“NCLEX-RN” Study Guide: All-In-One Guide + 4 Exam Practice Test (3000 Questions), Latest for “National Council Licensure Examination for Registered Nurses (NCLEX-RN)”,(NCSBN)

16 of 150. A client in the active phase of labor at 6 cm dilation has just received an epidural for pain management. The electronic fetal monitor suddenly displays repetitive late decelerations with a decrease in maternal blood pressure. Which intervention should the nurse implement?

30 of 150. A fire breaks out in the soiled utility room of a pediatric unit. A nurse discovers the fire while returning from the medication room. Several children are in the playroom nearby, and one child is in isolation for neutropenia in a room across the hall. Which action should the nurse perform?

29 of 150. A 75-year-old male with Stage 2 Dementia is admitted to the medical-surgical unit for a urinary tract infection. The nurse observes the client repeatedly pulling at the door handles and pacing near the exit. Which intervention is most appropriate to include in the security plan?

28 of 150. A 75-year-old client with obstructive sleep apnea and obesity reports feeling “skipped beats” during periods of rest. The nurse performs a targeted assessment for cardiovascular rhythm disturbances.

27 of 150. A client with moderate chronic obstructive pulmonary disease (COPD) and exertional dyspnea wants to increase their physical activity. Which breathing technique should the nurse teach the client to use during exercise?

26 of 150. A 62-year-old male with a BMI of 42 is 24 hours post-abdominal surgery and requires a transfer from the bed to a bedside commode. The patient is alert but reports significant surgical pain and demonstrates poor core stability during the initial assessment.

25 of 150. A nurse from the Labor and Delivery unit is floated to a Medical-Surgical floor to assist with a high patient census. Which patient assignment should the charge nurse give to the float nurse to ensure the safest care?

24 of 150. A nurse notes an order for “Digoxin 0.25 mg IV daily” for a client with heart failure whose heart rate is currently 52 beats per minute.

23 of 150. A 68-year-old male with end-stage renal disease presents to the emergency department with substernal chest pressure that began 4 hours ago. The initial high-sensitivity Troponin T is 45 ng/L (reference <14 ng/L), and the electrocardiogram shows no acute ST-segment changes. Which action should the nurse perform to accurately interpret these results?

22 of 150. A nurse is caring for a client who received naloxone for respiratory depression following a surgical procedure. The client is now reporting excruciating surgical pain and is requesting medication. The healthcare provider prescribes a small dose of intravenous morphine. Which response by the nurse is most clinically sound regarding the administration of this morphine?

20 of 150. A nurse is assessing an 82-year-old client who has been bedbound following a femoral neck fracture. The nurse notes a localized area of intact, non-blanchable, deep maroon skin over the right calcaneus that feels boggy compared to the surrounding tissue.

19 of 150. During a sterile dressing change for a post-operative patient with a deep vein thrombosis, the nurse needs to add sterile normal saline to a container on the sterile field. The nurse holds the bottle two inches above the sterile bowl.

18 of 150. A nurse in the emergency department is caring for a patient experiencing acute psychosis who becomes combative during the administration of an intramuscular antipsychotic medication. After the injection is completed, the patient attempts to grab the nurse’s arm. Which action by the nurse most effectively minimizes the risk of a needlestick injury in this high-stress environment?

17 of 150. A 10-year-old child with type 1 diabetes is participating in a hospital-based support group. The facilitator organizes a scavenger hunt where the children must divide into teams, assign a leader, and follow a set of rules to find hidden items. The nurse recognizes this as which type of play to promote social development?

1 of 150. A patient is 48 hours post-thermal burn with partial-thickness injuries to the entire right arm. During the dressing change, the nurse notes that the arm is increasingly edematous, and the radial pulse is significantly weaker than it was four hours ago. Which action is the nurse’s priority?

15 of 150. The nurse is observing an unlicensed assistive person (UAP) repositioning a patient who has a Stage III pressure injury and diabetic neuropathy. Which action by the UAP requires the nurse to intervene immediately?

14 of 150. A 54-year-old client with a history of deep vein thrombosis reports severe hot flashes that disrupt her sleep. Which medication should the nurse anticipate the provider will prescribe?

13 of 150. A patient with paranoid schizophrenia is admitted to the emergency department after threatening a neighbor with a knife. The patient is currently pacing the room, muttering about “justice,” and refusing to sit down. The nurse notes the patient has a history of non-compliance with medications and previous violent outbursts. Which intervention should the nurse implement to ensure a safe environment?

12 of 150. A 55-year-old patient in the intensive care unit suddenly develops pulseless ventricular tachycardia. The patient has an implanted permanent pacemaker in the left subclavicular region and is currently diaphoretic. When preparing to deliver a shock with a biphasic defibrillator, which technique should the nurse employ?

11 of 150. A 42-year-old female smoker who takes oral contraceptives recently returned from a 12-hour international flight. She presents to the clinic complaining of unilateral leg swelling and a sensation of “tightness” in her right lower extremity.

10 of 150. A client who has been taking high-dose inhaled corticosteroids for chronic obstructive pulmonary disease (COPD) reports a “fuzzy” feeling on the tongue. The nurse observes white, curd-like patches on the buccal mucosa. The nurse should perform which assessment action to differentiate the condition?

9 of 150. A patient with a history of rheumatoid arthritis is recovering from a total hip replacement. During hygiene care, the nurse observes the patient attempting to wash their feet. Which intervention is most appropriate to ensure mobility precautions are maintained?

8 of 150. A nurse is evaluating a client on postoperative day three following a radical neck dissection. The Jackson-Pratt drain has produced 22 mL of serous fluid over the last 24 hours. Based on this finding, which action should the nurse anticipate?

7 of 150. A client is admitted to the intensive care unit following exertional heat stroke with a peak temperature of 106.2°F. Twenty-four hours after stabilization, the nurse notes new ecchymosis at venipuncture sites and a heart rate of 112 beats per minute. Which action should the nurse take?

6 of 150. A 45-year-old client with a history of opioid use disorder is 12 hours post-appendectomy. The client is agitated, reporting 10/10 pain, and is pulling at the surgical dressing. Which action should the nurse prioritize?

5 of 150. A patient with chronic heart failure is being seen in a home health setting. The LPN reports the patient has gained two pounds in 24 hours and has 1+ pedal edema. Which action is most appropriate for the RN to delegate to the LPN?

4 of 150. A 72-year-old female with a history of ischemic stroke and gastroesophageal reflux disease is taking clopidogrel 75 mg and omeprazole 20 mg daily. She presents to the clinic reporting a new episode of transient unilateral weakness. Which action by the nurse demonstrates the most appropriate evaluation of the client’s pharmacological response?

3 of 150. A patient with chronic alcohol use disorder is admitted to the emergency department with palpitations. The EKG reveals a polymorphic ventricular tachycardia known as Torsades de Pointes. The nurse notes a serum magnesium level of 1.1 mg/dL. Which action should the nurse perform?

2 of 150. A registered nurse (RN) on a surgical unit observes a colleague, who is also an RN, withdrawing a vial of hydromorphone for a patient who is not assigned to that colleague. The colleague then enters the staff restroom with the syringe. The observing RN notices the colleague appears drowsy and slurs their speech later in the shift.