NCLEX-RN (Registered Nurse) Practice Exam — Question Explanations
Practice questions for the NCLEX-RN (National Council Licensure Examination for Registered Nurses). Covers safe and effective care management, safety and infection control, health promotion, psychosocial integrity, basic care, pharmacology, risk reduction, physiological adaptation, clinical judgment, and prioritization with realistic Canadian and North American hospital scenarios.
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NCLEX-RN Registered Nurse Licensure Exam at a glance
Administered by NCSBN / Provincial Nursing Regulators · NCLEX-RN (Registered Nurse)
- Authority
- NCSBN / Provincial Nursing Regulators
- Questions
- 75
- Pass mark
- 70%
- Time limit
- 300 min
Independent practice — not affiliated with NCSBN / Provincial Nursing Regulators. Always confirm current requirements with the official authority.
Informed consent requires the patient to understand:
Valid informed consent: nature of procedure, risks, benefits, alternatives, right to refuse — and the patient must be competent. Nurse witnesses signature; prov
Before administering digoxin, the nurse MUST assess:
Digoxin slows the heart. Hold and notify provider if apical HR <60 (adults) or <90–110 (infants). Also monitor K+ — hypokalemia potentiates toxicity.
A patient on heparin develops active bleeding. Which antidote should the nurse anticipate?
Protamine sulfate reverses heparin. Vitamin K reverses warfarin. Naloxone — opioids. Flumazenil — benzodiazepines.
Which task can the RN safely delegate to an unregulated care provider (UCP/PSW)?
Delegation rules: stable patients, predictable outcomes, no assessment/teaching/IV meds. ADLs and routine I&O are appropriate; assessment and sterile procedures
Four patients call the nurse at once. Who should be seen FIRST?
Apply ABCs: airway/breathing first. Hypoxia and dyspnea are life-threatening and take priority over comfort or routine tasks.
A patient with a history of heart failure is prescribed a loop diuretic. Which electrolyte imbalance is the…
Loop diuretics often lead to potassium excretion, increasing the risk of hypokalemia, which can cause cardiac dysrhythmias.
What is the most effective method for preventing the spread of Clostridioides difficile (C. diff)?
Alcohol-based hand sanitizers are not effective against C. diff spores; soap and water handwashing is essential.
A client with dysphagia is prescribed oral medications. What is the safest way for the nurse to administer …
Administering pills individually with thickened liquid can help prevent aspiration in clients with dysphagia. Crushing all medications is not always safe or app
A nurse delegates vital sign measurement to an unregulated care provider (UCP). What should the nurse asses…
It's crucial that the UCP can identify and immediately report any vital signs outside the normal range, as this requires the nurse's assessment and intervention
When administering a medication that requires a 'second check' by another nurse, what is the primary purpose?
The primary purpose of a second check is to provide an independent verification of the 'rights' of medication administration, significantly reducing the chance
A client is experiencing an allergic reaction to a newly administered medication. What is the nurse's prior…
The priority action for an allergic reaction to a medication is to stop the administration immediately to prevent further exposure and worsening of the reaction
Which client should the nurse assess first after receiving the morning shift report?
Shortness of breath in a client with pneumonia indicates a potential respiratory emergency requiring immediate assessment.
A nurse is reviewing medication orders. Which order requires clarification from the healthcare provider?
The PRN order for morphine lacks a frequency, which is necessary for safe medication administration.
A patient is scheduled for surgery and states, 'I'm scared I won't wake up.' What is the most appropriate n…
Acknowledging the patient's feelings and exploring specific concerns is a therapeutic communication technique that builds trust and provides opportunity for edu
Which finding in a patient receiving warfarin therapy requires immediate reporting to the healthcare provider?
A sudden severe headache in a patient on warfarin can indicate intracranial bleeding, a life-threatening emergency. Petechiae warrants assessment but is less ac
When donning sterile gloves, which step is crucial to maintain sterility?
Picking up the first glove by the folded cuff allows the nurse to insert the hand without touching the sterile exterior of the glove.
Which medication dosage calculation requires the most careful verification by two nurses?
Insulin is considered a high-alert medication due to its potential for serious harm if administered incorrectly. Double-checking is crucial for patient safety.
A client is prescribed intravenous vancomycin. The nurse understands that routine monitoring of which labor…
Vancomycin is nephrotoxic, so monitoring renal function (creatinine, BUN) is crucial to prevent kidney damage.
Which statement by a patient indicates understanding of proper ostomy care?
A dusky or blue stoma indicates compromised blood flow and requires immediate medical attention. Pouches are changed every 3-7 days, and alcohol is irritating.
A nurse is preparing to administer insulin. Which type of insulin can be administered intravenously?
Only regular insulin can be administered intravenously, typically in emergency situations for rapid glucose control. Other insulin types are designed for subcut
When donning personal protective equipment (PPE) for airborne precautions, which item should be applied last?
Gloves are donned last to protect clean hands from contaminated surfaces during other PPE application and to ensure they remain clean when touching the patient.
A nurse is preparing to administer insulin. What is essential to verify before administration?
Insulin dosing is often adjusted based on the patient's current blood glucose level to prevent hypoglycemia or hyperglycemia. Verifying this is paramount.
When removing sterile gloves, the nurse should:
Grasping the outer surface near the wrist of the first glove allows for its removal without touching the contaminated outer surface with bare hands, maintaining
A nurse is caring for a patient experiencing an anaphylactic reaction. Which medication should the nurse an…
Epinephrine is the first-line treatment for anaphylaxis due to its vasoconstrictive and bronchodilatory effects. Other medications are adjunctive.
A nurse is observing a new UAP performing perineal care. Which action requires intervention by the nurse?
Hand hygiene must be performed before putting on gloves and after removing them to prevent pathogen transmission.
A patient is receiving a continuous intravenous infusion of heparin. Which laboratory value is most critica…
The aPTT measures the intrinsic pathway of coagulation and is used to monitor heparin therapy. PT and INR are used for warfarin monitoring.
How often should a nurse assess a patient's peripheral IV site for signs of phlebitis or infiltration?
Regular assessment (at least every 4 hours for adults) is essential to detect and prevent complications like phlebitis or infiltration.
Which action by the nurse is required before administering a blood transfusion?
Obtaining informed consent for a blood transfusion is a critical ethical and legal requirement before administration. Other actions like warming in a microwave
When donning sterile gloves, the nurse should ensure that:
The first glove is picked up by the folded cuff to avoid contaminating the sterile outer surface, ensuring sterility is maintained.
A patient is experiencing an anaphylactic reaction to a medication. What is the nurse's first action?
The first and most critical action is to stop the causative agent, which in this case is the medication infusion. This prevents further exposure and worsening o
Which action is most critical for preventing the spread of methicillin-resistant Staphylococcus aureus (MRSA)?
Meticulous hand hygiene is the single most effective measure to prevent the transmission of MRSA and other healthcare-associated infections. MRSA is primarily s
A nurse is responding to a fire alarm on the unit. What is the immediate priority action?
The primary immediate action in a fire (RACE acronym) is to Rescue/Remove patients, then Alarm, Contain (close doors), and Extinguish. Closing doors contains th
A client is admitted with suspected pulmonary tuberculosis. Which type of isolation precautions should the …
Pulmonary tuberculosis is an airborne disease, requiring airborne precautions to prevent the spread of microorganisms via small particle aerosols.
Which statement indicates effective teaching about airborne precautions to a family member visiting a patie…
Airborne precautions require a N95 respirator mask and keeping the door closed to maintain negative pressure. Hand hygiene is always important, but not specific
A client is admitted with bacterial meningitis. Which personal protective equipment (PPE) is most appropria…
Bacterial meningitis requires droplet precautions, which involve a surgical mask, gloves, and gown. An N95 respirator is for airborne precautions.
A client is experiencing an anaphylactic reaction. What is the nurse's priority intervention?
Administering epinephrine intramuscularly is the priority intervention for an anaphylactic reaction as it rapidly reverses the effects of histamine and improves
What is the most effective way for a nurse to prevent catheter-associated urinary tract infections (CAUTIs)?
Meticulous perineal hygiene and proper catheter care, including sterile insertion and maintaining a closed drainage system, are critical to prevent biofilm form
A nurse is caring for a patient with a new order for levothyroxine. Which instruction should the nurse prov…
Levothyroxine should be taken on an empty stomach, typically 30-60 minutes before breakfast, for optimal absorption.
Which medication requires the nurse to monitor for signs of ototoxicity?
Furosemide, a loop diuretic, is known to have ototoxicity as a potential adverse effect, especially with high doses or rapid IV administration. Nurses should mo
A patient is hypotensive and dizzy. The nurse should immediately:
Elevating the legs can promote venous return to the heart, potentially increasing blood pressure and alleviating dizziness caused by hypotension.
A nurse is caring for a patient with Clostridium difficile (C. diff). Which personal protective equipment (…
Contact precautions are necessary for C. diff. Gowns and non-sterile gloves are essential to prevent transmission.
Which of the following tasks can a registered nurse (RN) safely delegate to an unlicensed assistive personn…
Assisting with ambulation for a stable patient is a task within the scope of practice for a UAP, as it does not require clinical judgment or assessment.
Which type of fire extinguisher is appropriate for a fire involving electrical equipment?
Class C fire extinguishers are specifically designed for electrical fires, as they contain non-conductive agents.
A patient is admitted with a suspected pulmonary embolism. Which finding requires immediate nursing interve…
Sudden dyspnea and chest pain are classic signs of pulmonary embolism and indicate acute respiratory distress, requiring immediate intervention.
A patient with newly diagnosed Type 1 Diabetes is learning to self-administer insulin. Which action by the …
Aspirating for blood return before injecting insulin is no longer recommended and increases discomfort without providing additional safety benefits.
Which task can a registered nurse (RN) safely delegate to a licensed practical nurse (LPN/LVN) for a stable…
Administering scheduled oral medications to a stable client is within the scope of practice for an LPN/LVN. Initial assessments, IV push medications, and care p
A patient with a history of seizures is prescribed phenytoin. Which adverse effect is most important for th…
Gingival hyperplasia is a common and dose-related adverse effect of phenytoin, requiring good oral hygiene and regular dental check-ups.
A nurse needs to delegate tasks to a UAP. Which task is appropriate for the UAP to perform?
Assisting with activities of daily living, such as feeding, is within the scope of practice for a UAP. Medication administration, assessment, and patient educat
Which task can a registered nurse (RN) delegate to an unregulated care provider (UCP)?
Assisting with ambulation is within the scope of practice for a UCP. Administering medications, assessments, and care planning are RN responsibilities.
A nurse is teaching a patient about self-care for a new colostomy. Which instruction is essential to preven…
A proper-fitting pouch opening prevents stool leakage onto the skin, which is the primary cause of peristomal skin irritation.
A client with active pulmonary tuberculosis is being discharged home. What instruction is most important fo…
Completing the full course of medication is paramount to eradicate the infection and prevent drug resistance, which is a major concern with tuberculosis. Non-ad
A nurse is teaching a client about self-administration of subcutaneous insulin. Which statement by the clie…
When mixing insulins, regular (short-acting) insulin should be drawn up before NPH (intermediate-acting) to avoid contaminating the regular vial.
When delegating care to an unlicensed assistive personnel (UAP), the nurse must ensure the UAP has which co…
The nurse must ensure the UAP possesses the necessary skills and competence to perform the delegated task safely and effectively. Assessment, medication adminis
A nurse is preparing to administer vaccines to a child. What is the most appropriate action to minimize dis…
Distraction techniques are highly effective in reducing pain and anxiety during injections in children.
Which action by the nurse ensures proper disposal of contaminated sharps?
Sharps should be immediately placed into a dedicated puncture-resistant container without recapping to prevent needlestick injuries.
What is the nurse's priority action when a patient states, 'I want to hurt myself'?
Any statement indicating self-harm requires immediate initiation of a suicide risk assessment to determine the level of danger and implement appropriate safety
A client reports severe pain in their right leg, 30 minutes after receiving oral pain medication. What is t…
The priority is to reassess the client's pain level and characteristics to determine the effectiveness of the administered medication and to guide further inter
A nurse is assigning tasks to a Licensed Practical Nurse (LPN). Which task is appropriate to assign?
Administering enteral feedings to a stable client is within the LPN's scope of practice, as it is a routine procedure for a stable patient.
A client is experiencing chest pain radiating to the left arm and jaw. What is the most appropriate initial…
Administering oxygen and calling for an ECG are critical initial steps for suspected cardiac chest pain to improve oxygenation and assess cardiac function.
A nurse is preparing to administer medications to a client. Which action is an essential step in ensuring m…
Checking the medication against the MAR three times (before removal, after removal, and at the bedside) is a critical safeguard to prevent medication errors.
A nurse is teaching a patient about home care after cataract surgery. Which instruction is crucial to preve…
Avoiding bending at the waist prevents an increase in intraocular pressure, which could lead to complications like hemorrhage or wound dehiscence after cataract
A patient is experiencing orthostatic hypotension. Which intervention should the nurse implement?
Orthostatic hypotension is caused by a sudden drop in blood pressure upon standing. Slow position changes allow the body to compensate and prevent symptoms.
A patient is prescribed a new medication and asks about potential side effects. What is the best response b…
Nurses have a responsibility to educate patients about common and serious side effects of medications to ensure safe use.
The nurse is preparing to administer an intramuscular (IM) injection to an adult client. Which needle gauge…
A 20-gauge, 1-inch needle is typically appropriate for an adult deltoid IM injection, providing sufficient length for muscle penetration and a suitable gauge fo
A patient with a new prescription for atorvastatin reports muscle pain. What is the immediate nursing action?
Muscle pain (myalgia) can indicate rhabdomyolysis, a serious adverse effect of statins, requiring immediate medical evaluation.
Which task can the nurse delegate to an unlicensed assistive personnel (UAP) for a stable client with heart…
Documenting intake and output is within the scope of practice for a UAP for a stable client. Medication administration, assessment, and education require the sk
Which patient finding would the nurse prioritize when caring for multiple patients on a medical-surgical unit?
Sudden confusion and restlessness can indicate an acute change in neurological status, hypoxia, or other serious conditions requiring immediate assessment.
A nurse is educating a client on how to use an albuterol inhaler. Which instruction is most important?
Inhaling slowly and deeply ensures the medication reaches the lower airways effectively. Holding breath for 5-10 seconds is usually sufficient, not 30.
A nurse is preparing to administer insulin. What is the most critical assessment to perform before administ…
Blood glucose level is essential to determine the correct insulin dose and prevent hypoglycemia.
Which action should the nurse take first when a patient with a central venous catheter develops a fever and…
Fever and chills in a patient with a central line suggest a central line-associated bloodstream infection (CLABSI). Blood cultures are needed to identify the pa
A patient with a prescription for vancomycin reports ringing in the ears. What action should the nurse take…
Tinnitus (ringing in the ears) is a sign of ototoxicity, a serious adverse effect of vancomycin, requiring immediate notification of the provider.
During a mass casualty event, which patient would receive the highest priority for immediate care using the…
An unconscious patient breathing spontaneously is categorized as immediate (Red tag) because they have a high potential for survival with rapid intervention.
What is the primary reason for placing a patient in a private room with negative pressure airflow?
Negative pressure airflow rooms are designed to contain airborne pathogens within the room, preventing their spread to other areas of the hospital. This is esse
A nurse is teaching a client about discharge medications. Which strategy is most effective to ensure client…
Having the client repeat instructions (teach-back method) is the most effective way to verify understanding and identify gaps in knowledge.
A client is receiving IV vancomycin. The nurse notes flushing and a rash on the client's upper body. What i…
This describes 'Red Man Syndrome,' common with rapid vancomycin infusion. Slowing the rate is the immediate intervention.
A nurse is caring for a client with a continuous bladder irrigation post-TURP. The drainage in the collecti…
Bright red drainage with clots indicates active bleeding. Increasing the irrigation rate helps to flush out clots and prevent obstruction.
The nurse identifies a medication error that occurred an hour ago. What is the immediate nursing action?
The immediate priority after discovering a medication error is to assess the client for any adverse effects or harm caused by the error, to ensure their safety
What is the primary purpose of obtaining a sputum culture before initiating antibiotic therapy?
A sputum culture identifies the specific microorganism causing the infection, allowing for targeted antibiotic therapy and reducing the risk of antibiotic resis
A nurse enters a client's room and finds them unresponsive. What is the nurse's priority action?
When a client is found unresponsive, the priority is to activate the emergency response system (e.g., call a code) to ensure immediate assistance and resuscitat
A 70-year-old patient post-total hip arthroplasty reports sudden shortness of breath and chest pain. What i…
The patient's symptoms suggest a pulmonary embolism. Administering oxygen and assessing vital signs are immediate life-saving interventions.
When donning sterile gloves, which step should the nurse perform first after opening the outer package?
The first step after opening the package is to grasp the cuff of the dominant hand's glove, touching only the inside surface to maintain sterility.
During a measles outbreak, which type of precaution is most appropriate for a newly admitted patient with s…
Measles is transmitted via airborne droplets and requires airborne precautions, including a negative-pressure room and N95 respirator.
A nurse is supervising an unlicensed assistive personnel (UAP) who is ambulating a patient with a new hip r…
Allowing full weight-bearing on a new hip replacement can dislocate the prosthesis or cause injury. Partial weight-bearing or non-weight-bearing is typically pr
Which of the following interventions is most effective in preventing ventilator-associated pneumonia (VAP)?
Frequent oral care with chlorhexidine reduces oral bacterial colonization, a primary source of pathogens in VAP.
Which of the following is the most effective way to prevent the spread of C. difficile in a healthcare sett…
Alcohol-based hand sanitizers are not effective against C. difficile spores. Soap and water handwashing is crucial for removing spores.
A nurse observes a colleague violating aseptic technique during a sterile procedure. What is the nurse's mo…
Immediate intervention is required to prevent potential patient harm. Reporting or documenting without intervention risks patient safety.
A patient has a prescription for a clear liquid diet. Which item is appropriate for the nurse to offer?
Clear liquid diets include liquids that are transparent and can be seen through, such as apple juice, gelatin, or broth.
A nurse working in a busy emergency department. Which task should NOT be delegated to a UAP?
Patient education requires a nurse's assessment, teaching skills, and ability to evaluate understanding, which falls outside the scope of practice for a UAP.
What is the most effective way to prevent catheter-associated urinary tract infections (CAUTIs)?
Maintaining a closed drainage system prevents bacterial entry, and prompt removal minimizes the time the catheter is a source of infection, reducing CAUTI risk.
A client is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate nursing…
Fever in a client receiving TPN can indicate an infection, possibly a central line-associated bloodstream infection (CLABSI), which is a serious complication. T
A nurse is caring for a client with Clostridium difficile infection. Which personal protective equipment (P…
C. difficile requires contact precautions, which include wearing a gown and gloves to prevent transmission through direct contact with the patient or contaminat
A nurse is educating a client on proper hand hygiene. Which action indicates the client understands the tea…
Thorough rinsing removes loosened microorganisms and soap residue. Washing for 5 seconds is too short, alcohol rubs are not for visibly soiled hands, and reusab
A patient is prescribed warfarin. Which food should the nurse advise the patient to consume in consistent a…
Foods high in Vitamin K, like spinach, can affect warfarin's effectiveness. Consistent intake is crucial to maintain therapeutic levels.
A nurse is caring for a patient who has a new colostomy. What is the most important initial teaching point?
Protecting the peristomal skin from irritation and breakdown is critical for comfort, preventing complications, and ensuring proper pouch adherence.
A client is diagnosed with tuberculosis (TB). Which type of isolation precautions should the nurse implement?
Tuberculosis is transmitted via airborne particles, requiring airborne precautions, which include a private room with negative pressure airflow and an N95 respi
What is the primary purpose of a 'time-out' before a surgical procedure?
The primary purpose of a 'time-out' is to prevent wrong patient, wrong site, and wrong procedure errors, ensuring patient safety.
Which medication administration route provides the fastest onset of action?
Intravenous administration delivers medication directly into the bloodstream, bypassing absorption barriers and leading to the fastest onset of action.
A patient with newly diagnosed Type 1 diabetes is learning to administer insulin. Which action by the patie…
Massaging the injection site can alter insulin absorption and is not recommended. Other actions are appropriate for insulin administration.
Which patient finding should the nurse prioritize for immediate assessment?
Decreased urine output and restlessness in a postoperative patient can indicate hypovolemia or other serious complications, requiring immediate assessment.
Which action by the nurse would violate patient confidentiality?
Leaving a patient's chart open in a public area risks unauthorized individuals seeing patient information, which violates confidentiality.
A nurse is preparing to administer a subcutaneous injection. Which angle of insertion is generally recommen…
A 45-degree angle is typically used for subcutaneous injections to ensure the medication is deposited into the subcutaneous tissue without reaching muscle.
A client refuses their prescribed medication, stating, 'I don't need it.' What is the nurse's best initial …
Exploring the client's reasons for refusal allows the nurse to understand their concerns, provide clarification, and potentially address misconceptions.
A nurse is teaching a patient about fall prevention at home. Which suggestion is most important?
Clutter-free walkways reduce tripping hazards, which is a primary cause of falls. Other options are not as effective or are counterproductive.
When educating a patient about home oxygen therapy, which statement indicates a need for further teaching?
Petroleum jelly is oil-based and flammable, posing a fire risk with oxygen therapy. Water-based lubricants should be used.
A patient is prescribed an opioid analgesic for severe pain. What is the most important assessment to perfo…
Opioid analgesics can cause respiratory depression, so assessing the patient's respiratory status is crucial to ensure safety before administration.
A client is experiencing hyperkalemia (potassium 6.8 mEq/L). Which medication would the nurse anticipate ad…
Regular insulin with dextrose helps shift potassium into cells, rapidly lowering serum potassium levels in hyperkalemia.
A patient with clostridium difficile infection is being discharged. What discharge instruction is most impo…
Thorough hand washing with soap and water is essential for C. difficile as alcohol-based hand rub is not effective against its spores. This prevents spread and
A client with a new prescription for warfarin is being discharged. Which instruction is essential regarding…
Warfarin's anticoagulant effect is affected by vitamin K intake. Clients should maintain a consistent, not necessarily restricted, intake of vitamin K-containin
Which finding requires immediate intervention by the nurse during rounds?
A confused patient attempting to climb out of bed is at high risk for falls and injury, requiring immediate intervention to ensure safety.
A nurse is preparing to administer medication to a patient with a nasogastric tube. What initial action is …
Verifying tube placement is crucial to prevent medication from entering the lungs, which could lead to aspiration pneumonia. All other options are incorrect or
A client refuses a prescribed medication. What is the nurse's initial action?
The initial action is to educate the client about the medication and the implications of refusing it, upholding their right to informed refusal.
A nurse is teaching a patient about self-administration of subcutaneous enoxaparin. Which instruction is es…
For enoxaparin, the prefilled syringe contains a small air bubble that should not be expelled as it ensures the full dose is delivered and seals the medication
A patient develops sudden chest pain, shortness of breath, and diaphoresis. What is the nurse's immediate p…
These symptoms suggest a potential cardiac event or pulmonary emergency. Elevating the head of the bed and applying oxygen addresses respiratory and cardiac com
A nurse is assessing a patient experiencing acute pain. Which characteristic is most subjective?
Pain is a subjective experience, and the patient's self-report (rating) is the most reliable measure, even if physiological signs are present.
A nurse enters a room and finds a patient unresponsive with no pulse. What is the immediate priority action?
Immediate initiation of chest compressions is critical for basic life support and improving outcomes in cardiac arrest. Time is muscle for the heart.
A patient is prescribed furosemide. The nurse should instruct the patient to report which common adverse ef…
Furosemide is a loop diuretic that can cause electrolyte imbalances, especially hypokalemia, which can manifest as muscle cramps.
A patient with a history of heart failure is prescribed digoxin. Before administering the medication, what …
Digoxin can cause bradycardia, so the nurse must assess the apical pulse rate for one full minute and hold the medication if it is below 60 bpm (or per prescrib
A patient is hypotensive and dizzy. The nurse delegates vital sign monitoring to a UAP. What instruction is…
Given the patient's hypotension and dizziness, immediate reporting of any blood pressure changes is critical for prompt nursing assessment and intervention to p
Which finding is most indicative of fluid overload in an adult client?
Crackles in the lung bases indicate fluid accumulation in the lungs, a classic sign of fluid overload.
Which statement best describes the purpose of a sentinel event review?
A sentinel event review focuses on identifying underlying system failures and root causes to prevent future adverse events, not on individual blame.
Which action is most important to prevent ventilator-associated pneumonia (VAP) in an intubated client?
Performing oral care with chlorhexidine solution regularly is a key intervention in preventing VAP by reducing oral bacterial colonization.
A patient is hypotensive and unresponsive. Which position should the nurse place the patient in?
Elevating the legs in a supine position can promote venous return to the heart and brain, improving blood pressure.
A nurse is preparing to administer medication via a nasogastric (NG) tube. What is the most critical step b…
Confirming NG tube placement is essential to prevent administering medication into the lungs, which can lead to aspiration pneumonia.
The nurse is reviewing a patient's medication list and notes an order for vancomycin. What is a critical as…
Vancomycin has a narrow therapeutic index and is nephrotoxic and ototoxic. Monitoring peak and trough levels ensures therapeutic levels while minimizing toxicit
A nurse is caring for four clients. Which client should the nurse assess first?
Chest pain radiating to the left arm could indicate an acute cardiac event and requires immediate assessment due to potential for life-threatening complications
Which task can a registered nurse (RN) safely delegate to a licensed practical nurse (LPN/LVN)?
LPNs can perform sterile dressing changes on stable wounds, as this is within their scope of practice for routine procedures.
A nurse is observing a new unlicensed assistive personnel (UAP) perform care. Which action by the UAP requi…
Feeding a client with dysphagia thin liquids without a swallow assessment or appropriate thickening can lead to aspiration, which is a serious safety risk.
A nurse is caring for a client with Clostridium difficile. Which cleaning agent is most effective for disin…
Household bleach solution is highly effective against C. difficile spores, which are resistant to many other disinfectants. Alcohol-based rubs are not sporicida
Which of the following patients should the nurse assess first?
Sudden onset shortness of breath and wheezing indicates an acute respiratory compromise, which is a life-threatening condition requiring immediate intervention.
A nurse is caring for a patient with a new prescription for warfarin. Which food should the nurse instruct …
Fluctuations in vitamin K intake (found in leafy greens like spinach, broccoli, kale) can affect warfarin's anticoagulant effect. Consistent intake, not avoidan
A client receiving warfarin has an INR of 5.8. The nurse should anticipate an order for which medication?
An INR of 5.8 is elevated for a client on warfarin, indicating an increased risk of bleeding. Vitamin K is the antidote for warfarin.
Which nursing intervention is most effective in preventing pressure injuries for an immobile patient?
Regular repositioning relieves pressure on bony prominences, which is the primary intervention for preventing pressure injuries.
A client is receiving warfarin therapy. Which laboratory value should the nurse monitor to assess the effec…
Warfarin therapy is monitored using the PT and INR to ensure therapeutic anticoagulation and minimize bleeding risk.
Which client should the nurse assess first after receiving the morning report?
The client with asthma exhibiting expiratory wheezing and an elevated respiratory rate indicates acute respiratory distress, which is a life-threatening conditi
A patient reports sudden, severe chest pain radiating to the left arm. What is the nurse's priority action?
Sudden, severe chest pain radiating to the left arm indicates a potential myocardial infarction, requiring immediate medical intervention.
The charge nurse is making assignments for the shift. Which patient should be assigned to the most experien…
A patient with new onset atrial fibrillation with RVR is unstable and requires continuous monitoring and rapid intervention, best managed by an experienced nurs
A patient with a urinary catheter complains of lower abdominal pain and urgency. What is the nurse's initia…
Lower abdominal pain and urgency with a catheter often indicate a blocked or kinked catheter, preventing urine drainage.
Which medication error prevention strategy is most effective in reducing medication administration errors?
Barcode scanning systems significantly reduce medication administration errors by verifying the '5 rights' at the bedside.
A patient with dysphagia requires feeding. What nursing intervention is most appropriate to prevent aspirat…
Thickened liquids are easier to control in the mouth and throat, and sufficient time reduces rushed swallowing, minimizing aspiration risk.
When assessing a patient's pain, which question is most important for the nurse to ask initially?
Asking the patient to describe their pain helps to understand its characteristics (e.g., sharp, dull, throbbing), which guides further assessment and treatment.
A nurse is caring for a client with a nasogastric tube (NGT) for gastric decompression. Which finding indic…
The presence of greenish-yellow fluid draining into the collection canister indicates that the NGT is effectively decompressing the stomach.
The nurse receives a hand-off report for four patients. Which patient should the nurse assess first?
A new onset of confusion and slurred speech suggests a potential neurological emergency, requiring immediate assessment to prevent further deterioration.
A patient receiving continuous enteral feedings develops diarrhea. Which nursing intervention should the nu…
Diarrhea in enteral feedings often indicates intolerance, necessitating communication with the provider to adjust the rate or formula. Assessing dehydration is
Which action demonstrates appropriate use of personal protective equipment (PPE) for a client with airborne…
An N95 respirator is required for airborne precautions to filter small airborne particles. The client's door should remain closed.
What is the most critical intervention for a client experiencing an anaphylactic reaction?
Epinephrine is the first-line treatment for anaphylaxis due to its vasoconstrictive and bronchodilatory effects.
A patient with a penicillin allergy is prescribed cefazolin. What action should the nurse take?
Cefazolin (a cephalosporin) has a potential cross-sensitivity with penicillin. The nurse should hold the medication and notify the prescriber to clarify the ord
The nurse is preparing to administer medication via a percutaneous endoscopic gastrostomy (PEG) tube. What …
Aspirating gastric contents and checking the residual volume is crucial to assess gastric emptying and prevent aspiration.
What is the primary reason for administering epinephrine in a cardiac arrest scenario?
Epinephrine's alpha-adrenergic effects cause vasoconstriction, shunting blood to the core organs (heart and brain), improving coronary perfusion pressure.
A patient reports feeling dizzy when standing up quickly. What is the most appropriate nursing recommendation?
Changing positions slowly helps the cardiovascular system adapt to changes in posture, mitigating orthostatic hypotension.
The nurse is preparing to insert a peripheral intravenous (IV) catheter. Which action demonstrates adherenc…
Allowing the antiseptic solution (e.g., chlorhexidine) to air dry completely ensures its full antimicrobial effect. Clean gloves are insufficient; sterile glove
A client is experiencing severe pain (9/10) after surgery. Which pain medication administration route would…
Intravenous (IV) medication administration provides the most rapid onset of action, crucial for severe acute pain.
A client is prescribed furosemide. The nurse should instruct the client to consume foods rich in which elec…
Furosemide is a loop diuretic that causes potassium excretion, so clients should increase potassium intake to prevent hypokalemia.
Which action by the nurse is most effective in preventing catheter-associated urinary tract infections (CAU…
Maintaining a closed urinary drainage system prevents introduction of microorganisms and is a key CAUTI prevention strategy.
Which task can a Registered Nurse (RN) delegate to a Licensed Practical Nurse (LPN) in a stable patient set…
Administering oral medications to a stable patient is within the scope of practice for an LPN, unlike complex assessments or blood transfusions.
A nurse is assessing a patient experiencing an anaphylactic reaction. Which clinical manifestation requires…
Wheezing and dyspnea indicate airway compromise, which is a life-threatening symptom of anaphylaxis requiring immediate intervention to maintain patency.
Which client should the nurse see first, considering potential for rapid deterioration?
Sudden chest pain and shortness of breath can indicate a life-threatening cardiac or pulmonary emergency, requiring immediate assessment.
Which finding is most indicative of a worsening condition in a patient with heart failure?
A rapid weight gain of 1 kg (2.2 lbs) in 24 hours often indicates fluid retention, a common sign of worsening heart failure and decompensation. This requires pr
The nurse is preparing to administer an opioid analgesic to a client. Which parameter must be assessed prio…
Opioid analgesics can cause respiratory depression. Therefore, it is crucial to assess the client's respiratory rate before administering the medication to ensu
When assessing a patient's pain, what is the most reliable indicator of pain intensity?
The patient's self-report is the most reliable and primary source of information regarding their pain experience. Pain is subjective, and only the patient can t
Which task can a registered nurse (RN) delegate to an unlicensed assistive personnel (UAP)?
Assisting with ambulation for a stable patient is within the scope of practice for a UAP, as it does not require clinical assessment or judgment.
A nurse is preparing to administer insulin. What is the most appropriate site for subcutaneous injection?
The abdomen provides consistent absorption and is readily accessible. Other sites are typically for intramuscular injections or less preferred for routine subcu
A nurse is caring for a patient experiencing an anaphylactic reaction. After ensuring airway patency, what …
Epinephrine is the first-line treatment for anaphylaxis due to its bronchodilator and vasoconstrictor effects.
Which patient should the nurse see first upon receiving the morning report?
A blood glucose of 3.2 mmol/L (hypoglycemia) is a critical finding that requires immediate intervention to prevent neurological damage or loss of consciousness.
A patient on contact precautions needs to be transported to another department. What is the nurse's priorit…
Notifying the receiving department ensures uninterrupted application of isolation precautions and prevents potential spread of infection in the new environment.
Which action by the nurse best demonstrates a commitment to patient advocacy?
Patient advocacy involves speaking up for the patient's rights, needs, and concerns, ensuring their voice is heard within the healthcare system.
A nurse is caring for a patient experiencing an acute asthma exacerbation. Which medication should the nurs…
Albuterol is a short-acting beta-agonist (SABA) and is the first-line bronchodilator for acute asthma exacerbations.
A client with a new tracheostomy requires suctioning. Which pressure setting should the nurse use for adult…
For adult clients, the recommended suction pressure for tracheostomy suctioning is typically 80-120 mmHg to effectively remove secretions without causing mucosa
A nurse is preparing to administer medication via a nasogastric tube. What is the priority action before ad…
Ensuring correct tube placement is critical to prevent aspiration of medications into the lungs.
Which task can a registered nurse (RN) delegate to a licensed practical nurse (LPN) for a stable client?
Administering oral medications to a stable client and documenting effects falls within an LPN's scope of practice. The other tasks require RN-level assessment o
A nurse is preparing to remove personal protective equipment (PPE) after caring for a client on contact pre…
Gloves are removed first as they are the most contaminated, followed by the gown, then eye protection, and finally the mask, to minimize self-contamination.
A nurse is preparing to administer medication via a nasogastric tube. What action is most important to ensu…
Verifying tube placement is crucial to prevent aspiration of medications into the lungs. This is a fundamental safety check for nasogastric tube administration.
Which action is most effective in preventing ventilator-associated pneumonia (VAP)?
Frequent oral care with chlorhexidine helps reduce oral pathogens that can migrate to the lungs and cause VAP.
A client has a potassium level of 2.8 mEq/L. Which cardiac finding would the nurse anticipate?
Hypokalemia (low potassium) is associated with the presence of prominent U waves on an electrocardiogram.
A nurse is assessing a client receiving a continuous opioid infusion for pain management. Which finding req…
A respiratory rate of 8 breaths/minute indicates significant respiratory depression, a serious adverse effect of opioid infusions requiring immediate interventi
What is the primary purpose of incident reports in healthcare?
Incident reports are crucial tools for quality improvement, helping organizations identify root causes of errors, implement preventative measures, and enhance p
A nurse is caring for a patient who is confused and at high risk for falls. Which intervention is most appr…
Placing the patient close to the nursing station allows for increased observation and quicker intervention, reducing fall risk without resorting to restraints o
Which situation warrants the use of standard precautions only?
Standard precautions apply to all patients, regardless of diagnosis, when there is potential contact with blood or body fluids. The other options require additi
A nurse is preparing to insert an indwelling urinary catheter. What is the most important principle to main…
Aseptic technique is paramount during catheter insertion to prevent the introduction of microorganisms and reduce the risk of catheter-associated urinary tract
A nurse is preparing to administer medication via an NG tube. After checking placement, what is the next pr…
Flushing the tube with water before medication administration ensures patency and prevents medication interaction with residual feeding.
Which task can a registered nurse (RN) safely delegate to a licensed practical nurse (LPN)?
Administering enteral feedings through an established PEG tube falls within the scope of practice for an LPN. The other options require the advanced assessment
The nurse is orienting a new graduate nurse. Which task can the new graduate nurse safely delegate to an ex…
Assisting with ambulation and ADLs falls within the UCP's scope of practice, while the other tasks require nursing judgment and skill.
A patient reports sudden, sharp chest pain and shortness of breath. The nurse's immediate action should be to:
Sudden chest pain and shortness of breath indicate a potential cardiac or respiratory emergency. Placing the patient in a high-Fowler's position and applying ox
A nurse receives report on four patients. Which patient should the nurse assess first?
Increased wheezing and shortness of breath in an asthma patient indicate a potential respiratory emergency, requiring immediate assessment and intervention.
When educating a client about self-administration of insulin, which statement indicates a need for further …
Needles should never be reused, even for personal use, due to increased risk of infection, pain, and dulling of the needle.
A client is diagnosed with Clostridium difficile (C. difficile). What is the most important infection contr…
Soap and water hand hygiene is critical for C. difficile because alcohol-based hand rubs are ineffective against C. difficile spores.
Which client presents the highest priority for the nurse to assess first?
New onset confusion and slurred speech can indicate a stroke or other neurological emergency, requiring immediate assessment and intervention.
A client is prescribed gentamicin. The nurse should closely monitor for which adverse effect?
Gentamicin, an aminoglycoside antibiotic, is known for its potential to cause nephrotoxicity (kidney damage) and ototoxicity. Monitoring kidney function (BUN, c
A patient exhibits signs of a stage 2 pressure injury. What is the priority nursing intervention?
Regular repositioning relieves pressure and promotes circulation, which is crucial for preventing further skin breakdown and healing existing injuries.
Before administering medication, what is the BEST way to verify patient identity?
Joint Commission/Accreditation Canada standards require two identifiers (typically name and DOB) plus wristband verification before any medication, procedure, o
When is alcohol-based hand rub NOT acceptable, requiring soap and water instead?
Alcohol rubs don't kill C. difficile spores and don't remove visible soil. Soap and water is required in these cases.
Which precautions are required for a patient with active pulmonary tuberculosis?
TB requires airborne precautions: N95 respirator, negative-pressure room, door closed. Droplet (mask) is for flu/pertussis; contact for MRSA/C. diff.
Which finding is MOST concerning in a 32-week pregnant patient?
Severe hypertension + headache + visual changes suggest severe preeclampsia → risk of eclampsia/HELLP. Emergent provider notification and magnesium sulfate may
A patient reports crushing chest pain radiating to the left arm. The FIRST nursing action is:
Suspected MI requires immediate 12-lead ECG, oxygen if SpO2<90, aspirin, nitroglycerin per protocol, and rapid provider notification. Time is muscle.
Oxygen delivery for a COPD patient should usually target:
Chronic CO2 retainers rely on hypoxic drive. Target SpO2 88–92% to avoid suppressing respiratory drive. Use lowest effective FiO2.
Which finding in the FAST acronym for stroke is INCORRECT?
FAST = Face, Arms, Speech, Time. Tachycardia is not part of the screen; sudden focal neuro deficits are.
A conscious diabetic patient with blood glucose 3.0 mmol/L should receive:
Rule of 15: 15 g fast carbs, wait 15 min, recheck. Glucagon is reserved for unconscious patients with no IV access.
A patient says, 'I have a plan to end my life tonight.' The nurse's PRIORITY action is:
Imminent suicide risk requires immediate safety measures: continuous observation, environmental safety, and provider notification. Never leave the patient alone
Earliest sign of dehydration in an infant is:
Decreased wet diapers (<6/day) is the earliest, easily-monitored sign. Sunken fontanelle and weight loss are later/severe signs.
Which is NOT one of the traditional 'rights' of medication administration?
The classic rights are patient, drug, dose, route, time, documentation, reason, and response. Brand name is not a 'right.'
A patient receives regular (short-acting) insulin SC at 0800. Peak action occurs at approximately:
Regular insulin onset 30 min, peak 2–4 hr, duration 6–8 hr. Monitor for hypoglycemia at peak.
A 72-year-old client with a history of heart failure is prescribed furosemide 40 mg orally daily. Which fin…
Furosemide is a loop diuretic that causes potassium excretion. A potassium level of 2.8 mmol/L is profoundly hypokalemic and could lead to cardiac dysrhythmias,
A nurse is caring for an 80-year-old client with end-stage heart failure who has an advance directive refus…
The nurse's priority is to address the conflict between the client's advance directive and the family's wishes by involving the healthcare team. The physician n
A 65-year-old client is scheduled for a colonoscopy tomorrow. The nurse has just explained the procedure, r…
For informed consent to be valid, the client must understand the information provided. If the client expresses remaining questions or a lack of understanding, t
A case manager is reviewing the discharge plan for a 72-year-old client recovering from a fractured hip. Th…
Given the client's age, living situation, and recovery from a fractured hip, home health care services would provide direct assistance with ADLs, medication man
A nurse is preparing a client for discharge after a stroke. The client has residual right-sided weakness an…
For a client with new neurological deficits like right-sided weakness and speech difficulty, continuity of care relies on structured, ongoing rehabilitation. Co
A nurse is caring for four clients. Which client should the nurse assess first?
The client post-hip replacement complaining of new onset shortness of breath is the priority. New onset shortness of breath can indicate a serious and life-thre
A registered nurse (RN) is supervising a licensed practical nurse (LPN) and an unregulated care provider (U…
Administering a prescribed oral antibiotic to a client with a stable urinary tract infection is within the scope of practice for an LPN. Initiating blood transf
A client with a new diagnosis of heart failure is being discharged. The nurse determines that the client wi…
A home health nurse can provide comprehensive, ongoing support, monitoring, and education regarding medication adherence, dietary modifications, and symptom man
A 75-year-old client, who legally appointed their daughter as power of attorney for personal care, becomes …
When there is a conflict between urgent medical recommendations and the decision of a power of attorney for personal care, especially involving a client who lac
A nurse is preparing a client for an emergency appendectomy. The client is anxious and states, 'I didn't ha…
Informed consent requires the client to understand the procedure, risks, and benefits fully. If a client expresses a lack of understanding or feels rushed, even
A client receiving a blood transfusion begins to develop chills, fever, and lumbar pain 15 minutes after th…
These symptoms are indicative of an acute hemolytic transfusion reaction, which is life-threatening. The immediate priority is to stop the transfusion to preven
A nurse case manager is working with a client newly diagnosed with amyotrophic lateral sclerosis (ALS). The…
While all options are important, for a client with a progressive neurological condition like ALS, initiating early intervention with an occupational therapist i
A client is being discharged after a myocardial infarction. To ensure effective continuity of care, which i…
For a client discharged after a myocardial infarction, it is critical they understand when to seek immediate medical attention for potential complications and h
A nurse is leading a team that includes another RN and two UCPs. A new admission arrives who requires a com…
The RN is responsible for performing the initial comprehensive assessments (head-to-toe and psychosocial) on a new admission. Frequent vital signs for an unstab
A client with chronic obstructive pulmonary disease (COPD) is frequently admitted to the hospital due to ex…
Given the client's frequent admissions due to non-adherence to nebulizer medications, a home care nurse can provide direct, personalized teaching, supervision,
A nurse is caring for an older adult client who has a history of falls and is prescribed a new medication t…
Instructing the client to use the call bell before ambulating directly addresses the immediate risk of falling by ensuring assistance is available, making it th
A client is admitted with suspected pulmonary tuberculosis (TB). What is the priority nursing action regard…
Placing the client in a negative pressure room immediately contains airborne pathogens, preventing the spread of TB to others. While obtaining cultures and clie
A client with hepatic encephalopathy is prescribed lactulose. The nurse explains to the client that the pri…
Lactulose works by promoting the excretion of ammonia, a byproduct of protein metabolism, through the stool. High ammonia levels are a key factor in the develop
The nurse is preparing to insert a peripheral intravenous (IV) catheter for a client. Which action best ref…
Cleaning the insertion site with an antiseptic using a specific technique from inner to outer creates a sterile field on the skin, which is a key principle of s
A client with delirium is attempting to climb out of bed and repeatedly pulling at their IV line. The nurse…
A dedicated staff member provides continuous, direct observation and allows for immediate intervention with less restrictive means, prioritizing safety and dign
The nurse is responding to a chemical spill of a cytotoxic medication in the medication room. What is the i…
The immediate priority in any hazardous material spill is to ensure the safety of all individuals by evacuating non-essential personnel from the contaminated ar
A nurse is preparing to administer penicillin G to a client. The client states, 'The last time I had penici…
The client describes a severe allergic reaction (anaphylaxis) to penicillin. The nurse must immediately notify the prescriber and withhold the medication to pre
A client has a surgical wound with purulent drainage. Which type of transmission-based precautions should t…
Purulent drainage from a wound suggests a potential infection that can be spread by direct or indirect contact, necessitating contact precautions. Standard prec
The nurse identifies a client's dose of warfarin is 10 mg PO daily, but the client's current INR is 3.5 (th…
An INR of 3.5 is above the therapeutic range, indicating an increased risk of bleeding. The nurse's priority is to immediately notify the prescriber before admi
A nurse is inserting an indwelling urinary catheter. During the procedure, the nurse accidentally touches t…
Touching the sterile catheter with a non-sterile hand contaminates the catheter, requiring its replacement with a new sterile one to maintain surgical asepsis a
A client is found attempting to climb over the bed rails. The nurse identifies that the client is confused …
Reorienting the client is a less restrictive intervention that addresses the underlying confusion and may prevent further agitational behavior and falls. Raisin
A nurse is teaching a new graduate nurse about standard precautions. Which statement by the new graduate nu…
Standard precautions are a set of infection control practices that apply to all clients, encompassing proper hand hygiene and the appropriate use of PPE (gloves
A client expresses concern about the hospital's universal sharps container being nearly full and asks the n…
Sharps containers should be replaced when they are two-thirds to three-quarters full to prevent accidental needlesticks and overfilling, which is a critical saf
A 68-year-old client with a history of hypertension and osteoarthritis lives alone. During a home visit, th…
Removing tripping hazards like throw rugs and improving lighting directly addresses immediate environmental risks for falls, which are a major cause of injury a
The nurse is providing education to a 28-year-old pregnant client in her first trimester. The client expres…
Folic acid supplementation and intake of folate-rich foods is critical in the periconceptional period and during early pregnancy to prevent neural tube defects.
A 16-year-old client is being seen for a sport physical. The client admits to occasional vaping with friend…
Vaping, particularly with nicotine-containing e-liquids, can lead to nicotine addiction and significantly increases the risk of transitioning to traditional cig
A 45-year-old client with no significant medical history informs the nurse they have been feeling more fati…
For a 45-year-old, fatigue can be a non-specific symptom of various conditions, and a fasting lipid panel and blood glucose screening are crucial for identifyin
A nurse is educating a group of parents about recommended childhood immunizations. A parent expresses conce…
The recommended immunization schedule is carefully developed based on scientific evidence to provide protection against diseases when children are most vulnerab
A 52-year-old male client reports regularly eating red meat, drinking sugary beverages daily, and having a …
Assessing the client's readiness for change and starting with small, achievable goals (e.g., walking 10 minutes a day, replacing one sugary drink with water) al
The nurse is conducting a developmental assessment on a 4-year-old child. Which finding, if present, would …
By age 4, a child should typically be using longer, more complex sentences (4-5 words) and be able to understand 2-3 step commands. Frequently using only two-wo
A 45-year-old client is admitted to the psychiatric unit after a suicide attempt. During the initial assess…
Option C uses clarification and open-ended questions, encouraging the client to express feelings without judgment, which is a key principle of therapeutic commu
A 32-year-old client with a history of generalized anxiety disorder presents to the clinic reporting increa…
Teaching progressive muscle relaxation addresses the immediate physiological and psychological manifestations of anxiety and stress, providing a direct coping m
A registered nurse is working in an emergency department when a 16-year-old client is brought in by police …
The immediate priority in crisis intervention for a client experiencing trauma is to ensure physical safety and create a supportive, private environment to fost
A 78-year-old client with end-stage heart failure is receiving palliative care at home. The client's daught…
Option B provides accurate information about common physiological changes during the dying process, normalizing the client's symptoms and addressing the daughte
A 55-year-old Indigenous client is hospitalized with a chronic illness. The client's family wants to perfor…
Advocating for an exception demonstrates cultural competence by recognizing the importance of traditional practices for the client's well-being and seeking to a
The charge nurse observes a newly hired Registered Nurse (RN) delegating the task of feeding a client with …
Delegating feeding a client with dysphagia and a history of aspiration pneumonia to a PSW is unsafe delegation, as this task requires specialized assessment and
A hospice nurse is caring for a 68-year-old client who recently lost their spouse of 45 years. The client s…
While the client is grieving, the significant weight loss, isolation, and profound statements of hopelessness (e.g., 'don't see the point anymore') indicate a p
A 78-year-old client with advanced Parkinson's disease is admitted to a long-term care facility. The nurse …
Given the client's signs of dysphagia and ineffective cough, the priority is to obtain a professional assessment to determine the safest and most appropriate fe
A nurse is caring for a 65-year-old client who underwent a total hip arthroplasty yesterday. The client rep…
Addressing the client's severe pain (8/10) is the priority to promote comfort and facilitate participation in other therapeutic activities. Pain relief is a bas
A 45-year-old client with a colostomy expresses concern about odour and leakage, making them reluctant to s…
Regular changing of the ostomy appliance (typically every 3-5 days or as recommended by the manufacturer/WOCN) helps maintain skin integrity, prevent leakage, a
An 82-year-old client with moderate Alzheimer's disease is admitted to a nursing home. The client is restle…
Establishing a consistent and predictable routine, especially at bedtime, is often the most effective non-pharmacological first approach for clients with dement
A nurse is assisting a client with left-sided weakness to ambulate using a cane. The client is cooperative …
When using a cane, it should be held on the client's strong (unaffected) side to provide maximum support and balance to the weaker side. The cane should advance
A nurse is preparing to assist a 68-year-old client with severe rheumatoid arthritis with their morning hyg…
A warm shower or bath can help reduce joint stiffness and pain associated with rheumatoid arthritis, making it easier for the client to participate in personal
A client presents with a new onset of right foot drop after a stroke, requiring the use of an ankle-foot or…
Clients using an AFO typically require shoes that fit properly over the orthosis to ensure stability and comfort. Regular loose-fitting shoes may not accommodat
A client with a new prescription for metformin 500 mg orally twice daily at breakfast and dinner asks the n…
If a dose of metformin is missed, the client should skip that dose and resume their regular schedule. Taking two doses at once or taking it without food increas
A nurse is preparing to administer acetaminophen 325 mg orally for a client complaining of a headache (pain…
The last dose was 3 hours ago, and acetaminophen is typically dosed every 4-6 hours. The client's pain level is moderate, and the prescribed dose is within the
A nurse is caring for a client receiving a continuous IV infusion of heparin. The client's activated partia…
First, calculate the current infusion rate in units/kg/hr: 1200 units/hr / 75 kg = 16 units/kg/hr. Then, decrease the rate by 2 units/kg/hr: 16 - 2 = 14 units/k
A client is prescribed 1 litre of 0.9% Normal Saline to infuse over 8 hours. The IV tubing has a drop facto…
To calculate the mL/hr, divide the total volume in mL by the total time in hours: 1000 mL / 8 hours = 125 mL/hr. The drop factor is irrelevant for infusion pump
A nurse is administering a unit of packed red blood cells (PRBCs) to a client. Fifteen minutes after the in…
The client is exhibiting signs of an acute allergic transfusion reaction (urticaria, itching). The immediate priority is to stop the transfusion to prevent furt
A client receiving opioid analgesia via a patient-controlled analgesia (PCA) pump has a respiratory rate of…
A respiratory rate of 8 breaths/minute and difficulty arousing indicate opioid-induced respiratory depression, a life-threatening complication. The priority is
A nurse is preparing to administer insulin glargine to a client with type 2 diabetes. Which statement by th…
Insulin glargine (Lantus) is a long-acting insulin and should never be mixed with any other type of insulin. Mixing can alter its pH and lead to unpredictable a
A client is receiving total parenteral nutrition (TPN) and reports sweating, tremors, and feeling light-hea…
The client is experiencing signs of severe hypoglycemia, which is an acute and life-threatening condition. Administering a bolus of 50% dextrose is the fastest
A nurse is reviewing the medication orders for a client who is NPO and has a standing order for oral ibupro…
Since the client is NPO (nothing by mouth), administering an oral medication is contraindicated. The nurse should contact the primary healthcare provider to obt
A client with a history of heart failure reports sudden onset of shortness of breath. The nurse notes crack…
The client is experiencing acute dyspnea and hypoxemia. Administering supplemental oxygen is the most immediate intervention to improve oxygenation and alleviat
A new order is received for vancomycin 1 gram IV every 12 hours for a client with a suspected MRSA infectio…
Vancomycin is renally excreted and nephrotoxic. The client's elevated creatinine and BUN indicate impaired renal function, increasing the risk of vancomycin tox
A nurse is preparing to administer warfarin to a client. The client's INR is 1.2. The target INR range for …
An INR of 1.2 is subtherapeutic, meaning the client's blood is not adequately thinned for the target range of 2.0-3.0. The nurse should administer the ordered d
A nurse is administering hydromorphone 1 mg IV push to a client with severe post-operative pain. After admi…
Hydromorphone is a potent opioid that can cause respiratory depression and sedation, especially when administered intravenously. Assessing the client's level of
A 72-year-old client is admitted with a hip fracture and is scheduled for surgery. The nurse notes the clie…
An INR of 3.5 is elevated and indicates an increased risk for bleeding, which is a significant concern before hip fracture surgery. Notifying the healthcare pro
A client undergoes a thoracentesis for pleural effusion. Thirty minutes after the procedure, the nurse asse…
A respiratory rate of 28 breaths per minute with shallow respirations after a thoracentesis can indicate a pneumothorax or further compromise in lung expansion,
The nurse is caring for a client who is receiving a continuous intravenous infusion of unfractionated hepar…
An aPTT of 120 seconds is significantly above the therapeutic range, indicating a high risk for bleeding. The nurse's priority action is to immediately stop the
A client is 4 hours post-abdominal surgery. The nurse notes the client's blood pressure is 90/50 mmHg, hear…
The client's vital signs (hypotension, tachycardia) and low urine output are indicative of potential hypovolemia or hemorrhage, which are serious post-operative
The nurse is preparing a client for a scheduled colonoscopy. The client reports severe abdominal cramping a…
Incomplete bowel preparation can hinder visualization during a colonoscopy, potentially leading to a missed diagnosis or the need to reschedule the procedure. T
A client with a new peripherally inserted central catheter (PICC) line complains of sudden onset of ipsilat…
New onset shoulder pain and arm swelling ipsilateral to a PICC line can indicate a deep vein thrombosis (DVT), a potentially serious complication. Measuring arm
A client admitted for dehydration has a potassium level of 2.8 mmol/L (normal range: 3.5-5.0 mmol/L). The h…
Adequate urine output is essential before administering intravenous potassium, as the kidneys are responsible for potassium excretion. Administering potassium t
A client is 6 hours post-open cholecystectomy. The nurse notes the client's temperature is 38.8°C (101.8°F)…
A temperature of 38.8°C (101.8°F) within 6 hours post-op can indicate an infection, atelectasis, or other serious complications, requiring immediate assessment
The nurse is taking vital signs for a client with a history of hypertension. The client's blood pressure is…
Before initiating any intervention for an elevated blood pressure reading (especially if asymptomatic), it is crucial to confirm the reading. Rechecking the blo
A client is scheduled for a cardiac catheterization. Which statement by the client indicates a need for fur…
Metformin can interact with contrast dye used during a cardiac catheterization, potentially leading to acute kidney injury (lactic acidosis). The nurse must not
A nurse is caring for a client with a nasogastric (NG) tube after gastric surgery. The nurse notes abdomina…
Abdominal distension and nausea with minimal NG drainage suggest a clogged or improperly positioned tube. The priority is to assess and restore patency by irrig
A 78-year-old client with a history of heart failure is admitted with shortness of breath, bilateral pittin…
Increasing intravenous fluid intake in a client with signs and symptoms of fluid volume overload, such as those seen in heart failure, would exacerbate their co
A client presents to the emergency department with a 2-day history of severe vomiting and diarrhea. Arteria…
A pH of 7.28 indicates acidosis. A normal PaCO2 (40 mmHg) rules out a primary respiratory issue, while a low HCO3 (18 mEq/L) points to a metabolic origin, consi
A 55-year-old client post-cardiac surgery is receiving continuous norepinephrine infusion titrated to maint…
The client's low blood pressure (MAP = (80 + 2*40)/3 = 53.3 mmHg) indicates inadequate perfusion, falling below the target of 65 mmHg. The priority is to adjust
The nurse is caring for a client with Addisonian crisis. Which electrolyte imbalance is most commonly assoc…
Addisonian crisis results from a severe deficiency of adrenal hormones, including aldosterone, which is responsible for sodium reabsorption and potassium excret
A client with chronic kidney disease (CKD) reports increasing fatigue, pruritus, and leg cramps. Laboratory…
Anemia in chronic kidney disease is primarily caused by decreased production of erythropoietin by the kidneys. Epoetin alfa is an erythropoiesis-stimulating age
The nurse is reviewing the medication administration record for a new admission with myasthenia gravis. The…
Myasthenia gravis is characterized by a reduction in acetylcholine receptors at the neuromuscular junction. Pyridostigmine is an acetylcholinesterase inhibitor,
A 68-year-old client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Th…
The client's ABGs indicate acute respiratory acidosis with hypoxemia (low pH, very high PaCO2, low PaO2). Oxygen at 2 L/min might not be sufficient, and aggress
A client with a history of alcoholism and cirrhosis is admitted with ascites and peripheral edema. The clie…
Hyponatremia in clients with cirrhosis and fluid overload (ascites, edema) is dilutional hyponatremia due to excess fluid, not true sodium deficiency. Fluid res
The nurse is assessing a client diagnosed with deep vein thrombosis (DVT) in the right leg who is receiving…
Petechiae are small, pinpoint hemorrhages that indicate capillary bleeding, a sign of increased bleeding risk, which is a significant complication of heparin th
A client with suspected septic shock has a central venous pressure (CVP) of 2 mmHg and a mean arterial pres…
Vasopressors should ideally be administered through a central venous catheter because of their potent vasoconstrictive properties, which can cause severe tissue
A client is admitted with diabetic ketoacidosis (DKA). The nurse anticipates that the initial goals of trea…
The immediate priorities in DKA management are fluid resuscitation to correct dehydration and address electrolyte imbalances (especially potassium) caused by os
A 78-year-old client with a history of heart failure is admitted to the emergency department reporting incr…
Recognizing cues involves identifying relevant data points from the client's assessment. The nurse observes and collects objective and subjective information, s
A 65-year-old client post-abdominal surgery on day 3 reports increasing incisional pain, rating it 8/10. Up…
Analyzing cues involves interpreting the collected data and linking it to the client's condition. The shallow respirations in the presence of severe pain sugges
A nurse is caring for a 42-year-old client admitted with asthma exacerbation. The client reports increasing…
Prioritizing hypotheses involves ranking the possible reasons for the client's condition based on the immediacy and severity of the threat. Acute asthma symptom
A 55-year-old client with type 2 diabetes receiving continuous subcutaneous insulin infusion reports feelin…
Generating solutions involves developing a range of possible interventions to address the client's needs. Before implementing, the nurse considers various optio
An 82-year-old client with a history of falls is ambulating to the washroom with a walker. The nurse observ…
Taking action involves implementing the prioritized solution. Given the client's unsteadiness, lightheadedness, and history of falls, the immediate priority is
A 30-year-old client with a severe peanut allergy received an accidental exposure to peanuts. The nurse imm…
Evaluating outcomes involves comparing the client's current status to the desired outcomes following an intervention. The improvement in respiratory rate, wheez
A client is admitted with community-acquired pneumonia. The nurse recognizes the client's fever, productive…
After implementing interventions, the nurse must continuously evaluate the client's response. The emergence of new rhonchi despite some improvement indicates a
A client with advanced dementia frequently wanders away from their room. The nurse has implemented various …
Engaging a client in a distracting activity is a task that can be delegated to a UAP under the Right Direction/Supervision, as it does not require clinical judg
A newly admitted term neonate is observed to have transient tachypnea (respiratory rate 70 breaths/min) and…
Analyzing cues involves linking clinical findings to underlying pathophysiology and risk factors. Gestational diabetes is a significant risk factor for delayed
A 78-year-old client with a history of heart failure is admitted to the emergency department reporting sudd…
The client's SpO2 of 88% and respiratory distress indicate impaired gas exchange, which is an immediate life threat. Applying oxygen via non-rebreather mask at
The nurse is caring for an older adult client who became agitated and pulled out their peripheral intraveno…
Obtaining vital signs is within the scope of practice for a UAP. Reinserting an IV, applying a sterile dressing to an open wound, and assessing neurological sta
A 55-year-old client with type 2 diabetes and a history of peripheral neuropathy reports a new, non-healing…
While all options are important, assessing for systemic infection (e.g., fever, elevated white blood cell count) is the priority. Localized infection of a non-h
A registered nurse (RN) is supervising an experienced registered practical nurse (RPN) on a medical-surgica…
Providing routine wound care and dressing changes for a stable client falls within the scope of practice for an RPN. Initial assessments, administering high-ris
A client is admitted to the emergency department after a motor vehicle collision. They are conscious, stati…
Even with stable vital signs and a visible leg injury, it is crucial to assess for potentially more life-threatening injuries (e.g., internal bleeding, head inj
The nurse has received the following report on four clients. Which client should the nurse assess first?
A blood glucose level of 3.2 mmol/L indicates hypoglycemia, which can rapidly worsen and lead to seizures or loss of consciousness. This is an acute, life-threa
A client with a terminal illness expresses sadness about their impending death and states, 'I wish I could …
Maslow's Hierarchy of Needs prioritizes love/belonging and self-actualization once physiological and safety needs are adequately addressed. Addressing the clien
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Other Canadian certifications candidates often prepare for alongside this one.