which action should the practical nurse (PN) prioritize to provide comfort and safety?
Explanation: The priority is to use the least restrictive intervention that will ensure safety and provide comfort. Having a familiar person, like a family member, at the bedside can be very calming and reassuring for a client with delirium. This approach, often called 'sitter' observation, avoids restraints and potentially sedating medications.