NCLEX RN Practice Test

The correct answer is to ask the client about their understanding of the condition and how they feel about learning more. This approach centers the client, enabling the nurse to understand the client’s current knowledge, emotional state, and motivation, which are key aspects of readiness to learn. Simply providing educational materials without assessing readiness does not ensure that the client is open or able to engage with the information. Observing posture and eye contact or evaluating readiness based solely on attendance focuses on superficial aspects that may not accurately reflect the client’s actual psychological or emotional state, leading to an incomplete understanding of their readiness to learn.

Performing thorough hand hygiene immediately before touching any sterile supplies is the first and most effective barrier against introducing microorganisms during an aseptic procedure. CDC identifies hand hygiene as the single most important practice to reduce transmission, and the WHO/CDC "Five Moments" specify cleaning hands just before an aseptic task. While disinfecting the work surface, wearing gloves, and keeping the sterile field in sight are important aspects of sterile technique, none of them will protect the supplies or the wound if the nurse's hands are already contaminated.

The correct answer focuses on involving a social worker to provide support and identify resources that can help the client manage their health while dealing with occupational and financial stressors. This approach is aligned with holistic care principles, ensuring the client has access to the support needed to balance work, family, and health responsibilities.

Other options might seem appropriate but do not directly address the root issue. For instance, offering relaxation techniques or lifestyle coaching could benefit the client long term but do not immediately help address the stress caused by their specific situation. Similarly, suggesting that the client reduce work commitments might not be realistic without a concrete plan or resources in place to support such a change.

Breath sounds, such as wheezing or stridor, indicate potential airway obstruction or impaired ventilation and require prompt action to prevent further respiratory compromise. These findings are critical and directly assessed during a focused respiratory examination.

Chest tenderness to palpation, while it may be uncomfortable, often points to musculoskeletal issues or localized inflammation that typically does not require emergency intervention. Decreased oxygen saturation warrants close monitoring but does not automatically indicate an emergent issue unless it is severe or accompanied by other signs of respiratory distress. Warm, dry skin suggests systemic stability and is not associated with acute respiratory concerns.

The correct answer is "Contact the healthcare provider to clarify the administration timing." Acetaminophen has a maximum daily dose of 4,000 mg to prevent liver toxicity. Administering the medication earlier than the prescribed interval increases the risk of approaching or exceeding this threshold. The nurse must contact the healthcare provider before proceeding to ensure client safety and compliance with the prescribed timing. Simply researching prior documentation will not resolve the timing issue. Giving the medication without clarification creates significant risk, and documenting refusal without seeking provider input neglects client needs for pain relief and the possibility of adjusting the order.

Early ambulation after a vaginal delivery improves blood circulation, helping to reduce the risk of deep vein thrombosis (DVT) by preventing blood from pooling in the legs. It also facilitates general recovery, though it does not directly speed up perineal healing, eliminate pain, or significantly resolve post-partum mood changes. Educating clients about the primary goal of early ambulation helps them prioritize activities essential for recovery.

The correct answer involves identifying a task consistent with the assistive personnel’s training and scope of practice. Assisting with bathing and personal hygiene falls within the role of assistive personnel because it is a basic care activity. Teaching a client how to use medical equipment requires clinical judgment and falls under the scope of practice of a registered nurse. Adjusting oxygen flow rates and administering medications require knowledge and skills exclusive to licensed nurses and are not safe to delegate to assistive personnel. Choosing appropriately delegated tasks ensures the team works safely and efficiently in providing care.

The correct answer involves initiating a conversation to explore the client's challenges and emotions while collaborating to establish realistic and achievable goals. This approach acknowledges the difficulty of the life change and empowers the client to take gradual, manageable steps. Asking open-ended questions about their feelings and challenges helps identify specific concerns and barriers, while goal-setting promotes self-efficacy. The other answers are incorrect because focusing on solely providing education without addressing emotional barriers or redirecting the focus to others may not fully support the client in coping with the significant lifestyle modifications needed.

The correct answer focuses on arranging professional home health support, which is critical when a client experiences significant barriers such as fatigue and mobility limitations. This intervention provides direct assistance while also allowing for further assessment of the client's needs in the home environment. Educational interventions, while important, may not address the immediate physical barriers to care. Encouraging medical equipment purchases or lifestyle adjustments may help in the long term but fail to prioritize the evaluation and support needed to manage the client’s current difficulties effectively. Professional support is a priority to ensure safety and establish a foundation for ongoing care management.

The nurse must follow proper protocol for wasting a controlled substance. Controlled substances must be disposed of in the presence of a witness (such as another licensed nurse) to comply with federal regulations and prevent misuse or diversion. Documenting the disposal is essential to account for the medication and remain compliant. Securing the medication in the cart temporarily without wasting it is not appropriate, as the medication has already been removed from the secure storage system. Returning the medication to the client's bedside is unsafe and does not align with regulatory guidelines. Administering the medication despite the client’s refusal violates patient autonomy.

The correct answer is that the client is unable to perform basic activities of daily living (ADLs), such as bathing, dressing, or toileting, due to physical limitations. These tasks are fundamental to the client’s independence and safety at home. If the client cannot perform these tasks, they would require assistance to prevent injury and maintain hygiene. The other answers may describe challenges but do not directly indicate an inability to manage basic care needs. For example, inability to safely navigate stairs is important but may be mitigated with modifications rather than daily help, and forgetfulness, while concerning for medication adherence, does not immediately indicate a need for assistance with personal care.

The correct answer is to initiate seizure precautions because a serum sodium level of 118 mEq/L indicates severe hyponatremia, which places the client at high risk of neurological complications, including seizures. Hypotonic fluids would worsen the sodium level and are contraindicated. While a daily weight is helpful to evaluate fluid status, it does not address the immediate risk associated with neurological complications. A high-sodium diet may be part of a long-term treatment plan, but it is not an immediate priority.

Using a professional medical interpreter is the most appropriate step when a language barrier exists between healthcare providers and the client. Professional interpreters are trained to ensure accurate communication between all parties and maintain confidentiality. Family members, although helpful in some situations, may not accurately translate medical information due to a lack of training or personal bias, and this could compromise care. Hand gestures and pictures can supplement communication but should not replace professional interpretation services, as they are less precise and may lead to misunderstandings.

The correct answer is to explore the client’s feelings and discuss ways to adapt to the vision changes while finding meaningful activities. By focusing on the emotional impact of the client's situation and identifying ways to cope constructively, the nurse addresses both the client’s psychosocial needs and sense of purpose. Encouraging the client to adapt to the changes fosters resilience and minimizes feelings of helplessness. Reassuring the client without offering solutions does not fully acknowledge their emotional distress. Referring them to a therapist may be premature without first conducting a thorough assessment of their current coping mechanisms. Emphasizing their independence without addressing their emotional concerns may unintentionally dismiss the impact of their vision loss.

The correct answer recognizes the importance of using therapeutic communication to validate the client’s feelings and promote exploration of coping strategies. By acknowledging the client’s emotions and encouraging them to express more, the nurse helps the client begin to process their diagnosis. The incorrect answers fail to provide the emotional support necessary or dismiss the client's concerns. For example, providing false reassurance ('You will be okay') underestimates the challenges of adjusting to a progressive illness. Offering premature advice like focusing on treatments or implying the need for immediate positivity oversimplifies the emotional complexity involved in adjusting to a new chronic condition.

The correct answer emphasizes that involving the patient in care decisions aligns with their legal and ethical right to informed consent and fosters autonomy. The other options, while partially correct, lack the optimal focus on empowering the patient through active participation and understanding. Simply providing written materials or relying on staff discussion does not ensure comprehension or shared decision-making.

The correct answer is to verify the identity of the client, as this ensures all subsequent care, including documentation and labeling, is accurately performed. Identification prevents potential errors involving the deceased. Other options, such as washing the body or securing personal belongings, occur after proper identification is complete. Documentation is performed throughout but is not the initial step.

The correct answer involves the use of aseptic technique and confirming the functionality of the central line by aspirating for blood return before administration. This ensures that the line is patent and reduces the risk of complications like infiltration or infection. The alternative answers either include unnecessary steps, such as diluting the medication without specific orders, or omit key safety precautions, such as checking for blood return or engaging in standard protocol measures.

The correct answer is 'Practice deep breathing and coughing exercises several times an hour while awake.' This technique is a key intervention to prevent pulmonary complications like atelectasis and pneumonia after surgery. It improves lung expansion and helps remove secretions, reducing the risk of respiratory infections.

Ambulating early is also important for preventing complications such as deep vein thrombosis; however, clients should typically ambulate with assistance and as medically appropriate, which is not addressed in that option. While wearing an abdominal binder can provide support and comfort, it does not directly prevent complications like pulmonary issues or thrombosis. Avoiding solid foods is relevant to some recovery protocols but does not address the primary goal of avoiding complications like respiratory or circulatory issues after surgery.

The client is demonstrating signs of alcohol withdrawal syndrome, which can begin within hours of the last alcohol use. Symptoms such as tremors, agitation, diaphoresis, and nausea are hallmark indicators. Early identification is critical to minimize complications like seizures or delirium tremens (DTs). While conditions like delirium tremens, a panic attack, or a medical emergency can present with some overlapping symptoms, these usually have different onset patterns and clinical markers. For example, delirium tremens involves severe confusion and hallucinations, typically occurring 48–96 hours after alcohol cessation.