Question 1

A nurse is caring for four patients. Which patient should be assessed FIRST?

Accepted Answer

A patient with a pulse ox of 88% on room air. Oxygenation is the highest priority per the ABCs framework. SpO2 of 88% indicates hypoxia and requires immediate intervention.

Question 2

A charge nurse may appropriately delegate which task to an unlicensed assistive personnel (UAP)?

Accepted Answer

Measuring and recording urine output. UAPs can perform non-invasive, standardized tasks like measuring and recording I&O. Assessment, teaching, and medication administration require licensed staff.

Question 3

A patient on warfarin reports eating large amounts of spinach, broccoli, and kale daily. The nurse expects which lab result?

Accepted Answer

Decreased INR. Leafy greens are high in vitamin K, which antagonizes warfarin's anticoagulant effect, leading to a decreased INR (increased clotting ability).

Question 4

A patient develops peaked T-waves and a widened QRS on EKG. Which electrolyte imbalance does the nurse suspect?

Accepted Answer

Hyperkalemia. Hyperkalemia (elevated potassium) causes classic EKG changes: peaked T-waves, widened QRS, and eventually a sine wave pattern that can lead to cardiac arrest.

Question 5

A patient is admitted with active pulmonary tuberculosis (TB). Which precaution type is required?

Accepted Answer

Airborne precautions. TB is transmitted via airborne particles (droplet nuclei less than 5 microns). Airborne precautions require a negative pressure room and N95 respirator.

Question 6

A nurse notices a late deceleration on the fetal monitor. What is the FIRST nursing action?

Accepted Answer

Reposition the patient to the left lateral position. Late decelerations indicate uteroplacental insufficiency. Repositioning improves uterine blood flow by relieving vena cava compression.

Question 7

A patient has BP 88/56, HR 124, RR 28, temp 38.9°C, WBC 18,000, and urine output 20 mL/hr. Which condition does the nurse recognize?

Accepted Answer

Septic shock. The combination of fever, elevated WBC, hypotension, tachycardia, tachypnea, and decreased urine output is the clinical picture of septic shock.

Question 8

A patient with schizophrenia reports the government implanted a device in their brain. Which nursing response is most therapeutic?

Accepted Answer

"That sounds very frightening. Tell me more about what you're experiencing." Therapeutic communication acknowledges feelings without reinforcing or challenging delusions.

Question 9

An ABG shows pH 7.31, PaCO2 52 mmHg, HCO3 24 mEq/L. The nurse interprets this as:

Accepted Answer

Respiratory acidosis. pH < 7.35 = acidosis. Elevated PaCO2 (>45) = respiratory cause. Normal HCO3 indicates no metabolic compensation yet.

Question 10

A 2-year-old has had a fever for 2 days. Which finding requires IMMEDIATE provider notification?

Accepted Answer

A bulging anterior fontanelle. This indicates increased intracranial pressure — a medical emergency requiring immediate evaluation for meningitis or hydrocephalus.

NCLEX Practice Quiz