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In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, ''Forget all those rules. I always get along well with the nurses.'' Which nursing response to him would be most effective?
(A) This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. (B) This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. (C) This answer is incorrect. It appears to have a negative connotation. There was no limit setting. (D) This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set.
A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within:
(A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2--4 weeks before improvement of symptoms is noted. (C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication. (D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug therapy.
A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
(A) Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. (B) Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. (C) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. (D) Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.
Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:
(A) Skeletal traction, including the weights that are applying the traction, is never released by the nurse. (B) It is necessary to keep the pin site clean and free from infection. (C) When first placed in traction, the client may experience increased discomfort as a result of the traction pull fatiguing the muscle. (D) When the child in traction is allowed to participate in his care, it gives him a measure of control and helps him to cope with the situation.
When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 4--8) of pregnancy is so critical.
(A) Duplication of genetic material occurs during the preembryonic period (weeks 1--3) following conception. The exact duplication of genetic material is essential for cell differentiation, growth, and biological maintenance of the organism. (B) Weeks 4--8, known as the embryonic period, are the time organogenesis occurs and pose the greatest potential for major congenital malformations. All major internal and external organs and systems are formed. (C) Subcutaneous fat does not develop until the latter weeks of gestation. (D) Kidneys begin to secrete urine during the 13th--16th week.
The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
(A) Cool air will often relieve pruritus without damaging the cast or irritating the skin. (B) The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. (C) Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. (D) This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.
A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
(A) Pneumonia may be reflected by patchy infiltrates. In addition, fever, an increasing white blood cell count, and copious sputum production would be present. (B) Blunt chest traumacauses a bruising process in which interstitial and alveolar edema and hemorrhage occur. This is manifest by gradual deterioration over 24 hours of arterial blood gases and the continued production of bloody sputum. Patchy infiltrates are evident on chest xray 24 hours postinjury. (C) Pulmonary edema usually results from left heart failure. It is manifest by pink, frothy sputum; increasing dyspnea; tachycardia; and crackles on auscultation. (D) Tension pneumothorax is a potential complication for someone with rib fractures and a chest tube. It is manifest by diminished breath sounds on the affected side, rapidly deteriorating arterial blood gases in the presence of an open airway, and shock that is unexplained by other injuries.
Exam domains verified against: Official NCLEX NCLEX-RN exam guide, last checked October 2026.
Assess clients for allergies and environmental safety hazards. Apply infection prevention principles including hand hygiene, aseptic technique, isolation precautions, and use of protective equipment. Properly identify clients, handle biohazardous materials, and report unsafe practice by healthcare personnel.
Sample question from this domain above: Q1
Provide care and education across the lifespan from newborn through older adults. Assess clients' readiness to learn and ability to manage care at home. Educate clients about preventative care, health maintenance, and management of high-risk health behaviors.
Assess clients for abuse, substance abuse, and potential for violence. Support clients through life changes, grief, loss, and acute and chronic mental health issues. Incorporate cultural practices and beliefs into care planning, and use therapeutic communication techniques.
Manage client pain, nutrition, bowel and bladder elimination, and skin integrity. Perform irrigations, dressing changes, and positioning to promote circulation and comfort. Assess activities of daily living and provide non-pharmacological comfort measures.
Sample question from this domain above: Q3
Prepare and administer medications using the rights of medication administration and perform accurate calculations. Review contraindications and potential interactions before administration. Handle high-risk and controlled substances according to regulatory guidelines and educate clients about medications.
Manage care for clients with acute and chronic conditions including fluid and electrolyte imbalances, hemodynamic alterations, and oxygenation issues. Perform postoperative and emergency care procedures. Assist with invasive procedures and manage devices like ventilators, chest tubes, and dialysis equipment.
Common questions about the exam itself
