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NHRA Nurse Exam study materials
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NHRA Nurse Exam practice questions

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Question 1Patient Assessment and Clinical Judgment

A nurse is assessing a client who reports sudden onset of severe chest pain that radiates to the left arm, along with nausea and diaphoresis. Which action should the nurse take first?

  1. Document the findings and reassess in 30 minutes
  2. Administer the prescribed oral antacid
  3. Obtain a 12-lead ECG and notify the provider immediately Correct answer.
  4. Encourage the client to ambulate to relieve discomfort

Explanation

Sudden severe chest pain radiating to the arm with diaphoresis and nausea suggests acute coronary syndrome, which is time-critical. The priority is rapid cardiac evaluation with a 12-lead ECG and prompt provider notification so reperfusion decisions can be made. Delaying assessment risks irreversible myocardial damage.

Question 2Patient Assessment and Clinical Judgment

Which finding best indicates that a client is experiencing an acute asthma exacerbation rather than a stable state?

  1. Respiratory rate of 16 breaths per minute
  2. Occasional end-expiratory wheeze after exercise
  3. Use of accessory muscles and inability to speak full sentences Correct answer.
  4. Oxygen saturation of 96% on room air

Explanation

Accessory muscle use and inability to speak in full sentences are clinical signs of severe airway obstruction and increased work of breathing during an acute asthma exacerbation. These findings reflect significant respiratory distress requiring immediate intervention. Stable indicators such as normal rate and saturation do not signal acute deterioration.

Question 3Patient Assessment and Clinical Judgment

A nurse is assessing a client for dehydration. Which combination of findings most supports this conclusion?

  1. Polyuria, polyphagia, and weight loss
  2. Bilateral crackles, jugular venous distention, and weight gain
  3. Dry mucous membranes, orthostatic hypotension, and decreased urine output Correct answer.
  4. Bradycardia, hypertension, and warm flushed skin

Explanation

Dry mucous membranes, orthostatic hypotension, and decreased urine output are classic indicators of intravascular volume depletion. Orthostatic hypotension reflects reduced circulating volume, and oliguria reflects renal conservation of fluid. Together they point to dehydration requiring fluid replacement.

Question 4Patient Assessment and Clinical Judgment

When assessing a client's level of consciousness using a standardized scale, which parameter change is the earliest indicator of neurologic deterioration?

  1. Decerebrate posturing
  2. Fixed and dilated pupils
  3. Decreasing level of consciousness Correct answer.
  4. Loss of gag reflex

Explanation

A declining level of consciousness is often the earliest and most sensitive sign of neurologic deterioration because it reflects early cortical dysfunction. Pupillary changes, loss of protective reflexes, and posturing occur later as pressure and injury progress. Frequent neurologic checks focus on detecting this early change.

Question 5Patient Assessment and Clinical Judgment

A nurse is assessing pain in a client who is unable to verbalize due to sedation. Which approach is most appropriate?

  1. Assume the client feels no pain because they cannot report it
  2. Use a behavioral pain scale that scores facial expression and body movement Correct answer.
  3. Wait until sedation is reversed before assessing pain
  4. Rely solely on the family's estimate of pain

Explanation

Clients who cannot self-report pain should be assessed with a validated behavioral tool that scores indicators such as facial expression, body movement, and ventilator compliance. Pain is common in sedated and nonverbal clients and must not be assumed absent. Behavioral scales provide objective, reproducible assessment.

Question 6Patient Assessment and Clinical Judgment

Which assessment finding should prompt a nurse to suspect a hypoglycemic episode in a client with diabetes?

  1. Deep rapid respirations and fruity breath
  2. Gradual onset of polyphagia over weeks
  3. Tremors, diaphoresis, and confusion Correct answer.
  4. Polyuria and excessive thirst

Explanation

Tremors, diaphoresis, and confusion reflect the adrenergic and neuroglycopenic effects of low blood glucose. These symptoms develop relatively quickly and require prompt glucose measurement and treatment. Fruity breath and deep respirations instead suggest ketoacidosis.

Question 7Patient Assessment and Clinical Judgment

A nurse notes that a client's radial pulse is irregular and the rate is 120 beats per minute. Which additional assessment is most important to perform next?

  1. Auscultate the apical pulse for a full minute Correct answer.
  2. Palpate the pedal pulses bilaterally
  3. Obtain a capillary blood glucose level
  4. Measure the blood pressure in both arms

Explanation

When the radial pulse is irregular and rapid, the apical pulse should be auscultated for a full minute to accurately determine rate and rhythm. Apical assessment detects dysrhythmias and pulse deficits that radial palpation may miss. This guides further cardiac evaluation and treatment.

Question 8Patient Assessment and Clinical Judgment

A client reports a sudden onset of sharp flank pain and visible blood in the urine. Which focused assessment question is most relevant?

  1. Have you changed your diet in the past week?
  2. Have you recently traveled outside the country?
  3. Do you have a history of seasonal allergies?
  4. Have you passed any small stones or gravel in your urine? Correct answer.

Explanation

Sharp flank pain with hematuria suggests urolithiasis, and asking about passed stones or gravel helps confirm the diagnosis. Stone passage is a hallmark finding that supports the clinical picture. Travel, allergies, and diet changes are less directly related to this presentation.

Question 9Patient Assessment and Clinical Judgment

A nurse is caring for a client with a suspected bowel obstruction. Which assessment finding is most consistent with this diagnosis?

  1. Rebound tenderness localized to the right lower quadrant
  2. Hyperactive bowel sounds with diarrhea and low-grade fever
  3. Absent bowel sounds with a scaphoid abdomen and hunger
  4. Abdominal distention with high-pitched, frequent bowel sounds early in the course Correct answer.

Explanation

Early mechanical bowel obstruction produces hyperactive, high-pitched bowel sounds as the intestine works against the blockage, along with distention. As obstruction progresses, bowel sounds may diminish. Localized right lower quadrant tenderness instead suggests appendicitis.

Question 10Patient Assessment and Clinical Judgment

A client with a head injury has a blood pressure of 168/58 mm Hg, a heart rate of 48 beats per minute, and irregular respirations. What do these findings indicate?

  1. Cushing triad, suggesting increased intracranial pressure Correct answer.
  2. Neurogenic shock from spinal cord injury
  3. Normal physiologic response to pain
  4. Septic shock with compensatory tachycardia

Explanation

Hypertension with widened pulse pressure, bradycardia, and irregular respirations form Cushing triad, a sign of increased intracranial pressure and impending herniation. This is a neurologic emergency requiring immediate provider notification. The pattern reflects brainstem compression rather than a normal response.

Question 11Patient Assessment and Clinical Judgment

A nurse is assessing an older adult who reports feeling dizzy when standing. Which action provides the most useful information about orthostatic hypotension?

  1. Ask the client to describe the dizziness in detail
  2. Obtain a single blood pressure reading in the supine position
  3. Measure blood pressure only while the client is seated
  4. Measure blood pressure and heart rate while supine, then after standing Correct answer.

Explanation

Orthostatic hypotension is assessed by comparing blood pressure and heart rate in the supine position with values obtained after the client stands. A significant drop in systolic or diastolic pressure upon standing confirms the diagnosis. Single-position readings cannot detect postural changes.

Question 12Patient Assessment and Clinical Judgment

A client's arterial blood gas shows a pH of 7.28, PaCO2 of 55 mm Hg, and bicarbonate of 24 mEq/L. How should the nurse interpret these results?

  1. Respiratory acidosis without metabolic compensation Correct answer.
  2. Metabolic acidosis with respiratory compensation
  3. Metabolic alkalosis
  4. Respiratory alkalosis

Explanation

A low pH with an elevated PaCO2 and a normal bicarbonate indicates uncompensated respiratory acidosis. The retained carbon dioxide lowers pH, and the normal bicarbonate shows the kidneys have not yet compensated. This pattern is common in hypoventilation.

Question 13Patient Assessment and Clinical Judgment

A nurse is assessing a client who has just returned from surgery. Which finding should be reported to the provider immediately?

  1. A respiratory rate of 8 breaths per minute with shallow breathing Correct answer.
  2. Serosanguineous drainage on the dressing
  3. A temperature of 37.6 degrees Celsius
  4. A pain level of 4 out of 10

Explanation

A respiratory rate of 8 with shallow breathing suggests respiratory depression, possibly from anesthesia or opioids, and requires immediate intervention. Shallow breathing can lead to hypoventilation and hypoxia. The other findings fall within expected postoperative ranges.

Question 14Patient Assessment and Clinical Judgment

A client with heart failure reports increasing shortness of breath when lying flat and needs three pillows to sleep. Which term should the nurse document for this finding?

  1. Dyspnea on exertion
  2. Cheyne-Stokes respiration
  3. Paroxysmal nocturnal dyspnea
  4. Orthopnea Correct answer.

Explanation

Orthopnea is dyspnea that occurs when lying flat and is relieved by elevating the head with pillows. It reflects pulmonary congestion from fluid redistribution in heart failure. Paroxysmal nocturnal dyspnea instead describes sudden nocturnal breathlessness after sleep onset.

Question 15Patient Assessment and Clinical Judgment

A nurse is assessing a client with suspected acute pancreatitis. Which finding most supports this diagnosis?

  1. Burning epigastric pain relieved by food
  2. Painless jaundice with dark urine
  3. Epigastric pain radiating to the back with elevated serum lipase Correct answer.
  4. Right lower quadrant pain with rebound tenderness

Explanation

Acute pancreatitis classically produces severe epigastric pain that radiates to the back, along with elevated serum lipase. Lipase elevation is a key diagnostic marker. Right lower quadrant pain and food-relieved pain suggest other gastrointestinal conditions.

Question 16Patient Assessment and Clinical Judgment

A nurse is evaluating a client for possible sepsis. Which set of findings best meets the criteria for a systemic inflammatory response?

  1. Temperature 36.8 degrees Celsius, heart rate 70, respiratory rate 14
  2. Temperature 36.0 degrees Celsius, heart rate 88, respiratory rate 18
  3. Temperature 38.6 degrees Celsius, heart rate 104, respiratory rate 24 Correct answer.
  4. Temperature 37.0 degrees Celsius, heart rate 60, respiratory rate 12

Explanation

Fever, tachycardia, and tachypnea are components of the systemic inflammatory response that raise concern for sepsis. These values exceed normal thresholds and warrant further evaluation and prompt intervention. The other sets fall within normal ranges.

Question 17Patient Assessment and Clinical Judgment

A nurse observes a client with a tracheostomy who is coughing and has decreased oxygen saturation. Which action should the nurse take first?

  1. Reposition the client to a supine position
  2. Suction the airway while monitoring oxygenation Correct answer.
  3. Document the event and continue monitoring
  4. Increase the oxygen flow rate and reassess in 10 minutes

Explanation

Coughing with falling oxygen saturation in a client with a tracheostomy suggests airway obstruction by secretions, so suctioning is the priority. Oxygenation should be monitored during the procedure. Delaying suctioning can worsen hypoxia.

Question 18Patient Assessment and Clinical Judgment

A client reports a headache that began suddenly and is described as the worst headache of their life. Which action is most appropriate?

  1. Encourage the client to rest in a dark room
  2. Administer the prescribed over-the-counter analgesic and reassess
  3. Urgently notify the provider for immediate neurologic evaluation Correct answer.
  4. Schedule a routine follow-up appointment

Explanation

A sudden, severe headache described as the worst of one's life raises concern for a subarachnoid hemorrhage, a neurologic emergency. Immediate provider notification and urgent evaluation are required. Routine measures would dangerously delay diagnosis.

Question 19Patient Assessment and Clinical Judgment

A nurse is assessing a client with a suspected deep vein thrombosis in the left leg. Which finding is most consistent with this condition?

  1. Unilateral calf tenderness with warmth and swelling Correct answer.
  2. Bilateral pitting edema with cool skin
  3. Absent pedal pulses with pale, cold toes
  4. Sharp chest pain that worsens with inspiration

Explanation

Deep vein thrombosis typically produces unilateral calf pain, warmth, and swelling from venous obstruction and inflammation. The findings are usually asymmetric. Bilateral edema or absent pulses suggest other vascular problems.

Question 20Patient Assessment and Clinical Judgment

A nurse is assessing a newborn 1 hour after birth. Which finding requires immediate intervention?

  1. Nasal flaring with intercostal retractions and grunting Correct answer.
  2. Heart rate of 140 beats per minute
  3. Acrocyanosis of the hands and feet
  4. Respiratory rate of 50 breaths per minute

Explanation

Nasal flaring, retractions, and grunting are signs of respiratory distress in a newborn and require immediate evaluation. These findings indicate increased work of breathing and possible respiratory distress syndrome. The other findings are expected in the immediate newborn period.

Question 21Patient Assessment and Clinical Judgment

A client with chronic obstructive pulmonary disease has a oxygen saturation of 88% on room air and reports increasing breathlessness. Which assessment finding would most concern the nurse?

  1. Use of accessory muscles
  2. Pursed-lip breathing
  3. A chronic productive cough
  4. A change in mental status with drowsiness Correct answer.

Explanation

A change in mental status such as drowsiness in a client with COPD may indicate worsening hypoxemia or carbon dioxide retention. Mental status changes are a sensitive indicator of respiratory failure. Pursed-lip breathing, accessory muscle use, and chronic cough are expected in COPD.

Question 22Patient Assessment and Clinical Judgment

A nurse is caring for a client receiving intravenous opioids who has a respiratory rate of 10, pinpoint pupils, and increasing sedation. Which action should the nurse take first?

  1. Administer the next scheduled opioid dose
  2. Stimulate the client and prepare to administer naloxone Correct answer.
  3. Encourage the client to drink fluids and reassess in 1 hour
  4. Place the client in a supine position and document

Explanation

Pinpoint pupils, sedation, and slowed respirations indicate opioid-induced respiratory depression, which is life-threatening. The nurse should stimulate the client to breathe and prepare to administer the opioid antagonist naloxone. Continuing opioids or delaying intervention could be fatal.

Question 23Patient Assessment and Clinical Judgment

A client with a spinal cord injury at T4 suddenly reports a severe pounding headache and has a blood pressure of 210/110 mm Hg. Which action should the nurse take first?

  1. Sit the client upright and assess for bladder distention Correct answer.
  2. Check the blood pressure again in 15 minutes
  3. Place the client flat and apply a warm blanket
  4. Administer the prescribed antihypertensive and wait for effect

Explanation

Severe headache with marked hypertension in a client with a high spinal cord injury suggests autonomic dysreflexia, a medical emergency. The first action is to sit the client upright to reduce blood pressure and identify and remove the trigger, such as bladder distention. Prompt intervention prevents stroke and seizures.

Question 24Patient Assessment and Clinical Judgment

A nurse is assessing a client with severe hyponatremia. Which neurologic finding is most concerning?

  1. A headache relieved by acetaminophen
  2. Mild fatigue
  3. Dry mucous membranes
  4. New-onset confusion with a seizure Correct answer.

Explanation

Severe hyponatremia causes cerebral edema, which can present with confusion and progress to seizures and coma. New confusion with seizure activity indicates a neurologic emergency requiring urgent correction. Mild fatigue and headache are less specific findings.

Question 25Patient Assessment and Clinical Judgment

A client with a suspected abdominal aortic aneurysm reports sudden severe back pain and has a blood pressure of 80/50 mm Hg. Which action should the nurse take first?

  1. Obtain a urine specimen for analysis
  2. Palpate the abdomen deeply to confirm the mass
  3. Notify the provider immediately and prepare for fluid resuscitation Correct answer.
  4. Administer oral fluids to raise the blood pressure

Explanation

Sudden severe back pain with hypotension in a client with a known or suspected abdominal aortic aneurysm suggests rupture, a catastrophic emergency. The priority is immediate provider notification and preparation for fluid resuscitation and surgery. Deep palpation is contraindicated because it may worsen the rupture.

Question 26Patient Assessment and Clinical Judgment

A nurse is assessing a client who is drowsy but opens the eyes when the nurse speaks the client's name, answers questions slowly, and localizes to a painful stimulus. How should the nurse document the Glasgow Coma Scale score?

  1. Eye opening 3, verbal 4, motor 5, total 12 Correct answer.
  2. Eye opening 2, verbal 4, motor 5, total 11
  3. Eye opening 3, verbal 3, motor 5, total 11
  4. Eye opening 3, verbal 4, motor 6, total 13

Explanation

Opening the eyes to a spoken request scores 3, confused but coherent conversation scores 4, and localizing to pain scores 5, giving a total of 12. Each component is scored independently and then summed, so the nurse must rate the best response in each category.

Question 27Patient Assessment and Clinical Judgment

During a skin assessment, a nurse finds a firm, nonblanching, purplish area over the client's sacrum that does not resolve with pressure and feels slightly warm. How should the nurse classify and document this finding?

  1. A stage 2 pressure injury
  2. A stage 1 pressure injury
  3. A deep tissue pressure injury Correct answer.
  4. A moisture-associated skin breakdown

Explanation

Intact skin with a persistent, nonblanchable deep purple or maroon discoloration indicates a deep tissue pressure injury, reflecting damage to underlying tissue. Stage 1 presents as nonblanchable redness, while stage 2 involves partial-thickness skin loss.

Question 28Patient Assessment and Clinical Judgment

A nurse is assessing a client's pain using a numeric scale. Which client report best reflects the quality of pain that the nurse should document as neuropathic?

  1. A sharp pain that worsens with deep breathing
  2. A burning, shooting pain with tingling in the toes Correct answer.
  3. A dull, aching pressure deep in the joint
  4. A cramping sensation that comes in waves

Explanation

Neuropathic pain arises from nerve injury and is characteristically described as burning, shooting, electric, or tingling. Recognizing the quality of pain guides selection of adjuvant medications such as gabapentinoids rather than simple analgesics alone.

Question 29Patient Assessment and Clinical Judgment

A nurse is assessing a client for dehydration. Which combination of findings most strongly supports a fluid volume deficit?

  1. Peripheral edema, weight gain, and jugular venous distention
  2. Warm flushed skin, hypertension, and polyuria
  3. Dry mucous membranes, weight loss, and concentrated urine Correct answer.
  4. Bounding pulses, distended neck veins, and crackles

Explanation

Fluid volume deficit produces dry mucous membranes, orthostatic changes, decreased skin turgor, acute weight loss, and low-volume concentrated urine. Daily weights are the most reliable single indicator because they reflect actual fluid change.

Question 30Patient Assessment and Clinical Judgment

A nurse is assessing a client who has a new onset of unilateral facial droop and slurred speech that began 40 minutes ago. Which action should the nurse take first?

  1. Document the findings and reassess in 30 minutes
  2. Ask the client to walk to assess gait and balance
  3. Activate the emergency stroke response and record the time symptoms began Correct answer.
  4. Give the client a sip of water to test swallowing

Explanation

Sudden unilateral facial droop with speech change suggests acute stroke, and time-sensitive reperfusion therapy depends on knowing symptom onset. Activating the emergency stroke pathway and documenting the last known well time take priority over other assessments.

Question 31Patient Assessment and Clinical Judgment

A nurse is assessing a client with a suspected tension pneumothorax. Which cluster of findings should the nurse expect?

  1. Pleuritic pain that resolves with leaning forward
  2. Gradual onset of dry cough with bilateral wheezing
  3. Tracheal deviation toward the affected side with crackles
  4. Sudden dyspnea, absent breath sounds on one side, and hypotension Correct answer.

Explanation

Tension pneumothorax produces sudden severe dyspnea, absent or diminished breath sounds on the affected side, hyperresonance, hypotension, and tracheal deviation away from the affected side. It is a life-threatening emergency requiring immediate decompression.

Question 32Patient Assessment and Clinical Judgment

A nurse is reviewing the medication list of an older adult who reports new confusion and unsteady gait. Which medication is most likely contributing to this change?

  1. Metformin
  2. Levothyroxine
  3. Atorvastatin
  4. Diphenhydramine Correct answer.

Explanation

Anticholinergic drugs such as diphenhydramine commonly cause confusion, dry mouth, urinary retention, and falls in older adults. Reviewing for anticholinergic burden is a key step when an older client develops acute mental status change.

Question 33Patient Assessment and Clinical Judgment

A nurse is assessing a client with a suspected small bowel obstruction. Which finding should the nurse expect during the physical examination?

  1. Hyperactive high-pitched bowel sounds with abdominal distention Correct answer.
  2. Rebound tenderness isolated to the right lower quadrant
  3. Absent bowel sounds with a scaphoid abdomen
  4. Tympanic sounds limited to the left upper quadrant

Explanation

Early mechanical small bowel obstruction produces hyperactive, high-pitched bowel sounds as the bowel attempts to move contents past the blockage, along with distention, cramping pain, and vomiting. Bowel sounds become absent only later as the bowel fatigues.

Question 34Patient Assessment and Clinical Judgment

A nurse is assessing a client with a new onset of generalized weakness and a serum potassium level of 6.9 mEq/L. Which assessment should the nurse perform first?

  1. Check the client's most recent hemoglobin level
  2. Measure the client's abdominal girth
  3. Inspect the client's skin for bruising
  4. Auscultate the heart rhythm and obtain an electrocardiogram Correct answer.

Explanation

Severe hyperkalemia can cause peaked T waves, widened QRS complexes, and fatal dysrhythmias, so cardiac monitoring is the priority. The nurse should also notify the provider and prepare for treatments such as calcium gluconate and insulin with glucose.

Question 35Patient Assessment and Clinical Judgment

A nurse is assessing a client who is receiving a blood transfusion and reports chills, low back pain, and dark urine. Which action should the nurse take first?

  1. Stop the transfusion and maintain intravenous access with normal saline Correct answer.
  2. Administer the prescribed antihistamine and continue the transfusion
  3. Obtain a urine sample and continue the transfusion at a slower rate
  4. Slow the transfusion and reassess vital signs in 15 minutes

Explanation

Fever, chills, flank or back pain, and dark urine suggest an acute hemolytic transfusion reaction, which requires stopping the transfusion immediately while keeping the line patent with normal saline. The nurse then notifies the provider and blood bank and monitors for shock.

Question 36Patient Assessment and Clinical Judgment

A nurse is assessing a client who has been vomiting for three days. The client is lethargic with a respiratory rate of 10 breaths per minute. Which arterial blood gas result is most consistent with these findings?

  1. pH 7.48, PaCO2 48 mm Hg, bicarbonate 34 mEq/L Correct answer.
  2. pH 7.30, PaCO2 50 mm Hg, bicarbonate 25 mEq/L
  3. pH 7.20, PaCO2 30 mm Hg, bicarbonate 12 mEq/L
  4. pH 7.50, PaCO2 30 mm Hg, bicarbonate 24 mEq/L

Explanation

Prolonged vomiting causes loss of gastric acid and metabolic alkalosis with compensatory hypoventilation, producing an elevated pH, elevated bicarbonate, and raised PaCO2. The slow respiratory rate reflects the lungs retaining carbon dioxide to offset the alkalosis.

Question 37Patient Assessment and Clinical Judgment

A nurse is caring for a client who is 24 hours after major abdominal surgery. The client is restless and confused, with a respiratory rate of 26 breaths per minute and an oxygen saturation of 89% on room air. Which action should the nurse take first?

  1. Administer the prescribed opioid for pain
  2. Obtain a blood culture before any intervention
  3. Reassure the client and document the findings
  4. Apply supplemental oxygen and encourage incentive spirometry Correct answer.

Explanation

Restlessness, confusion, tachypnea, and hypoxemia after abdominal surgery suggest atelectasis or another hypoxic process, so improving oxygenation with supplemental oxygen and lung expansion is the priority. The nurse should also elevate the head of the bed and notify the provider.

Question 38Patient Assessment and Clinical Judgment

A nurse is assessing a client with cirrhosis who has become increasingly drowsy. Which finding is most consistent with hepatic encephalopathy?

  1. A fine tremor of the hands that worsens with arms extended Correct answer.
  2. High-pitched bowel sounds and diarrhea
  3. Crackles at both lung bases
  4. A positive Babinski reflex on one side only

Explanation

Asterixis, a flapping tremor elicited when the client extends the arms with wrists dorsiflexed, is a hallmark of hepatic encephalopathy. It is accompanied by altered mental status, and ammonia levels may be elevated, though clinical assessment guides treatment.

Question 39Patient Assessment and Clinical Judgment

A nurse is assessing a client who has a cast on the lower leg. The client reports increasing pain that is not relieved by the prescribed analgesic, and the toes are pale with prolonged capillary refill. Which action should the nurse take?

  1. Administer a stronger dose of the prescribed analgesic
  2. Document the findings and reassess in one hour
  3. Notify the provider immediately and prepare for cast removal Correct answer.
  4. Elevate the leg above heart level and apply ice

Explanation

Worsening pain unrelieved by analgesia, pallor, paresthesia, and delayed capillary refill suggest compartment syndrome, which threatens limb viability. The nurse must notify the provider immediately because a tight cast or dressing may need to be released without delay.

Question 40Patient Assessment and Clinical Judgment

A nurse is assessing a client for possible malnutrition. Which combination of findings is most consistent with a nutritional deficit?

  1. Increased appetite with a body mass index of 24 kg/m2
  2. Stable weight with a prealbumin level in the normal range
  3. Body mass index of 30 kg/m2 with triceps skinfold above normal
  4. Unintentional weight loss of 8% over three months with low serum albumin Correct answer.

Explanation

Unintentional weight loss greater than 5% in three months, low serum albumin or prealbumin, and reduced muscle mass suggest malnutrition. Weight trend and intake history are more reliable than a single measurement.

Question 41Provision of Care and Clinical Interventions

A client in the post-anesthesia care unit has a respiratory rate of 8 breaths per minute and an oxygen saturation of 88%. Which action should the nurse take first?

  1. Obtain a full set of vital signs before intervening
  2. Document the findings and reassess in 15 minutes
  3. Raise the head of the bed and encourage coughing
  4. Stimulate the client and open the airway Correct answer.

Explanation

A respiratory rate of 8 with oxygen saturation of 88% indicates inadequate ventilation and oxygenation, which is an immediate threat to airway and breathing. The nurse's first priority is to stimulate the client, position the airway, and support breathing before any further assessment or documentation. Delaying intervention to complete vital signs or reassess later risks hypoxic injury.

Question 42Provision of Care and Clinical Interventions

Which finding should the nurse report immediately for a client receiving a blood transfusion?

  1. Heart rate of 92 beats per minute
  2. Temperature of 37.6 degrees Celsius
  3. Urticaria with reports of chills and back pain Correct answer.
  4. Mild itching at the intravenous site

Explanation

Urticaria accompanied by chills and back pain suggests an acute hemolytic or severe allergic transfusion reaction, which requires stopping the transfusion immediately and notifying the provider. These signs reflect a systemic reaction rather than a localized nuisance symptom. Prompt recognition prevents further hemolysis and cardiovascular collapse.

Question 43Provision of Care and Clinical Interventions

A client with a new colostomy asks how to care for the stoma. Which instruction should the nurse include?

  1. Cleanse the stoma gently with warm water and pat dry Correct answer.
  2. Apply lotion to the stoma after each pouch change
  3. Keep the stoma uncovered to promote drying
  4. Scrub the stoma vigorously with soap to prevent infection

Explanation

A healthy stoma is fragile mucosa and should be cleansed gently with warm water and patted dry before pouching. Vigorous scrubbing, lotions, and leaving the stoma exposed can damage tissue or impair pouch adhesion. Gentle technique preserves skin integrity and supports a secure seal.

Question 44Provision of Care and Clinical Interventions

The nurse is preparing to administer digoxin to an adult client. Which assessment finding requires withholding the dose and notifying the provider?

  1. Serum potassium of 4.2 mEq/L
  2. Respiratory rate of 18 breaths per minute
  3. Apical pulse of 52 beats per minute Correct answer.
  4. Blood pressure of 138/84 mm Hg

Explanation

Digoxin slows conduction through the atrioventricular node, so a heart rate below 60 beats per minute is a standard reason to hold the dose and contact the provider. Administering digoxin to a bradycardic client risks worsening bradycardia and heart block. The other listed values fall within expected ranges.

Question 45Provision of Care and Clinical Interventions

Which action best prevents catheter-associated urinary tract infection in a client with an indwelling catheter?

  1. Changing the catheter every 48 hours
  2. Maintaining a closed drainage system and dependent loop Correct answer.
  3. Irrigating the catheter routinely every shift
  4. Disconnecting the tubing to obtain urine samples

Explanation

Maintaining a closed, unobstructed drainage system with dependent tubing prevents urine stasis and retrograde bacterial migration, which are key mechanisms of catheter-associated infection. Routine irrigation, frequent catheter changes, and unnecessary disconnections all introduce organisms and should be avoided.

Question 46Provision of Care and Clinical Interventions

A client is placed in restraints for acute agitation. Which nursing action is required?

  1. Obtain a new provider order every 24 hours
  2. Keep the restraint in place until the client sleeps
  3. Release the restraint and assess circulation at regular intervals Correct answer.
  4. Tie the restraint to the side rail of the bed

Explanation

Restraints require frequent, regular release and assessment of circulation, skin integrity, and safety to prevent injury and neurovascular compromise. Restraints must be secured to a fixed part of the bed frame, not side rails, and orders for violent behavior are time-limited and must be renewed per policy. Regular monitoring is the core safety requirement.

Question 47Provision of Care and Clinical Interventions

Which client statement indicates correct understanding of a low-sodium diet?

  1. I can use soy sauce freely because it is not salt
  2. I should add table salt to improve flavor
  3. I will read food labels and choose fresh foods instead of canned Correct answer.
  4. I will drink bouillon daily for hydration

Explanation

A low-sodium diet requires reading labels and selecting fresh foods over processed or canned items, which are typically high in sodium. Soy sauce, table salt, and bouillon are all concentrated sodium sources and should be limited. This choice reflects accurate dietary knowledge.

Question 48Provision of Care and Clinical Interventions

When transferring a client from bed to a chair, which action protects both the client and the nurse?

  1. Bend at the waist while pulling the client upward
  2. Raise the bed to a comfortable working height and use a gait belt Correct answer.
  3. Keep the bed in the lowest position and twist to pivot
  4. Have the client wrap arms around the nurse's neck

Explanation

Raising the bed to working height reduces the nurse's bending and reaching, and a gait belt provides a secure handhold during transfer. Proper body mechanics and assistive devices reduce injury to both parties. Twisting, pulling with the waist, and neck-holding are unsafe practices.

Question 49Provision of Care and Clinical Interventions

A client receiving furosemide reports muscle weakness and has a serum potassium of 3.1 mEq/L. Which action should the nurse take?

  1. Withhold all fluids until potassium normalizes
  2. Encourage a high-sodium diet and reassess tomorrow
  3. Document the finding as expected and continue monitoring
  4. Notify the provider and prepare to administer potassium replacement Correct answer.

Explanation

Furosemide is a loop diuretic that promotes potassium loss, and a level of 3.1 mEq/L with muscle weakness indicates hypokalemia requiring provider notification and replacement. Hypokalemia can progress to dysrhythmias if untreated. Sodium loading and fluid restriction do not address the potassium deficit.

Question 50Provision of Care and Clinical Interventions

A client with type 1 diabetes has a blood glucose of 48 mg/dL and is awake but confused. Which action should the nurse take first?

  1. Start an intravenous line for dextrose
  2. Recheck the glucose in one hour
  3. Give 15 grams of a fast-acting oral carbohydrate Correct answer.
  4. Administer the scheduled insulin dose

Explanation

For a conscious client with hypoglycemia, the priority is rapid oral glucose replacement using the 15-gram rule, followed by rechecking in about 15 minutes. Intravenous dextrose is reserved for clients who cannot safely swallow or are unresponsive. Withholding insulin and delaying rechecks allow hypoglycemia to worsen.