NCLEX-RN Examination Questions and Correct Answers

NCLEX-RN® EXAMINATION Questions and Correct Answers with Detailed Rationales Question 1 What type of nursing position would most likely experience the type of nursing situations upon which the NCLEX® Exam questions are based? A. Home care nurse B. Psychiatric staff nurse C. Staff nurse in an ambulatory pediatric clinic D. Staff nurse in a medical-surgical inpatient unit ANSWER: D. Staff nurse in a medical-surgical inpatient unit. RATIONALE: The largest percentage of content on the test platform is based on physiologic integrity, which includes physical and mental comfort, pharmacologic and pain management therapies, reduction of risk potential, and physiologic adaptation. Research shows that the majority of new graduates begin their job in a hospital medical-surgical environment, and the exam reflects entry-level practice in this setting. Question 2 Which statement by the nursing professor is accurate about the NCLEX-RN® exam? The purpose of the NCLEX-RN® test plan is to ensure that all: A. Test takers answer items of comparable difficulty B. Test takers answer approximately the same number of items C. Test items are job related D. Clinical specialties will be equally represented ANSWER: C. Test items are job related. RATIONALE: The content of the NCLEX® Exam is based on a test plan determined by the National Council. This plan reflects entry-level nursing practice as identified through research and the job analysis study of newly licensed nurses. The focus of the exam is not on clinical specialties; it is on the competencies needed for safe and effective practice. Question 3 A nurse is preparing a client for a procedure. Which action demonstrates the nurse's understanding of informed consent? A. Explaining the procedure to the client B. Obtaining the client's signature on the consent form C. Witnessing the client's signature on the consent form D. Determining that the client understands the procedure ANSWER: C. Witnessing the client's signature on the consent form. RATIONALE: The nurse's role in informed consent is to witness the client's signature, ensure the consent was voluntarily given, and confirm that the client appears to understand the information provided. The healthcare provider is responsible for explaining the procedure. Determining understanding is part of the nurse's assessment. Question 4 A client tells the nurse, "I don't want to take that medication. It makes me feel sick." What is the nurse's best response? A. "The doctor prescribed it for you, so you need to take it." B. "Tell me more about how the medication makes you feel." C. "I will call the doctor to change the prescription." D. "You should take it with food to prevent nausea." ANSWER: B. "Tell me more about how the medication makes you feel." RATIONALE: The nurse should use therapeutic communication to explore the client's concerns. Asking the client to elaborate validates their feelings and provides important information for assessment. Telling the client they "need to take it" dismisses their concern and does not address the issue. Question 5 A nurse is caring for a client who has a living will. What is the nurse's responsibility regarding this document? A. To ensure the document is followed B. To interpret the document for the family C. To determine if the document is valid D. To make decisions based on the document ANSWER: A. To ensure the document is followed. RATIONALE: The nurse's responsibility is to ensure that the living will is available and that the healthcare team follows the client's documented wishes regarding end-of-life care. Interpretation and validation of the document are the responsibility of the healthcare provider and legal counsel. Question 6 A nurse is caring for a client who is confused and attempting to remove their IV line. Which intervention should the nurse implement first? A. Apply wrist restraints B. Place the client in a room near the nurses' station C. Use a soft mitt restraint D. Assess the client's needs and provide alternative interventions ANSWER: D. Assess the client's needs and provide alternative interventions. RATIONALE: The least restrictive intervention should be used first. The nurse should assess the client's needs, such as pain, anxiety, or the need to use the bathroom, and provide alternative interventions. Restraints should only be used as a last resort. Question 7 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Verify the client's identity with another licensed nurse B. Check the blood product for any discoloration C. Prime the IV tubing with normal saline D. Assess the client's vital signs ANSWER: A. Verify the client's identity with another licensed nurse. RATIONALE: The first action is to verify the client's identity and the blood product with another licensed nurse to prevent a transfusion reaction from incompatible blood. This is a critical safety step. Question 8 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper tube placement? A. The client is able to speak clearly B. The pH of aspirated fluid is 4.0 C. The tube is draining green fluid D. The client reports no discomfort ANSWER: B. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. Checking pH is one method to verify NG tube placement. Auscultating air insufflation is no longer considered a reliable method. The client speaking clearly does not confirm placement. Question 9 A nurse is providing discharge teaching to a client with heart failure. Which instruction should the nurse include? A. "Weigh yourself weekly and report any gain of 2 pounds." B. "Weigh yourself daily and report any gain of 2 pounds in 24 hours." C. "Weigh yourself daily and report any loss of 2 pounds." D. "Weigh yourself weekly and report any loss of 2 pounds." ANSWER: B. "Weigh yourself daily and report any gain of 2 pounds in 24 hours." RATIONALE: Clients with heart failure should weigh themselves daily at the same time. A weight gain of 2 pounds in 24 hours or 5 pounds in a week may indicate fluid retention and should be reported to the healthcare provider. Question 10 A nurse is assessing a client who is postoperative. Which finding should the nurse report to the healthcare provider? A. Pain level of 3 on a scale of 0-10 B. Temperature of 99.0°F (37.2°C) C. Heart rate of 110 beats per minute D. Blood pressure of 120/80 mm Hg ANSWER: C. Heart rate of 110 beats per minute. RATIONALE: Tachycardia (heart rate >100 bpm) may indicate pain, dehydration, bleeding, or infection and should be reported. A temperature of 99.0°F may be normal postoperatively. Pain of 3 is manageable. Blood pressure of 120/80 is normal. Question 11 A nurse is teaching a client about a low-sodium diet. Which food should the nurse instruct the client to avoid? A. Fresh fruits B. Fresh vegetables C. Processed meats D. Whole grains ANSWER: C. Processed meats. RATIONALE: Processed meats (bacon, sausage, deli meats) are high in sodium and should be avoided on a low-sodium diet. Fresh fruits, fresh vegetables, and whole grains are naturally low in sodium. Question 12 A nurse is caring for a client receiving morphine sulfate. Which finding indicates an adverse effect? A. Respiratory rate of 22 breaths per minute B. Respiratory rate of 10 breaths per minute C. Heart rate of 80 beats per minute D. Blood pressure of 130/80 mm Hg ANSWER: B. Respiratory rate of 10 breaths per minute. RATIONALE: Respiratory depression (rate <12 breaths per minute) is a serious adverse effect of morphine. The nurse should monitor for respiratory depression and have naloxone available. Question 13 A nurse is assessing a client who is experiencing shortness of breath. Which position should the nurse place the client in? A. Supine B. High-Fowler's C. Prone D. Lateral ANSWER: B. High-Fowler's. RATIONALE: High-Fowler's position promotes lung expansion and ease of breathing by reducing pressure on the diaphragm. This position is ideal for clients with respiratory distress. Question 14 A nurse is administering insulin to a client with diabetes. Which action is correct? A. Shake the insulin vial vigorously B. Roll the insulin vial gently if it is NPH C. Store insulin in the freezer D. Use insulin that is cloudy for regular insulin ANSWER: B. Roll the insulin vial gently if it is NPH. RATIONALE: NPH insulin is a cloudy suspension and should be rolled gently to mix it. Shaking can cause frothing. Regular insulin is clear. Insulin should be stored in the refrigerator, not the freezer. Question 15 A nurse is assessing a client who has a pressure injury. Which finding indicates wound healing? A. Purulent drainage B. Red, inflamed edges C. Pink granulation tissue D. Dark, necrotic tissue ANSWER: C. Pink granulation tissue. RATIONALE: Pink granulation tissue is a sign of wound healing. Purulent drainage, red inflamed edges, and dark necrotic tissue indicate infection or poor healing. Question 16 A nurse is caring for a client with a fever of 102°F (38.9°C). Which intervention should the nurse implement first? A. Administer acetaminophen B. Apply a cooling blanket C. Remove excessive blankets D. Assess for signs of infection ANSWER: C. Remove excessive blankets. RATIONALE: The first intervention is to remove excessive blankets to promote heat loss. Other interventions include administering antipyretics and assessing for infection. Question 17 A nurse is preparing to administer a medication via IM injection. Which site is preferred for a Z-track injection? A. Deltoid B. Vastus lateralis C. Ventrogluteal D. Dorsogluteal ANSWER: C. Ventrogluteal. RATIONALE: The ventrogluteal site is preferred for Z-track injections because it has no major nerves or blood vessels. The Z-track technique is used to prevent medication leakage into subcutaneous tissue. Question 18 A nurse is caring for a client who is NPO. Which action should the nurse take? A. Offer the client ice chips B. Remove water pitcher from the bedside C. Allow the client to have clear liquids D. Place the client on a liquid diet ANSWER: B. Remove water pitcher from the bedside. RATIONALE: For a client who is NPO (nothing by mouth), the nurse should remove all food and fluids from the bedside, including water pitchers, to prevent the client from eating or drinking. Question 19 A nurse is assessing a client's pain. Which question should the nurse ask first? A. "What is your pain level on a scale of 0-10?" B. "Where is your pain located?" C. "What does your pain feel like?" D. "What makes your pain worse?" ANSWER: A. "What is your pain level on a scale of 0-10?" RATIONALE: The nurse should first assess the intensity of the pain using a pain scale to determine the severity. This provides a baseline for evaluation and treatment. Question 20 A nurse is providing discharge teaching to a client taking warfarin. Which instruction should the nurse include? A. "Avoid foods high in vitamin K such as broccoli." B. "Increase foods high in vitamin K such as spinach." C. "Take the medication with a full glass of milk." D. "Monitor for signs of bleeding." ANSWER: D. "Monitor for signs of bleeding." RATIONALE: Clients taking warfarin should monitor for signs of bleeding (bruising, petechiae, blood in urine or stool). They should maintain consistent vitamin K intake, not avoid or increase it excessively. Question 21 A nurse is assessing a client who is 24 hours postoperative. Which finding should the nurse report immediately? A. Heart rate of 88 beats per minute B. Temperature of 100.4°F (38°C) C. Blood pressure of 110/70 mm Hg D. Respiratory rate of 18 breaths per minute ANSWER: B. Temperature of 100.4°F (38°C). RATIONALE: A temperature of 100.4°F or higher 24 hours postoperatively may indicate infection and should be reported. Other vital signs are within normal limits. Question 22 A nurse is caring for a client with an indwelling urinary catheter. Which action is correct? A. Hang the drainage bag on the bedrail B. Keep the drainage bag below the level of the bladder C. Empty the drainage bag every 24 hours D. Clamp the catheter tubing when ambulating ANSWER: B. Keep the drainage bag below the level of the bladder. RATIONALE: The drainage bag should be kept below the level of the bladder to prevent backflow of urine and infection. The bag should be emptied every 8 hours or when full, and should not be hung on the bedrail. Question 23 A nurse is assessing a client who is receiving oxygen via nasal cannula. Which finding indicates the oxygen is being delivered effectively? A. SpO2 of 92% B. SpO2 of 95% C. SpO2 of 88% D. SpO2 of 90% ANSWER: B. SpO2 of 95%. RATIONALE: Normal SpO2 is 95-100%. An SpO2 of 92% or below indicates hypoxemia and may require adjustments in oxygen therapy. Question 24 A nurse is caring for a client with a tracheostomy. Which action should the nurse take first? A. Suction the tracheostomy B. Clean the stoma site C. Assess the client's respiratory status D. Check the tracheostomy cuff pressure ANSWER: C. Assess the client's respiratory status. RATIONALE: The first action is to assess the client's respiratory status to ensure the airway is patent. Suctioning, cleaning, and checking cuff pressure are done after assessment. Question 25 A nurse is administering a blood transfusion. Which finding indicates a transfusion reaction? A. Client reports feeling warm B. Client reports nausea C. Client reports itching D. All of the above ANSWER: D. All of the above. RATIONALE: All of these findings can indicate a transfusion reaction. Other signs include fever, chills, hypotension, and back pain. The nurse should stop the transfusion immediately. Question 26 A nurse is providing care to a client with a wound. Which intervention promotes wound healing? A. Keep the wound dry B. Keep the wound moist C. Apply heat to the wound D. Apply cold to the wound ANSWER: B. Keep the wound moist. RATIONALE: Moist wound healing promotes epithelialization and wound healing. Dry wounds can delay healing and cause pain. Question 27 A nurse is assessing a client who is 2 hours postpartum. Which finding should the nurse report? A. Fundus firm at the umbilicus B. Moderate lochia rubra C. Saturating one pad per hour D. Blood pressure 120/80 mm Hg ANSWER: C. Saturating one pad per hour. RATIONALE: Saturating one pad per hour indicates excessive bleeding (postpartum hemorrhage) and should be reported. Fundus firm at the umbilicus, moderate lochia rubra, and blood pressure 120/80 are expected findings. Question 28 A nurse is teaching a client about breastfeeding. Which statement indicates understanding? A. "I should feed my baby on a strict schedule." B. "I should feed my baby every 2-3 hours." C. "I should give my baby water between feedings." D. "I should only use one breast per feeding." ANSWER: B. "I should feed my baby every 2-3 hours." RATIONALE: Breastfeeding should be on demand, typically every 2-3 hours. Feeding on a strict schedule is not recommended, and water is not necessary for breastfed infants. Question 29 A nurse is assessing a newborn. Which Apgar score indicates the newborn is in good condition? A. 4 B. 6 C. 8 D. 10 ANSWER: C. 8. RATIONALE: Apgar scores of 7-10 indicate the newborn is in good condition. Scores of 4-6 indicate moderate distress, and scores of 0-3 indicate severe distress requiring immediate intervention. Question 30 A nurse is caring for a client who is receiving chemotherapy. Which finding should the nurse report immediately? A. Nausea and vomiting B. Alopecia C. Temperature of 101°F (38.3°C) D. Fatigue ANSWER: C. Temperature of 101°F (38.3°C). RATIONALE: Fever (temperature >100.4°F) in a client receiving chemotherapy may indicate neutropenia and infection, which is a medical emergency. The nurse should report it immediately. Question 31 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Decorticate posturing C. Blood pressure 110/70 mm Hg D. Heart rate 80 bpm ANSWER: B. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 32 A nurse is providing discharge teaching to a client with a new colostomy. Which instruction should the nurse include? A. Change the pouch daily B. Change the pouch when it is one-third full C. Use adhesive remover to prevent skin irritation D. Use soap and water to clean the stoma ANSWER: C. Use adhesive remover to prevent skin irritation. RATIONALE: Adhesive remover should be used to gently remove the ostomy appliance to prevent skin irritation. The pouch should be changed every 3-7 days and emptied when onethird to one-half full. Question 33 A nurse is caring for a client with a seizure disorder. Which action should the nurse take during a seizure? A. Place a tongue blade in the client's mouth B. Restrain the client's limbs C. Turn the client to the side D. Administer oral diazepam ANSWER: C. Turn the client to the side. RATIONALE: Turning the client to the side helps prevent aspiration. Placing a tongue blade in the mouth or restraining limbs can cause injury. Oral medications should not be administered during a seizure. Question 34 A nurse is assessing a client with a urinary tract infection. Which finding should the nurse expect? A. Dysuria B. Polyuria C. Polydipsia D. Anuria ANSWER: A. Dysuria. RATIONALE: Dysuria (painful urination) is a classic symptom of a urinary tract infection. Polyuria and polydipsia are associated with diabetes, and anuria is associated with renal failure. Question 35 A nurse is providing care to a client with dementia. Which intervention promotes safety? A. Place the client in a room near the nurses' station B. Keep the client in bed at all times C. Use physical restraints for wandering D. Allow the client to wander freely ANSWER: A. Place the client in a room near the nurses' station. RATIONALE: Placing the client in a room near the nurses' station allows for closer observation. Restraints should be avoided, and promoting safe ambulation is encouraged. Question 36 A nurse is assessing a client who is taking digoxin. Which finding indicates digoxin toxicity? A. Heart rate of 72 bpm B. Vision changes (yellow halos) C. Blood pressure of 140/90 mm Hg D. Respiratory rate of 20 bpm ANSWER: B. Vision changes (yellow halos). RATIONALE: Yellow-green halos around lights, nausea, and vomiting are classic signs of digoxin toxicity. Other signs include bradycardia and cardiac dysrhythmias. Question 37 A nurse is preparing to insert a urinary catheter. Which action is correct? A. Insert the catheter until urine flows, then advance 1-2 inches B. Use sterile technique and lubricate the catheter with petroleum jelly C. Clean the perineum from back to front D. Insert the catheter 2-3 inches for a female client ANSWER: A. Insert the catheter until urine flows, then advance 1-2 inches. RATIONALE: After urine flows, the catheter should be advanced an additional 1-2 inches to ensure the balloon is fully in the bladder. Water-soluble lubricant should be used, not petroleum jelly. The perineum is cleaned from front to back. Question 38 A nurse is providing education to a client taking an ACE inhibitor. Which adverse effect should the nurse instruct the client to report? A. Dry cough B. Weight gain C. Tachycardia D. Constipation ANSWER: A. Dry cough. RATIONALE: ACE inhibitors commonly cause a persistent dry cough due to bradykinin accumulation. If the cough becomes bothersome, the provider may switch to an ARB. Weight gain, tachycardia, and constipation are not typical adverse effects. Question 39 A nurse is caring for a client with a deep vein thrombosis (DVT). Which intervention is appropriate? A. Massage the affected leg B. Apply heat to the affected leg C. Elevate the affected leg D. Encourage ambulation ANSWER: C. Elevate the affected leg. RATIONALE: Elevating the affected leg promotes venous return and reduces swelling. Massaging can dislodge the clot, and heat can increase swelling. Ambulation may be restricted initially. Question 40 A nurse is assessing a client with a history of diabetes and chronic kidney disease. Which laboratory value should the nurse monitor closely? A. Hemoglobin A1c B. Serum potassium C. Serum sodium D. Serum calcium ANSWER: B. Serum potassium. RATIONALE: Clients with chronic kidney disease are at risk for hyperkalemia. Potassium levels should be monitored closely, especially in clients with diabetes and kidney disease. Question 41 A nurse is providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD). Which instruction should the nurse include? A. "Use oxygen at 6 L/min as needed." B. "Use pursed-lip breathing during exertion." C. "Avoid all physical activity." D. "Increase fluid intake to 1 liter per day." ANSWER: B. "Use pursed-lip breathing during exertion." RATIONALE: Pursed-lip breathing helps keep airways open and is beneficial for clients with COPD. Oxygen should be used at the prescribed rate, and fluid intake should be adequate to thin secretions. Question 42 A nurse is caring for a client with a new tracheostomy. Which finding should the nurse report immediately? A. Pink, moist stoma site B. Small amount of bloody drainage C. Respiratory rate of 28 breaths per minute D. Client able to speak softly ANSWER: C. Respiratory rate of 28 breaths per minute. RATIONALE: Tachypnea (respiratory rate >24) indicates respiratory distress and should be reported. Pink, moist stoma site, small bloody drainage, and ability to speak softly are expected findings. Question 43 A nurse is administering a medication via subcutaneous injection. Which site is appropriate? A. Ventrogluteal B. Vastus lateralis C. Abdomen D. Dorsogluteal ANSWER: C. Abdomen. RATIONALE: The abdomen is a common site for subcutaneous injections. The ventrogluteal and vastus lateralis are used for intramuscular injections. Question 44 A nurse is assessing a client who is in hypovolemic shock. Which finding should the nurse expect? A. Hypertension B. Tachycardia C. Jugular vein distention D. Peripheral edema ANSWER: B. Tachycardia. RATIONALE: Hypovolemic shock causes tachycardia, hypotension, and decreased urine output. Jugular vein distention and peripheral edema are signs of fluid overload or heart failure. Question 45 A nurse is providing education to a client with a new prescription for warfarin. Which statement by the client indicates understanding? A. "I will take ibuprofen for pain." B. "I will use an electric razor for shaving." C. "I will avoid all leafy green vegetables." D. "I will stop the medication if I bruise easily." ANSWER: B. "I will use an electric razor for shaving." RATIONALE: Using an electric razor reduces the risk of cuts and bleeding. Ibuprofen should be avoided, leafy green vegetables should be consumed consistently, and the medication should not be stopped without consulting the provider. Question 46 A nurse is assessing a client with a head injury. Which finding indicates improved neurological status? A. Pupils unequal and reactive B. Glasgow Coma Scale (GCS) score of 15 C. Decerebrate posturing D. Blood pressure of 160/90 mm Hg ANSWER: B. Glasgow Coma Scale (GCS) score of 15. RATIONALE: A GCS score of 15 indicates the client is alert and oriented, which is a sign of improved neurological status. Unequal pupils, decerebrate posturing, and hypertension are signs of deterioration. Question 47 A nurse is caring for a client with a chest tube. Which action is correct? A. Clamp the chest tube when ambulating B. Keep the collection device above the level of the chest C. Monitor for continuous bubbling in the water seal chamber D. Strip the chest tube to maintain patency ANSWER: C. Monitor for continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber may indicate an air leak and should be reported. The collection device should be below chest level, chest tubes should not be clamped, and stripping is not recommended. Question 48 A nurse is assessing a client who is 4 hours postpartum. Which finding should the nurse report? A. Fundus firm and midline B. Moderate lochia rubra C. Blood pressure 100/60 mm Hg D. Saturating two pads in 15 minutes ANSWER: D. Saturating two pads in 15 minutes. RATIONALE: Saturating two pads in 15 minutes indicates excessive bleeding (postpartum hemorrhage). Fundus firm and midline, moderate lochia rubra, and blood pressure 100/60 are expected findings. Question 49 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 50 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 51 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 52 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 53 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 54 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 55 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 56 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 57 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 58 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 59 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 60 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 61 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 62 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 63 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 64 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 65 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 66 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 67 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 68 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 69 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 70 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 71 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 72 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 73 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 74 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 75 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 76 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 77 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 78 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 79 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 80 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 81 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 82 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 83 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 84 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 85 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 86 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 87 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 88 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 89 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 90 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 91 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 92 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 93 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 94 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 95 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 96 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 97 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 98 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 99 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 100 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 101 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 102 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 103 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 104 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 105 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 106 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 107 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 108 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 109 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 110 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 111 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 112 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 113 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 114 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 115 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 116 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 117 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 118 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 119 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 120 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 121 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 122 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 123 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 124 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 125 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 126 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 127 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 128 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 129 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 130 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 131 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 132 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 133 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 134 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 135 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 136 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 137 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 138 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 139 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 140 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 141 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 142 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 143 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 144 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 145 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 146 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 147 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 148 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 149 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 150 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 151 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 152 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 153 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 154 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 155 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 156 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 157 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 158 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 159 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 160 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 161 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 162 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 163 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 164 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 165 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 166 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 167 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 168 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 169 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 170 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 171 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 172 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 173 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 174 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 175 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 176 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 177 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 178 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 179 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 180 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 181 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 182 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 183 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 184 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 185 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 186 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 187 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 188 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration. Question 189 A nurse is assessing a client who is postoperative. Which finding indicates a wound infection? A. Pink granulation tissue B. Purulent drainage C. Edges approximated D. No drainage ANSWER: B. Purulent drainage. RATIONALE: Purulent drainage (pus) indicates a wound infection. Pink granulation tissue, approximated edges, and no drainage are signs of healing. Question 190 A nurse is providing education to a client with a new prescription for warfarin. Which food should the nurse instruct the client to avoid? A. Apples B. Broccoli C. Chicken D. Rice ANSWER: B. Broccoli. RATIONALE: Broccoli and other leafy green vegetables are high in vitamin K, which can interfere with warfarin. Clients should maintain consistent vitamin K intake rather than avoiding it entirely. Question 191 A nurse is caring for a client with a chest tube. Which finding indicates an air leak? A. Continuous bubbling in the water seal chamber B. Intermittent bubbling in the suction chamber C. Drainage of 50 mL in 4 hours D. Tidaling in the water seal chamber ANSWER: A. Continuous bubbling in the water seal chamber. RATIONALE: Continuous bubbling in the water seal chamber indicates an air leak. Intermittent bubbling in the suction chamber is normal, and tidaling is expected with respiration. Question 192 A nurse is assessing a client with a head injury. Which finding indicates increased intracranial pressure? A. Pupils equal and reactive B. Blood pressure 110/70 mm Hg C. Heart rate 80 bpm D. Decorticate posturing ANSWER: D. Decorticate posturing. RATIONALE: Decorticate posturing (flexion of arms, wrists, and fingers with extension of legs) is a sign of increased intracranial pressure. The other findings are normal. Question 193 A nurse is providing education to a client with a new prescription for metformin. Which adverse effect should the nurse instruct the client to report? A. Muscle pain and weakness B. Weight gain C. Constipation D. Dizziness ANSWER: A. Muscle pain and weakness. RATIONALE: Muscle pain and weakness may indicate lactic acidosis, a rare but serious adverse effect of metformin. Clients should report these symptoms immediately. Question 194 A nurse is caring for a client with a nasogastric tube. Which finding indicates proper placement? A. The client is able to speak B. The pH of aspirated fluid is 6.0 C. The pH of aspirated fluid is 4.0 D. The tube is draining brown fluid ANSWER: C. The pH of aspirated fluid is 4.0. RATIONALE: Gastric aspirate typically has a pH of 4.0 or less. A pH of 6.0 may indicate the tube is in the intestine or lungs. The client's ability to speak does not confirm placement. Question 195 A nurse is preparing to administer a blood transfusion. Which action should the nurse take first? A. Assess the client's vital signs B. Verify the blood product with another nurse C. Prime the IV tubing with normal saline D. Administer an antihistamine ANSWER: B. Verify the blood product with another nurse. RATIONALE: The first action is to verify the client's identity and blood product with another licensed nurse to prevent transfusion reactions. Vital signs, priming tubing, and premedication are performed after verification. Question 196 A nurse is assessing a client with a suspected myocardial infarction. Which finding should the nurse expect? A. Chest pain relieved by rest B. Chest pain described as sharp and stabbing C. Chest pain radiating to the left arm D. Chest pain worsened by deep breathing ANSWER: C. Chest pain radiating to the left arm. RATIONALE: Chest pain radiating to the left arm, jaw, or back is a classic sign of myocardial infarction. The pain is typically described as pressure or squeezing and is not relieved by rest. Question 197 A nurse is providing education to a client with a new prescription for an SSRI. Which statement by the client indicates understanding? A. "I will take this medication with grapefruit juice." B. "I will stop taking this medication if I feel better." C. "It may take 2-4 weeks for the medication to work." D. "I can take St. John's wort with this medication." ANSWER: C. "It may take 2-4 weeks for the medication to work." RATIONALE: SSRIs typically take 2-4 weeks to achieve therapeutic effects. Grapefruit juice and St. John's wort should be avoided, and the medication should not be stopped abruptly. Question 198 A nurse is assessing a client with a fractured femur in skeletal traction. Which finding should the nurse report? A. Capillary refill of 2 seconds B. Pain relieved by repositioning C. Drainage at the pin site D. Toes warm and pink ANSWER: C. Drainage at the pin site. RATIONALE: Drainage at the pin site indicates infection and should be reported. Capillary refill of 2 seconds, pain relieved by repositioning, and warm, pink toes are expected findings. Question 199 A nurse is providing education to a client with a new diagnosis of type 2 diabetes. Which statement indicates understanding? A. "I will check my blood glucose before meals." B. "I will avoid all carbohydrates." C. "I will only take insulin if I feel symptoms." D. "I will eat large meals to maintain my blood sugar." ANSWER: A. "I will check my blood glucose before meals." RATIONALE: Clients with diabetes should check their blood glucose before meals to manage their condition. Carbohydrates should be balanced, insulin should be taken as prescribed, and meal portions should be appropriate. Question 200 A nurse is caring for a client with a fever. Which intervention should the nurse implement? A. Administer an antipyretic B. Apply a cooling blanket C. Provide increased fluids D. All of the above ANSWER: D. All of the above. RATIONALE: Fever management includes administering antipyretics, applying cooling blankets if prescribed, and increasing fluid intake to prevent dehydration.