NCLEX RN Practice Test

The correct answer is about directly assessing the client’s self-care ability through observation, which provides insight into their functional capacity and identifies potential challenges. Test questions focusing on direct observation are effective because they highlight practical assessment strategies over assumptions or indirect evaluation. Other answers are incorrect because they just rely on third-party input or client verbal confirmation, which may not accurately reflect actual ability. For example, a verbal description of foot care techniques might not reveal technical inaccuracies, and relying on family member reassurance does not account for the client’s own capacity.

The correct response involves assessing whether the complementary therapy is safe for the client. Lavender aromatherapy is generally safe, and the nurse can use this opportunity to educate the client about its potential benefits while ensuring the client does not have any contraindications, such as respiratory issues or allergies. Suggesting a different therapy without reason or immediately discouraging its use misses the opportunity to engage the client in shared decision-making and support their autonomy. Encouraging the client to rely solely on complementary therapies is contraindicated, as they should be used alongside, not in place of, standard medical treatments.

The correct answer is alcohol withdrawal, a condition resulting from the abrupt cessation of alcohol in clients who are physically dependent on it. Symptoms include tremors, sweating, nausea, high blood pressure, and hallucinations. These symptoms reflect the body's response to the absence of alcohol, which had been suppressing certain brain functions. This differs from stimulant overdose, which typically presents with agitation, paranoia, and heightened energy levels, and opioid withdrawal, where symptoms often include muscle aches, diarrhea, and pupil dilation. Benzodiazepine toxicity, on the other hand, would exhibit symptoms like confusion, drowsiness, and respiratory depression, rather than withdrawal-related autonomic instability.

Recommending a Mediterranean-style diet rich in vegetables, fruits, whole grains, lean proteins, and healthy fats is the most beneficial because it is supported by substantial evidence in reducing the risk of CVD. This dietary pattern lowers cholesterol, reduces inflammation, and improves heart health. While increasing physical activity is helpful, it is less effective without complementary dietary changes. Replacing carbohydrates with protein without professional guidance may result in an imbalanced diet. Routine fasting is not strongly supported as an effective long-term strategy for reducing CVD risk.

The correct answer focuses on empowering the client to feel involved in managing their condition and providing personalized support. Discussing the client’s feelings and concerns promotes therapeutic communication and allows the nurse to address specific stressors, fostering effective coping strategies. Suggesting the client join a support group is incorrect because, while it may be helpful in the long term, it does not address the immediate emotional and psychological needs. Providing a list of dietary restrictions without discussing emotions focuses only on the physical aspect of the diagnosis, ignoring the psychological impact. Encouraging the client to focus on how diabetes is manageable without exploring their immediate concerns does not validate the client’s feelings and may come across as dismissive.

The correct answer is to confirm updates on the client’s current condition and whether symptoms persist, as this provides insight into the client’s response to treatment and helps the receiving nurse prioritize care. Details like the time the medication was administered or its dosage are not as critical after the medication has already been administered. Information regarding a history of medication-related allergies might be useful in a different context but is not the most important point to clarify during this hand-off.

The correct action is to stop the transfusion to prevent further exposure to a potentially harmful reaction. Chills and an elevated temperature after a transfusion is started can indicate a febrile non-hemolytic transfusion reaction or another serious reaction. While notifying the healthcare provider and assessing the client are essential follow-ups, those actions do not address the immediate need to halt the transfusion, which is required to prevent worsening symptoms. Additionally, administering a fever medication without intervening to stop the transfusion could mask critical symptoms and delay treatment of the reaction.

Administering oxygen via a non-rebreather mask is the most appropriate initial intervention for a client with severe respiratory distress and SpO₂ of 83%. This device delivers a high concentration of oxygen rapidly, which is critical to stabilizing the client. High Fowler's position can improve breathing mechanics, but it is insufficient alone for such low oxygen saturation. Suctioning should only be attempted if there are clear signs of secretion buildup obstructing the airway, and in this case, there is no evidence of obstruction. Encouraging deep breathing exercises is helpful in mild respiratory difficulty but would not adequately address an SpO₂ of 83%, which is life-threatening.

Restlessness and confusion in the late afternoon, often referred to as 'sundowning,' are common in clients with Alzheimer's disease. The provision of a quiet, well-lit environment is the most effective intervention as it minimizes sensory overstimulation and reduces shadows that might contribute to increased confusion. Redirecting attention using sensory stimulation activities is generally more appropriate for earlier parts of the day to avoid overstimulating the client in the evening. Encouraging independent problem solving is unsuitable for clients with cognitive impairments since their ability to effectively concentrate and solve problems is diminished. Minimizing all forms of interaction isolates the client and neglects the need for comfort-oriented communication, which is essential for their psychological well-being.

The correct answer highlights prevention of accidental ingestion of cleaning agents and medications, which is a significant risk for preschool-aged children due to their developmental tendency to explore and put objects in their mouths. Securely locking up harmful substances reduces this risk. While other options address safety considerations, they are either less relevant for a preschool-aged child or provide insufficient strategies to prevent injury. For example, wearing helmets is important but primarily pertains to older preschoolers or school-age children actively engaged in physical activities like biking. Electrical outlet covers are also relevant but address a risk more common in infants and younger toddlers. Lastly, teaching safety concepts such as asking for help before touching dangerous objects is developmentally advanced for most preschool-aged children.

It is critical to assess the client’s current serum potassium level before administering potassium chloride. This ensures that the client's potassium is still below the normal range and avoids the risk of hyperkalemia, which can cause serious complications such as arrhythmias. Although renal function (BUN/creatinine) impacts potassium excretion and blood pressure is important for monitoring during therapy, these are secondary to the need to confirm serum potassium levels prior to administration. Blood glucose is unrelated to potassium chloride administration.

The correct answer is to verbally describe the room layout to the client and ensure personal belongings are within easy reach. This addresses the client’s specific visual impairment by helping them orient to the environment, reducing the risk of falls and ensuring a sense of autonomy. Other interventions, like simply reminding the client to use the call bell or focusing on intermittent physical assistance, may not fully address the client’s need for environmental orientation and independence. Encouraging independent ambulation without proper support could increase the risk of injury.

Confidentiality of patient information is a cornerstone of nursing practice and is required under legal standards like HIPAA. Discussing client information in a public setting, such as an open nurses' station, risks violating these standards. Instead, the nurse should relocate to a private area or ensure others cannot overhear the details being shared. This action reduces the risk of unauthorized disclosure and secures the client’s privacy. Lowering your voice is insufficient in many cases as it doesn't substantively eliminate the risk of being overheard by others nearby.

The correct answer emphasizes the nurse's role as an advocate for the client. It is essential to ensure that clients fully understand the risks, benefits, and alternatives to procedures before signing a consent form. Notifying the healthcare provider ensures the correct professional is involved in addressing the client’s questions. Explaining the importance of the consent form (option 2) may clarify its role, but it does not address the client's expressed need to understand the risks in detail. Providing information about the surgical team's qualifications (option 3) may offer comfort but does not tackle the specific concern. Documenting the concerns without escalation (option 4) does not resolve the client’s lack of understanding, failing the advocacy responsibility.

The correct answer is to report the findings to the appropriate authorities, as mandated reporters are legally and ethically obligated to report suspicions of abuse or neglect. This action ensures the initiation of an investigation to protect the client. While documenting findings, asking indirect questions, and assessing injuries are essential parts of care, failing to report suspected abuse leaves the client vulnerable to ongoing harm. Reporting should be done even if there is only reasonable suspicion, as investigators determine validity—not the nurse.

Proper hand hygiene is the single most effective way to prevent healthcare-associated infections (HAIs). This includes cleaning hands with soap and water or an alcohol-based hand sanitizer at appropriate times, such as before and after client contact. While wearing gloves and gowns, cleaning equipment, and isolating infected clients are important, they address specific aspects of infection control. These measures are effective in conjunction with, but not as a substitute for, proper hand hygiene.

The correct answer highlights the defining psychological feature of anorexia nervosa, which involves an intense fear of gaining weight and a distorted body image. This leads to a restriction of food intake and extreme behaviors to maintain a lower weight. Other options, such as focusing on overeating or purging behaviors, describe related but separate conditions like bulimia nervosa. Similarly, while weight loss can be a result of anorexia nervosa, it is a symptom and not the defining psychological characteristic of the diagnosis.

Dark, tarry stools are a potential sign of gastrointestinal bleeding, a serious adverse effect of anticoagulant therapy. Prompt reporting allows evaluation of the client's coagulation status and prevents life-threatening hemorrhage. Mild fatigue, ankle swelling after prolonged standing, or a dry mouth are not typical indicators of bleeding related to warfarin and do not require urgent evaluation.

Acknowledging a client’s emotional response fosters trust and demonstrates empathy, which is key to promoting positive coping strategies. Encouraging the client to express their concerns helps identify specific fears or misconceptions that can be addressed during the teaching session. This approach prioritizes understanding the client's perspective and lays the groundwork for effective care planning. Conversely, advising the client to focus on the benefits of their new routine might unintentionally minimize their current emotional struggle. Reassuring statements, such as 'It will get easier,' lack specificity and do not explore the deeper reasons behind the client’s distress. Offering solutions before fully understanding the client's perspective may hinder the therapeutic communication process and might not align with the client's immediate emotional needs.

The correct answer involves ensuring the client fully understands their discharge instructions, as this supports continuity of care, adheres to hospital policies, and reduces the risk of complications or readmissions due to misunderstood post-discharge care. While verifying transportation is necessary, it does not directly address continuing care. Similarly, retrieving personal belongings is important but secondary to providing clinical instructions. Notifying ancillary services like dietary in this context is not a discharge priority unless specified by the plan of care.