NCLEX RN Practice Test

Using proper positioning ensures the client’s comfort and safety, particularly reducing the risk of aspiration when eating. Positioning the client upright at 90 degrees ensures that food and fluids are safely swallowed. Other answers, such as offering food by hand at their usual speed, ignore safety considerations like aspiration risk. Similarly, placing food on the weak side of the mouth may increase the difficulty of chewing and swallowing.

The correct answer emphasizes removing small objects within the infant's reach, which directly addresses the risk of choking caused by the infant's tendency to explore objects orally. Other potential answers, such as placing gates at staircases, are important for preventing falls, not choking. Offering age-appropriate toys ensures safety during play but misses the broader issue of managing potentially hazardous objects in the environment. Supervising during feeding is critical to prevent choking when eating but does not extend to general choking hazards in the home.

Encouraging a client to limit their alcohol consumption to moderate drinking levels is supported by evidence-based guidelines to reduce health risks, such as liver disease, cardiovascular issues, and impaired judgment. Drinking water with alcohol, while helpful for hydration, does not mitigate the health risks associated with excessive alcohol consumption. Avoiding mixed drinks may aid digestion in some cases but does not address the actual quantity of alcohol consumed. Similarly, choosing beverages with lower alcohol content may reduce the immediate effects but does not address overall consumption behavior effectively.

The nurse should clamp the catheter below the sampling port, cleanse the port with an antiseptic swab, and withdraw a fresh urine sample through the port using a sterile syringe before transferring it to a sterile container. Urine from the drainage bag or from disconnecting the catheter is likely to be contaminated or stale and can lead to inaccurate culture results. Collecting urine after simply replacing the drainage bag also allows old urine to mix with new urine, again risking contamination. Proper aseptic technique at the sampling port preserves specimen integrity and supports accurate diagnosis.

The correct answer is consulting the nutritionist to help the client receive tailored dietary recommendations and support recovery. Collaborating with other healthcare professionals is key in addressing client concerns that fall outside the direct scope of nursing practice. The physical therapist focuses on mobility, so while they are involved in care, they are not equipped to address nutritional concerns. Informing the primary healthcare provider may be necessary later if further dietary interventions are required, but involving the nutritionist upfront ensures the client’s immediate needs are addressed effectively. Reporting the client’s concern without action does not resolve the issue and reflects poor collaboration.

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.

The correct action involves notifying the healthcare provider and interdisciplinary team. This ensures that proper interventions, such as mental health or palliative support, can be initiated for the client. While advocating for autonomy is critical in nursing, respecting autonomy does not permit inaction when a client expresses intentions of self-harm. Encouraging family involvement without addressing the immediate concern could delay necessary professional support, and maintaining confidentiality in this scenario is inappropriate as it conflicts with the nurse’s duty to prevent harm.

The correct answer is to offer verbal explanations and provide written materials in an accessible format, such as large print, to support comprehension for clients with vision impairments. Macular degeneration affects central vision, which makes small text difficult to read. Providing information in a format more accessible to their remaining vision while also using verbal reinforcement promotes understanding and autonomy. The other options are incorrect as they fail to address the primary barrier (vision loss) effectively. Re-explaining without adjustments is unlikely to improve understanding, and assuming cognitive impairment without assessment could delay appropriate interventions. Encouraging the use of inaccessible materials may reinforce frustration rather than independence.

The correct action is to report these findings and statements to authorities designated to investigate potential abuse, such as Child Protective Services (CPS). Legal and ethical guidelines mandate that healthcare providers report reasonable suspicions of abuse immediately to protect the child. While documenting observations is necessary, it alone does not fulfill the obligation to act. Speaking directly with the caregiver risks compromising the child’s safety and could interfere with a proper investigation. Providing emotional support to the child is important but cannot substitute the legally required step of escalating concerns to the appropriate authorities for investigation. Nurses must prioritize safety and act within their role as mandated reporters.

The correct answer is installing assistive devices, such as grab bars, which directly addresses the client's immediate safety risks. These devices reduce the likelihood of falls by providing the client with support when moving around their home, especially in high-risk areas like the bathroom. Educating on proper reach or adjusting the medication without addressing physical barriers doesn't address the immediate fall risk, while consulting physical therapy is more focused on mobility improvement rather than environmental adaptations.

According to the U.S. Preventive Services Task Force (USPSTF) and American Cancer Society (ACS), colorectal cancer screening for average-risk individuals should begin at age 45. This is a critical priority due to the rising incidence of colorectal cancer in younger adults and its high treatability when detected early. While mammograms are recommended for women starting at age 40, colorectal cancer screening is a priority for all clients in this age group, regardless of gender. The shingles vaccine is typically recommended for adults beginning at age 50. General advice like using sunscreen, while important, is not considered a primary, age-specific screening priority in the same way as cancer screening.

The correct answer involves redirecting or engaging the client in a calming activity. This approach addresses the agitation by providing structure and reducing confusion, commonly seen during 'sundowning' in dementia. Attempting to orient the client during acute agitation may heighten their distress, as individuals with dementia may struggle to process such information. Physical restraints are not a first-line intervention and can escalate agitation or cause harm. Sedative use should be a last resort when non-pharmacological methods fail, as it can lead to dependency and adverse effects.

The correct answer is to teach the client how to ensure the ostomy pouch fits properly to the size of the stoma and adheres to the skin. An ill-fitting pouch can result in stool leakage, leading to significant skin irritation and potential breakdown. While cleaning the peristomal skin regularly is important for general hygiene, it does not address potential leakage and irritation caused by improper pouch fitting. Similarly, emptying the pouch before it becomes full lowers the risk of leakage but does not prevent skin irritation due to poor adhesion. Lastly, monitoring stoma color is an essential part of overall stoma care for recognizing potential complications but does not pertain to preventing skin irritation.

Offering the client a quiet space helps de-escalate agitation by removing external stimuli that may be contributing to the behavior. This approach is rooted in therapeutic communication and emphasizes creating an environment conducive to calming down. Other incorrect options, such as instructing the client to stop yelling or preparing for restraints, are either dismissive or escalate the situation prematurely without therapeutic engagement. Calling security is often a later-stage intervention and not an initial step in managing agitation therapeutically.

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.

The correct answer is the most effective because asking the client what they already know evaluates their baseline understanding of the disease and identifies knowledge gaps. This allows the nurse to tailor teaching to the client's current level of understanding, enhancing engagement and retention. Asking only about stress focuses on emotional readiness but may overlook essential educational needs. Providing printed materials or checking for supplies addresses resources but does not establish whether the client is prepared to learn at that moment.

The correct answer ensures that the nurse collaborates with relevant interdisciplinary team members who can provide specialized education to meet the client's needs. A nutritionist, for example, is trained to assess the client's needs and support the development of a dietary plan for optimal blood glucose management. Other options, while seemingly valid, fail to utilize resources effectively, neglect key client education strategies, or do not reflect updates to the plan of care based on client feedback when barriers are identified.

The correct answer is appropriate because school-age children benefit from having clear, concrete information about what to expect in a developmentally understandable way. It reduces anxiety by addressing fears of the unknown, empowering the child to feel more in control. While reassurance and distractions can help, they don't directly address the child’s need for understanding and coping. Encouraging the child to only share when they are ready may overlook opportunities for timely emotional support.

The correct answer is aligned with the best practice of using at least two identifiers to confirm client identity as mandated by safety guidelines. Asking the client to state their name and date of birth ensures active participation from the client. Matching these identifiers with the medical record reduces the chance of error. The incorrect answers fail to meet the criteria of using two reliable identifiers or are not aligned with safe practices. For example, room numbers are not unique identifiers and could lead to errors when clients are moved or rooms are misinterpreted.

The best course of action is to collaborate with the healthcare provider (HCP) to determine if the medication can be administered in tablet form. Oral medications are generally less expensive and require fewer resources to administer compared to their injectable counterparts. Choosing this option maintains client safety and avoids unnecessary costs. Delaying administration puts the client’s health at risk. Borrowing injectable medication from another unit is suitable for urgent needs but does not address cost-effectiveness. Withholding treatment disregards the client’s need altogether, which is neither safe nor ethical.