NCLEX EXAM STUDY

NOTES 2025-2026
600+ High-Yield Practice Questions, Smart Study Hacks & Test-
Taking Tips for Confident First-Time Passes

JASPER M. RAYNE
Copyright © 2025 by Jasper M. Rayne
All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or
transmitted in any form or by any means, whether electronic, mechanical, photocopying,
recording, or otherwise, without the express written permission of the author, Jasper M. Rayne .
The unauthorized scanning, uploading, or distribution of this book through the internet or any
other means is prohibited by law and is subject to legal action.
DISCLAIMER
This book is a study guide designed to assist individuals preparing for the NCLEX-RN exam.
While every effort has been made to ensure that the information presented is accurate and
valuable, it should not be seen as a substitute for formal nursing education, hands-on clinical
experience, or guidance from licensed professionals.
The author and any associated publishers or affiliates are not liable for any errors, omissions, or
negative outcomes that arise from applying the information provided. Readers are advised to
consult the official NCLEX-RN materials and follow their nursing programs for the most current
standards and regulations.
This book is not endorsed or affiliated with the National Council of State Boards of Nursing
(NCSBN) or the NCLEX-RN exam. References to the NCLEX-RN exam are made solely for
informational purposes.
LEGAL NOTICE
The author has taken every measure to ensure the accuracy of the content within this book.
However, because medical standards, exam formats, and guidelines are subject to change, some
of the information may become outdated. The author cannot guarantee the timeliness or accuracy
of all material. The content provided in this guide is intended for educational purposes only. The
use of this material is at the user’s own discretion and risk. The author and publisher are not
responsible for any adverse effects, losses, or damages resulting from the use or misuse of the
information presented.
 Table of Contents

INTRODUCTION _________________________________________________________________________ 6
Part 1: Understanding the NCLEX Exam Structure _______________________________________________ 7
Chapter 1: Introduction to the NCLEX Exam ___________________________________________________ 8
1.1 Overview of the NCLEX _________________________________________________________ 8
1.2 The Purpose and Importance of the NCLEX Exam _____________________________________ 9
1.3 NCLEX Exam Format and Structure ________________________________________________11
1.4 Understanding the Exam’s Clinical Judgment Focus _____________________________________14
Chapter 2: Key Areas Tested in the NCLEX-RN ________________________________________________ 18
2.1 NCLEX-RN Test Plan Breakdown: Domains and Categories ______________________________18
2.2 Weighting of Major NCLEX Topics _________________________________________________22
2.3 Critical Thinking and Question Analysis ______________________________________________26
Types of NCLEX Questions and How to Tackle Them _____________________________________27
Part 2: Smart Study Hacks and Test-Taking Strategies ___________________________________________ 31
Chapter 3: Effective Study Strategies __________________________________________________________ 32
3.1 How to Organize Your Study Time for Maximum Impact ________________________________32
3.2 Using Spaced Repetition for Long-Term Retention _____________________________________35
3.3 The Pomodoro Technique for Focused Study Sessions___________________________________37
Chapter 4: Mastering Test-Taking Strategies ___________________________________________________ 41
Techniques to Minimize Test Anxiety and Improve Focus ___________________________________43
The Importance of Selecting the Safest Option: Prioritization in NCLEX Questions _______________45
Part 3: Key Topics Tested on the NCLEX Exam ________________________________________________ 48
Chapter 5: Management of Care (15%-21%) ____________________________________________________ 49
5.1 Prioritization and Delegation Strategies_______________________________________________49
5.2 Effective Communication and Collaboration in Nursing Care _____________________________62
5.3 Legal and Ethical Responsibilities in Nursing __________________________________________66
5.4 Coordinating Patient Care Plans and Advocacy_________________________________________69
Chapter 6: Safety and Infection Control (10%-16%) ______________________________________________ 73
6.1 Standard Precautions and Isolation Procedures _________________________________________73
6.2 Preventing Healthcare-Associated Infections __________________________________________76
6.3 Safe Medication Administration and Equipment Handling ________________________________82
6.4 Emergency Response Protocols and Safety Measures ____________________________________86
Chapter 7: Health Promotion and Maintenance (6%-12%) ________________________________________ 91
7.1 Patient Education and Health Promotion Strategies _____________________________________91
7.2 Disease Prevention and Screening Guidelines __________________________________________95
7.3 Nutrition and Wellness Counseling __________________________________________________99
7.4 Lifespan Development and Preventive Care Techniques_________________________________ 103
Chapter 8: Psychosocial Integrity (6%-12%) ___________________________________________________ 109
8.1 Coping Mechanisms and Stress Management Interventions ______________________________ 109
8.2 Mental Health Disorders: Diagnosis and Nursing Interventions ___________________________ 113
8.3 Supporting Patients with Chronic Conditions _________________________________________ 118
8.4 End-of-Life Care and Family Support _______________________________________________ 122
Chapter 9: Basic Care and Comfort (6%-12%) __________________________________________________ 127
9.1 Assisting with Activities of Daily Living (ADLs) _______________________________________ 127
9.2 Pain Management Strategies for Acute and Chronic Pain ________________________________ 131
9.3 Comfort and Palliative Care Principles ______________________________________________ 135
8.4 Ensuring Patient Safety in Routine Care _____________________________________________ 140
Chapter 10: Pharmacological and Parenteral Therapies (13%-19%) ________________________________ 146
10.1 Understanding Drug Classifications and Actions______________________________________ 146
10.2 Medication Administration: Dosage Calculations and Routes ____________________________ 150
10.3 Managing Side Effects, Contraindications, and Drug Interactions _________________________ 155
10.4 Parenteral Medications, IV Therapy, and Infusions ____________________________________ 159
10.5 Cardiology Medications and Nursing Interventions____________________________________ 163
10.6 Oncology Medications and Therapies ______________________________________________ 169
Chapter 11: Reduction of Risk Potential (9%-15%) ______________________________________________ 174
11.1 Identifying Risk Factors in Patient Assessments ______________________________________ 174
11.2 Preventive Measures and Health Surveillance ________________________________________ 178
11.3 Monitoring Patient Status and Vital Signs ___________________________________________ 182
11.4 Early Detection of Complications and Health Deterioration _____________________________ 187
Chapter 12: Physiological Adaptation (11%-17%) _______________________________________________ 193
12.1 Managing Acute and Chronic Physiological Conditions ________________________________ 193
12.2 Response to Trauma, Shock, and Infection __________________________________________ 197
12.3 Fluid and Electrolyte Imbalances: Management and Interventions ________________________ 201
12.4 Respiratory and Cardiovascular Disorders: Nursing Interventions ________________________ 206
12.5 Oncology and Cardiology Nursing Interventions and Care ______________________________ 212
Part 4: Practice Questions & Model Exams ___________________________________________________ 217
Chapter 13: High-Yield Practice Questions ____________________________________________________ 218
A. Safe and Effective Care Environment _______________________________________________ 218
B. Health Promotion and Maintenance _________________________________________________ 239
C. Psychosocial Integrity____________________________________________________________ 256
D. Physiological Integrity ___________________________________________________________ 273
Answers and Detailed Review _______________________________________________________________ 290
A. Safe and Effective Care Environment _______________________________________________ 290
B. Health Promotion and Maintenance _________________________________________________ 313
C. Psychosocial Integrity____________________________________________________________ 340
D. Physiological Integrity ___________________________________________________________ 364
Appendices ______________________________________________________________________________ 373
NCLEX Tips ____________________________________________________________________ 373
Strategies to Use for the NCLEX _____________________________________________________ 373
Substance Use and Withdrawal: ______________________________________________________ 374
Medical Procedures and Pre/Post Care Instructions _______________________________________ 376
Cardiac Catheterization: ____________________________________________________________ 377
Lumbar Puncture:_________________________________________________________________ 378
Drainage Types: __________________________________________________________________ 378
Normal Postpartum Vitals: __________________________________________________________ 378
Normal Pediatric Vitals: ____________________________________________________________ 379
Urinary Frequency Teaching: ________________________________________________________ 379
Food and Diets: __________________________________________________________________ 380
Normal Chemistry Values: __________________________________________________________ 381
Words to Remember for Laws and Prioritization _________________________________________ 381
ABC Prioritization Keywords ________________________________________________________ 381
Donning and Doffing Personal Protective Equipment (PPE) ________________________________ 383
Normal Hours of Sleep by Age_______________________________________________________ 384
 INTRODUCTION
The NCLEX-RN exam is a challenging and crucial step toward becoming a licensed nurse. It tests
not just your theoretical knowledge, but your ability to think critically, apply your learning in
practical scenarios, and manage real-world situations in healthcare. With the pressure of passing
on your first attempt, you need more than just basic facts—you need a strategic, focused, and
efficient study plan that will set you apart from the crowd.
This book has been meticulously crafted to provide you with exactly that. With over 600 high-
yield practice questions spread across all critical domains of the NCLEX exam, you’ll cover
everything from Safe and Effective Care Environment, Health Promotion and Maintenance,
Psychosocial Integrity, to Physiological Integrity. Each question has been carefully chosen to
reflect the actual exam content and difficulty level, ensuring you're well-prepared for what’s to
come.
But this book is not just a collection of questions. We’ve paired every question with detailed,
comprehensive answer explanations to ensure you understand the reasoning behind each correct
and incorrect response. This feedback will strengthen your grasp of the material, improve your
ability to identify key concepts, and refine your test-taking skills. It’s not just about memorizing
facts—it’s about building the confidence to apply that knowledge effectively under pressure.
In addition to practice questions, you'll find invaluable study hacks, test-taking strategies, and tips
that help you stay focused, manage stress, and optimize your exam performance. Whether you
struggle with time management, test anxiety, or simply need a more organized approach to your
study schedule, this book offers practical solutions that make your preparation easier and more
effective.
This study guide is designed with your success in mind. From the moment you begin, you’ll be
guided through each content domain and subcategory in a structured yet flexible format that suits
your personal study style. And with frequent self-assessments and end-of-chapter quizzes, you’ll
track your progress and feel more confident as your exam day approaches.
Are you ready to take on the NCLEX-RN with confidence and pass on your first try? Let’s get
started. Your future as a licensed nurse begins here!
Part 1: Understanding the
NCLEX Exam Structure
 Chapter 1: Introduction to the
NCLEX Exam
1.1 Overview of the NCLEX
The NCLEX (National Council Licensure Examination) is a critical part of becoming a licensed
nurse in the United States. It is designed to assess whether a candidate has the knowledge, skills,
and abilities required to practice safely and effectively as an entry-level nurse. Every year,
thousands of nursing graduates take this exam to become registered nurses (RNs) or practical
nurses (LPNs). The NCLEX is not just a test of knowledge; it focuses on your ability to apply
that knowledge in a clinical setting, make decisions that prioritize patient safety, and demonstrate
sound clinical judgment.
For the NCLEX-RN (Registered Nurse) exam, the test assesses whether you are ready to begin
practice as a safe, competent nurse. It includes various topics ranging from pharmacology to
patient care, from mental health nursing to management of care, and more. The exam evaluates
the ability to synthesize information, apply critical thinking, and prioritize patient care.
This exam is necessary for all nursing graduates to ensure that they meet the minimum standard
of practice required to enter the profession. Without passing the NCLEX, a nursing graduate
cannot legally practice as a nurse in the United States.
The NCLEX is administered by Pearson VUE on behalf of the National Council of State Boards
of Nursing (NCSBN), and it is used by nursing boards in all 50 states, the District of Columbia,
and several U.S. territories. It plays an essential role in ensuring that the nursing workforce is well-
equipped to handle the challenges of the healthcare environment.
There are two main versions of the NCLEX exam: the NCLEX-RN, for those aiming to become
Registered Nurses, and the NCLEX-PN, for Practical Nurses. The NCLEX-RN is for those who
wish to become Registered Nurses, and it assesses a broader range of topics compared to the
NCLEX-PN, which focuses on entry-level practical nursing care.
Both versions of the exam are similar in structure but differ in their scope and depth. The
NCLEX-RN covers a wide variety of topics, including patient care, pharmacology, health
promotion, infection control, and more. The exam is computer-adaptive, meaning that the
questions change based on your performance, making it highly personalized.
The NCLEX-RN is designed to be a comprehensive assessment, making sure that successful
candidates are prepared to handle the multifaceted demands of nursing practice. To pass the exam,
you must answer a sufficient number of questions correctly to demonstrate that you possess the
necessary skills and knowledge for safe and effective nursing practice.
Key Points of the NCLEX Exam:

 Purpose: To assess whether a candidate can provide safe and effective care as a beginning
nurse.
 Examination Format: The exam uses computer-adaptive testing (CAT), adjusting the
level of difficulty based on your performance.
 Content Areas: The NCLEX-RN covers a wide range of nursing areas, such as
pharmacology, patient care, infection control, health promotion, and psychosocial
integrity.
 Validity: Passing the NCLEX ensures that you are qualified to practice as a nurse and are
prepared to handle patient care in real-world situations.
The exam is not designed to simply test your knowledge but also to challenge your ability to apply
that knowledge in dynamic clinical situations. Understanding the structure and content of the
exam will help you better prepare for the challenges it presents.

1.2 The Purpose and Importance of the NCLEX Exam

The primary purpose of the NCLEX is to ensure that individuals entering the nursing profession
have the minimum competency required to provide safe and effective care to patients. Nursing is
a highly specialized and critical field where patient safety is paramount, and the NCLEX is
designed to test if you possess the knowledge, skills, and decision-making ability to work
effectively in a clinical environment. Nurses often deal with high-pressure situations where
mistakes can have severe consequences. By passing the NCLEX, you prove that you are prepared
to make crucial decisions in situations that could involve life or death.
This exam also serves to protect the public from unsafe practices. Nursing is a profession where
decisions need to be based on evidence, clinical reasoning, and the ability to assess patient
conditions correctly. Without adequate knowledge and clinical judgment, nurses can put patients
at risk. The NCLEX evaluates these core competencies to confirm that the candidate is ready to
face these responsibilities with competence and confidence.

NCLEX as a Safety Measure

The NCLEX is structured not just to test knowledge but to assess whether the candidate can
make safe, effective decisions in a variety of real-world scenarios. It is a safety exam designed to
ensure that those who become licensed as nurses can deliver high-quality care that adheres to
both ethical and medical standards. This shift in focus from theoretical knowledge to practical
decision-making is an essential characteristic of the NCLEX. The exam is designed to test not
only what you know, but how you apply that knowledge to ensure patient safety.
Nurses are frequently faced with situations where the right answer may not be immediately clear.
The NCLEX is designed to test your ability to approach these uncertain situations and make the
best possible decision under pressure. The test evaluates how you prioritize patient safety,
administer medications correctly, recognize the need for medical intervention, and manage
complications, all of which are core aspects of nursing practice.

The NCLEX Covers More Than Just Facts

While memorizing medical facts and procedures might seem like an obvious part of becoming a
nurse, the NCLEX goes beyond that. It does not test whether you can simply recall facts but
whether you can synthesize that information and apply it in real clinical situations. The NCLEX
expects you to show critical thinking and clinical reasoning skills. For example, you might know
the correct medication for a disease, but the exam will challenge you to apply that knowledge to
a patient who has multiple conditions or to prioritize which action should be taken first in an
emergency.
Critical thinking plays a significant role in how nursing candidates must approach the exam. This
is especially important because the NCLEX often features complex case studies that mimic real-
life patient scenarios. These questions require you to assess situations, gather information, make
decisions, and evaluate outcomes. They are designed to test your ability to make decisions based
on patient conditions, ethical considerations, and safe nursing practice.

NCLEX Provides a Universal Standard

The NCLEX helps ensure that nurses entering the profession meet a universal standard of
competence. This is especially important in the United States, where nurses may be trained in a
variety of settings and systems, with differing educational backgrounds and clinical experiences.
By standardizing the licensure process, the NCLEX ensures that all nurses, regardless of where
or how they were trained, meet the same basic standards for practice.
The uniformity of the NCLEX allows state boards of nursing to have confidence that every
licensed nurse has passed the same rigorous test. Regardless of whether a nurse is working in a
bustling urban hospital or a rural healthcare clinic, they have demonstrated the ability to meet the
same minimum standard for patient care and safety. This contributes to the overall quality of care
provided across the healthcare system.

Impact on Your Career

Passing the NCLEX is essential not only for licensure but also for the broader career
opportunities it unlocks. Once you pass the exam, you will be able to work as a registered nurse
(RN) or a licensed practical nurse (LPN), depending on the version of the exam you took. This
opens the door to a wide range of nursing careers in various specialties, from pediatrics to
geriatrics, emergency care to psychiatric nursing. Additionally, passing the NCLEX allows you to
pursue advanced practice roles, further education, and certifications in specialized nursing areas.
However, obtaining licensure is just the beginning. The NCLEX is designed to prepare you for
the challenges of nursing practice by testing your ability to adapt to a wide range of scenarios that
you will encounter in your professional career. By passing the NCLEX, you will have
demonstrated the skills needed to manage a variety of patient situations, collaborate with
multidisciplinary teams, and manage the complexities of modern healthcare.

1.3 NCLEX Exam Format and Structure

The NCLEX is a computer-adaptive test (CAT), which means that the exam adjusts the
difficulty of questions based on how well you are performing. If you answer a question correctly,
the next question will be more challenging. If you answer incorrectly, the next question will be
easier. This adaptive system ensures that the exam accurately measures your knowledge and ability
across a range of difficulty levels. The NCLEX-RN exam is typically composed of anywhere
between 75 to 145 questions, while the NCLEX-PN exam contains 85 to 205 questions.
The NCLEX is divided into several sections that focus on different areas of nursing practice.
These sections correspond to the major categories in the NCLEX test plan, such as Management
of Care, Safety and Infection Control, and Physiological Adaptation, among others. The
questions will cover topics relevant to each category and assess both your theoretical knowledge
and practical ability.

Computer-Adaptive Testing (CAT) Model

The NCLEX uses a computer-adaptive test (CAT) system, which is one of the most important
features of the exam. With CAT, each test taker receives a different set of questions, depending
on how they perform on the exam. The questions are presented sequentially, with each question
tailored to the candidate’s ability level.
Here’s how it works:
 Initial Question Difficulty: The first question of the NCLEX is designed to be of average
difficulty for all candidates. From there, the computer assesses your ability based on your
responses.
 Adaptive Process: If you answer a question correctly, the next question will be slightly
more difficult, increasing the difficulty level as you continue answering correctly.
Conversely, if you answer incorrectly, the questions will adjust to a lower level of difficulty.
 Ending the Exam: The exam continues until the computer is confident that your level of
knowledge falls within a specific range that reflects whether you have passed the exam.
This can occur after answering between 75 and 145 questions for the NCLEX-RN exam.
If you reach the minimum of 75 questions and the system determines that you have
demonstrated the required competency, the exam will end early. On the other hand, if you
fail to demonstrate the required competency, the exam can extend to 145 questions.
 Uncertainty of Results: The nature of CAT means you will not know whether you have
passed until the exam is completed. The system determines your performance based on
the number of questions answered, the difficulty of those questions, and the accuracy of
your responses.
The beauty of this adaptive testing approach is that it provides a more personalized assessment.
The questions are specifically designed to match your knowledge and ability, rather than asking
the same set of questions to everyone. It allows the exam to accurately measure your skills and
knowledge with fewer questions.
Number of Questions
For the NCLEX-RN, the exam consists of a minimum of 75 questions and can go up to a
maximum of 145 questions. The length of the exam depends on your performance during the
test. As mentioned, if you are performing well, the exam could end after just 75 questions. If you
are struggling, the exam may extend to the full 145 questions.
Question Types
The NCLEX is made up of a variety of question types, designed to evaluate your ability to apply
nursing concepts in real-world scenarios. These include:

 Multiple-Choice Questions: These are the most common question type on the NCLEX.
They present a question and offer four possible answers. You must choose the one that
best answers the question. Some multiple-choice questions are straight factual recall, while
others require clinical reasoning and critical thinking.
 Select All That Apply (SATA): These questions present a scenario and require you to
select all correct answers from a list. These questions are challenging because they test not
only your knowledge but also your ability to evaluate multiple aspects of patient care.
  Fill-in-the-Blank (Calculation Questions): You may encounter questions that require
you to perform basic math, such as calculating drug dosages, fluid rates, or infusion rates.
These questions test your ability to apply mathematical skills in clinical situations.
 Multiple-Response: These questions may require you to choose more than one correct
answer. For example, a question may ask you to select the most important interventions
for a particular clinical situation.
 Hot Spot: Hot spot questions involve identifying a part of an image (such as a diagram or
medical chart) that corresponds to a given question. You may be asked to click on the part
of the image that is most relevant to the question.
 Drag-and-Drop: These questions require you to arrange options in the correct order. For
instance, you may be asked to prioritize a series of interventions based on their urgency.
 Case Studies: Case studies are longer, scenario-based questions that require you to apply
clinical reasoning skills. You may be asked to assess a patient's situation, determine
priorities, and decide on the best course of action. Case studies test your ability to
synthesize complex information and apply your knowledge to real-life situations.
Exam Sections and Content Areas
The NCLEX exam is organized into content areas that are designed to test specific areas of
nursing knowledge and clinical judgment. These sections align with the test plan, which outlines
the major categories of nursing knowledge. The NCLEX-RN exam typically covers the following
areas:

 Management of Care (15%-21%): This section tests your ability to manage patient care
effectively, including prioritization, delegation, and coordination of care. Key skills tested
include communication, patient advocacy, and managing the healthcare team.
 Safety and Infection Control (10%-16%): This section focuses on ensuring the safety of
both patients and healthcare providers. Topics include infection control protocols,
medication safety, and safe use of equipment.
 Health Promotion and Maintenance (6%-12%): This area tests your knowledge of
health promotion, disease prevention, and patient education. You may be asked about age-
related care, immunizations, and lifestyle modifications that promote long-term health.
 Psychosocial Integrity (6%-12%): This section assesses your ability to provide mental
health support to patients, including managing stress, coping mechanisms, and psychiatric
disorders.
  Basic Care and Comfort (6%-12%): This area covers the basic needs of patients,
including assisting with activities of daily living (ADLs), pain management, and comfort
measures.
 Pharmacological and Parenteral Therapies (13%-19%): This is a critical section that
tests your knowledge of medications, their actions, side effects, and administration. It
includes intravenous (IV) therapy, drug interactions, and dosage calculations.
 Reduction of Risk Potential (9%-15%): This section focuses on identifying and
managing risks to patient health, including recognizing early signs of complications,
monitoring vital signs, and managing patient health changes.
 Physiological Adaptation (11%-17%): This section tests your ability to manage patients
with acute and chronic conditions, including respiratory, cardiovascular, and metabolic
disorders. It also covers the management of trauma, shock, and infection.
Timing of the Exam
The NCLEX-RN exam is designed to be completed in 6 hours. This includes time for breaks,
which you can take at any point during the exam. However, the clock continues to run while you
are on a break, so it’s important to manage your time wisely.
If you reach the maximum number of questions (145) and still haven’t passed, the system will
automatically end the exam. However, if you answer enough questions correctly early on, the
system may end the exam at the minimum (75 questions), which typically indicates that the system
is confident in your ability to pass.
What Determines a Pass?
The NCLEX uses a method called statistical decision theory to determine if you pass or fail
the exam. As the test is computer-adaptive, it measures the probability that you are answering
questions correctly based on your performance. The goal is for the system to be 95% confident
that your level of competence lies above or below the passing standard. If the system determines
with that confidence that you are capable of providing safe and effective care, you will pass. If
not, you will fail.

1.4 Understanding the Exam’s Clinical Judgment Focus

Clinical judgment plays a crucial role in nursing practice and is woven into every aspect of the
NCLEX exam. It is the foundation on which safe and effective patient care is built. Nurses must
assess patient conditions, make quick decisions, and prioritize interventions—sometimes with
incomplete information. The NCLEX exam, therefore, tests candidates on their ability to apply
the principles of clinical judgment in diverse, real-world situations.
The exam uses multiple question types designed to assess clinical judgment, including case
studies, select-all-that-apply (SATA) questions, and multiple-choice questions that require
you to assess scenarios and make decisions. These questions are not about memorizing facts; they
are about recognizing patterns in patient care, evaluating evidence, and applying best practices.
Key Elements of Clinical Judgment in the NCLEX

 Assessment: Clinical judgment begins with gathering information. Nurses are expected to
accurately assess patients’ conditions, which includes reviewing medical history,
conducting physical examinations, monitoring vital signs, and analyzing lab results.
NCLEX questions often test a candidate’s ability to assess patient conditions, identify risks,
and collect relevant data from various sources. For example, a case study question may
provide a patient's symptoms and lab results, asking you to determine the most appropriate
initial assessment or intervention based on the patient’s condition.
 Diagnosis and Identification of Problems: After collecting data, nurses must analyze
the information to identify problems or risks to the patient. This could involve recognizing
signs of deterioration, identifying potential complications, or diagnosing new conditions.
In the NCLEX, you may encounter questions that challenge you to identify problems
based on the data provided. A typical example would be a question about a patient showing
signs of shock or hypoxia. You must identify the correct clinical issue and prioritize
treatment interventions, making sure to focus on the patient’s immediate needs.
 Planning: Once problems have been identified, nurses must plan interventions based on
the most appropriate evidence-based practices. The NCLEX tests candidates on their
ability to prioritize interventions, delegate tasks, and develop care plans that address patient
needs. This is where clinical judgment and prioritization come into play. For instance, a
question may present a situation where you need to prioritize between two patients—one
with chest pain and the other with a fever. You must use clinical judgment to assess which
patient requires immediate attention.
 Implementation: Implementation involves taking action to address the identified
problems and needs. Clinical judgment is required to execute interventions safely and
effectively. The NCLEX focuses on your ability to implement evidence-based nursing
interventions, whether that involves administering medications, providing wound care, or
coordinating care with other healthcare providers. In the exam, you might be asked about
the best intervention for a patient with acute pain or how to manage a post-operative
patient’s recovery. The goal is to determine your understanding of appropriate actions
based on the patient’s status.
  Evaluation: After interventions have been implemented, nurses must evaluate the
outcomes to determine if the care plan was effective. In the NCLEX, you will encounter
questions that assess your ability to evaluate whether your chosen interventions were
successful and to adjust the plan of care if necessary.
Evaluation in NCLEX questions often comes in the form of follow-up questions. For example,
after implementing an intervention, you may be asked to assess the results or decide the next steps
based on the patient’s response.
Clinical Judgment in NCLEX Question Types
The NCLEX uses a range of question formats to evaluate clinical judgment skills. Here are a few
key types of questions designed to test clinical judgment:

 Case Studies: These questions typically present a detailed patient scenario with various
medical facts, symptoms, and lab results. You must apply clinical judgment to analyze the
information and decide the next best action. Case study questions assess your ability to
synthesize complex data and make decisions that ensure patient safety and well-being.
 Select-All-That-Apply (SATA): These questions test your ability to consider multiple
factors and make judgments based on a range of potential solutions. SATA questions
challenge you to think critically about multiple possible interventions and select all the
correct ones.
 Priority Questions: These questions assess your ability to prioritize care. You may be
given a list of tasks and need to determine which should be performed first. These
questions test your ability to apply clinical judgment to situations where multiple issues
must be addressed, but only one or two are truly urgent.
 Scenario-Based Multiple-Choice: These questions often ask you to assess a clinical
situation and make a decision based on your judgment. They may involve choosing the
most appropriate nursing intervention or identifying the most critical piece of information
that would affect patient care.
Critical Thinking in Clinical Judgment
Critical thinking is integral to clinical judgment and is one of the central competencies that the
NCLEX tests. Critical thinking involves analyzing, evaluating, and synthesizing information,
considering different possibilities, and making well-informed decisions. Nurses must be able to
use critical thinking to make judgments about patient care that reflect sound clinical knowledge,
patient safety, and ethical practice.
NCLEX questions often present complex situations where you must determine the most
appropriate course of action. Your ability to analyze the facts, consider the patient’s history and
clinical presentation, and apply best practices will determine your success in these questions. The
key to answering clinical judgment questions is not just recognizing correct information, but also
evaluating the scenario to select the best possible nursing response.
Clinical Judgment and Patient Safety
Ultimately, the clinical judgment aspect of the NCLEX is designed to ensure that nurses can
prioritize patient safety. This focus on patient safety is emphasized throughout the exam, with
many questions assessing your ability to recognize when a situation is deteriorating or when there
is a risk of harm to the patient.
In clinical judgment questions, you may need to identify red flags that indicate a patient is at risk
for complications. For example, questions might ask you to recognize the signs of sepsis,
hypovolemic shock, or respiratory distress. The ability to identify these risks and respond
appropriately is a crucial skill that the NCLEX tests.
Preparing for the Clinical Judgment Focus
To prepare for the clinical judgment focus of the NCLEX, you should:

 Practice Critical Thinking: Engage in activities that challenge you to think critically.
Analyze case studies, review clinical scenarios, and simulate real-life patient care situations.
 Study Prioritization: Many NCLEX questions will test your ability to prioritize care.
Work through practice questions that require you to decide which patient needs care first
or which intervention is most urgent.
 Understand Evidence-Based Practices: The NCLEX will require you to make decisions
based on best practices. Familiarize yourself with current evidence-based nursing
interventions and guidelines for patient care.
 Work on Delegation and Communication: Effective delegation and communication
with your healthcare team are essential for patient safety. Prepare for questions that assess
your ability to delegate tasks appropriately and communicate effectively in team settings.
 Review Your Knowledge: Clinical judgment is closely tied to your overall nursing
knowledge. Make sure you have a solid understanding of key nursing concepts,
pharmacology, physiology, and patient care techniques.
 Chapter 2: Key Areas Tested in
the NCLEX-RN
2.1 NCLEX-RN Test Plan Breakdown: Domains and Categories
The NCLEX-RN exam is a comprehensive test designed to assess a nursing candidate's ability to
provide safe, effective, and high-quality care in various clinical settings. The test is divided into
several key domains, each representing a fundamental aspect of nursing practice. Understanding
the structure and content breakdown of these domains is essential for effective preparation, as it
helps you focus your study efforts on the areas that are most critical to your success.
Below is an outline of the NCLEX-RN Test Plan based on the National Council of State
Boards of Nursing (NCSBN). The plan organizes the test into four major categories: Safe and
Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity,
and Physiological Integrity. Each category is further subdivided into specific topics, with
weighted percentages that indicate how much each section contributes to the overall exam.
1. Safe and Effective Care Environment (25%-37%)
This broad category focuses on ensuring that nurses can provide safe and effective care in various
clinical environments. It tests the ability to prioritize care, delegate tasks appropriately, and
safeguard both patient and healthcare provider well-being. Nurses must be able to manage patient
care effectively, communicate with the healthcare team, and handle various safety concerns in
clinical settings.
a. Management of Care (15%-21%)
This domain assesses a nurse's ability to manage patient care in real-world situations. It includes
prioritization, delegation, and coordination of care. Nurses must demonstrate skills in making
decisions about patient needs and ensuring that the healthcare team functions effectively.
Questions related to management of care will evaluate your ability to act as a patient advocate,
coordinate care, and effectively use resources.
Key Areas Tested:

 Prioritization: Knowing how to assess and prioritize patient needs is essential. You will
encounter questions where you must determine which patient requires immediate attention
and which tasks should be delegated to other team members.
  Delegation: Nurses often have to delegate tasks to others in the healthcare team.
Understanding who is qualified to perform specific tasks is critical, especially in high-
pressure scenarios.
 Patient Advocacy: Nurses must advocate for the best interests of their patients, ensuring
they receive safe, competent care while respecting their rights and preferences.
b. Safety and Infection Control (10%-16%)
Safety and infection control focus on the nurse’s ability to ensure both patient and provider safety
in healthcare settings. This includes infection prevention practices, correct medication
administration, and emergency response protocols.
Key Areas Tested:

 Infection Control: Nurses must prevent the spread of infections through proper hand
hygiene, sterilization techniques, and the use of personal protective equipment (PPE).
You’ll be asked to identify procedures that prevent or control infections in various
healthcare settings.
 Patient Safety: This includes medication safety, equipment safety, and protecting patients
from harm during care. The NCLEX will assess your ability to recognize safety hazards
and implement safety protocols to avoid errors.
2. Health Promotion and Maintenance (6%-12%)
This section covers the nurse’s role in promoting and maintaining health through education,
prevention, and early detection of health problems. Nurses are expected to provide patient
education on healthy lifestyle practices, disease prevention, and regular screenings.
Key Areas Tested:

 Health Education: Nurses are responsible for educating patients and their families on
various health topics such as diet, exercise, stress management, and preventing chronic
conditions. The NCLEX will test your ability to deliver clear, effective health education.
 Disease Prevention: Early detection of diseases and risk factors is crucial for improving
patient outcomes. Questions in this section will cover the nurse’s role in preventive care,
including immunization schedules, cancer screenings, and chronic disease management.
3. Psychosocial Integrity (6%-12%)
The Psychosocial Integrity category assesses your ability to provide emotional and mental support
to patients and their families. This section emphasizes the importance of understanding mental
health disorders, coping mechanisms, and supporting patients through life changes or stressful
situations.
Key Areas Tested:

 Mental Health: Nurses must be able to recognize common psychiatric disorders,

including anxiety, depression, schizophrenia, and bipolar disorder. You’ll need to
understand how to assess, manage, and support patients with these conditions.
 Coping Mechanisms: Nurses are tasked with helping patients cope with stress, illness,
and emotional crises. The NCLEX will test your understanding of therapeutic
communication and techniques for managing patient stress and anxiety.
 End-of-Life Care: The ability to provide compassionate care to patients and families
during end-of-life care is critical. Questions may involve assessing the needs of terminally
ill patients and their families, as well as supporting the emotional aspects of the dying
process.
4. Physiological Integrity (41%-59%)
This section focuses on the nurse’s ability to manage patients’ physiological needs, addressing
conditions such as trauma, infection, chronic illness, and acute emergencies. It tests your
knowledge of the body's physiological processes and your ability to manage patient conditions
that affect those processes.
a. Basic Care and Comfort (6%-12%)
This subcategory assesses your ability to provide basic care, comfort, and assistance with activities
of daily living (ADLs). This includes pain management, assisting with mobility, and providing
emotional support to patients.
Key Areas Tested:

 Assisting with ADLs: Basic tasks such as bathing, dressing, feeding, and assisting with
mobility are essential for patient well-being. The NCLEX will test your ability to provide
these services with attention to patient dignity and safety.
 Pain Management: Nurses are expected to manage pain through a variety of methods,
including both pharmacological and non-pharmacological interventions. The NCLEX will
test your ability to select appropriate pain management strategies for patients.
b. Pharmacological and Parenteral Therapies (13%-19%)
This domain assesses your knowledge of medications, their administration, and potential side
effects and interactions. It also covers IV therapy, injections, and other parenteral routes of
administration.
Key Areas Tested:

 Drug Classifications: You must be familiar with various classes of medications, including
antibiotics, analgesics, antihypertensives, and more. The NCLEX tests your knowledge of
these drug categories, their uses, and potential adverse effects.
 Medication Administration: Questions will focus on safe medication administration,
including dosage calculations, drug interactions, and the proper administration of IV fluids,
injections, and oral medications.
 Parenteral Therapy: Nurses must administer medications through various parenteral
routes, such as intramuscular (IM), subcutaneous (SC), and intravenous (IV). You will be
tested on your ability to safely handle and administer these medications.
c. Reduction of Risk Potential (9%-15%)
This section focuses on identifying potential risks to patient health and preventing complications.
Nurses must be able to assess patients’ conditions, recognize early signs of deterioration, and take
preventive measures.
Key Areas Tested:

 Risk Assessment: Nurses are expected to identify and assess risk factors for
complications, such as falls, infections, and heart attacks. The NCLEX will test your ability
to identify these risks and implement measures to reduce their impact.
 Preventive Care: This includes preventive strategies, such as lifestyle changes, health
screenings, and monitoring for signs of complications in chronic conditions.
 Monitoring for Deterioration: The NCLEX tests your ability to identify early signs of
clinical deterioration, such as abnormal vital signs or changes in mental status, and respond
with appropriate interventions.
d. Physiological Adaptation (11%-17%)
This domain tests your ability to manage patients who are experiencing acute or chronic
physiological changes. It includes managing disorders related to the cardiovascular, respiratory,
endocrine, and other systems.
Key Areas Tested:
  Acute Conditions: Nurses must manage patients experiencing acute conditions like
shock, respiratory failure, or trauma. The NCLEX will assess your ability to stabilize
patients in crisis and prevent further complications.
 Chronic Disease Management: Nurses are responsible for helping patients with chronic
conditions manage their symptoms and maintain quality of life. The exam will test your
knowledge of managing conditions like diabetes, hypertension, and chronic respiratory
diseases.
 Fluid and Electrolyte Balance: Maintaining the proper balance of fluids and electrolytes
is vital in many conditions. The NCLEX will assess your ability to recognize and correct
imbalances, particularly in critical care settings.

2.2 Weighting of Major NCLEX Topics

The NCLEX exam tends to revisit certain topics repeatedly because they are essential to providing
safe and effective care. These topics often include “must-know” signs and symptoms, nursing
interventions, side effects, and medications. In addition to offering a broad understanding of
clinical care, the NCLEX places a strong emphasis on patient safety, so you’ll need to master
both the theory and the practical application of these concepts.
By focusing on high-yield topics, you can strengthen your preparation and channel your study
efforts toward areas that are most commonly tested.
1. Labs
Understanding lab values and what they represent in terms of patient care is a key area of focus
for the NCLEX. Knowing normal ranges, interpreting abnormal results, and recognizing what
they imply for patient care is critical for making timely and safe decisions. Below are some of the
common lab values that are often tested on the NCLEX:
Potassium: 3.5-5.0 mEq/L
Sodium: 135-145 mEq/L
Calcium: 9-11 mg/dL
Chloride: 95-105 mEq/L
Magnesium: 1.5-2.5 mg/dL
BUN (Blood Urea Nitrogen): 7-20 mg/dL
Creatinine: 0.6-1.2 mg/dL
RBCs: 4.5-5.5 x10⁶ /µL
WBCs: 4,500-11,000 /µL
Platelets: 150,000-450,000 /µL
aPTT: 30-40 secs (without heparin); 47-70 secs (with heparin)
INR: < 1 sec (without warfarin); 2-3 secs (with warfarin)
For example, potassium is crucial for cardiac function, and a level above 5.0 mEq/L can lead to
life-threatening arrhythmias. Similarly, elevated BUN and creatinine levels indicate impaired
kidney function. The NCLEX may test your ability to correlate abnormal lab results with
appropriate nursing interventions. For instance, if a patient’s potassium level is critically high, the
nurse needs to anticipate treatments such as potassium-lowering medications and continuous
monitoring of the patient’s heart rhythm.
2. Neuro
The neurological system plays a significant role in patient care, particularly when it comes to brain
injuries, increased intracranial pressure (ICP), and neurological assessments. For instance,
understanding the signs of Cushing’s triad—a sign of increasing ICP (elevated systolic BP,
bradycardia, and irregular breathing patterns)—is vital for identifying life-threatening conditions.
Normal ICP: 10-15 mmHg
Cushing’s Triad: Increased systolic BP, bradycardia, irregular breathing
Glasgow Coma Scale: (Score of 15 is best)
A scenario might describe a patient with signs of increased ICP, and you’d be expected to
recognize the need for immediate intervention, such as reducing ICP or managing the underlying
cause. Questions may also include Glasgow Coma Scale (GCS) scoring to assess a patient’s level
of consciousness. Nurses must be prepared to act swiftly based on changes in a patient’s neuro
status, which the NCLEX frequently tests.
3. Respiratory
The respiratory system is another area that is frequently tested. Conditions like COPD (Chronic
Obstructive Pulmonary Disease), asthma, and pneumonia often appear in NCLEX
questions. Understanding the differences between emphysema and chronic bronchitis within
the COPD umbrella, recognizing signs of respiratory distress, and applying interventions like
incentive spirometry are essential for the exam.
COPD Types:
Emphysema (Pink Puffers): Difficulty exhaling, barrel chest
Chronic Bronchitis (Blue Bloaters): Productive cough, cyanosis
You should be able to identify which treatments are appropriate for each condition. For example,
emphysema patients benefit from pursed-lip breathing to help exhale carbon dioxide. Similarly,
incentive spirometers are used postoperatively to prevent atelectasis, and understanding the
technique for their use is critical. The exam may ask about proper patient education related to
COPD, including breathing techniques and medications (e.g., bronchodilators like albuterol).
The NCLEX will also test you on acute respiratory problems, such as pneumonia or
pulmonary embolism, where oxygen therapy and antibiotics might be prescribed. The exam
expects nurses to prioritize oxygenation in a crisis and correctly administer treatments.
4. Cardiac
Cardiac care is a cornerstone of the NCLEX, with a focus on conditions like heart failure,
myocardial infarction (MI), arrhythmias, and cardiogenic shock. Knowledge of EKG
changes and recognizing signs of heart failure (left vs. right-sided) is vital.
Cardiac Conditions:
Heart Failure (Left vs. Right-Sided): Left-sided failure causes pulmonary congestion (crackles,
dyspnea), while right-sided failure leads to systemic symptoms (edema, ascites).
Digoxin Toxicity: Watch for vision changes or "halos" around lights.
A question might present a patient with chest pain, shortness of breath, and ST-segment
elevation on an EKG—these symptoms would require immediate intervention as they suggest
acute MI. Likewise, digoxin toxicity can lead to bradycardia and should be managed with
specific interventions, such as digoxin level checks and possibly administering Digibind if the
toxicity is severe.
Questions may also include antihypertensive medications like ACE inhibitors and their
potential side effects (e.g., dry cough or hyperkalemia). NCLEX will test your ability to identify
these side effects and know the appropriate nursing actions, such as holding the medication and
notifying the healthcare provider.
5. GI and Renal
Both the gastrointestinal (GI) and renal systems are critical areas on the NCLEX. Conditions
like appendicitis, pancreatitis, renal failure, and dialysis often appear in exam scenarios. In
particular, knowing the differences between acute kidney injury (AKI) and chronic kidney
disease (CKD) is essential for providing effective care.
GI Conditions:
Appendicitis: Rebound tenderness at McBurney’s point, McBurney’s sign
Pancreatitis: Cullen’s sign, Grey Turner sign
For appendicitis, knowing when to recognize it and the appropriate surgical intervention
(appendectomy) is key. In pancreatitis, recognizing Cullen’s sign and Grey Turner sign can
indicate severe bleeding, requiring urgent attention. The NCLEX also tests your understanding
of NG tube management and potential complications (e.g., nasogastric tube placement and
correct aspiration techniques).
The renal system on the NCLEX focuses on AKI vs. CKD, with a heavy emphasis on lab values
like creatinine, BUN, and potassium levels. The exam might test your ability to differentiate
between these conditions and respond appropriately, whether by dialysis care, managing
electrolyte imbalances, or patient education for UTI prevention or dialysis access site care.
6. Mental Health
Mental health and psychosocial topics are integral to patient care and thus appear prominently in
the NCLEX. Common mental health conditions, including bipolar disorder, depression, and
schizophrenia, are frequently tested.
Mental Health Topics:
Bipolar Disorder (Manic Phase): Assessing risk for self-harm, understanding the importance
of hydration and nutrition during mania
Dementia vs. Delirium: Differentiating these two cognitive disorders is key, as management
strategies differ significantly.
Therapeutic communication and safety precautions for patients with mental health disorders are
frequent NCLEX themes. For example, manic episodes require specific strategies like
providing small, high-calorie snacks and ensuring the patient remains hydrated during the
manic phase. Dementia vs. delirium questions will test your ability to identify which condition
is acute and reversible versus chronic and progressive, requiring tailored care strategies.
The NCLEX also integrates medications used in mental health care, such as MAOIs
(Monoamine Oxidase Inhibitors), which require careful management of dietary restrictions
due to potential hypertensive crises.
2.3 Critical Thinking and Question Analysis
Critical thinking on the NCLEX refers to the ability to engage with questions in a way that goes
beyond recall. While knowledge of facts is necessary, you must also demonstrate your ability to
make decisions that are grounded in best practices and patient safety.
On the exam, this means that you will often need to:
Analyze clinical scenarios: Recognize key information in patient cases and use it to determine
the most appropriate nursing interventions.
Prioritize care: In scenarios where multiple actions could be taken, determine which is most
urgent, necessary, or beneficial for the patient’s well-being.
Apply nursing knowledge: Use your understanding of pathophysiology, pharmacology, and
nursing interventions to address the needs of the patient in a logical manner.
Critical thinking is not limited to just answering questions; it involves thinking about the rationale
behind the answer and considering multiple possibilities, even when one answer seems right. This
mindset is essential for success on the NCLEX.
Question Breakdown: Identifying Key Components
To foster critical thinking during the exam, it's essential to break down each question carefully.
NCLEX questions are often structured to test more than one concept or knowledge area at a
time, requiring the test-taker to recognize several components in each question.
Key steps to analyze a question include:

 Identify the Key Words: In every question, there are certain key terms or concepts that
give you direction. For example, if the question involves a patient with respiratory distress,
your key focus will be on interventions related to the airway and breathing.
 Understand the Stem: The stem is the core of the question, and understanding it is
critical. Read the scenario carefully, noting any details about the patient's condition, age,
medications, and other relevant factors. Don’t rush through the stem – it is often where
you’ll find the critical clues that will guide your decision-making.
 Analyze the Answer Choices: After reading the question, review all the answer choices
carefully. The NCLEX often includes distractors—answers that might seem reasonable
but are ultimately incorrect. Use your critical thinking skills to narrow down choices based
on patient safety, evidence-based practice, and established protocols.
 Consider the Rationale: For each choice, think about why it is right or wrong. What is
the rationale behind each answer? Is the answer supported by clinical guidelines or
 research? This helps develop your clinical judgment and reasoning skills, which are essential
for the exam.

Types of NCLEX Questions and How to Tackle Them

The NCLEX-RN exam includes a variety of question formats, and each one requires its own
approach. In this section, we’ll explore four major types of questions that you are likely to
encounter: Multiple-Choice Questions (MCQs), Select-All-That-Apply (SATA), Case
Studies, and Priority Questions. Understanding how to analyze each question type is crucial for
successful test-taking.
3.1 Multiple-Choice Questions (MCQs)
MCQs are the most common format and test your ability to recall facts, understand principles,
and apply them in clinical situations. They provide a question followed by several answer choices,
and your job is to pick the most appropriate answer.
How to Approach MCQs:
Focus on the clinical scenario: Look for information in the stem that relates to patient safety,
nursing interventions, or best practices.
Use the process of elimination: If you're unsure, rule out the obviously incorrect answers first.
This will increase your chances of selecting the right answer.
Think about priorities: The NCLEX prioritizes safe and effective patient care, so focus on
answers that align with safety protocols and nursing best practices.
Example MCQ:
What is the nurse’s priority action for a patient who has just been admitted with chest pain and diaphoresis?
A) Obtain a 12-lead ECG
B) Administer nitroglycerin as ordered
C) Place the patient on oxygen
D) Assess the patient's medical history
Answer: C) Place the patient on oxygen
This is the correct answer. In a patient with chest pain and diaphoresis, oxygen administration is
the priority to ensure that the heart is receiving adequate oxygen. The other actions are important
but secondary to oxygenation.
3.2 Select-All-That-Apply (SATA)
SATA questions require you to select all correct answers from a list of choices. They can be tricky
because multiple answers may seem plausible. These questions assess your ability to identify
several factors or interventions that are appropriate in a clinical scenario.
How to Approach SATA:
Check each option independently: Unlike MCQs where one answer is correct, SATA questions
may have several correct answers. Evaluate each option individually before selecting it.
Use your knowledge of nursing best practices: The correct answers usually align with
evidence-based nursing interventions and guidelines.
Focus on patient safety: When in doubt, select answers that prioritize patient safety.
Example SATA:
Which of the following are common interventions for a patient with a diagnosis of heart failure?
(Select all that apply)
A) Monitor daily weight
B) Administer prescribed diuretics
C) Encourage high-sodium foods
D) Restrict fluid intake
E) Perform deep breathing exercises
Answer: A) Monitor daily weight
B) Administer prescribed diuretics
D) Restrict fluid intake
These are the correct interventions for heart failure management, aimed at reducing fluid
overload. Encouraging high-sodium foods is incorrect, and deep breathing exercises are not a
primary intervention for heart failure.
3.3 Case Studies
Case Studies present detailed clinical scenarios that require you to apply your knowledge of
nursing theory and practice. They often test your ability to assess the patient, prioritize care, and
make clinical decisions based on the scenario.
How to Approach Case Studies:
Analyze the clinical situation: Read the case carefully. Identify key data, such as the patient's
condition, vital signs, and lab results.
Determine the most urgent needs: Case studies often present a series of actions. You must
determine which action should be taken first, based on the patient’s most urgent needs.
Use your critical thinking skills: Think about what you know from nursing theory and clinical
practice. What interventions are most appropriate? What will likely lead to the best patient
outcomes?
Example Case Study:
A 68-year-old male patient is admitted with pneumonia. The patient is confused, has a fever of
101.2°F, and his vital signs are unstable. His oxygen saturation is 88%. What should be the nurse’s
priority action?
A) Administer antibiotics as ordered
B) Initiate oxygen therapy
C) Monitor the patient’s temperature
D) Begin a sputum culture
Answer: B) Initiate oxygen therapy
This is the correct choice. The patient’s oxygen saturation is low, indicating a need for immediate
intervention to improve oxygenation. Administering oxygen takes priority to address respiratory
distress.
3.4 Priority Questions
Priority questions ask you to identify the most urgent action in a clinical scenario. These questions
assess your ability to determine what needs to be addressed first, given the severity of the situation.
How to Approach Priority Questions:
Identify the most critical need: When multiple problems are presented, determine which one
is life-threatening or could result in serious harm if not addressed immediately.
Use Maslow’s Hierarchy of Needs: Prioritize physiological needs (airway, breathing,
circulation) over psychological or lower-level needs.
Consider patient safety: Always choose the action that maintains or improves patient safety
first.
Example Priority Question:
The nurse is caring for a patient who has just been admitted with a stroke. Which of the following
interventions should the nurse implement first?
A) Assess the patient’s neurological status
B) Initiate IV access
C) Administer thrombolytics if prescribed
D) Monitor vital signs closely
Answer: A) Assess the patient’s neurological status
This is the priority intervention because a stroke requires immediate assessment to determine the
extent of neurological impairment. Other interventions follow, but initial assessment is always the
first step.
Part 2: Smart Study Hacks and
Test-Taking Strategies
 Chapter 3: Effective Study
Strategies
3.1 How to Organize Your Study Time for Maximum Impact
When preparing for the NCLEX-RN exam, time management plays a crucial role in ensuring that
you study effectively and avoid unnecessary stress. Many test-takers find themselves overwhelmed
by the sheer volume of content, the variety of question formats, and the pressure of preparing for
the exam within a set timeframe. The key to passing the NCLEX with confidence is not only
about how much time you spend studying but also how you structure your study time to optimize
learning and retention.
Here are some practical steps and strategies for organizing your study time in a way that aligns
with your goals, maximizes your productivity, and improves your chances of success on the
NCLEX.
1. Establish Your Study Schedule
One of the most effective ways to organize your study time is by setting a clear, structured study
schedule. Having a study plan reduces anxiety and ensures that you cover all the critical areas
before exam day.
Create a Weekly Study Plan:

 Assess Your Strengths and Weaknesses: Start by identifying the areas in which you are
confident and the topics where you may need more review. This will help you prioritize
subjects based on their complexity and your familiarity with them.
 Set Specific Goals: For each study session, set a clear goal for what you hope to achieve,
such as reviewing a specific chapter, answering a set number of practice questions, or
focusing on one subject area (e.g., cardiovascular or pharmacology).
 Balance Your Schedule: Study across different domains to prevent burnout. For
example, mix heavy subjects like pharmacology with lighter topics like health promotion
and maintenance to keep your brain engaged without overwhelming it.
 Include Breaks and Rest Days: Include at least one or two rest days each week to
recharge and avoid study fatigue. Additionally, shorter breaks during study sessions (such
as a 5-10 minute break every 45-60 minutes) can help maintain focus.
2. Maximize Your Focus During Study Sessions
You can structure your study time effectively by incorporating proven techniques that promote
focus and active engagement with the material. Here are some tips to ensure that your study
sessions are as productive as possible.

 Use the Pomodoro Technique: This time management technique involves studying in
blocks of time (typically 25 minutes), followed by a short 5-minute break. After completing
four blocks, take a longer break (15-30 minutes). This method helps prevent burnout and
allows you to sustain your focus throughout the study session. For example, you might
study pharmacology for 25 minutes, then take a 5-minute break to stretch or hydrate before
diving back into another session.
 Time Management Tools: Use timers, apps, or digital tools to track your study blocks
and ensure you stay on track. Apps like Forest or Be Focused allow you to set study
intervals and avoid distractions during each session.
 Study in Intervals: Studies have shown that information is retained better when studied
in shorter, spaced-out intervals rather than in marathon sessions. This strategy, known as
spaced repetition, ensures that you revisit concepts at strategic intervals to move
information from short-term to long-term memory.
 Focus on Active Learning: Engaging actively with the material helps reinforce your
learning. As you study, don’t just passively read through notes or textbooks. Instead, try to
summarize the content in your own words, teach it to someone else, or draw diagrams that
represent the relationships between concepts. This technique improves comprehension
and retention.
3. Prioritize High-Yield Topics
In your preparation, focus on the areas that are most likely to appear on the NCLEX. High-yield
topics are those that are frequently tested and that form the core of the nursing knowledge
required for safe, effective practice.
Key Areas to Focus on:

 Management of Care: Prioritization, delegation, and coordination of care are essential

topics. Understand the principles behind delegating tasks to unlicensed assistive personnel
(UAP) and recognizing situations that require the nurse’s direct involvement.
 Safety and Infection Control: Infection control measures, such as standard precautions
and isolation procedures, are often tested. Be sure to review these concepts thoroughly.
 Pharmacology and Parenteral Therapies: Medications, their side effects, and proper
dosing and administration are heavily tested. Focus on common drug classes, their
mechanisms of action, and adverse reactions.
  Health Promotion and Maintenance: Understand the principles behind disease
prevention, health education, and screenings, particularly for chronic conditions like
hypertension and diabetes.
Be Strategic with Your Time Allocation:

 Focus on High-Volume Areas: Allocate more study time to subjects with a higher
volume of questions on the NCLEX, like pharmacology, management of care, and
physiological adaptation.
 Use Practice Questions: Regularly test yourself with NCLEX-style practice questions,
especially those that cover high-yield topics. You can find these practice questions within
this book, so be sure to use them to your advantage. Practicing with questions designed to
simulate the real exam will help reinforce your knowledge and improve your ability to
recognize the correct answer under exam conditions.
4. Simulate the NCLEX Experience
One of the best ways to prepare for the NCLEX is by simulating the exam experience. This not
only helps you become accustomed to the format but also trains you to pace yourself during the
exam.

 Set a Timer for Practice Tests: During practice exams, set a timer to replicate the actual
test duration. Completing 75-150 questions in one sitting will help you get used to the
pressure of completing the test within the allotted time frame.
 Track Your Progress: Regularly evaluate your performance on practice tests. Identify
areas where you consistently struggle and allocate additional time to review these topics.
 Replicate Exam Conditions: Find a quiet, distraction-free environment similar to the
testing center. Treat practice sessions as if they are the real exam to help reduce test anxiety.
5. Be Flexible and Adapt Your Study Plan
Flexibility is key in your NCLEX study plan. Life happens, and there may be days when your
study schedule is interrupted or when you don’t feel like studying. The important thing is to adapt
and stay on course.

 Adjust as Needed: If a particular subject is taking longer than expected, or if you’re

struggling to retain a specific concept, don’t be afraid to adjust your schedule. Try not to
stress over minor deviations from your original plan.
  Prioritize Mental Health: Stress and burnout can hinder your ability to retain
information. If you feel overwhelmed, take a break, go for a walk, or relax. Staying healthy
and focused is more important than sticking rigidly to a schedule.
6. Track Your Performance and Adjust
Regularly assess your progress and adjust your study techniques based on your performance. Many
NCLEX prep resources offer self-assessment tools that can help identify weaknesses and gauge
your readiness.

 Use the Practice Questions in This Book: Regularly test yourself with the NCLEX-
style practice questions included in this book. These questions are designed to mirror the
format of the exam, providing you with a realistic representation of what you’ll encounter
on test day. Review both correct and incorrect answers and analyze why the correct
answers are right. This will help you hone your critical thinking skills.
 Assess Your Readiness: As you near the exam date, take full-length practice exams that
simulate the actual test environment. This will help you identify any last-minute gaps in
your knowledge and allow you to fine-tune your approach.
By structuring your study time strategically and focusing on the right areas, you can efficiently
prepare for the NCLEX and increase your chances of passing on the first attempt. Stay consistent,
stay focused, and trust the process—you’re capable of achieving your goal of becoming a licensed
nurse!

3.2 Using Spaced Repetition for Long-Term Retention

Spaced repetition is a highly effective learning technique that has been proven to significantly
enhance long-term retention of information. Unlike cramming, which leads to quick forgetting,
spaced repetition helps to move information from short-term to long-term memory by revisiting
and reinforcing concepts at intervals. This method capitalizes on the brain's natural ability to retain
information more efficiently when exposure to that information is spaced out over time, rather
than being bunched together in one or two study sessions.
In the context of NCLEX-RN exam preparation, spaced repetition can be particularly beneficial.
The vast amount of material covered in the exam can feel overwhelming, but by organizing your
study plan to incorporate spaced repetition, you can ensure that you're not only familiarizing
yourself with the material but also retaining and recalling it when it matters most.
To implement spaced repetition effectively, you need to use a strategy that schedules your reviews
at the optimal intervals. There are different methods to do this, including digital tools and physical
flashcards, which can help you reinforce your knowledge.
Create a Study Schedule
Begin by breaking down your NCLEX material into smaller chunks. This might include reviewing
specific topics like pharmacology, cardiac arrhythmias, or infection control. Once you have
broken the material down, schedule regular study sessions with spaced repetition intervals.
Active Recall and Spaced Repetition
Active recall involves testing yourself on what you’ve just studied, rather than passively reviewing
notes. Combining active recall with spaced repetition is a powerful strategy. Once you've learned
a topic, test yourself on it after a short period, then extend the time between subsequent tests.
This forces your brain to work harder to retrieve the information, which strengthens memory
retention.
For example, when studying pharmacology, you can ask yourself questions like:
"What are the side effects of ACE inhibitors?"
"What is the mechanism of action of a beta-blocker?"
As you continue to review these questions using spaced repetition, the time between each review
session increases, and the likelihood of remembering the material long-term becomes much
higher.
Spaced Repetition in Practice Questions
One of the most effective ways to implement spaced repetition is through regular practice with
NCLEX-style questions. This allows you to not only test your knowledge but also familiarize
yourself with the exam format.
Using Practice Questions for Spaced Repetition:

 Start with Initial Reviews: Begin by answering questions from each subject area, such as
cardiovascular health, respiratory conditions, or pharmacology. Once you get the answers,
mark the ones you got wrong and review them.
 Review Incorrect Answers: After completing a practice test, review the incorrect answers
immediately, then set a reminder to review those questions again the next day. Over time,
extend the interval to a few days or a week. This reinforces your learning and helps you
retain the material.
You will find that repeated exposure to the same questions helps to strengthen your memory. By
integrating spaced repetition into your study schedule with the practice questions from this book,
you’ll increase your confidence and improve recall when it matters most on exam day.
Spaced Repetition Charts: Some students like to use physical charts to mark when they last
reviewed a certain topic and when the next review is scheduled. This can help you stay on track
and ensure you don’t neglect any areas.
The 80/20 Rule (Pareto Principle)
A key element in preparing for the NCLEX is to focus on the most important and frequently
tested topics. The 80/20 rule suggests that roughly 80% of the exam will be based on 20% of the
material, which are the high-yield areas that tend to show up most often. Spaced repetition can
help you focus on these critical topics while ensuring you don’t spend too much time on less
relevant material.
The Science Behind Spaced Repetition
Research in cognitive psychology has demonstrated that spaced repetition enhances the brain’s
ability to transfer information from short-term to long-term memory. When we learn new
information, our brains make neural connections, but without reinforcing those connections
through repetition, they fade over time. Spaced repetition provides the necessary intervals to
solidify these connections, ensuring you can recall the information when needed.
How to Structure Your Spaced Repetition for NCLEX
Here’s how you can structure your spaced repetition schedule for studying for the NCLEX:
Day 1: Study a new topic (e.g., infection control) and complete a set of practice questions. After
finishing, review the key points and test yourself on them.
Day 2: Review the topic from Day 1 again, paying particular attention to the questions you got
wrong in the previous session.
Day 3: Revisit the topic for a short review, then take a practice test. The time interval between
each review session should gradually lengthen.
Day 7: A week after you first studied the topic, test yourself again to reinforce your learning.
Day 14: Continue this cycle, with longer intervals for review.
The goal of spaced repetition is to maximize long-term retention, so be sure to incorporate it into
your routine and use it as an active tool to reinforce the material.

3.3 The Pomodoro Technique for Focused Study Sessions

The Pomodoro Technique is a time management method that is designed to maximize
productivity and minimize burnout, making it a highly effective tool for NCLEX preparation. The
method is simple: study in short, intense bursts followed by scheduled breaks. Each study session
lasts for 25 minutes, followed by a 5-minute break. After four 25-minute sessions (known as
Pomodoros), you take a longer break of 15 to 30 minutes. The idea is to give your brain focused,
uninterrupted time to absorb information, while also giving it the regular breaks it needs to stay
sharp and avoid fatigue. This approach is especially effective for preparing for the NCLEX, where
long hours of studying can otherwise lead to exhaustion and decreased focus.
By breaking your study time into manageable chunks, you’re able to stay on track without feeling
overwhelmed. The Pomodoro Technique helps to create a rhythm in your study sessions, making
it easier to stay engaged with the material. It’s particularly useful for studying complex subjects,
like pharmacology, pathophysiology, and medical-surgical nursing, as it allows you to focus on
each topic in depth while maintaining mental clarity.
The Pomodoro Technique is simple to implement and easy to adjust depending on your study
goals. The key is staying consistent with the intervals, taking short breaks to recharge, and using
the longer breaks for mental refreshment. This system is ideal for avoiding burnout while
maintaining high focus and productivity.
To use the Pomodoro Technique effectively in your NCLEX prep, you first need to set clear
study goals. Each Pomodoro session should have a specific purpose—whether it’s reviewing a
particular topic, going over practice questions, or memorizing essential lab values. Start each
Pomodoro by setting your timer for 25 minutes, and then focus exclusively on one task. For
example, you might want to review the signs and symptoms of heart failure, or focus on
understanding the mechanism of action for ACE inhibitors. After the timer goes off, take a 5-
minute break. Use this time to stand up, stretch, grab a drink of water, or engage in something
unrelated to studying. This brief respite will help you avoid mental fatigue and stay focused during
the next Pomodoro.
Once you’ve completed four Pomodoros, it’s time for a longer break. This break should last 15
to 30 minutes. During this time, step away from your study materials. Engage in something that
helps you recharge, like a walk, a light snack, or a chat with a friend. The goal is to give your brain
a longer rest so you’re ready for the next round of focused study. This structured approach to
studying can be particularly useful when reviewing large amounts of information, as it helps
prevent cognitive overload and improves your retention of key concepts.
The Pomodoro Technique is especially useful for NCLEX prep because it allows you to manage
both content review and practice questions in a way that maximizes learning while minimizing
fatigue. For instance, you might spend the first Pomodoro reviewing the pathophysiology of
stroke, and then spend the next Pomodoro practicing NCLEX-style questions on the topic. This
combination of content review and application through questions helps reinforce learning and
aids in long-term retention. Additionally, it encourages you to break complex topics into smaller,
digestible chunks, which is ideal for mastering the vast array of material you’ll encounter on the
NCLEX.
A typical study session might look like this:
Pomodoro 1: Review heart failure and the medications used to treat it. Focus on the mechanisms
of action for ACE inhibitors, beta-blockers, and diuretics.
Pomodoro 2: Take a 5-minute break.
Pomodoro 3: Complete 20 practice questions related to heart failure and its treatments. Analyze
your wrong answers to understand the rationale behind the correct choices.
Pomodoro 4: Take another 5-minute break.
Pomodoro 5: Review lab values associated with heart failure, such as BNP levels and potassium
levels.
Pomodoro 6: Take a 5-minute break.
Pomodoro 7: Complete another set of 20 practice questions related to the cardiovascular system.
Pomodoro 8: Take a longer break (15-30 minutes). Use this time to relax and refresh your mind.
The key to success with the Pomodoro Technique is consistency. The more regularly you
incorporate this study method into your routine, the easier it will be to maintain focus during your
study sessions. Additionally, it helps build mental endurance over time. When you use the
Pomodoro Technique consistently, you’ll become accustomed to working in short, focused
bursts, making it easier to stay engaged even during long study sessions.
One of the benefits of the Pomodoro Technique is that it encourages you to focus on one task at
a time, rather than multitasking. When studying for the NCLEX, multitasking can actually
decrease efficiency and retention. For instance, if you attempt to read about heart failure while
simultaneously completing practice questions on a different subject, you’re less likely to absorb
either topic fully. Instead, the Pomodoro Technique forces you to focus on one subject during
each Pomodoro, allowing you to dig deeper and retain the information more effectively.
You can also tailor the Pomodoro Technique to your individual needs. For example, if you find
that 25 minutes is too short for a specific topic, you can extend the time to 30 or 40 minutes.
Alternatively, if you find that a 5-minute break isn’t long enough to recharge, you can adjust the
length of the break. Some people even extend the Pomodoro length to 45 minutes of study time,
followed by a 10-minute break, depending on their personal focus and energy levels. The flexibility
of the Pomodoro Technique makes it adaptable to different study preferences and schedules.
Pomodoro sessions also work well when combined with other study strategies, such as spaced
repetition and active recall. After completing a Pomodoro session, you can review the material
again later in the day or the following week using spaced repetition to reinforce what you’ve
learned. By integrating multiple study techniques into your Pomodoro sessions, you’re able to
maximize retention and improve your performance on the NCLEX.
Additionally, practicing NCLEX questions regularly during Pomodoro sessions is essential. The
NCLEX exam tests not only your knowledge of nursing concepts but also your ability to apply
that knowledge in real-life clinical scenarios. Therefore, it’s important to balance content review
with practice questions. During Pomodoros dedicated to practicing questions, aim to work
through questions that reflect the format of the actual exam, including multiple-choice, Select-
All-That-Apply (SATA), and case study questions. Analyzing the rationale for both correct and
incorrect answers helps you understand the reasoning behind the content, which improves your
ability to answer questions on the exam.
To make the most of Pomodoro sessions for NCLEX prep, use apps or timers designed to track
your intervals and breaks. Many Pomodoro timers allow you to customize the session length and
break intervals, so you can tailor the technique to your preferences. Some apps also allow you to
track your progress, which can be motivating and help you stay on track with your study goals.
The Pomodoro Technique also promotes mental recovery, which is vital for long-term retention.
NCLEX preparation can be a long and demanding process, and mental exhaustion can lead to
decreased focus and performance. By taking regular breaks, you give your brain the time it needs
to rest, preventing burnout and ensuring that you remain mentally sharp. The Pomodoro
Technique is a sustainable study method that encourages consistency, prevents procrastination,
and helps maintain high levels of productivity throughout your NCLEX preparation.
 Chapter 4: Mastering Test-
Taking Strategies
The NCLEX-RN exam is designed to evaluate your ability to apply your nursing knowledge in a
clinical environment. As daunting as it may seem, one of the key elements to succeeding is
approaching the questions with confidence and a well-prepared mindset. It’s not just about
memorizing facts; it’s about understanding how to apply those facts to real-world nursing
situations. Knowing how to confidently approach each question can significantly improve your
performance on the exam.
First, it is important to recognize the different types of questions on the NCLEX. Multiple-choice
questions are a staple, but they can also include alternate formats, such as Select-All-That-Apply
(SATA), case studies, and ordered response questions. Familiarizing yourself with these various
formats will help you feel more at ease when sitting for the exam. When answering multiple-
choice questions, take a moment to carefully read the entire question, paying attention to
keywords. The NCLEX often uses critical thinking scenarios, and knowing how to dissect them
is vital. Keywords like “priority,” “first,” and “most important” are often used to guide you to the
safest choice.
The NCLEX exam’s primary focus is on patient safety, so whenever you're unsure, think about
what would be the safest course of action for the patient. This focus on safety is an essential
principle to guide your decision-making process. For example, if a patient is experiencing
symptoms such as chest pain, your first response would be to assess vital signs, administer
necessary medication, and make sure that the patient is safe before conducting a more detailed
assessment.
Another critical strategy in confidently approaching the NCLEX is prioritization. Many questions
will ask you to prioritize tasks or interventions, which can be overwhelming if you don’t have a
clear method for decision-making. The safest approach is always to prioritize interventions that
directly affect patient safety. If the question presents you with a set of symptoms or actions to
take, your goal should be to identify which task addresses the immediate risk to the patient’s
health. For instance, if a question involves a patient in respiratory distress, the priority would be
to provide oxygen first before assessing further symptoms or lab results. This is because ensuring
adequate oxygenation is immediately life-saving, while other actions can be done later.
Time management is also a crucial component of approaching NCLEX questions with
confidence. The exam is timed, and many candidates often feel pressured by the clock. To avoid
unnecessary stress, practice pacing yourself during your study sessions. Simulating exam
conditions by setting a timer for each practice question can help you develop a sense of timing
and ensure that you don’t spend too long on any one question. If you come across a question that
stumps you, move on and come back to it later. This will help you avoid spending too much time
on a question and potentially missing out on others. Remember, you can always return to
questions at the end if time allows.
It is also crucial to recognize the difference between thinking you know the answer and knowing
the answer. When you're studying, take the time to review why the correct answer is right and
why the incorrect answers are wrong. This is not just about memorizing facts; it’s about
understanding the rationale behind each decision. The NCLEX often includes questions where
multiple answers seem right, but the key is to pick the answer that is safest and most appropriate
for the specific situation at hand. By thoroughly reviewing the rationale behind each choice, you'll
strengthen your understanding and increase your chances of choosing the correct option under
exam conditions.
Another way to build confidence in answering questions is through consistent practice. The more
questions you answer, the more familiar you’ll become with the types of questions that are likely
to appear on the exam. Use reputable practice resources to simulate exam conditions, and be sure
to review your wrong answers thoroughly. Understanding why an answer is incorrect is just as
important as knowing why the correct answer is right. Make sure to review practice questions
regularly so that you can recognize patterns and be prepared for similar questions during the actual
exam.
When practicing with sample questions, focus on learning from your mistakes. In practice, you
may often make errors, but understanding those mistakes will allow you to avoid repeating them
on the actual exam. The key is to develop a solid understanding of the material and refine your
decision-making process with each practice session. Eventually, you will find that you’re able to
recognize the best course of action for each patient situation presented in the questions.
It’s also important to remain calm and focused during the exam. Test anxiety is common, but it
can cloud your judgment. To combat anxiety, practice deep breathing or other relaxation
techniques before entering the exam room. Remind yourself that you have studied extensively
and that you are well-prepared. The NCLEX is not designed to trick you; it’s a test of your ability
to apply your nursing knowledge in a clinical setting. Trust yourself, and take each question one
step at a time. Staying calm and collected will help you approach the questions with a clear mind
and confidence.
Understanding the structure of the NCLEX is another step toward answering questions
confidently. The test is computer-adaptive, meaning that the difficulty of the questions adjusts as
you progress through the exam based on your answers. This means that as you correctly answer
more questions, the system will provide harder questions to assess your abilities further. On the
other hand, if you get answers wrong, the system will provide easier questions to assess your
baseline level of knowledge. The test is designed to evaluate your competence, so understand that
the changing difficulty is not something to fear. Instead, focus on doing your best with each
question, knowing that your performance is being assessed accurately.
One final strategy to approach the NCLEX with confidence is maintaining a positive mindset.
Instead of focusing on the difficulty of the exam or what you don’t know, remind yourself of
what you do know. Trust in your ability to apply the knowledge you have gained and stay positive
throughout the exam. When you approach the NCLEX with confidence, you’re more likely to
remain focused and calm, which will help you answer questions accurately and efficiently.

Techniques to Minimize Test Anxiety and Improve Focus

Test anxiety is a common challenge for many nursing students when preparing for the NCLEX.
This anxiety can negatively affect focus, decision-making, and overall performance during the
exam. However, several techniques can help manage and reduce anxiety, enabling you to perform
at your best. Implementing these techniques consistently before and during the exam will help
you stay calm, focused, and confident.
1. Deep Breathing and Relaxation Techniques
One of the simplest and most effective ways to reduce anxiety is through controlled breathing.
Deep breathing helps activate the body's parasympathetic nervous system, which promotes
relaxation and counteracts the fight-or-flight response that anxiety triggers. When you feel anxious
during the exam, try the following breathing technique:
Inhale deeply through your nose for a count of 4 seconds.
Hold the breath for 4 seconds.
Exhale slowly through your mouth for a count of 6 seconds.
Pause briefly, then repeat for a few cycles.
This technique slows down your heart rate, clears your mind, and helps lower physical tension,
which will help you regain focus.
2. Visualization: See Yourself Succeeding
Visualization is another powerful technique for reducing test anxiety. Before the exam, spend a
few minutes each day imagining yourself in the testing room, answering questions confidently,
and passing the NCLEX with ease. This technique creates a mental picture of success, which
helps your brain prepare for the real experience by reducing fear and increasing your confidence.
Try to envision yourself remaining calm, answering questions accurately, and feeling satisfied with
your progress.
Visualization activates the brain’s emotional centers, helping to reduce feelings of fear. When you
practice visualization, you create positive associations with the exam, making it easier to stay calm
during the actual test.
3. Establishing a Structured Routine
Having a study plan and a routine reduces uncertainty and the feeling of being overwhelmed. By
creating a consistent study schedule that prioritizes practice questions and NCLEX study material,
you avoid cramming at the last minute, which can exacerbate anxiety. Set aside specific times each
day to study, and be sure to take breaks to refresh your mind.
When preparing for the NCLEX, include practice exams under timed conditions to simulate the
real test environment. This prepares you to deal with pressure and can help to prevent feeling
overwhelmed on exam day. Consistent practice with full-length exams can also help you identify
areas that need improvement, giving you a sense of control over your preparation.
4. Staying Physically Active and Eating Well
Physical activity and proper nutrition play significant roles in managing anxiety. Regular exercise
releases endorphins, chemicals in the brain that promote feelings of well-being. Even a brisk walk
can reduce stress and help you feel calmer. Exercise can also improve your concentration, which
will benefit your focus during study sessions.
Nutrition also impacts your ability to concentrate. Eating foods rich in omega-3 fatty acids, like
fish, can enhance brain function and reduce stress. Avoiding excessive caffeine or sugar before
the exam can prevent jitteriness, which can worsen anxiety. On exam day, ensure you have a
nutritious breakfast that will keep your energy levels stable throughout the test.
5. Time Management: Practice Under Exam Conditions
Effective time management is crucial to overcoming test anxiety. Many students feel stressed
because they fear running out of time on the exam. To counter this, simulate exam conditions by
timing yourself while answering practice questions. Allocate a set amount of time for each
question, then move on if you are unsure of the answer. Practice pacing yourself, as this helps you
develop a rhythm for answering questions efficiently during the actual exam.
6. Mindfulness and Meditation
Mindfulness practices are also beneficial for reducing anxiety. Meditation and mindfulness allow
you to focus on the present moment, which helps prevent your mind from wandering to anxious
thoughts about the exam. By incorporating mindfulness into your daily routine, you can improve
your ability to stay calm and focused during the test. Apps like Headspace and Calm offer guided
meditation exercises specifically designed to reduce stress and enhance focus.

The Importance of Selecting the Safest Option: Prioritization in

NCLEX Questions
The NCLEX exam is designed to assess your ability to apply critical thinking and clinical judgment
in a healthcare setting. One of the most critical skills evaluated in the exam is your ability to
prioritize patient care. In many questions, you will be asked to identify which intervention should
be performed first, and often, several options may seem reasonable. However, selecting the safest
and most appropriate intervention is essential to demonstrate your clinical competence.
1. Understand the Basic Principles of Prioritization
When prioritizing care, always keep patient safety as your top priority. Life-threatening conditions
should always be addressed first, followed by conditions that may lead to complications or further
harm. To help guide your decision-making process, remember the basic principles of
prioritization, which are often referred to as the "ABCs" — airway, breathing, and circulation.
Airway: Ensure that the patient’s airway is clear and unobstructed. If the airway is compromised,
it must be addressed before anything else. For instance, if a patient is choking or in respiratory
distress, your first action should be to ensure their airway is open.
Breathing: If the airway is clear, the next priority is breathing. If the patient is unable to breathe
properly, oxygen should be administered, and respiratory interventions should be initiated.
Circulation: The third priority is circulation. If the patient has an adequate airway and is
breathing, but they are showing signs of poor circulation, such as low blood pressure or
hemorrhage, you must act quickly to restore circulation to avoid shock or organ failure.
2. The Nursing Process: Assessment, Diagnosis, Planning, Implementation, and Evaluation
Prioritization is also closely tied to the nursing process. You must assess the patient’s condition,
identify the most critical issue, and then implement the appropriate interventions based on the
diagnosis. The steps of the nursing process — assessment, diagnosis, planning, implementation,
and evaluation — can guide your prioritization decisions.
For example, consider a patient with chest pain, a history of myocardial infarction, and an elevated
blood pressure. The first step is to assess the patient’s vital signs and pain level. Based on the
findings, you would identify that pain relief and the stabilization of blood pressure are top
priorities. Once those interventions are complete, you would implement further plans for
additional tests or medications.
3. The Urgency of Interventions: Assess, Intervene, Reassess
The NCLEX frequently presents scenarios where you must assess the urgency of an intervention.
While all patient concerns are important, some require immediate action to prevent further harm.
For example, a patient exhibiting signs of shock (hypotension, rapid pulse, pale skin) would
require immediate interventions like administering IV fluids, oxygen, and possibly vasopressors
to restore perfusion to vital organs.
On the other hand, less urgent concerns, such as a patient asking about the effects of a newly
prescribed medication, can be addressed after the more immediate life-threatening concerns are
resolved.
4. Prioritizing Based on Maslow’s Hierarchy of Needs
Another helpful tool for prioritization is Maslow’s Hierarchy of Needs, which is a psychological
theory that organizes human needs into five levels. When prioritizing patient care, focus on
addressing physiological needs first, followed by safety, love and belonging, esteem, and self-
actualization.
For example, consider a patient who is depressed, anxious, and experiencing pain after surgery.
Maslow's Hierarchy suggests addressing the patient's physiological pain and comfort needs first
(level one), followed by addressing the patient's psychological and emotional needs (level two).
Once those needs are met, the focus can shift to addressing the patient’s self-esteem and overall
emotional well-being.
5. Identifying High-Risk and Life-Threatening Conditions
The NCLEX places heavy emphasis on identifying high-risk and life-threatening conditions,
which require immediate attention. These conditions typically involve acute or sudden changes in
a patient’s vital signs, such as:

 Severe bleeding or hemorrhage

 Cardiac arrest
 Respiratory failure or severe distress
 Severe allergic reactions
  Uncontrolled pain
If you encounter a prioritization question involving any of these issues, it’s crucial to select
interventions that address the immediate threat to the patient’s life. For example, if a patient is in
shock, the first action should be to administer IV fluids or blood products as ordered to stabilize
the patient’s circulation.
6. Delegation and Prioritization
Delegation is another crucial aspect of prioritization. In nursing, not every task requires the
attention of a registered nurse (RN). Some tasks can be safely delegated to nursing assistants,
licensed practical nurses (LPNs), or other healthcare professionals. However, the RN is
responsible for delegating tasks appropriately based on the patient's condition and the skill set
required for each task.
For example, if a patient is stable and needs assistance with hygiene, a nursing assistant can be
delegated to assist with this task. However, if a patient is in respiratory distress, the RN must
intervene directly, as this is a life-threatening situation that requires clinical expertise.
Part 3: Key Topics Tested on the
NCLEX Exam
 Chapter 5: Management of Care
(15%-21%)
5.1 Prioritization and Delegation Strategies
In the NCLEX-RN and daily nursing practice, effective prioritization and delegation are critical
components of safe patient care. These skills enable nurses to address the most urgent patient
needs first and to utilize the healthcare team efficiently while maintaining safety and
accountability. This section provides a structured overview of prioritization principles—such as
Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing, Circulation), and key safety
considerations—and outlines strategies for safe delegation using the Five Rights of Delegation.
We also discuss common errors to avoid and how to apply these concepts in managing multiple
patients and in emergency situations, aligning with NCLEX-RN standards for safe and effective
care management.
Principles of Prioritization in Nursing Care
Understanding Prioritization: Prioritization in nursing care involves deciding which patient needs
or problems require immediate action and which can be safely addressed later
The NCLEX-RN often tests this skill by asking what action the nurse should take “first” or which
patient to see “first,” reflecting the exam’s focus on client safety and critical thinking. To
determine priorities, nurses rely on established frameworks that rank patient needs by urgency
and potential for harm.
Airway, Breathing, Circulation (ABC)
One fundamental priority-setting framework is the “ABC” method: Airway, Breathing, and
Circulation. Issues with a patient’s airway or breathing are addressed before all other concerns, as
these are immediate life-threatening problems. A compromised airway (e.g. obstruction or severe
swelling) or ineffective breathing (e.g. respiratory distress) requires prompt intervention because
without adequate oxygen, the patient cannot survive. Circulatory problems (such as severe
bleeding or shock) come next, as they affect oxygen delivery to tissues. In practice, this means a
patient showing signs of airway obstruction, inadequate breathing, or hemodynamic instability
will be the nurse’s top priority over patients with other, less critical issues
The ABC principle ensures that vital functions necessary for life are secured before attending to
other needs. Always check for and address any airway compromise, breathing difficulty, or
circulation impairment first; only after those are managed should the nurse move on to other
concerns.
Maslow’s Hierarchy of Needs
Maslow’s Hierarchy of Needs is a classic framework that guides prioritization by categorizing
human needs from the most basic physiological necessities to higher-level psychological needs.
According to this hierarchy, fundamental physiological needs must be met before an individual
can attend to safety, love/belonging, esteem, or self-actualization needs. In nursing priorities, this
means physiological issues (airway, breathing, circulation, hydration, nutrition, elimination, etc.)
generally outrank other concerns like emotional or social problems
For example, a patient’s need for oxygen, fluids, or critical pain relief (physiological needs) will
take priority over feelings of loneliness or anxiety (psychosocial needs) until the physical need is
stabilized. Safety needs come next after physiological needs
Safety includes both physical safety (protection from injury, infection, falls, etc.) and psychological
security. Only after a patient’s immediate physical and safety needs are ensured should the nurse
address higher-level needs such as social support or emotional reassurance. Using Maslow’s
hierarchy as a guide helps ensure that no critical basic need is overlooked. It’s also important to
note that in NCLEX context, “pain” is often considered a psychosocial need (related to comfort)
unless it is due to an acute physiological problem. For instance, signs of infection like fever or
chills (a physiological issue) would take precedence over pain if the pain is not life-threatening
Maslow’s framework thus helps avoid the mistake of focusing on emotional comfort when critical
physical issues are present.
Safety and Risk Reduction
Beyond ABCs and Maslow’s basic needs, nurses must always consider patient safety and risk
reduction. After life-threatening problems are addressed, the next priority is anything that poses
a risk of harm if not managed promptly. This means identifying situations that could quickly
deteriorate or cause injury and addressing them early. If none of the patients has an obvious ABC
issue, the nurse should ask: “Which situation has the potential to cause the most harm soonest if
I don’t intervene now?” For example, a post-surgical patient who is becoming confused and has
a dropping blood pressure (possible early shock) is a higher priority than another post-surgical
patient who is awake, alert, and complaining of moderate pain. In NCLEX terms, this principle
is sometimes called “safety and risk reduction” – choose the option that addresses the greatest
safety risk first. It aligns closely with Maslow’s second level (safety) and with the idea of dealing
with actual problems before potential ones. An actual problem that is happening now or is very
likely to happen immediately (e.g. active hemorrhage) comes before a potential problem that
might happen later
For instance, controlling active bleeding is more urgent than administering prophylactic
anticoagulants for a potential clot that hasn’t formed. By focusing on actual threats and high-risk
situations, the nurse reduces the chance of a patient’s condition worsening. Another aspect of
safety is choosing interventions that are least restrictive or least invasive while still effective. If
two interventions can address an issue, the nurse should try the safer or less invasive one first (as
long as it will not compromise the outcome) to minimize patient harm or discomfort.
Acute vs. Chronic Needs
When evaluating multiple patient needs, acute problems typically take precedence over chronic
problems. Acute conditions or sudden changes often pose more immediate risk because they
represent a deviation from the patient’s baseline. A patient experiencing a new, acute issue – for
example, the sudden onset of shortness of breath or chest pain – is likely in more urgent need of
assessment and intervention than a patient with a long-standing chronic issue that is currently
stable or expected
NCLEX questions often highlight words like “sudden,” “new,” or “acute exacerbation” to
indicate an acute situation that should be prioritized. In contrast, chronic conditions (e.g., a
routine complaint from a patient with long-term diabetes or arthritis) generally do not take priority
over a new acute problem unless the chronic condition has flared into an acute crisis. (If a chronic
condition does lead to an acute crisis – for example, a patient with chronic hypertension now
having an acute hypertensive emergency – then that acute crisis becomes the priority.) The key is
to distinguish what is new or rapidly changing from what is ongoing or expected, and prioritize
the new or changing situation first
In other words, always prioritize acute vs. chronic needs by dealing with the acute situation before
the chronic one
Unstable vs. Stable Conditions
A related principle is to determine who is unstable versus stable. An unstable patient is one whose
condition is actively changing, unpredictable, or not within normal/expected parameters, posing
a risk of rapid deterioration. Signs of instability include sudden changes in vital signs, altered level
of consciousness, new severe symptoms, or any indication that the patient’s condition is getting
worse. For example, a patient who is newly confused and has a significant drop in blood pressure
or a post-operative patient who develops acute bleeding is unstable and requires immediate
nursing attention. Stable patients, by contrast, have predictable conditions and vital signs within
normal or expected ranges for their situation
They are not at immediate risk of deterioration. If a question asks which patient the nurse should
see first, the correct choice is usually the unstable patient over the stable one. (NCLEX questions
may imply stability by describing a patient with expected findings for their condition or one who
is resting comfortably with normal vital signs—such patients can likely wait.) Unstable patients,
especially those with new status changes or life-threatening problems, must be attended to first.
A helpful tip: if a patient’s situation “requires a great deal of nursing judgment and close
assessment, then that patient can be considered unstable” and should be seen first
Assessment and the Nursing Process
Another prioritization principle is to use the nursing process as a guide – specifically, to start with
assessment whenever appropriate. If a question asks, “What is the first action?” and none of the
answer choices involves an immediate life-saving measure, the correct answer is often to further
assess the patient. Gathering more data is crucial when the situation isn’t completely clear. As a
rule, assessment should be done before planning or implementing interventions whenever a nurse
is faced with uncertainty
For example, if a diabetic patient is feeling unwell, the nurse should first check the blood glucose
rather than immediately administering juice or insulin, because the blood sugar reading will
determine the appropriate intervention
Similarly, if a patient’s status is unclear or you don’t have enough information, you should obtain
vital signs or perform a focused assessment to guide your next steps. In practice, unless a patient
is in obvious distress that requires an immediate action (e.g. the patient is not breathing and needs
rescue intervention right away), the nurse’s initial priority is often to assess the patient and collect
relevant data. This approach prevents errors that can occur from acting on incomplete
information. It’s essentially a safety net—when in doubt, assess
By thoroughly assessing first, the nurse can correctly identify who is in the most urgent need and
what specifically needs to be done, thereby aligning with both the nursing process and safe
prioritization.By applying these prioritization principles—addressing ABCs first, using Maslow’s
hierarchy to meet physiological and safety needs before attending to higher needs, focusing on
safety risk reduction, and recognizing acute vs. chronic and unstable vs. stable scenarios—nurses
can make sound decisions about who or what needs attention first. These frameworks often
overlap and should be used in combination. (For instance, an unstable patient with an airway
problem clearly trumps a stable patient with a chronic issue.) Nurses must also continually
reassess; priorities can change if a patient becomes unstable or if new information emerges.
Mastery of prioritization ensures that critical needs are never left waiting, and it is essential for
safe patient care and for success on the NCLEX-RN.
Effective Delegation Strategies: The Five Rights of Delegation
Delegation in nursing is the process of transferring to a competent individual the authority and
responsibility to perform a selected nursing task, while the nurse (delegator) retains accountability
for the outcome
In other words, the RN assigns certain duties to other team members (such as Licensed
Practical/Vocational Nurses or unlicensed assistive personnel), but the RN remains ultimately
responsible for ensuring the task is completed correctly and that patient safety is maintained.
Effective delegation is vital for managing workload and ensuring that patient needs are met in a
timely manner. It involves knowing what tasks can be delegated, under what circumstances, to
whom, and with what instructions and supervision.To delegate safely, nurses follow the Five
Rights of Delegation, which were developed by the American Nurses Association to assist nurses
in making safe delegation decisions
The Five Rights provide a checklist to ensure that every aspect of a delegated task is appropriate.
They are: the Right Task, Right Circumstance, Right Person, Right Direction/Communication, and Right
Supervision/Evaluation
Below is a breakdown of each:
Right Task: Identify a task that is appropriate to delegate. Not every nursing activity can be
delegated. The right task is one that can be performed by someone else without requiring the
nursing judgment unique to an RN. Generally, tasks that do not require ongoing assessment,
critical decision-making, or complex patient knowledge can be delegated. Routine, non-complex
tasks with predictable outcomes are usually suitable. For example, taking routine vital signs on a
stable patient, assisting with bathing or feeding, or transporting a non-critical patient are tasks that
can often be delegated. In contrast, any task that involves extensive assessment, interpretation, or
decision-making should not be delegated
A common memory aid is never delegate what you can “E.A.T.” – that stands for Evaluate,
Assess, Teach. Initial patient assessments, evaluation of care outcomes, and initial patient teaching
are core RN responsibilities and must be performed by the RN
If a task requires the nurse’s specialized knowledge or judgment (for instance, creating a nursing
care plan or triaging a patient), it is not the right task to delegate.
Right Circumstance: Evaluate the context and ensure the situation is appropriate for delegation.
Even a normally straightforward task might not be safe to delegate if the patient’s condition or
environment isn’t suitable. The patient’s condition must be stable or predictable if the task is to
be handed off
If the patient is unstable or has complex, rapidly changing needs, the RN should personally handle
the critical tasks and avoid delegating them. Timing and setting matter as well; the delegatee should
have the resources and time to do the task properly. Importantly, the nurse should be able to
provide supervision and support if needed. For example, it may be appropriate for a UAP to feed
a patient who is recovering well, but it would not be appropriate to delegate feeding for a patient
who has a high aspiration risk or requires a swallow evaluation, because in that circumstance the
task carries high risk
In summary, the right circumstance means the patient is in the right condition (no high-risk
instability) and the environment is favorable for the task to be done safely.
Right Person: Choose a delegatee who has the appropriate skills, training, and scope of practice
to perform the task. This means both selecting the right category of worker and the right
individual. The RN must be aware of the qualifications and competencies of team members
For instance, LPN/LVNs are trained to perform many treatments and administer certain
medications, but they are not licensed for independent initial assessments or complex decision-
making. Unlicensed assistive personnel can assist with activities of daily living (ADLs) and routine
tasks, but they cannot perform any task that requires a nursing license (such as medication
administration or assessment). Ensuring the “right person” involves matching the task’s
requirements to the delegatee’s job description and proven competence. The RN should also
consider the individual’s current workload—delegating a task to someone who is already
overwhelmed might not be effective or fair. In practice, this might mean assigning an experienced
LPN to perform a dressing change on a stable wound, while asking a nursing assistant to take
vital signs and help with ambulation. The RN should be confident that the person delegated to
has the knowledge and ability to do the task correctly and safely. If not, the RN should either not
delegate that task or provide additional instruction or supervision.
Right Direction and Communication: Provide clear, concise instructions for the task, including
the expected result and timeline, and confirm that the delegatee understands. Effective delegation
is a two-way street – it requires the RN to communicate exactly what needs to be done and how,
and it allows the delegatee to ask questions and clarify expectations
The nurse should include any specific patient considerations or precautions in the instructions.
For example, instead of saying, “Can you walk Mr. Jones?”, a clearer instruction would be: “Please
help Mr. Jones walk to the restroom now. He has been dizzy, so stay with him the whole time,
and make sure he uses his walker. If he becomes unsteady or feels worse, assist him to sit and call
me immediately.” This communication covers what to do, how to do it, and what to watch for.
The RN should also specify what and when to report back – for instance, “Let me know Mr.
Jones’s blood pressure after the walk, because it was low earlier.” Clear directions help prevent
misunderstandings. The delegatee should repeat back or acknowledge instructions to ensure
understanding
The RN should never assume the person knows the nuances of care for that specific patient
without being told. In short, the right communication means no ambiguity: the delegatee knows
what to do, what to report, and when to ask for help.
Right Supervision and Evaluation: Even after a task is delegated, the RN must appropriately
monitor its progress and evaluate the outcome. The “right supervision” means the nurse provides
guidance, intervention, and follow-up as needed
The RN should remain available or assign someone as available for questions or assistance while
the task is being done. The level of supervision will depend on the task and the delegatee’s
experience; some tasks might just require a quick check-in, while others may need direct oversight.
After the task is completed, the RN is responsible for evaluating whether it was done correctly
and whether the desired result was achieved. For example, if an LPN was delegated to administer
a pain medication, the RN might later ask, “What is the patient’s pain level now?” and observe
the patient to ensure their pain is improving without adverse effects. If a UAP turned a bedridden
patient, the RN should later inspect the skin to ensure no breakdown is occurring. Documentation
is also ultimately the RN’s responsibility – the nurse must ensure the task and its outcomes are
properly documented (whether by the delegatee or by the RN per facility policy). Nursing
regulations and practice acts require that RNs provide adequate supervision for all delegated tasks
If problems or unexpected findings arise, the RN should address them promptly. Right
supervision is about maintaining accountability: the RN delegated the task, so the RN must
confirm it is completed correctly and intervene if it was not.
By adhering to the Five Rights of Delegation, nurses can delegate tasks effectively while
safeguarding patient care. For example, a nurse on a busy unit might delegate a non-critical task
(right task) in an appropriate situation (right circumstance) to a qualified staff member (right
person), give clear instructions (right communication), and then monitor the outcome (right
supervision). Throughout this process, the RN remains accountable for the task’s completion and
the patient’s outcome
That is why careful delegation and follow-up are so important: if something goes wrong with a
delegated task, it is the RN who is ultimately responsible for recognizing and correcting it.It’s also
important to know what should not be delegated. As noted above, tasks that require clinical
reasoning, critical decision-making, or the core nursing process (assessment, planning, evaluation)
generally cannot be delegated. The functions of assessment, teaching, and evaluation of patient
care must be done by the RN
In practice, this means an RN should never delegate the initial nursing assessment of a new
admission, the creation of a nursing care plan, patient education for a new diagnosis or discharge,
or the evaluation of whether a treatment was effective. (This is the essence of “don’t delegate
what you can E.A.T.” – Evaluate, Assess, Teach.) LPN/LVNs may collect data or monitor
ongoing conditions and they can reinforce teaching, but the RN must perform the initial
assessment and initial patient education and must validate the LPN’s findings. Likewise, LPNs
and all nurses must not delegate any nursing-only functions to unlicensed staff. An LPN should
not delegate a task to a nursing assistant that is outside the assistant’s role, such as assessment or
medication administration
UAPs (nurse aides, techs, etc.) are limited to non-invasive, routine tasks such as hygiene,
ambulation, positioning, taking vital signs on stable patients, and feeding (if the patient has no
swallowing risk). By keeping these boundaries in mind, the RN ensures that delegation is done
within legal and safety limits. When in doubt about a delegatee’s scope or ability, the nurse should
either verify their competency or retain the task. Effective delegation means the RN assigns tasks
in a manner that is safe and appropriate, provides guidance and oversight, and always keeps the
most critical aspects of care under the RN’s direct management.
Common Errors in Prioritization and Delegation (and How to Avoid Them)
Even with clear frameworks, nurses can fall into common pitfalls when prioritizing care or
delegating tasks. Being aware of these errors—and knowing how to avoid them—is essential for
safe practice and for answering NCLEX questions correctly.
Common Prioritization Pitfalls
Failing to recognize a life-threatening situation: One of the most serious errors is not
identifying when a patient’s condition is dangerously unstable. For example, a nurse might
overlook the early signs of an airway obstruction or not notice a rapidly dropping blood pressure,
resulting in delayed intervention. How to avoid: Always apply the ABCs first and assess patients
for any signs of immediate crisis. Train yourself to scan each scenario for indications of imminent
danger to life (airway compromise, breathing difficulty, circulation collapse). If such signs are
present, they trump everything else. Never proceed to a lower-priority task without ensuring these
vital functions are addressed.
Prioritizing comfort over critical needs: Another mistake is addressing a patient’s comfort
(pain, anxiety, etc.) before attending to physiological urgencies. While pain management and
emotional support are important, they should not overrule airway, oxygenation, or circulation
issues. For instance, administering a PRN pain medication to a patient in pain should not come
before treating a different patient’s severe respiratory distress or acute chest pain. How to avoid:
Use Maslow’s hierarchy and the physical-vs-psychosocial principle as a guide – ensure
physiological stability and safety first
Remind yourself that pain, although distressing, is usually a lower priority than issues like
inadequate oxygenation, compromised circulation, or signs of critical illness. Address pain and
other comfort needs as soon as it is safe to do so, but not at the expense of stabilizing essential
physical needs.
Not distinguishing actual problems from potential problems: Nurses may become preoccupied
with what might happen and miss what is happening. For example, focusing on the risk that a
stable post-op patient could develop a complication (potential problem) while another patient is
actually experiencing signs of a stroke is a prioritization error. How to avoid: Tackle present, active
problems before hypothetical future issues
In NCLEX questions, that means symptoms or findings indicating an existing problem take
priority over preventive measures for a risk. Always ask, “Is this an existing issue or just a possible
one?” Deal with the existing issue first. (For example, treat acute chest pain now rather than calling
a provider about a mildly high cholesterol reading.)
“Whoever screams loudest” syndrome: In a busy environment, there’s a temptation to respond
first to patients who are calling out the most or demanding attention, rather than those who are
quiet. This can lead to a situation where a quieter but very ill patient is overlooked. How to avoid:
Base priorities on clinical data and patient condition, not on volume of requests. Sometimes the
sickest patient is the one who cannot call for help. Make rounds and check critical indicators for
all your patients, not just the ones ringing the call bell. Let objective assessment findings and
established priority frameworks guide you, instead of the noise level or patient insistence.
Sticking to routines or schedules rigidly: Focusing on task completion in a set order (med
pass, charting, etc.) without adjusting to a patient’s changing condition is a pitfall. For example,
continuing with routine charting while a patient is developing acute signs of sepsis is a serious
lapse. How to avoid: Stay flexible and ready to reprioritize. If an assessment reveals a new problem
or a patient’s status changes, pause your routine and address the new priority. Regularly ask
yourself, “Does anything require immediate attention right now?” If yes, that becomes the focus.
Time management is important, but it should never overshadow an emerging critical need.
To avoid prioritization errors, it’s crucial to apply the priority-setting frameworks consistently and
to remain vigilant. Many mistakes occur when a nurse either doesn’t use these guides or second-
guesses them by considering unlikely “what if” scenarios. In fact, new graduates sometimes
overthink the “what ifs” and imagine hypothetical complications that can distract from the real
issue at hand
Trust the evidence in front of you. Address the most critical, life-threatening or safety-threatening
condition first. If you are unsure what’s going on or what to do, gather more data (assess) rather
than acting on assumptions. By following these principles, you ensure the truly urgent needs are
met promptly.
Common Delegation Pitfalls
Delegating tasks outside of the delegatee’s scope or competence: A frequent error is asking
a team member to do something they are neither trained nor legally permitted to do. For example,
telling a nursing assistant to administer a medication or assess a patient’s lung sounds is
inappropriate and unsafe, as those tasks are outside the UAP scope. Similarly, assigning an
inexperienced nurse or LPN to manage a highly unstable, complex patient without adequate
support can endanger the patient. How to avoid: Always verify the scope of practice and
competency of the person before delegating. Know the roles: UAPs cannot perform nursing
assessments, administer meds, or do sterile procedures; LPNs have a defined scope that usually
excludes initial assessments, care planning, IV pushes in some settings, and so on. Use the Five
Rights as a checklist – if the task doesn’t fit the person’s role or training, do not delegate it
It’s better to take on a critical task yourself or find the properly qualified person than to delegate
inappropriately.
Inadequate or unclear instructions: Delegation can fail if the RN gives incomplete or vague
directions. If a nurse simply says, “Watch Mrs. Smith this afternoon,” the assistive staff may not
know what to watch for or what to do. Likewise, saying “Help Mr. Lee exercise” without specifics
could lead to misunderstanding (what kind of exercise? how far? what precautions?). How to
avoid: Provide clear, specific instructions every time you delegate
Include the what, when, and how of the task, and any patient-specific precautions. For example:
“Please walk Mr. Lee for 5 minutes in the hallway using his walker. He should wear his oxygen
during activity. Stay with him and let me know if he experiences any shortness of breath or
dizziness.” Encourage the delegatee to ask questions if anything is unclear, and confirm their
understanding. Also, be explicit about what needs to be reported back (e.g., pain level after
walking, or if the patient refused). Clear communication is key to ensuring the task is done
correctly
.
Lack of supervision and follow-up: One of the biggest delegation mistakes is “dumping” a task
on someone and then never checking back on the outcome. If the RN does not monitor or
evaluate, errors or omissions can go unnoticed. For instance, if turning and repositioning a patient
is delegated to a UAP but the RN never later checks the patient’s skin or asks if the turns were
done, the patient could develop pressure injuries without intervention. Or if an LPN is asked to
monitor a postoperative patient’s blood pressure and the RN doesn’t review the readings, a
downward trend could be missed. How to avoid: Always follow through on every delegated task
– this is the “right supervision” part of delegation. Set a mental (or written) reminder to check the
results of the task. This could be as simple as asking, “Did Mrs. Smith eat her lunch? What was
her appetite like?” after delegating feeding, or independently verifying that a dressing change was
done and inspecting the wound. For important tasks, specify a follow-up time: “I’ll come back in
an hour to see what that dressing looks like.” By remaining actively involved and available, you
not only catch any problems early but also reinforce that you retain accountability
Effective supervision shows your team that you are all working together and that you, as the RN,
will ensure nothing falls through the cracks.
Not adjusting delegation when conditions change: Delegation plans should be dynamic. A
task that was appropriate to delegate at one time may need to be rescinded if the situation changes.
For example, you delegated vital sign checks on a post-op patient to an aide when the patient was
stable, but now the patient’s blood pressure is trending down and they’re becoming lethargic – at
this point, the RN needs to take over monitoring more closely and assess the patient personally.
How to avoid: Stay alert to changes in patient status and be ready to step in or change assignments.
Instruct delegatees to report any change in condition immediately. If a delegatee comes to you
and says, “Mr. Doe’s oxygen saturation dropped to 85%,” you should recognize that this patient
may no longer be appropriate for delegated care alone – the RN must get directly involved. Always
be willing to re-prioritize your own tasks and, if necessary, reassign or take back a delegated task
in light of new information
Delegation is not “set it and forget it”; it requires continual awareness.
Avoiding delegation errors comes down to adhering to the Five Rights and maintaining good
communication and oversight. Delegate thoughtfully: choose appropriate tasks and people,
communicate clearly, and supervise diligently. Remember that the RN is ultimately accountable
for all delegated activities, so never delegate something if you cannot ensure its safe completion.
If you’re ever unsure about a delegation decision, it’s safer to do it yourself or consult a supervisor.
Effective delegation should improve efficiency and patient care, not compromise it. By being
vigilant about these pitfalls, nurses ensure that delegation is a tool for extending care quality, not
a risk to patient safety.
Application of Prioritization in Multi-Patient Settings and Emergency Care
Prioritization and delegation skills become especially critical when managing care for multiple
patients or responding to emergencies. In these situations, the nurse must make swift, sound
decisions about who to attend to first and how to allocate resources for the best outcomes.
Managing Multiple Patients
On a typical shift, an RN may care for several patients. Applying prioritization principles in a
multi-patient assignment means continuously deciding which patient requires immediate attention
and which tasks can be done a bit later or by someone else. At the start of the shift (and
throughout), the nurse should quickly identify any patients with immediate, critical needs. For
example, among a group of patients, a fresh post-operative patient with dropping oxygen
saturation or signs of respiratory distress will demand attention before a patient who is stable and
awaiting a routine dressing change. Similarly, a patient with an acute change (fever spike, new
severe pain, confusion, bleeding) generally takes priority over patients whose conditions are
unchanged or improving as expected. In other words, the nurse must rapidly determine if any
patient is “on fire” (clinically speaking) and put out that fire first.Time management and delegation
are indispensable in multi-patient settings. Often the nurse must address a high-priority patient
personally while ensuring that other patients’ needs are not neglected. This is where effective
delegation comes in: the RN can assign appropriate tasks to other team members to free herself
to focus on the critical patient. For example, while the RN assesses and stabilizes a patient with a
sudden drop in blood pressure, she might ask a nursing assistant to help another patient to the
bathroom and request an LPN to administer a scheduled pain medication to a third patient
In doing so, the urgent issue gets full RN attention, and lower-priority tasks are still completed
via the team. Communication in such moments is key – the RN should clearly delegate those tasks
and inform team members of any pertinent information (e.g., “Stay with that patient until they
are safely back in bed,” or “Let me know if his pain isn’t relieved after 30 minutes”). After the
critical situation is handled, the RN should circle back to confirm the delegated tasks were done
and assess those patients.Another strategy in multi-patient management is clustering tasks and
being efficient once the most urgent needs are met. For instance, after addressing all critical issues,
the nurse might decide to combine activities: while checking on a moderately stable patient, she
could also bring the next dose of medication due for that patient, or while walking past another
room, quickly ask if that patient needs anything. However, no matter how efficient you try to be,
patient safety comes first. The nurse must be ready to drop less urgent tasks if a new priority
arises. It’s a constant process of re-evaluation.In summary, when managing multiple patients, the
nurse should:
Attend to patients with life-threatening or urgent needs first. Use ABCs and your assessment to
identify who has the most critical issue (e.g., difficulty breathing, unstable vitals, acute change)
and see them immediately.
Next, address patients with important but not immediately life-threatening needs, such as timely
pain management, routine post-op care, or other interventions that are important for recovery
but can safely follow the truly emergent care.
Leave the most stable patients or routine tasks for last. Tasks like a scheduled bath or a routine
medication for a stable patient can be postponed until urgent matters are handled.
Delegate appropriately to balance the workload. Assign routine or non-nursing tasks to nursing
assistants or stable patient care to an LPN as allowed, so that while they attend to those, you can
focus on the critical patient. This ensures every patient’s basic needs are met in a timely manner.
Reprioritize continually. After each round of interventions or if there’s any change in a patient’s
status, reassess the overall picture. Be prepared to shift your focus if a patient’s condition worsens
or a new problem arises.
By systematically applying priority principles across the patient group and leveraging the help of
the healthcare team, the nurse can ensure that all patients receive appropriate attention and that
the most serious issues are addressed promptly. This is exactly what the NCLEX wants to see in
“who do you see first?” questions: the ability to pick out the highest-acuity patient or issue from
a set of patients.
Emergency and Triage Considerations
In emergency situations, prioritization is crucial and sometimes follows specialized protocols like
triage systems. In an emergency department or disaster scenario, nurses perform triage, which
means sorting patients by urgency of need. Those with the most critical, life-threatening
conditions are classified as emergent and are treated first, whereas those with less severe problems
are classified as urgent or non-urgent and may wait longer. For example, a patient with crushing
substernal chest pain and shortness of breath will be triaged ahead of a patient with a sprained
ankle. In other words, the greater the threat to life, the higher the priority in treatment order
This triage principle aligns with our prioritization frameworks: address airway, breathing, and
circulation threats immediately. In a hospital emergency like a code blue (cardiac/respiratory
arrest) or a rapidly deteriorating patient, the nurse must instantly apply prioritization knowledge
and often take immediate action. There may be no time to methodically think through Maslow’s
hierarchy; instead, the nurse automatically focuses on ABCs and uses protocols such as Advanced
Cardiac Life Support (ACLS). For instance, if a nurse finds an unresponsive patient with no pulse,
the priority is clear: call for help and begin CPR (circulation support) right away. During such
critical events, delegation and teamwork are vital: one person initiates chest compressions, another
calls the code and brings the crash cart, another secures the airway and provides ventilation, and
so on. The nurse’s leadership in an emergency involves assigning these roles quickly (often to
whoever is available and trained) and ensuring all life-saving measures are in progress.
Communication in emergencies should be concise and direct, and everyone must understand their
role.It’s worth noting that in mass casualty or disaster situations, the usual prioritization rules have
a specific twist. In disaster triage (such as using colored tags in a multiple-victim incident), the
goal is to save as many lives as possible with limited resources. This can mean that a patient with
likely fatal injuries may be labeled expectant (lowest priority for treatment), so that patients with
serious but potentially survivable injuries can be treated first. For example, a person with no
respirations even after airway repositioning (indicating a fatal condition) might not receive
extensive intervention in a mass disaster setting, whereas a person with an open fracture and
bleeding (who can survive with timely care) is tagged emergent and treated sooner. This is an
exception to the normal one-on-one clinical priority rule. However, in standard hospital
emergency care and NCLEX questions (unless specifically framing a disaster scenario), you should
assume the priority is to treat the patient with the most life-threatening condition first
In any emergency, after the situation is under control, the team should evaluate the outcome and
possibly debrief. For the individual nurse, reflecting on what went well or what could be improved
in the response is how we continuously get better at handling the next emergency. But during the
event, the focus remains: stabilize airway, breathing, and circulation, ensure patient safety, and
direct resources (including other people) to where they are most needed.Overall, whether juggling
a normal assignment of multiple patients or responding to a crisis, the core principles remain
consistent. The nurse always asks: “Who is at greatest risk right now? What needs to be done right
now to keep the patient safe and alive?” Address those priorities first. Use your team through
delegation to extend your reach, but maintain accountability. Then move on to the next priorities.
By mastering prioritization and delegation, nurses fulfill their role as coordinators of care, ensuring
that no patient is left in jeopardy. These are exactly the skills the NCLEX-RN exam tests in the
Management of Care domain, and more importantly, they are skills that protect patients’ lives
every day in real practice.

5.2 Effective Communication and Collaboration in Nursing Care

Effective communication and collaboration in nursing care are foundational skills that contribute
to the delivery of safe, high-quality patient care. These skills are not only vital for providing
optimal patient outcomes but are also crucial for success on the NCLEX-RN exam. Nurses must
be skilled in communicating effectively with patients, families, and other healthcare professionals
in order to ensure clear, accurate, and timely exchanges of information. Furthermore,
collaboration with an interdisciplinary healthcare team is essential for comprehensive care. This
section explores the principles and strategies for effective communication and collaboration in
nursing, emphasizing their role in ensuring patient safety, enhancing teamwork, and improving
patient satisfaction.
Communication is central to every aspect of nursing care. Whether interacting with patients to
assess their condition, providing education, or relaying information to other members of the
healthcare team, effective communication facilitates understanding and guides decision-making.
One of the fundamental principles of effective communication is clarity. Nurses must ensure that
their messages are clear and concise, minimizing the risk of misunderstandings. For example,
when instructing an unlicensed assistive personnel (UAP) to assist a patient with mobility, the
nurse must give clear, specific instructions to prevent errors. Clarity in communication also
extends to written documentation, where clear and accurate notes are essential for continuity of
care. Nurses must always ensure that the information they provide is understood by the recipient.
This is particularly important when conveying critical information about a patient's status or
treatment plan.
Active listening is another key communication principle that allows nurses to fully understand the
concerns, needs, and preferences of patients and colleagues. By listening attentively, nurses can
gather more accurate information, which is essential for making informed clinical decisions.
Active listening also helps build rapport with patients, making them feel valued and heard, which
can enhance their experience of care. For example, when a patient expresses concerns about their
treatment plan, a nurse who listens attentively can address those concerns and provide
reassurance, ensuring that the patient is well-informed and involved in their care.
In addition to verbal communication, non-verbal communication plays a significant role in
nursing practice. Body language, facial expressions, eye contact, and tone of voice all convey
information about a nurse’s emotions and attitudes. Non-verbal cues can also provide additional
context to verbal interactions, helping to reinforce or clarify the message being communicated. A
nurse's ability to recognize and respond appropriately to non-verbal cues is essential for effective
patient care. For example, a patient who is experiencing pain may not always verbalize it, but their
body language may indicate distress. A nurse who is attuned to these cues can intervene quickly
to address the patient’s discomfort, improving the patient’s experience and preventing
complications.
Empathy is another cornerstone of effective communication in nursing. When interacting with
patients, nurses must not only communicate information but also demonstrate understanding and
compassion. Empathy helps foster trust and builds therapeutic relationships, which are essential
for promoting healing and improving patient outcomes. For example, a nurse who shows empathy
when discussing a patient’s diagnosis or treatment plan can help alleviate feelings of fear or
anxiety, contributing to a more positive patient experience. In situations where patients are facing
significant challenges, such as a terminal diagnosis or a difficult procedure, empathy can help
provide comfort and emotional support, allowing the nurse to offer holistic care.
Professionalism in communication is equally important. Nurses must maintain a professional
demeanor in all interactions, whether with patients, families, or colleagues. Professional
communication includes using appropriate language and tone, respecting boundaries, and
maintaining confidentiality. This level of professionalism is essential for maintaining trust and
ensuring that care is delivered in a respectful and ethical manner. In the context of patient
education, for example, a nurse must communicate complex medical information in a way that is
understandable while respecting the patient’s level of health literacy. Professional communication
also involves the ability to adapt one’s communication style to suit different situations. For
example, communicating with a patient who is experiencing an acute medical crisis may require a
more direct, concise approach, while a patient who is stable and well-informed may benefit from
a more detailed, explanatory conversation.
Collaboration in nursing is also a critical aspect of patient care. Nurses work closely with a variety
of healthcare professionals, including physicians, physical therapists, dietitians, social workers, and
pharmacists, to provide comprehensive care. Collaboration ensures that each aspect of a patient’s
needs is addressed by the most appropriate professional, preventing gaps in care and reducing the
risk of errors. Effective collaboration is built on mutual respect, trust, and a shared commitment
to the patient’s well-being. Nurses must communicate openly with other members of the
healthcare team, providing updates on the patient’s condition, sharing concerns, and discussing
treatment options. This collaborative approach helps ensure that the patient receives the most
appropriate care at every stage of their treatment. For instance, when a nurse notices a change in
a patient’s condition, they must communicate this to the physician immediately to ensure timely
intervention. Similarly, when a nurse identifies a patient’s need for rehabilitation, they collaborate
with physical therapists to develop a care plan that meets the patient’s goals and maximizes their
recovery potential.
In the healthcare environment, nurses must be adept at managing conflicts that may arise among
team members. Disagreements or differences in opinion are inevitable in any collaborative setting,
but it is essential that nurses handle these situations professionally and constructively. Conflict
resolution strategies, such as active listening, respectful dialogue, and finding common ground,
can help nurses resolve conflicts without compromising patient care. When conflicts arise, nurses
should focus on the best interests of the patient and work to find solutions that promote positive
outcomes. For example, if there is a disagreement between team members about the appropriate
course of action for a patient, the nurse should remain focused on the patient’s needs and advocate
for the best possible care, while maintaining respect for differing viewpoints.
A significant aspect of nursing collaboration is delegation. Nurses are responsible for ensuring
that tasks are assigned to the appropriate team member, based on their skills, experience, and
scope of practice. Proper delegation ensures that care is delivered efficiently and that all team
members are working within their scope of practice. Delegation is a key component of time
management in nursing, as it allows the nurse to focus on higher-level tasks while ensuring that
routine tasks are completed by other team members. When delegating tasks, nurses must ensure
that they provide clear instructions and offer appropriate supervision to ensure that the task is
completed safely and effectively. For example, a nurse may delegate a routine task, such as taking
vital signs, to a UAP while they attend to more complex clinical responsibilities. The nurse is still
responsible for monitoring the patient’s overall condition and ensuring that the delegated task is
carried out properly.
Effective delegation also requires an understanding of the roles and responsibilities of other
healthcare professionals. Nurses must be familiar with the scope of practice for LPNs, UAPs, and
other team members in order to delegate tasks appropriately. For example, a nurse may delegate
a medication administration task to an LPN, but they must ensure that the LPN is trained and
competent to perform the task and that it falls within their scope of practice. Additionally, nurses
must be aware of the patient’s condition and ensure that tasks are delegated based on the patient’s
needs. For instance, a patient who is unstable or requires complex care should remain under the
nurse’s direct supervision, while a patient who is stable and has routine needs can be managed by
other team members with appropriate supervision.
The ability to collaborate with interdisciplinary teams also extends to patient and family
communication. Nurses must work closely with patients and their families to develop care plans
that align with the patient’s goals and values. Family members play an integral role in the patient’s
recovery and overall well-being, and involving them in the care process helps ensure that the
patient’s needs are met. For example, a nurse may collaborate with a patient’s family to ensure
that they understand the patient’s treatment plan and provide support during the recovery process.
Collaboration with families also helps the nurse gain valuable insights into the patient’s
preferences and lifestyle, which can inform care decisions and improve patient satisfaction.
Cultural competence is another essential aspect of communication and collaboration. Nurses must
be able to communicate effectively with patients from diverse cultural backgrounds,
understanding how cultural differences can influence health beliefs, practices, and communication
styles. By being culturally competent, nurses can ensure that they are providing care that is
respectful, effective, and tailored to the patient’s needs. Nurses should be aware of cultural norms
related to health and illness, as well as the patient’s preferences regarding communication and
decision-making. For example, in some cultures, patients may prefer to receive medical
information through family members rather than directly from the healthcare provider. By
understanding and respecting these preferences, nurses can foster better relationships with their
patients and provide care that is both effective and culturally sensitive.

5.3 Legal and Ethical Responsibilities in Nursing

Nurses have a profound responsibility to provide safe, effective, and compassionate care to their
patients, but they must also adhere to legal and ethical standards. Understanding legal and ethical
responsibilities is not only fundamental to nursing practice but also essential for success on the
NCLEX-RN exam. This section explores the various legal and ethical obligations nurses must
fulfill in their practice, emphasizing patient rights, professional conduct, and the laws that guide
nursing practice. Nurses must demonstrate an understanding of both legal principles and ethical
frameworks, ensuring they protect the rights of patients while delivering quality care.
Legal Responsibilities in Nursing
Nurses operate within a complex legal framework that governs healthcare delivery. These laws
protect both patients and healthcare providers by ensuring that care is delivered safely and
ethically. A nurse’s legal responsibilities include adhering to established standards of care,
maintaining confidentiality, obtaining informed consent, and protecting patients from harm.
Understanding these legal obligations is vital for preventing malpractice claims and ensuring
patient safety.
One of the core legal responsibilities in nursing is maintaining standard of care. The standard of
care refers to the level of care that is expected of a nurse, as defined by professional nursing
organizations, regulatory bodies, and state laws. Nurses must provide care that meets the accepted
practices and procedures for their area of practice. For example, a nurse must assess a patient’s
vital signs regularly in accordance with hospital policies, administer medications safely, and
provide education on treatment options when necessary. When a nurse deviates from the standard
of care, and this deviation leads to patient harm, it may result in a malpractice lawsuit. Nurses
should always follow the best practices and institutional protocols to prevent negligence and
ensure that patients receive the appropriate care.
Confidentiality and patient privacy are also legal requirements for nurses. Under the Health
Insurance Portability and Accountability Act (HIPAA), nurses are legally obligated to protect
patients' personal health information (PHI). Nurses should only share patient information with
other healthcare professionals who are directly involved in the patient’s care and with the patient’s
consent. Unauthorized disclosure of PHI can lead to legal consequences and damage to the
nurse’s professional reputation. Additionally, nurses must take extra precautions to ensure that
patient records are secured and that sensitive information is not disclosed inadvertently. For
instance, patient information should never be discussed in public areas or in the presence of others
who are not involved in the patient's care.
Another critical aspect of nursing practice involves obtaining informed consent. Informed
consent is the process by which a nurse or healthcare provider ensures that the patient
understands the risks, benefits, and alternatives of a proposed treatment or procedure before
agreeing to it. The nurse must verify that the patient comprehends the information and that their
decision is made voluntarily. This includes ensuring that patients have the mental capacity to make
an informed decision. If a patient is unable to provide consent due to age, mental capacity, or
emergency conditions, a legal guardian or proxy may provide consent on their behalf. Nurses
must always document that informed consent was obtained and ensure that the patient’s
autonomy and right to make decisions about their care are respected.
Negligence and malpractice are key legal concepts that nurses need to be aware of. Negligence
refers to a failure to provide the standard of care that a reasonably prudent nurse would offer,
resulting in harm to a patient. This can include errors such as administering the wrong medication,
failing to monitor a patient’s condition, or neglecting to educate a patient on important aspects of
their care. When negligence results in patient harm, it may constitute malpractice, which is a legal
term used to describe professional negligence. Nurses should always be vigilant in their practice,
adhering to guidelines and protocols to avoid mistakes that could lead to legal action.
Liability is another important legal concept in nursing practice. Nurses are personally liable for
their actions, meaning they are responsible for their decisions and conduct during patient care.
However, the institution or employer may also be held liable for actions performed by nurses
within the scope of their employment. In addition, nurses are expected to practice within the
limits of their scope of practice, as defined by their state’s Nurse Practice Act. Practicing beyond
one’s scope or without the proper training and qualifications can result in legal consequences. It
is essential for nurses to be aware of their legal scope of practice and to work within their areas
of competence.
Ethical Responsibilities in Nursing
In addition to legal responsibilities, nurses must also navigate ethical challenges in their practice.
Ethical responsibilities involve making decisions that align with moral principles and professional
values. Ethical issues often arise in nursing practice, requiring nurses to consider the values of
beneficence (doing good), non-maleficence (avoiding harm), autonomy (respecting patient
choices), and justice (treating all patients fairly).
One of the primary ethical principles in nursing is autonomy. Autonomy is the right of patients
to make their own healthcare decisions, even if those decisions are contrary to medical advice.
Nurses must respect a patient's decision-making ability, provided they have the capacity to make
an informed choice. This includes supporting patients in making decisions about their care,
whether it involves accepting or refusing treatment. For example, if a patient decides to refuse a
certain medication, the nurse must respect their decision and document it properly. Nurses should
also provide patients with all necessary information to make informed choices, answering
questions and addressing concerns in a non-judgmental way.
Another ethical principle is beneficence, which refers to the nurse’s duty to act in the best interest
of the patient. Nurses should always strive to do what is best for their patients by promoting their
well-being, alleviating suffering, and ensuring that they receive the appropriate care. For example,
if a patient is in pain, a nurse must act promptly to administer pain relief and monitor the patient’s
response. Beneficence requires that nurses consider both the benefits and potential risks of any
intervention, aiming to provide the maximum benefit while minimizing harm.
Non-maleficence, or “do no harm,” is an essential principle in nursing ethics. Nurses must avoid
causing harm to patients, whether through acts of commission (doing something wrong) or
omission (failing to act when required). This includes taking steps to prevent errors, such as
verifying medication doses, ensuring patient safety during procedures, and being vigilant about
infection control practices. Nurses should be mindful of the potential risks of any treatment or
procedure and work to minimize any adverse outcomes. If harm is unavoidable, nurses are
ethically bound to ensure that patients are informed of the risks and that appropriate safeguards
are in place.
Justice in nursing involves treating all patients fairly and without bias. Nurses must provide equal
care to all individuals, regardless of their background, race, ethnicity, socioeconomic status, or
personal beliefs. This includes advocating for patients who may be disadvantaged or marginalized,
ensuring that they have access to necessary healthcare services. Nurses must also advocate for
patients who are unable to speak for themselves, ensuring that their rights and needs are addressed
in a fair and equitable manner. For example, if a patient is unable to communicate effectively due
to a language barrier, the nurse must take steps to find an interpreter or another means of
communication to ensure that the patient’s needs are met.
Ethical dilemmas frequently arise in healthcare settings, especially when it comes to issues such
as end-of-life care, patient confidentiality, and conflicts of interest. Nurses must be prepared to
navigate these complex situations, using their professional judgment to make decisions that
balance legal, ethical, and clinical considerations. Nurses should be familiar with institutional
ethics policies and may seek guidance from ethics committees when faced with particularly
challenging decisions. Collaboration with other healthcare professionals, including social workers,
chaplains, and physicians, can help nurses address complex ethical issues and ensure that patient
care is aligned with both ethical principles and legal requirements.
The Nurse's Role in Advocacy and Legal Protection
Nurses play a critical role in advocating for their patients. Patient advocacy involves supporting
patients’ rights and ensuring that they receive the care and services they need. Nurses must
advocate for their patients by ensuring that their concerns are heard, their wishes are respected,
and their access to care is not hindered by external factors. Advocacy is especially important for
vulnerable populations, including children, the elderly, and individuals with cognitive or physical
disabilities, who may be at risk of having their rights overlooked.
Nurses also have an ethical responsibility to advocate for patients in situations where they may be
at risk of harm, such as in cases of abuse, neglect, or exploitation. This may involve reporting
suspicions of abuse to the appropriate authorities or advocating for a change in care plans to
ensure the patient’s safety. Nurses must balance their role as advocates with their legal obligations,
ensuring that patient confidentiality is maintained while addressing any concerns that could
jeopardize the patient’s well-being.
In addition to advocating for patients, nurses must also be aware of their legal protections. Nurses
are protected by laws that provide legal immunity when they act within the scope of their practice
and in good faith. For example, the Good Samaritan laws protect healthcare professionals who
provide emergency care outside of their regular work environment from liability, as long as they
are acting within the bounds of their training and not engaging in gross negligence. Understanding
these legal protections is essential for nurses to feel confident in their decision-making and to
practice with a clear understanding of their rights and responsibilities.

5.4 Coordinating Patient Care Plans and Advocacy

A comprehensive and well-coordinated care plan is essential to ensuring that a patient receives
the appropriate treatment and services in a timely manner. A care plan outlines the patient’s
diagnosis, treatment goals, interventions, and expected outcomes. Developing a care plan requires
the nurse to conduct a thorough assessment of the patient’s health status, preferences, and
resources. Nurses must use their clinical judgment and knowledge of evidence-based practices to
develop a care plan that is tailored to the individual’s needs.
The care plan is a dynamic document that should be updated regularly to reflect changes in the
patient's condition or response to treatment. Nurses must monitor the patient’s progress and
communicate any changes to other members of the healthcare team. For example, if a patient’s
vital signs deteriorate or they experience complications, the nurse must notify the physician and
adjust the care plan as necessary. Effective communication with the healthcare team ensures that
the plan is cohesive and that all professionals are working toward the same goals.
A well-coordinated care plan also requires attention to the patient’s personal preferences and
values. Patients are more likely to adhere to their care plan when they are involved in decision-
making and when their concerns are heard. For example, a nurse may work with the patient to
determine their goals for recovery, such as regaining independence in daily activities or managing
chronic pain. By incorporating the patient’s preferences into the care plan, the nurse helps foster
a sense of ownership and responsibility for their care, which can lead to better outcomes.
In the context of NCLEX-RN questions, care plan coordination is often assessed by evaluating
how well the nurse integrates the patient’s needs, the scope of practice of the healthcare team,
and available resources. For example, the nurse may be presented with a scenario where a patient’s
condition requires a collaborative approach. The correct answer will likely reflect a coordinated
effort between various team members, ensuring that each aspect of the patient’s care is covered
efficiently.
Key Components of a Care Plan
A well-rounded care plan should address several key components:
Assessment: This includes gathering comprehensive data about the patient’s health status,
medical history, psychosocial factors, and support systems. A complete assessment helps identify
the patient’s needs and guides the development of the care plan.
Diagnosis: Nursing diagnoses are based on the assessment data and reflect the patient’s health
problems. These diagnoses are not medical conditions but nursing issues that need to be
addressed by the nursing team.
Goals and Outcomes: The care plan should include specific, measurable, and achievable goals
that are tailored to the patient’s needs. These goals should be realistic and aligned with the patient’s
preferences and values. For example, a goal could be “The patient will verbalize a reduction in
pain level to 3/10 within 48 hours.”
Interventions: These are the actions the nurse and other healthcare team members will take to
achieve the set goals. Interventions should be evidence-based and appropriate for the patient’s
condition. For example, if a patient is recovering from surgery, an intervention might involve
providing pain management strategies or assisting with mobility.
Evaluation: The care plan must be continually evaluated to ensure it is achieving the desired
outcomes. If the patient’s condition changes or they do not respond as expected to treatment, the
nurse may need to modify the care plan to address new concerns or challenges.
Coordination between healthcare providers is essential in ensuring that all aspects of the patient’s
care plan are being addressed. Nurses need to communicate effectively with physicians, specialists,
dietitians, physical therapists, and other professionals involved in the patient's care to ensure that
everyone is on the same page. This communication may involve attending team meetings, sending
updates on the patient’s progress, and discussing changes in the patient’s condition. Coordinating
care also involves managing the patient’s resources, such as making referrals for additional services
or ensuring that the patient has access to necessary medications and equipment.
The Role of Advocacy in Nursing
Patient advocacy is a fundamental aspect of nursing care. Nurses are ethically and legally obligated
to advocate for their patients, ensuring that their rights are protected, their needs are met, and
their wishes are respected. Advocacy can take many forms, from supporting patients in making
informed decisions about their care to advocating for equitable access to healthcare services.
A key element of advocacy is ensuring that patients understand their treatment options and have
the necessary information to make informed choices. Nurses must provide clear, accurate, and
culturally appropriate information about the patient’s condition, the proposed treatments, and the
potential risks and benefits. When patients are involved in decision-making and fully understand
their options, they are more likely to comply with their treatment plan and experience better
outcomes. Advocacy also involves respecting the patient’s autonomy and supporting their right
to make decisions about their care, even when those decisions may not align with the nurse’s
personal views or the medical team’s recommendations.
For example, a nurse may encounter a patient who decides to refuse a particular treatment or
procedure. In this case, the nurse must respect the patient’s decision, provided they are mentally
competent and have been fully informed about the risks. The nurse should also ensure that the
patient’s decision is documented and that they are supported throughout the process, addressing
any concerns or questions they may have.
Nurses also advocate for patients by ensuring that their voices are heard within the healthcare
system. This may involve advocating for improved care practices, better patient access to services,
or changes in hospital policies. In some cases, nurses may need to intervene on behalf of patients
who are unable to communicate their needs or desires, such as those with cognitive impairments,
limited English proficiency, or significant health challenges. In these situations, the nurse serves
as the patient’s voice, ensuring that their needs are not overlooked.
Advocacy in Ethical Dilemmas
Nurses often encounter ethical dilemmas that require them to navigate complex decisions in a
way that prioritizes patient well-being. These dilemmas may involve end-of-life care, conflicts
between family members and healthcare providers, or situations in which patients' preferences
conflict with medical recommendations. In these cases, nurses must act as patient advocates,
ensuring that the patient’s autonomy is respected while balancing their professional obligations.
For instance, in cases where a patient is terminally ill and requests to discontinue life-sustaining
treatment, the nurse must ensure that the patient’s decision is well-informed and voluntary. While
the nurse may not agree with the decision, their role as an advocate is to support the patient in
making their own choices and ensuring that those choices are respected by the healthcare team.
Similarly, when family members disagree about a patient’s treatment plan, the nurse may need to
mediate between the family and healthcare providers, advocating for the patient’s best interests
while maintaining a professional and empathetic approach.
Collaboration and Advocacy in Discharge Planning
Another key aspect of patient advocacy is ensuring that patients are adequately prepared for
discharge. Discharge planning involves coordinating the necessary care and services to ensure that
the patient’s transition from hospital to home is as smooth as possible. Nurses advocate for their
patients during discharge by ensuring that they have the resources, education, and support
necessary to manage their health independently. This may include providing instructions on
medication management, follow-up appointments, and home care needs.
The nurse may also be involved in arranging for home health services, rehabilitation, or social
services, depending on the patient’s needs. Effective discharge planning helps prevent
readmissions, improves patient outcomes, and ensures continuity of care after the patient leaves
the hospital. Advocacy in discharge planning also involves ensuring that patients and their families
understand the discharge instructions and are comfortable with the care plan. If the nurse
identifies any barriers to a successful discharge, such as financial constraints or lack of family
support, they may advocate for additional resources or services to assist the patient.
 Chapter 6: Safety and Infection
Control (10%-16%)
6.1 Standard Precautions and Isolation Procedures
Standard precautions, initially developed by the Centers for Disease Control and Prevention
(CDC), are a set of infection prevention practices that apply to all patients, regardless of their
diagnosis or presumed infection status. These precautions are designed to reduce the risk of
transmission of microorganisms from both recognized and unrecognized sources of infection.
Standard precautions include practices such as hand hygiene, personal protective equipment
(PPE), respiratory hygiene, safe injection practices, and environmental cleaning. These practices
are intended to prevent the transmission of infections in healthcare settings, where patients may
be vulnerable to infection due to their medical conditions.
Hand Hygiene: One of the most critical components of infection control is proper hand
hygiene. Nurses must wash their hands thoroughly before and after patient contact, after handling
any equipment or materials that may be contaminated, and after removing gloves. Handwashing
should be performed with soap and water if hands are visibly soiled, and alcohol-based hand
sanitizers are effective when hands are not visibly dirty. Good hand hygiene is essential for
preventing the spread of pathogens and reducing healthcare-associated infections (HAIs).
Personal Protective Equipment (PPE): PPE is designed to create a barrier between the nurse
and potentially harmful microorganisms. Standard precautions require the use of gloves, gowns,
masks, and eye protection based on the nature of patient care. For instance, gloves should be
worn when touching bodily fluids, mucous membranes, non-intact skin, or contaminated items.
Gowns should be used when contact with the patient’s clothing or skin is anticipated. Masks and
eye protection are required when there is a risk of splashing or spraying of bodily fluids.
Respiratory Hygiene: Respiratory hygiene and cough etiquette are essential for preventing the
spread of respiratory infections. This includes encouraging patients to cover their coughs and
sneezes with a tissue or their elbow, wearing a mask if necessary, and ensuring that tissues are
disposed of appropriately. Nurses should also wear masks when caring for patients with
respiratory symptoms, especially in cases of known or suspected infectious diseases like
tuberculosis or COVID-19.
Safe Injection Practices: Proper techniques for administering injections are essential to avoid
contamination. This includes using sterile needles and syringes, preventing contamination of
injection vials, and never reusing needles or syringes. Nurses must also be diligent about the
disposal of sharps in proper containers to avoid accidental needle-stick injuries.
Environmental Cleaning: Regular cleaning and disinfection of surfaces and equipment are
necessary to prevent the spread of infection. Nurses must ensure that high-touch surfaces like
bedrails, doorknobs, and call buttons are regularly cleaned. In addition, reusable equipment like
thermometers and stethoscopes must be cleaned after each use according to hospital protocols.
By following standard precautions, nurses ensure that every patient is treated with the same level
of care and protection, minimizing the risk of infection transmission.
Isolation Precautions
In addition to standard precautions, isolation precautions are used when a patient is known or
suspected to be infected with a transmissible pathogen. Isolation precautions are based on the
mode of transmission of the infectious agent and are designed to prevent the spread of infection
to others. Isolation precautions can be categorized into four types: contact precautions, droplet
precautions, airborne precautions, and protective (reverse) isolation.
Contact Precautions
Contact precautions are used when a patient is infected with a pathogen that can be transmitted
by direct or indirect contact. This includes infections caused by bacteria like Clostridium difficile
(C. diff), methicillin-resistant Staphylococcus aureus (MRSA), or vancomycin-resistant
enterococci (VRE). Contact precautions aim to prevent the spread of pathogens via direct physical
contact with the patient or their environment.
Nurses must wear gloves and gowns when interacting with patients on contact precautions. Hand
hygiene is critical after removing gloves, as contact transmission can occur if contaminated hands
touch surfaces or objects. Patients with infections that require contact precautions should have a
private room or be cohorted with others who have the same infection. Non-essential items, such
as shared equipment, should not be used for patients in isolation unless properly disinfected.
Droplet Precautions
Droplet precautions are implemented when a patient is infected with a pathogen that can be
transmitted through respiratory droplets. This includes conditions like influenza, pertussis, and
certain types of pneumonia. Droplets are generated when a patient coughs, sneezes, or talks, and
these droplets can travel short distances (usually less than 6 feet).
For droplet precautions, nurses must wear a surgical mask when within 3 feet of the patient, along
with gloves and gowns if there is a risk of exposure to body fluids. The patient should wear a
mask if they need to leave their room for procedures, and the room should be maintained with
adequate ventilation. In some cases, patients with droplet-transmitted infections may be placed in
a single room, but this is not always necessary if they are cohorted with others with the same
infection.
Airborne Precautions
Airborne precautions are used when a patient is infected with a pathogen that can be transmitted
through tiny airborne particles. These particles can remain suspended in the air for extended
periods and can travel long distances. Common infections requiring airborne precautions include
tuberculosis (TB), varicella (chickenpox), and measles.
For airborne precautions, nurses must wear an N95 respirator mask, which filters out small
particles that could be inhaled. In addition, patients on airborne precautions must be placed in a
negative pressure room, which ensures that air flows into the room and not out of it, preventing
the spread of airborne particles to other areas. If the patient needs to leave the room, they must
wear a surgical mask to reduce the risk of transmission.
Protective (Reverse) Isolation
Protective isolation, or reverse isolation, is used for patients who are immunocompromised and
at high risk for infection, such as those undergoing chemotherapy, stem cell transplants, or other
treatments that suppress the immune system. In these cases, the goal is to protect the patient from
infections that could be transmitted by others.
Nurses caring for patients in protective isolation should wear appropriate PPE, including gloves,
gowns, and masks, depending on the patient’s condition. The patient’s room should be well-
ventilated and free from potential sources of infection, and visitors may be restricted to reduce
the risk of transmission. Strict hand hygiene and the use of dedicated equipment (such as
thermometers and stethoscopes) are important to minimize the risk of introducing pathogens into
the patient’s environment.
Infection Control During Specific Procedures
In addition to standard and isolation precautions, certain procedures require additional infection
control measures to prevent the transmission of pathogens. Nurses must be particularly vigilant
when performing invasive procedures or handling equipment that can introduce pathogens into
a sterile area. For instance, during procedures such as catheter insertion or wound dressing
changes, nurses must use sterile technique to avoid contaminating the site.
The use of sterile gloves, gowns, and drapes is essential during these procedures. Nurses must
also ensure that equipment is sterilized or disinfected between uses to prevent cross-
contamination. It is vital that nurses follow infection control protocols when performing these
procedures to protect both the patient and themselves from infection.
Training and Education
Infection control practices are most effective when all healthcare workers are properly trained and
aware of the guidelines. Nurses should participate in ongoing education and training regarding
infection prevention and control, particularly when new pathogens or infection outbreaks are
identified. Hospitals and healthcare settings often provide updates on current best practices for
infection control, and nurses must stay informed about the latest protocols, especially when
dealing with emerging infectious diseases like COVID-19 or antibiotic-resistant organisms.
Effective education for patients is also a key component of infection control. Nurses must educate
patients and their families about the importance of hand hygiene, the use of PPE, and other
measures they can take to prevent the spread of infection, especially if they are being discharged
with infectious conditions. Patient education may involve teaching about proper wound care,
respiratory hygiene, or the need for isolation at home to prevent the spread of infection to others.
NCLEX Considerations for Infection Control
On the NCLEX-RN exam, questions related to infection control focus on a nurse’s ability to
apply standard precautions and isolation procedures to protect both patients and healthcare
workers. Candidates should be familiar with when to implement different types of isolation
precautions, the use of PPE, and how to educate patients and their families about infection
prevention. It’s important to understand the rationale behind infection control practices and to
apply that knowledge to clinical scenarios.
NCLEX questions may also test a candidate’s ability to identify appropriate actions when caring
for patients with known or suspected infectious diseases. For example, a question may present a
scenario where a nurse must decide the best course of action for a patient with a suspected
respiratory infection. The correct answer would likely involve ensuring the patient wears a mask,
wearing appropriate PPE, and placing the patient in a private room or cohorted with other
patients with the same infection.

6.2 Preventing Healthcare-Associated Infections

Healthcare-associated infections are infections that occur during the course of medical care. They
can be caused by a wide range of pathogens, including bacteria, viruses, fungi, and parasites, and
are often the result of exposure to contaminated equipment, medical devices, or the hospital
environment. Common types of HAIs include surgical site infections (SSIs), urinary tract
infections (UTIs), pneumonia, bloodstream infections (BSIs), and gastrointestinal infections such
as Clostridium difficile (C. diff).
HAIs can result from various factors, including:
Contaminated medical devices: Devices like catheters, ventilators, and IV lines can introduce
pathogens directly into a patient's body if not properly sterilized or managed.
Inadequate hand hygiene: Failure to wash hands thoroughly before and after patient contact is
a major contributor to the transmission of infections in healthcare settings.
Improper cleaning of surfaces: Contaminated surfaces, such as bedrails, doorknobs, and
medical equipment, can harbor pathogens and contribute to the spread of infection.
Antibiotic resistance: Overuse or misuse of antibiotics can lead to the development of
antibiotic-resistant organisms, which are more difficult to treat and can spread within healthcare
facilities.
Because of the potential severity and the impact on patient outcomes, preventing HAIs is a high
priority in nursing practice and patient safety initiatives.
Risk Factors for Healthcare-Associated Infections
Several factors increase a patient's risk of acquiring an HAI. These risk factors can be broadly
categorized into patient-related factors, healthcare-related factors, and environmental factors.
Understanding these risk factors helps nurses to prioritize infection prevention strategies for high-
risk patients.
Patient-Related Factors:
Age: Elderly patients and neonates are at higher risk for infections due to weakened immune
systems.
Comorbidities: Patients with chronic diseases such as diabetes, cancer, or heart disease may have
compromised immune systems or underlying conditions that make them more susceptible to
infections.
Immune System Status: Patients with weakened immune systems—due to conditions like
HIV/AIDS, chemotherapy, or immunosuppressive drugs—are at higher risk of infections.
Invasive Procedures: Patients undergoing surgery, catheterization, or other invasive procedures
are more susceptible to infections due to the introduction of foreign objects into the body.
Antibiotic Use: Prolonged use of antibiotics can disrupt the normal balance of microorganisms
in the body, leading to overgrowth of harmful bacteria like C. diff, which causes gastrointestinal
infections.
Length of Hospital Stay: The longer a patient stays in the hospital, the greater their exposure to
potential sources of infection.
Healthcare-Related Factors:
Invasive Devices: Medical devices like urinary catheters, ventilators, and central lines can
introduce pathogens directly into the body, leading to infections if not properly managed.
Surgical Procedures: Surgery introduces the risk of surgical site infections, particularly in
patients with compromised immunity or those undergoing major procedures.
Use of Inadequate or Improper Sterilization Techniques: Improper cleaning or sterilization
of equipment and instruments can lead to the spread of infections.
Healthcare Worker Behavior: Poor hand hygiene, improper use of PPE, and lapses in following
infection control protocols by healthcare staff can contribute to the transmission of infections.
Environmental Factors:
Hospital Environment: Contaminated surfaces, inadequate cleaning practices, and overcrowded
conditions in healthcare settings can facilitate the spread of infectious agents.
Airborne Contaminants: Hospitals that lack proper ventilation or isolation protocols for
patients with airborne diseases (e.g., tuberculosis, COVID-19) pose an increased risk of airborne
transmission of infections.
Patient Room Layout: Shared patient rooms or improper placement of patients with infectious
diseases may contribute to the spread of infection.
Preventive Measures for Healthcare-Associated Infections
Nurses play a crucial role in preventing HAIs by adhering to infection control protocols,
practicing proper hygiene, and educating patients and families about infection prevention. Several
strategies can be implemented to reduce the risk of HAIs:
1. Hand Hygiene
Hand hygiene is the single most effective way to prevent the spread of infections in healthcare
settings. Nurses should wash their hands with soap and water or use alcohol-based hand sanitizers
before and after patient contact, after handling equipment, and after touching potentially
contaminated surfaces.
When to wash hands:
Before and after patient contact
Before and after performing procedures (such as inserting an IV or catheter)
After handling bodily fluids, excretions, or contaminated objects
After touching surfaces in the patient’s environment
Proper hand hygiene reduces the likelihood of pathogen transmission and significantly decreases
the risk of HAIs.
2. Proper Use of Personal Protective Equipment (PPE)
Personal protective equipment (PPE) is essential in preventing direct contact with infectious
agents. PPE includes gloves, gowns, masks, and eye protection, and should be worn according to
the type of exposure anticipated. For example, gloves are essential when handling contaminated
equipment or performing invasive procedures, while gowns are required when there is a risk of
exposure to bodily fluids. Masks and eye protection should be used in situations where droplets
or splashes are likely to occur.
The correct use of PPE includes:
Ensuring that PPE is donned before patient contact
Disposing of or cleaning PPE after use
Performing hand hygiene after removing PPE
Nurses must be aware of the appropriate PPE required for different isolation categories, such as
contact precautions, droplet precautions, and airborne precautions, to prevent cross-
contamination and ensure patient safety.
3. Sterile Technique and Equipment Handling
Proper sterilization of medical equipment is a critical aspect of infection control. Nurses must
follow institutional protocols for sterilizing or disinfecting equipment that comes into contact
with patients or their environment. Reusable items such as thermometers, stethoscopes, and
wound care supplies must be cleaned thoroughly between uses.
Key sterilization practices include:
 Using sterile equipment for invasive procedures (e.g., catheters, IVs)
Following guidelines for the sterilization of surgical instruments
Disposing of single-use items properly after use (e.g., syringes, needles)
Maintaining a sterile environment is essential to prevent HAIs during procedures and when
handling contaminated materials.
4. Antibiotic Stewardship
Antibiotic stewardship programs aim to minimize the misuse and overuse of antibiotics, which
can contribute to antibiotic resistance. Nurses should encourage appropriate antibiotic use by
ensuring that antibiotics are prescribed only when necessary and that the correct drug, dosage,
and duration are followed.
For patients receiving antibiotics, nurses should:
Monitor for signs of resistance (e.g., lack of improvement despite treatment)
Educate patients about completing the full course of prescribed antibiotics
Be vigilant about potential side effects or complications of antibiotic use, such as C. difficile
infections
Preventing antibiotic resistance through effective stewardship is essential for controlling the
spread of multidrug-resistant organisms in healthcare settings.
5. Infection Control in High-Risk Areas
Certain areas of the hospital, such as intensive care units (ICUs), operating rooms, and dialysis
units, have higher risks for HAIs due to the nature of the procedures and the vulnerability of the
patients. Nurses in these areas must adhere to stringent infection control practices to minimize
the risk of infection.
Key strategies for infection control in high-risk areas:
Strict hand hygiene and PPE protocols
Enhanced environmental cleaning and disinfection
Limiting patient movement and minimizing exposure to infectious agents
6. Environmental Cleaning and Disinfection
Cleaning and disinfecting the environment are critical steps in preventing the spread of HAIs.
High-touch surfaces, such as bedrails, door handles, and light switches, must be cleaned frequently
to reduce the presence of pathogens. The hospital environment should be maintained in a way
that minimizes the risk of contamination, and appropriate cleaning agents must be used to
disinfect surfaces after patient contact.
Cleaning protocols include:
Routine cleaning of patient rooms, bathrooms, and common areas
Disinfection of shared equipment between patient use
Monitoring and auditing cleaning practices to ensure compliance with infection control
standards
7. Patient Education
Educating patients and their families about infection prevention is an essential part of nursing
care. Nurses should provide clear information on how patients can reduce their risk of infection
during hospitalization and after discharge. This includes teaching patients about proper hand
hygiene, how to care for surgical wounds, and the importance of following infection control
protocols (e.g., wearing a mask if required).
Nurses should also inform patients about signs and symptoms of infection, such as fever, redness,
or discharge, and when to seek medical attention. By empowering patients with knowledge, nurses
help reduce the likelihood of post-discharge infections and improve overall health outcomes.
NCLEX Considerations for Preventing Healthcare-Associated Infections
On the NCLEX-RN exam, questions related to preventing healthcare-associated infections test a
candidate's understanding of infection control protocols, their ability to apply standard
precautions and isolation procedures, and their knowledge of how to reduce the risk of infection
in a healthcare setting. Questions may ask candidates to identify the appropriate infection control
measures for specific scenarios or to prioritize actions based on infection risk.
To answer these questions correctly, candidates must:
Understand when and how to use standard precautions and isolation precautions
Recognize the risk factors for healthcare-associated infections
Apply infection control measures, such as hand hygiene, PPE use, and sterile techniques
Be familiar with hospital infection control policies and antibiotic stewardship programs
By mastering these infection control practices, nursing candidates can confidently answer
NCLEX questions related to HAIs and ensure they are prepared to prevent infections in clinical
practice.

6.3 Safe Medication Administration and Equipment Handling

Administering medications safely requires nurses to follow a structured process to ensure the
correct drug, dose, time, route, and patient are targeted for each medication administration.
Medication errors can have serious consequences, including adverse drug reactions, therapeutic
failures, and even patient death. Nurses must be knowledgeable about pharmacology, understand
the principles of drug interactions, and be adept in using safe practices to ensure that medications
are administered correctly.
The Five Rights of Medication Administration are a fundamental guideline for nurses to follow to minimize errors:
Right Patient: Verify the patient's identity using at least two identifiers (e.g., name, date of birth,
patient ID number). This is particularly important in settings where multiple patients may share
similar names.
Right Medication: Ensure that the correct medication is being administered. This involves
checking the medication order, verifying the medication label, and ensuring that it matches the
prescription or physician’s order.
Right Dose: The prescribed dose must be accurately measured and double-checked before
administration. Nurses should be familiar with standard dosage ranges for medications and be
cautious when calculating dosages, especially for high-risk medications.
Right Route: Medications must be administered through the prescribed route, such as oral,
intravenous, intramuscular, or topical. Nurses must verify the route as some medications cannot
be given by certain routes due to absorption or formulation issues.
Right Time: Administer the medication at the specified time. This may include specific time
windows (e.g., within an hour of the scheduled time) or adherence to specific timing instructions
(e.g., before meals, after meals, at bedtime).
In addition to the five rights, nurses should be aware of special considerations such as drug
interactions, allergies, and contraindications. It’s also essential to monitor for side effects or
adverse reactions after medication administration. For example, when administering an
intravenous medication, a nurse must observe the patient for any signs of infiltration or
extravasation, which can cause tissue damage.
Double-Checking Medications: Whenever possible, especially with high-risk drugs (e.g.,
insulin, anticoagulants, chemotherapeutic agents), medications should be double-checked by two
qualified healthcare providers (such as another nurse or a pharmacist) before administration. This
extra layer of verification helps to ensure that the correct drug and dose are being given.
Medication Administration Records (MARs): Nurses must accurately document medication
administration in the patient's MAR. This includes the name of the drug, the dose, the time of
administration, and any relevant observations or reactions. MARs also help track when
medications are due and when the patient last received a dose, ensuring proper adherence to the
prescribed regimen.
Patient Education: Part of safe medication administration includes educating patients about
their medications. Nurses should provide information on the purpose of the medication, potential
side effects, how to take the medication, and when to notify healthcare providers if something
seems wrong (e.g., unusual reactions, missed doses). Proper patient education helps to improve
medication adherence and patient outcomes.
Preventing Medication Errors
Medication errors can occur at any stage of the medication administration process, from
prescribing and dispensing to administering and monitoring. Some common medication errors
include:
Wrong drug: Administering a medication other than the one ordered by the healthcare provider.
Wrong dose: Administering too much or too little of a medication.
Wrong route: Administering a drug by the wrong method (e.g., giving oral medications
intravenously).
Wrong time: Administering medications at the wrong time, either too early, too late, or in
contradiction to specific instructions.
Omission errors: Failing to administer a medication that was ordered.
To reduce medication errors, nurses should:
Follow the Six Rights: Right patient, right medication, right dose, right route, right time, and
right documentation.
Use barcode scanning technology, where available, to ensure the right drug is administered to the
right patient.
Communicate effectively with the healthcare team about the patient's condition, any changes to
the prescribed regimen, and any patient concerns related to medications.
Report any errors immediately so that they can be addressed, and steps can be taken to prevent
future errors.
Equipment Handling
Medical equipment plays a vital role in diagnosing, monitoring, and treating patients. Proper
handling, maintenance, and use of medical equipment ensure that devices function properly and
safely, minimizing the risk of injury or harm to patients.
Types of Medical Equipment and Their Handling
Monitoring Equipment: This includes devices like blood pressure cuffs, thermometers, pulse
oximeters, and electrocardiograms (ECGs). Nurses must ensure these devices are calibrated
correctly and that they are used according to institutional protocols.
Routine Maintenance: Regular cleaning and sterilization of monitoring equipment are necessary
to prevent cross-contamination. For example, blood pressure cuffs should be disinfected after
each use, and thermometers should be cleaned or covered with disposable sheaths to prevent the
spread of infection.
Accurate Readings: Ensuring that equipment is functioning properly and correctly calibrated is
vital. Nurses should be knowledgeable about troubleshooting common issues with monitoring
equipment (e.g., false readings due to improper placement).
Infusion Pumps: These devices are used to deliver fluids, medications, or nutrition
intravenously. Nurses must ensure that infusion pumps are programmed correctly and that they
deliver the prescribed medication or fluid at the right rate. They must also monitor for signs of
infiltration, extravasation, or other complications.
Pump Settings: Nurses should double-check the settings before starting the infusion and
continuously monitor the patient during the process. They should be familiar with the specific
parameters for medications that require an infusion pump, especially with high-risk medications
like insulin or opioids.
Equipment Inspection: Before use, nurses must inspect infusion pumps and tubing for any
visible defects, leaks, or blockages.
Surgical Equipment: Sterilization and proper handling of surgical instruments are critical to
preventing infections. Instruments must be cleaned, disinfected, and stored according to hospital
procedures to ensure they are safe for use in surgeries.
Sterilization: Nurses involved in surgical procedures must follow sterile techniques to prevent
contamination. This involves ensuring that all instruments are sterilized, the surgical field is
maintained sterile, and all sterile supplies are handled according to infection control protocols.
Safe Disposal: Sharp objects such as scalpels, needles, and syringes must be disposed of in proper
sharps containers to prevent injury or infection transmission.
Assistive Devices: These include items such as catheters, oxygen masks, and feeding tubes.
Proper handling of these devices is crucial for patient safety. Nurses should be skilled in using
these devices appropriately, ensuring they are sterile when required, and monitoring the patient
for any adverse reactions or complications.
Catheters: Urinary catheters, for example, require meticulous attention to prevent infections.
Nurses must ensure proper insertion, maintenance, and removal, as well as educate patients on
care practices if the catheter is to remain in place for any period.
Oxygen Therapy: Nurses must ensure that oxygen delivery devices (e.g., nasal cannulas, face
masks) are working properly, and the flow rate is set according to the patient's needs. They should
also monitor the patient for any adverse effects such as oxygen toxicity or dry nasal passages.
Preventing Equipment Failures and Malfunctions
Nurses are responsible for ensuring that medical equipment is properly used, maintained, and
replaced as needed. Preventing equipment failure involves:
Routine Checks and Calibration: Nurses must check the equipment before each use to ensure
it is functioning properly. This includes checking for visible damage, ensuring the equipment is
clean, and confirming that settings or parameters are correct.
Reporting Faulty Equipment: If equipment malfunctions, nurses must report the issue
promptly, ensuring that the device is repaired or replaced. This prevents further complications
from equipment failures, especially in critical care areas.
Safe Handling and Storage: Proper handling and storage of equipment can prevent damage.
Equipment should be stored in a clean, dry place to avoid contamination and ensure longevity.
Documentation and Communication in Medication Administration and Equipment Handling
Accurate documentation and clear communication are critical in medication administration and
equipment handling. Nurses must document the administration of medications in the Medication
Administration Record (MAR), noting the time, dose, route, and any observed effects or side
effects. They should also communicate any changes in patient condition or equipment
functionality to the healthcare team to ensure continuous, safe care.
Documentation should include:

 The patient’s response to medications, including side effects, therapeutic effects, or adverse
reactions.
 Any changes in equipment settings or usage, including malfunction reports or maintenance.
 Changes in the treatment plan based on the patient’s response to medication or equipment
use.
NCLEX Considerations for Safe Medication Administration and Equipment Handling
On the NCLEX-RN exam, questions related to medication administration and equipment
handling will test a candidate’s ability to apply the principles of safe practice in clinical scenarios.
Candidates may be asked to identify the correct medication, dose, or route for a patient or
troubleshoot a problem with medical equipment. In these scenarios, candidates must demonstrate
knowledge of pharmacology, safe administration practices, and infection control principles.
For medication administration, the NCLEX may present scenarios involving complex calculations
or questions about drug interactions, side effects, or contraindications. For equipment handling,
candidates may be tested on their knowledge of proper equipment use, maintenance, and
troubleshooting techniques.

6.4 Emergency Response Protocols and Safety Measures

Emergency response protocols provide a structured, step-by-step approach for handling critical
situations. These protocols are designed to guide healthcare providers in making quick decisions
and taking the correct actions to stabilize patients, prevent further harm, and provide immediate
care. Nurses must be familiar with these protocols as they form the foundation of emergency
nursing practice. Key protocols often include:
1. Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS)
Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) are essential
protocols for nurses, particularly when responding to cardiac arrest, respiratory failure, or other
life-threatening emergencies.
Basic Life Support (BLS) focuses on providing immediate assistance to individuals who are
unresponsive, not breathing, or have no pulse. The primary actions involve performing CPR
(cardiopulmonary resuscitation) to restore circulation and breathing until further help arrives.
CPR Steps: The nurse should assess the patient’s airway, breathing, and circulation. If the patient
is not breathing, the nurse should immediately begin chest compressions and rescue breathing.
Defibrillation: In cases of cardiac arrest due to arrhythmia, an Automated External Defibrillator
(AED) may be used to administer shocks that can restore a normal rhythm.
Advanced Cardiovascular Life Support (ACLS) is used when patients experience more complex
cardiovascular emergencies, including severe arrhythmias, acute coronary syndromes, and strokes.
ACLS involves advanced procedures such as drug administration, endotracheal intubation, and
the use of defibrillators, in addition to the basic life support measures outlined above.
Both BLS and ACLS protocols are critical for nurses working in emergency rooms, intensive care
units (ICUs), or other acute care settings. These protocols guide nurses in how to react swiftly
and appropriately during a crisis, prioritizing patient survival and stabilization.
2. Emergency Response Systems
Hospitals and healthcare settings have specific emergency response systems in place to address
different types of emergencies. These systems ensure that help is rapidly deployed to patients in
need. Nurses must be familiar with their institution's emergency protocols, which may include:
Code Systems: Codes are commonly used in hospitals to alert staff to different emergency
situations. For example, a "Code Blue" typically signifies a cardiac arrest situation, and "Code
Red" may indicate a fire emergency. Nurses should know how to respond to these codes and
participate in the emergency response team when called.
Rapid Response Teams (RRTs): These teams are often activated when a patient’s condition
rapidly deteriorates but does not yet require full emergency code activation. Nurses may play a
role in initiating or supporting the RRT in order to prevent a code situation from arising.
Mass Casualty Incidents (MCI): These events, such as natural disasters or large-scale accidents,
may overwhelm healthcare facilities. Nurses must be prepared for triage and managing multiple
patients simultaneously, ensuring that resources are allocated efficiently and patients are
prioritized based on the severity of their condition.
3. Trauma Protocols
Trauma protocols are specific to the care of patients who have sustained severe injuries, such as
those from accidents, falls, or violence. Nurses must be trained to identify and manage life-
threatening injuries, such as bleeding, respiratory distress, or head trauma. Protocols may include:
Primary Survey (ABCDE): Nurses must perform a rapid primary survey to assess the patient’s
airway, breathing, circulation, disability (neurological status), and exposure to identify immediate
threats to life.
Secondary Survey: After stabilizing the patient, a more detailed assessment is conducted to
identify other injuries and medical concerns that require attention.
Triage: In situations where multiple patients require care simultaneously (e.g., in a mass casualty
incident), nurses may participate in triage, which involves sorting patients by the severity of their
injuries to ensure that those with the most urgent needs receive care first.
Safety Measures for Nurses in Emergency Situations
Nurses must also ensure their own safety during emergency situations. Emergency scenarios can
be chaotic, and nurses need to be mindful of potential hazards in the environment. Nurses should
follow safety protocols to minimize personal injury, infection risks, and other hazards.
1. Personal Protective Equipment (PPE)
In emergency settings, especially during procedures that involve blood, bodily fluids, or hazardous
substances, nurses must wear appropriate PPE to protect themselves. This may include:
Gloves: To protect against contact with blood or other body fluids.
Gowns and Aprons: To protect the nurse’s clothing and skin from contamination.
Masks and Respirators: To prevent inhalation of airborne pathogens or contaminants.
Respirators are particularly necessary in the presence of airborne diseases like tuberculosis or
COVID-19.
Face Shields or Goggles: To protect the eyes from splashes of blood or bodily fluids, as well as
from harmful chemicals or medications used in emergency care.
Proper use of PPE is crucial to preventing cross-contamination between the nurse, the patient,
and the environment. Nurses should follow the correct sequence for donning and doffing PPE,
ensuring that they remove it carefully to avoid contaminating themselves.
2. Handling Hazardous Materials
Emergency situations may involve hazardous materials, including medications, chemicals, or
biological substances. Nurses must be trained in handling hazardous materials safely and
understanding how to react if there is a spill or exposure. For example, exposure to chemicals
during an emergency response can result in burns or respiratory distress, so nurses must be
familiar with the procedures for decontamination and reporting exposure.
Chemical Spill Protocols: In cases of chemical spills, such as hazardous drugs or cleaning agents,
nurses must ensure the area is secured, evacuate the patient if necessary, and follow institution-
specific decontamination procedures. Chemical spills often require special PPE, such as gloves
and protective clothing, to safely manage the situation.
3. Fire Safety
In the event of a fire, nurses must be familiar with fire safety protocols, including the use of fire
extinguishers, evacuating patients, and assisting in fire drills. The RACE acronym is commonly
used for fire safety:
Rescue anyone in immediate danger.
Alarm: Activate the fire alarm system.
Contain the fire by closing doors and windows.
Extinguish the fire if it is small and manageable, or evacuate the area.
Nurses should also be prepared to move patients in a safe, calm, and orderly manner during a fire
evacuation. Specific emergency exits, evacuation routes, and assembly areas should be known by
all healthcare staff.
Special Considerations for Pediatric, Geriatric, and Pregnant Patients
In emergency situations, it is important to consider the unique needs of pediatric, geriatric, and
pregnant patients, as these groups may require different approaches for care.
1. Pediatric Patients
Children are particularly vulnerable in emergencies, and their treatment often differs from that of
adults. Nurses must be prepared to adapt emergency protocols to pediatric patients, including:
Pediatric Dosages: Drug doses must be adjusted according to the child's age, weight, and
developmental stage. Nurses should be familiar with pediatric pharmacology and drug
calculations.
Family Support: In pediatric emergencies, family members are often extremely anxious. Nurses
should be skilled in providing emotional support and communicating effectively with parents or
guardians.
2. Geriatric Patients
Elderly patients may have multiple chronic conditions, reduced mobility, and sensory impairments
that can complicate their response to emergencies. Nurses must be sensitive to these challenges
and prioritize:
Fall Prevention: Elderly patients may be more susceptible to falls, especially if they are weakened
or confused. Providing appropriate assistance during evacuation and avoiding unnecessary
movements is key.
Polypharmacy: Older adults often take multiple medications, and their response to drugs may
be different due to age-related changes in pharmacokinetics and pharmacodynamics. Nurses
should be aware of these factors when administering medications during an emergency.
3. Pregnant Patients
Pregnant women in emergencies require additional considerations, particularly if the situation
involves trauma or the risk of preterm labor. Key concerns include:
Monitoring for Maternal and Fetal Well-Being: Nurses should assess the health of both the
mother and the fetus during emergencies, ensuring that the pregnancy remains stable.
Positioning: In certain emergency situations, such as trauma or respiratory distress, positioning
the pregnant patient appropriately (e.g., on their left side) can enhance blood flow to the uterus
and improve fetal outcomes.
NCLEX Considerations for Emergency Response and Safety Measures
On the NCLEX-RN exam, questions related to emergency response and safety measures test your
ability to apply emergency protocols, prioritize patient care in crisis situations, and ensure safety
for both the patient and healthcare workers. The exam may include scenarios where you need to
identify the correct actions during a medical emergency, such as recognizing symptoms of a heart
attack or stroke, implementing CPR, or responding to a fire or chemical spill.
Key topics to focus on for the NCLEX:

 Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) procedures.
 Emergency response codes and when to activate them.
 Correct use of PPE and safety measures for hazardous materials.
 Fire safety procedures and emergency evacuation protocols.
 Special considerations for vulnerable populations (pediatric, geriatric, pregnant patients).
 Chapter 7: Health Promotion
and Maintenance (6%-12%)
7.1 Patient Education and Health Promotion Strategies
Patient education is the process by which nurses provide information to patients about their
health conditions, treatment options, and how to manage their health effectively. Nurses must
assess the patient’s current level of understanding, cultural background, learning preferences, and
readiness to learn before providing education. Effective patient education improves health
outcomes, increases patient satisfaction, and reduces hospital readmissions by promoting self-care
practices and enhancing adherence to treatment plans.
Key Elements of Patient Education
Assessing the Patient’s Learning Needs: Before providing education, nurses must evaluate
the patient’s level of knowledge, learning style, literacy, and readiness to learn. This can be done
through interviews, questionnaires, and observation. The nurse needs to consider if the patient
understands their diagnosis, treatment plan, and the importance of lifestyle changes.
Setting Clear and Achievable Goals: The nurse should set specific, measurable, attainable,
relevant, and time-bound (SMART) goals for patient education. These goals help patients focus
on what they need to learn and give a sense of direction. For example, “The patient will
demonstrate how to correctly administer insulin injections by the end of the teaching session” is
a SMART goal.
Tailoring the Information: Health literacy varies from person to person, so it is essential for
nurses to adapt their teaching to the patient’s abilities and preferences. This may involve using
simple language, visual aids, videos, or hands-on demonstrations. It’s crucial that the patient
understands the information clearly, and that it is relevant to their life and health situation.
Providing Ongoing Support: Learning is an ongoing process, and nurses must provide follow-
up education and resources. Support can include offering written materials, websites, or
connecting patients with support groups. Regular check-ins and encouragement help reinforce
learning and increase compliance with health plans.
Health Promotion Strategies in Nursing
Health promotion refers to activities that improve overall health and prevent illness before it
occurs. Nurses play an essential role in guiding patients toward healthy lifestyles, disease
prevention, and wellness. By focusing on health promotion, nurses help patients reduce the risk
of developing chronic conditions such as cardiovascular disease, diabetes, and obesity.
1. Encouraging Healthy Lifestyles
Healthy lifestyle changes are fundamental to preventing a range of health problems. Nurses can
promote lifestyle modifications by addressing areas such as diet, exercise, tobacco use, and alcohol
consumption. Some key strategies include:
Dietary Counseling: Nurses educate patients on the importance of balanced nutrition,
appropriate portion sizes, and the benefits of including more fruits, vegetables, whole grains, and
lean proteins in their diet. They may also provide tips for reducing the intake of unhealthy fats,
sugars, and salt.
Exercise Recommendations: Nurses encourage physical activity, which has numerous health
benefits, including weight management, improved cardiovascular health, and better mental well-
being. The nurse may advise patients to engage in at least 150 minutes of moderate-intensity
exercise per week, in line with the American Heart Association’s recommendations.
Smoking Cessation: Nurses provide education on the harmful effects of smoking and offer
strategies for quitting, such as counseling, nicotine replacement therapy, and support groups.
Quitting smoking reduces the risk of respiratory diseases, cardiovascular disease, and cancer.
Alcohol and Drug Use: Nurses educate patients on the risks of excessive alcohol consumption
and substance abuse, promoting moderation and helping patients access appropriate counseling
or support services if needed.
2. Immunizations and Preventive Screenings
Immunizations and screenings are essential for preventing diseases and identifying health issues
early, when they are easier to treat. Nurses have a vital role in promoting vaccination and
encouraging regular screenings.
Immunizations: Nurses ensure that patients are up to date with vaccinations, such as influenza,
pneumococcal, and hepatitis vaccines, as well as childhood vaccinations. In addition, they educate
patients about the importance of these vaccines in preventing serious illnesses.
Cancer Screening: Nurses emphasize the importance of routine screenings for cancers such as
breast, cervical, colorectal, and prostate cancer. Depending on the patient's age and risk factors,
the nurse may provide information about when and how often screenings should occur. For
example, mammograms should be done every year starting at age 40, and Pap smears should be
done every 3 years for women aged 21 to 65.
Blood Pressure, Cholesterol, and Diabetes Screenings: Nurses assess for signs of hypertension,
high cholesterol, and diabetes by recommending regular screening tests like blood pressure
measurements, lipid profiles, and blood glucose checks. Identifying risk factors early can prevent
complications and help manage chronic diseases effectively.
3. Mental Health Promotion
Mental health is an essential component of overall well-being. Nurses must address mental health
issues as part of health promotion efforts, including promoting self-care and stress management
techniques.
Stress Reduction: Nurses teach patients how to manage stress through relaxation techniques,
mindfulness, meditation, and deep breathing exercises. They may also recommend activities such
as yoga, walking, or journaling to help reduce stress levels.
Mental Health Education: Nurses provide information about common mental health disorders
such as depression and anxiety and educate patients about available treatments, including therapy,
medication, and lifestyle changes that can help improve mental health.
Cultural Sensitivity in Patient Education
Cultural competence is essential in patient education, as it helps nurses provide care that respects
the cultural, religious, and personal beliefs of patients. Nurses must be sensitive to the cultural
backgrounds of their patients and tailor health promotion and education strategies to be culturally
appropriate.
Understanding Health Beliefs: Nurses need to be aware that different cultures may have
varying beliefs about health, illness, and treatment. For example, some cultures may place high
value on traditional or alternative medicine, and nurses should acknowledge and incorporate these
beliefs into the care plan when possible.
Language Barriers: For patients who speak a different language, it’s essential to use professional
interpreters or translation services to ensure accurate communication. Written materials should
be available in the patient's primary language whenever possible to enhance understanding.
Patient Education for Chronic Disease Management
For patients with chronic conditions, ongoing education is essential for self-management. Nurses
must help patients understand their conditions and equip them with the tools they need to manage
their health on a daily basis.
1. Diabetes Education
Diabetes is one of the most common chronic diseases, and patients with diabetes require ongoing
education to manage their blood glucose levels and avoid complications. Nurses should educate
patients on:
Blood Glucose Monitoring: Teaching patients how to monitor their blood sugar levels using a
glucometer and understanding how diet, exercise, and medications impact their blood sugar levels.
Insulin Administration: For patients who need insulin, nurses should provide instruction on
how to properly administer insulin injections, rotate injection sites, and recognize signs of
hypoglycemia.
Dietary Modifications: Nurses help patients plan balanced meals that control blood sugar levels,
emphasizing the importance of portion control and understanding carbohydrate counting.
Foot Care: Because diabetes can lead to poor circulation and nerve damage, patients must be
educated on proper foot care to prevent infections and complications.
2. Hypertension Education
For patients with hypertension, nurses educate on lifestyle changes and medication adherence to
prevent complications such as stroke, heart attack, and kidney disease. Key topics include:
Monitoring Blood Pressure: Nurses educate patients on how to monitor their blood pressure
at home, stressing the importance of tracking measurements and sharing them with their
healthcare provider.
Medication Adherence: Nurses help patients understand the importance of taking
antihypertensive medications as prescribed and discuss potential side effects.
Diet and Lifestyle Changes: Nurses recommend a diet low in sodium and rich in fruits,
vegetables, and whole grains. They also encourage regular exercise and weight management.
NCLEX Considerations for Patient Education and Health Promotion
The NCLEX-RN exam includes questions that assess a nurse's ability to educate patients on
health promotion, disease prevention, and chronic disease management. These questions test your
knowledge of various patient education strategies, understanding of health promotion principles,
and ability to provide culturally competent education.
For NCLEX success, candidates should:

 Be familiar with health promotion guidelines for different age groups and populations.
 Understand the role of vaccines in preventing infectious diseases and promoting health.
  Be able to provide education on chronic disease management, including lifestyle
modifications, medications, and self-care techniques.

7.2 Disease Prevention and Screening Guidelines

Disease prevention refers to actions taken to reduce the likelihood of developing diseases,
particularly chronic conditions such as heart disease, diabetes, cancer, and respiratory illnesses.
Preventive care focuses on promoting health and addressing modifiable risk factors that
contribute to disease development. There are three primary levels of disease prevention: primary,
secondary, and tertiary.
1. Primary Prevention
Primary prevention focuses on preventing the onset of disease by addressing risk factors and
promoting health behaviors. This level of prevention aims to reduce the likelihood of individuals
developing diseases in the first place.
Health Promotion: Educating patients on healthy behaviors, including regular physical activity, a
balanced diet, proper sleep hygiene, and stress management, helps prevent many diseases. Nurses
should encourage patients to maintain a healthy weight, engage in regular exercise, and eat a diet
rich in fruits, vegetables, and whole grains. These lifestyle changes can significantly reduce the risk
of developing chronic conditions like obesity, cardiovascular diseases, and diabetes.
Vaccination: Vaccines are one of the most effective tools in preventing infectious diseases. Nurses
play an essential role in ensuring that patients are up to date on their immunizations, including
vaccines for influenza, pneumonia, hepatitis, human papillomavirus (HPV), and childhood
vaccines such as measles, mumps, and rubella. Immunizations help protect individuals and
communities by preventing the spread of preventable diseases.
Health Education: Nurses should educate patients on the importance of preventive measures such
as hand hygiene, smoking cessation, alcohol moderation, and safe sexual practices. These actions
can reduce the likelihood of contracting infectious diseases, prevent the spread of sexually
transmitted infections (STIs), and reduce the risk of liver disease and certain cancers.
2. Secondary Prevention
Secondary prevention focuses on detecting diseases at an early stage before symptoms appear,
allowing for early intervention and reducing the severity of the disease. The goal is to identify
individuals who may be at risk or have early signs of a disease to initiate treatment and prevent
progression.
Screening for Chronic Conditions: Nurses should encourage patients to undergo routine screenings for
conditions such as hypertension, high cholesterol, diabetes, and cancer. Early detection allows for
timely treatment and can prevent complications. Common screening tests include:
Blood Pressure Checks: Regular screening for high blood pressure (hypertension) is essential in
preventing heart disease and stroke. Nurses must educate patients about the importance of
monitoring blood pressure regularly and taking appropriate actions to manage hypertension.
Cholesterol Screening: Elevated cholesterol levels are a significant risk factor for cardiovascular
disease. Routine cholesterol screening can identify individuals at risk and help prevent heart
attacks and strokes.
Blood Glucose Testing: Screening for diabetes through fasting blood glucose tests or hemoglobin A1c
tests helps identify individuals with prediabetes or early-stage diabetes. Nurses can guide patients
in managing their blood glucose levels to prevent the development of complications such as
diabetic neuropathy, kidney disease, and cardiovascular issues.
Cancer Screenings: Regular cancer screenings are vital for detecting certain cancers at an early stage,
when they are most treatable. Common screenings include:
Mammograms: Mammograms are recommended for women beginning at age 40 or earlier for those
at high risk of breast cancer. Nurses should educate patients on the importance of regular
mammograms and how to conduct breast self-exams.
Pap Smears: Routine Pap smears help detect cervical cancer in its early stages. Nurses should
encourage women between the ages of 21 and 65 to undergo regular screenings every 3 years.
Colonoscopy: Colonoscopies are recommended for individuals starting at age 50 or earlier for those
with a family history of colorectal cancer. These screenings help detect early-stage colorectal
cancer and pre-cancerous polyps.
3. Tertiary Prevention
Tertiary prevention focuses on managing and mitigating the effects of already diagnosed diseases,
preventing further complications, and improving the quality of life for individuals with chronic or
advanced conditions. This level of prevention involves rehabilitation and long-term management
of diseases.
Chronic Disease Management: Nurses support patients with chronic conditions by helping them
manage symptoms, adhere to treatment plans, and maintain their quality of life. Education on
medication adherence, lifestyle changes, and regular monitoring (e.g., blood glucose checks for
diabetes or blood pressure monitoring for hypertension) is crucial for managing chronic diseases.
Rehabilitation and Palliative Care: For patients with advanced diseases, rehabilitation and palliative
care are essential components of care. Nurses assist in coordinating rehabilitation efforts, such as
physical therapy or occupational therapy, and help manage symptoms through palliative care
interventions, ensuring comfort and improving the patient's overall well-being.
Screening Guidelines
Screening tests are a cornerstone of secondary prevention. These guidelines help identify health
risks early so that appropriate interventions can be initiated before the disease progresses to a
more severe stage. Nurses should be familiar with the following common screening guidelines for
various diseases:
1. Hypertension Screening
Hypertension is a leading cause of heart disease, stroke, and kidney disease. Nurses should
encourage patients to have their blood pressure checked regularly, especially those with a family
history of hypertension, obesity, or diabetes. The American College of Cardiology (ACC)
recommends the following:
Screen all adults aged 18 and older regularly for hypertension.
If blood pressure readings are consistently 130/80 mmHg or higher, further assessment and
intervention are needed.
2. Cholesterol Screening
Cholesterol screening helps identify individuals at risk for heart disease. The American Heart
Association (AHA) recommends that adults age 20 and older have their cholesterol levels checked
every 4-6 years. Individuals with risk factors such as a family history of heart disease, obesity, or
smoking may need more frequent screening.
Fasting Lipid Profile: This test measures total cholesterol, low-density lipoprotein (LDL), high-
density lipoprotein (HDL), and triglycerides. A high level of LDL and triglycerides or low levels
of HDL can increase the risk of cardiovascular diseases.
3. Cancer Screening
Cancer screenings vary by type and risk factors. Nurses should be aware of the following
recommended guidelines:
Breast Cancer: The American Cancer Society recommends that women begin annual mammograms
at age 45 and continue until age 54. Women aged 55 and older should transition to biennial
mammograms or continue annual screenings if preferred.
Cervical Cancer: Women should begin screening with Pap smears at age 21, continuing every 3 years
until age 29. Between ages 30 and 65, women should have Pap smears and HPV testing every 5
years. After age 65, screening may be discontinued if there is a history of normal results.
Colorectal Cancer: Adults should begin colorectal cancer screening at age 45, with options including
colonoscopy every 10 years, stool-based tests, or flexible sigmoidoscopy every 5 years. Those with
a family history of colorectal cancer should begin screening earlier.
Prostate Cancer: Men should discuss the risks and benefits of prostate cancer screening with their
healthcare provider beginning at age 50, or earlier for those with risk factors.
4. Diabetes Screening
Diabetes screening is crucial for detecting individuals with prediabetes or early diabetes, allowing
for early intervention to prevent complications. The American Diabetes Association (ADA)
recommends:
Screening for adults aged 45 and older every 3 years, especially for those who are overweight or
obese.
Screening for younger adults who are overweight or have risk factors such as a family history of
diabetes, gestational diabetes, or hypertension.
The Nurse’s Role in Disease Prevention and Screening
Nurses play a key role in educating patients about disease prevention and encouraging adherence
to screening guidelines. Nurses should:
Assess Risk Factors: During patient assessments, nurses should inquire about family history, lifestyle
habits, and other risk factors that may predispose the patient to certain diseases. Based on this
information, nurses can recommend appropriate screenings and health promotion activities.
Provide Education: Nurses should provide information about the importance of screenings, how
they are conducted, and the benefits of early detection. This information can help patients make
informed decisions about their health.
Encourage Adherence: Nurses should remind patients of the importance of regular screenings and
encourage them to keep up with preventive care. This can be achieved through regular follow-up
appointments, reminders, or providing written materials to reinforce the information.
Coordinate Care: Nurses help coordinate care between the patient and healthcare providers,
ensuring that screenings and preventive measures are completed and results are reviewed in a
timely manner.
NCLEX Considerations for Disease Prevention and Screening
The NCLEX-RN exam will test your knowledge of disease prevention and screening guidelines,
particularly regarding the following:
The role of nurses in patient education about preventive measures and screening.
The recommended screening guidelines for various age groups, risk factors, and disease
conditions.
How to assess patient risk factors and determine which screenings are necessary.
Nurses must be able to assess risk factors, understand the guidelines for screening, and explain
their importance to patients. Be prepared to answer questions that involve selecting the
appropriate screening test for different patient scenarios.

7.3 Nutrition and Wellness Counseling

Nurses are often the first healthcare professionals patients consult when seeking advice on diet,
exercise, and general wellness. Nurses are also in a prime position to assess patients' nutritional
status and provide guidance on healthful lifestyle changes. By promoting good nutrition and
wellness practices, nurses can help prevent a variety of chronic diseases such as obesity, diabetes,
cardiovascular disease, and certain cancers. Nurses must be knowledgeable about basic nutrition
principles, the relationship between nutrition and health, and evidence-based guidelines for
counseling patients.
1. Assessing Nutritional Status
The first step in nutrition and wellness counseling is assessing the patient’s current nutritional
status. This assessment helps identify any nutritional deficiencies, imbalances, or unhealthy eating
patterns. Nurses should conduct a thorough assessment that includes:
Dietary History: Nurses should inquire about the patient's typical eating habits, meal frequency,
portion sizes, and preferred foods. Understanding a patient’s food preferences and cultural dietary
practices is crucial for providing realistic, individualized advice.
Health History: It’s important to review the patient’s health history, including any medical
conditions such as diabetes, hypertension, or gastrointestinal disorders, as these can affect
nutritional needs. Additionally, certain medications may interfere with the absorption of nutrients
or alter appetite, which must be considered when counseling patients.
Anthropometric Measurements: Measurements such as weight, height, body mass index (BMI), and
waist circumference provide valuable information about a patient's nutritional status and potential
risk for diseases like obesity or metabolic syndrome.
2. Identifying Nutritional Deficiencies
Based on the assessment, nurses can identify potential nutritional deficiencies or areas where
patients may need improvement. Common nutritional concerns include:
Macronutrient Imbalances: Ensuring that patients are consuming adequate amounts of carbohydrates,
proteins, and fats is important for overall health and energy. For example, a patient with a high-
fat diet may need guidance on reducing unhealthy fats while increasing healthy fats from sources
like avocados and nuts.
Micronutrient Deficiencies: Vitamins and minerals play crucial roles in maintaining bodily functions.
Common deficiencies include vitamin D, calcium, iron, and folic acid. Nurses can identify these
deficiencies by looking at patients' diets and recommending supplements or dietary changes as
necessary.
3. Setting Realistic Goals
Nurses must work with patients to establish specific, achievable goals related to their nutrition
and wellness. The goals should be:
Patient-Centered: Goals should align with the patient's values, preferences, and lifestyle. If a patient
dislikes vegetables, a goal could be to incorporate other healthy foods, like fruits or whole grains,
that they find more appealing.
Focused on Long-Term Health: The aim is not just short-term dietary changes, but the promotion of
a long-term, sustainable healthy lifestyle. This includes gradual modifications to improve diet
quality and support overall wellness.
Core Principles of Nutrition and Wellness Counseling
Nutrition and wellness counseling requires a blend of education, support, and practical strategies
to help patients adopt healthier habits. Nurses must focus on both educating patients about the
importance of nutrition and wellness and providing tools for patients to implement these changes
into their daily routines.
1. Healthy Eating Patterns
A healthy eating pattern forms the foundation of nutrition counseling. Nurses should provide
patients with evidence-based recommendations to improve the quality of their diet. Some key
principles of a healthy eating pattern include:
Balanced Diet: Encourage patients to eat a variety of foods from all food groups to ensure they get
a wide range of nutrients. This includes:
Fruits and Vegetables: Aim for at least five servings per day, emphasizing colorful and nutrient-
dense options.
Whole Grains: Advise patients to consume whole grains like brown rice, oats, and whole wheat
bread instead of refined grains, as whole grains provide more fiber and nutrients.
Lean Proteins: Suggest lean protein sources such as poultry, fish, beans, and legumes. Reducing the
intake of red meat can lower the risk of heart disease and cancer.
Healthy Fats: Encourage the consumption of healthy fats from sources like olive oil, nuts, seeds,
and fatty fish, while limiting unhealthy trans and saturated fats.
Portion Control: Nurses should educate patients on portion sizes and the importance of not
overeating. This can be achieved by using smaller plates, measuring food portions, and being
mindful of hunger cues.
2. Limiting Unhealthy Foods
While promoting healthy foods, it is also essential to limit the intake of foods and substances that
can negatively affect health. Nurses should guide patients to:
Reduce Sodium Intake: High sodium intake is linked to high blood pressure and cardiovascular
disease. Nurses should advise patients to limit processed foods, fast food, and high-sodium snacks
and to read nutrition labels carefully.
Limit Sugar: Excessive sugar consumption is a major contributor to obesity, type 2 diabetes, and
dental problems. Nurses should help patients reduce sugary beverages, snacks, and processed
foods.
Minimize Alcohol Consumption: While moderate alcohol consumption may be safe for some
individuals, excessive drinking is associated with liver disease, heart disease, and other health
problems. Nurses should counsel patients on drinking in moderation and discuss the risks of
alcohol abuse.
3. Promoting Hydration
Adequate hydration is essential for overall health, as it supports the body’s metabolic processes,
helps maintain healthy skin, and regulates body temperature. Nurses should educate patients on
the importance of drinking enough water and other fluids. The general recommendation is to
drink at least 8 cups (64 ounces) of water daily, although individual needs may vary based on
factors such as activity level and climate.
4. Physical Activity and Exercise
Physical activity is a cornerstone of wellness counseling, as it is crucial for preventing obesity,
improving cardiovascular health, and enhancing overall well-being. Nurses should encourage
patients to:
Engage in Regular Exercise: Aim for at least 150 minutes of moderate-intensity aerobic activity per
week, combined with strength training exercises at least twice a week. Activities such as walking,
swimming, cycling, and yoga are excellent choices.
Set Realistic Exercise Goals: Nurses can help patients set small, manageable goals to gradually
increase physical activity. This might include starting with short walks and gradually building up
to more intense workouts.
Promote an Active Lifestyle: Encourage patients to incorporate physical activity into their daily
routine, such as taking the stairs instead of the elevator, walking or biking instead of driving short
distances, and engaging in recreational activities that they enjoy.
Supporting Wellness Through Mental Health
In addition to physical health, wellness counseling also involves mental health. Nurses should
incorporate mental health strategies into their counseling by:
Encouraging Stress Management: Chronic stress can negatively impact both physical and mental
health, contributing to conditions such as hypertension, diabetes, and depression. Nurses should
teach stress reduction techniques such as deep breathing, meditation, progressive muscle
relaxation, and mindfulness.
Promoting Sleep Hygiene: Adequate sleep is vital for recovery and overall health. Nurses can educate
patients on healthy sleep habits, including establishing a regular sleep routine, limiting screen time
before bed, and creating a restful environment.
Nutrition Counseling for Chronic Disease Management
For patients with chronic conditions such as diabetes, heart disease, and kidney disease, nutrition
counseling is a crucial part of disease management. Nurses must be able to educate patients on
how to manage their conditions through diet and lifestyle changes.
Diabetes Management: Nurses should teach patients with diabetes about the importance of
monitoring blood glucose levels, carbohydrate counting, and adjusting insulin or medication as
needed. Nutrition counseling focuses on controlling blood glucose through a balanced diet and
portion control.
Heart Disease Prevention: For patients with heart disease or at risk for it, nurses should counsel on
reducing saturated fat, sodium, and cholesterol intake, as well as maintaining a healthy weight and
engaging in regular physical activity.
Renal Diet: Patients with kidney disease may need to limit their intake of sodium, phosphorus,
potassium, and protein. Nurses can provide tailored nutrition advice based on the stage of kidney
disease.
The Nurse’s Role in Nutrition and Wellness Counseling
Nurses are not only educators but also supporters of patients’ wellness goals. In addition to
providing factual information, nurses need to:
Encourage Behavioral Change: Nurses should use motivational interviewing techniques to help
patients feel empowered and motivated to make lasting changes in their eating habits and lifestyle.
Provide Resources: Nurses can offer patients resources such as dietitian referrals, support groups,
apps for tracking food intake or exercise, and literature on healthy eating.
Follow-Up and Monitor Progress: Nurses should regularly follow up with patients to monitor their
progress in meeting wellness goals and provide ongoing support and encouragement.
NCLEX Considerations for Nutrition and Wellness Counseling
For the NCLEX-RN exam, you will be expected to demonstrate a thorough understanding of
nutrition, wellness, and lifestyle counseling. Common areas of focus include:

 Knowledge of nutritional guidelines for various populations (e.g., pregnant women, elderly
adults, children).
 Screening and monitoring for nutritional deficiencies and chronic disease prevention.
 Educating patients on the benefits of a healthy lifestyle, including exercise, healthy eating,
and stress management.

7.4 Lifespan Development and Preventive Care Techniques

Lifespan development encompasses a series of predictable changes that occur as a person ages.
These changes can be categorized into several stages, each with unique needs and challenges.
Nurses must recognize the development needs of patients at each stage of life and apply
appropriate preventive care techniques. The lifespan can be divided into the following stages:
Infancy (0-1 year)
Early Childhood (1-5 years)
Middle Childhood (6-11 years)
Adolescence (12-18 years)
Young Adulthood (19-40 years)
Middle Adulthood (41-65 years)
Late Adulthood (65+ years)
Each of these stages is associated with unique physical, cognitive, emotional, and social
development. Nurses use their understanding of these stages to guide their care and implement
preventive strategies to help patients maintain optimal health throughout their lifespan.
Preventive Care Across the Lifespan
Preventive care is the cornerstone of healthy aging and disease prevention. Nurses work to ensure
that patients adopt preventive measures, such as health screenings, vaccinations, lifestyle
modifications, and education, to reduce the risk of chronic conditions and improve overall well-
being.
1. Infancy (0-1 Year)
Infancy is a critical period for development. During this stage, infants rely on caregivers for basic
needs such as nutrition, hygiene, and safety. Nurses focus on preventing health problems,
promoting safe infant care, and supporting parents in the care of their newborns.
Vaccinations: Immunizations are a key aspect of preventive care in infants. Nurses ensure that
infants receive recommended vaccinations, such as the DTaP, IPV, Hib, MMR, and Hepatitis B
vaccines, as well as the flu vaccine after 6 months of age.
Nutrition: Encouraging breastfeeding is a primary focus of infant care, as breast milk provides
essential nutrients and antibodies that boost the infant’s immune system. Nurses also educate
parents about the introduction of solid foods at around 6 months of age and the importance of a
balanced diet.
Developmental Milestones: Nurses educate parents about the expected developmental milestones,
such as motor skills, speech development, and social interaction. Regular well-child visits are
important for monitoring the infant’s growth and development.
Safety: Nurses provide guidance on infant safety, including safe sleep practices (e.g., placing babies
on their backs to sleep), preventing choking, and using car seats correctly.
2. Early Childhood (1-5 Years)
Early childhood is marked by rapid physical growth, cognitive development, and increased social
interaction. During this stage, children start to explore the world around them and form the
foundation for future learning and behavior.
Nutrition: Nurses help parents ensure that toddlers and preschoolers receive a balanced diet that
includes protein, vegetables, fruits, and whole grains. Proper nutrition during this stage supports
physical growth and cognitive development.
Immunizations: Continuing from infancy, early childhood is an important time for maintaining
vaccination schedules. Key vaccinations include the second doses of DTaP, IPV, MMR, and
varicella, along with flu shots.
Developmental Monitoring: Nurses track language skills, motor skills, and social development,
providing guidance on age-appropriate activities that support learning. Nurses also assist parents
in addressing common behavioral issues, such as tantrums and potty training.
Safety Education: Nurses teach parents and caregivers about childproofing the home, using car seats
correctly, and preventing accidents such as burns, falls, and poisoning.
3. Middle Childhood (6-11 Years)
Middle childhood is a time of steady growth and increased independence. Children in this stage
develop more advanced cognitive skills and begin to establish friendships outside the family.
Nutrition: Healthy eating habits become more important during middle childhood, as children
develop preferences for certain foods. Nurses educate parents and children about portion sizes,
balanced meals, and the importance of limiting sugary snacks and drinks.
Physical Activity: Encouraging physical activity is crucial at this stage. Nurses promote activities
such as outdoor play, organized sports, and other exercises that improve strength, coordination,
and social skills.
Health Screenings: Nurses ensure that children receive routine health screenings, including vision
and hearing tests, scoliosis checks, and obesity assessments. Early detection of health problems,
such as poor vision or hearing loss, can be addressed effectively at this stage.
Preventive Care: Nurses also educate families about the importance of mental health in children,
including promoting self-esteem, emotional regulation, and communication skills.
4. Adolescence (12-18 Years)
Adolescence is a time of physical maturation, emotional development, and identity formation.
During this stage, teens experience changes in their body, relationships, and cognitive abilities.
Nutrition: Nurses continue to educate adolescents about proper nutrition, including the
importance of consuming adequate amounts of calcium, iron, and other essential nutrients for
growth and development. Nurses also address issues such as eating disorders, body image
concerns, and the importance of a balanced diet.
Immunizations: Adolescents need to receive certain vaccines, including the HPV vaccine,
meningococcal vaccine, and booster doses of the DTaP and Tdap vaccines. Nurses help ensure
that these vaccines are administered on schedule.
Mental Health: Nurses recognize the importance of mental health during adolescence. Common
challenges include stress, anxiety, depression, and peer pressure. Nurses support healthy coping
strategies, provide resources for counseling, and encourage open communication about mental
health.
Risk Reduction: Nurses educate adolescents about the risks of substance abuse, unprotected sex,
and other risky behaviors. They promote safe practices, such as using seat belts, wearing helmets,
and practicing safe sex.
5. Young Adulthood (19-40 Years)
Young adulthood is a period of independence, career development, and forming intimate
relationships. Individuals in this stage often experience significant life changes and may begin to
develop lifestyle-related health problems.
Health Promotion: Nurses focus on promoting healthy habits that will reduce the risk of chronic
diseases later in life. They emphasize the importance of regular physical activity, maintaining a
healthy weight, and eating a balanced diet to prevent obesity, diabetes, and heart disease.
Mental Health: Nurses address mental health challenges such as stress, anxiety, and depression,
which may arise during transitions such as starting a career, entering relationships, or becoming
parents. Nurses encourage the use of coping mechanisms, mindfulness, and counseling when
necessary.
Preventive Screenings: Young adults should be encouraged to get routine screenings, such as blood
pressure checks, cholesterol screenings, and screenings for sexually transmitted infections (STIs).
For women, Pap smears begin at age 21, and for men, testicular self-exams can begin in early
adulthood.
Contraception and Family Planning: Nurses provide education on reproductive health, contraception
options, and family planning. They discuss safe sexual practices, including the prevention of STIs
and unintended pregnancies.
6. Middle Adulthood (41-65 Years)
Middle adulthood is characterized by both physical changes and the onset of chronic health
conditions. People in this age group may experience age-related health issues, such as joint pain,
weight gain, and changes in metabolism.
Chronic Disease Management: Nurses play an essential role in supporting patients with chronic
conditions like diabetes, hypertension, and heart disease. They help patients manage these
conditions through medication management, lifestyle changes, and regular health check-ups.
Preventive Screenings: Preventive care remains essential. Nurses promote cancer screenings (e.g.,
mammograms, colonoscopies, and prostate exams) and other tests like blood glucose and
cholesterol screenings. Early detection of diseases like breast cancer, colon cancer, and heart
disease can improve outcomes.
Health Promotion: Nurses encourage physical activity, a balanced diet, and stress management to
maintain good health and manage chronic conditions. Weight management, especially reducing
visceral fat, is crucial in preventing diabetes and heart disease.
Mental and Emotional Health: Midlife can bring emotional challenges, including stress related to
work, family, and life transitions. Nurses help patients manage stress, encourage social
engagement, and address mental health concerns such as depression or anxiety.
7. Late Adulthood (65+ Years)
Late adulthood is marked by aging, retirement, and the potential onset of multiple health
challenges. People in this stage may experience changes in mobility, cognitive function, and
sensory perception.
Chronic Disease Management: Nurses provide support for older adults with chronic diseases,
including arthritis, heart disease, diabetes, and Alzheimer’s disease. They assist in managing
symptoms, providing emotional support, and coordinating care with other healthcare providers.
Preventive Care: Nurses ensure that older adults stay on track with their health screenings, such as
mammograms, colonoscopies, vision and hearing tests, and bone density scans. Immunizations,
such as the annual flu shot and shingles vaccine, are also important at this stage.
Safety and Fall Prevention: Nurses assess the home environment for safety hazards and provide
guidance on fall prevention strategies. This may include recommending assistive devices,
improving lighting, and removing tripping hazards from the home.
Mental Health and Cognitive Function: Nurses support mental health by addressing conditions such
as depression, anxiety, and cognitive decline. Encouraging social engagement, mental exercises,
and providing resources for dementia care can help maintain cognitive function.
The Nurse's Role in Preventive Care
Nurses are instrumental in guiding patients through each stage of life, ensuring that they receive
the necessary education, support, and resources to maintain their health and prevent diseases. The
nurse’s role includes:
Assessment: Nurses assess patients’ physical, emotional, and social needs, identifying risk factors
and health concerns specific to their age and stage of development.
Education: Nurses provide tailored education about health promotion, disease prevention, and self-
care strategies. They offer resources and information about screenings, vaccinations, and healthy
lifestyle choices.
Support: Nurses offer emotional support to patients and their families, helping them cope with life
transitions, chronic disease management, and aging-related challenges.
NCLEX Considerations for Lifespan Development and Preventive Care
The NCLEX-RN exam evaluates nurses’ knowledge of lifespan development and preventive care
techniques. Questions may cover:

 Key developmental milestones and their impact on health at various life stages.
 Preventive care recommendations for different age groups, including immunizations,
screenings, and health education.
 The role of nurses in managing chronic diseases, supporting healthy aging, and providing
preventive care across the lifespan.
 Chapter 8: Psychosocial
Integrity (6%-12%)
8.1 Coping Mechanisms and Stress Management Interventions
The body reacts to stress through the activation of the sympathetic nervous system, often referred
to as the “fight or flight” response. This response is a biological process that prepares the body
to deal with perceived threats. Upon experiencing stress, the body releases hormones like
adrenaline and cortisol, which increase heart rate, blood pressure, and blood sugar levels while
diverting blood flow to essential muscles.
While this physiological response can be helpful in short-term stressful situations, chronic stress
can lead to serious health issues, including:

 Cardiovascular problems, such as hypertension and heart disease.

 Immune system suppression, which makes the body more susceptible to infections.
 Gastrointestinal issues, such as ulcers, acid reflux, or irritable bowel syndrome.
 Mental health problems, such as anxiety, depression, and sleep disorders.
Chronic stress can also lead to maladaptive coping mechanisms such as smoking, overeating, or
alcohol abuse, which further contribute to physical and mental health deterioration.
The Role of the Nurse in Stress Management
Nurses are in a unique position to assist patients in recognizing their stress triggers and developing
strategies to manage and cope with them. By teaching stress management techniques and
providing emotional support, nurses can enhance a patient’s coping abilities and improve their
overall health. Key strategies nurses can use include:
Coping Mechanisms: Identifying and Understanding Different Types
Coping mechanisms are the cognitive and behavioral strategies individuals use to manage stress.
Nurses should understand both adaptive and maladaptive coping mechanisms, as they play an
essential role in stress management and intervention.
1. Adaptive Coping Mechanisms
Adaptive coping strategies are healthy and constructive ways of dealing with stress. These
strategies help individuals deal with stress in a positive manner, contributing to better emotional
and physical well-being. Some examples of adaptive coping include:
Problem-Solving: Actively engaging in a solution-focused approach to address the stressor. This
involves assessing the situation, identifying options, and implementing solutions. Nurses can teach
patients how to break down stressful situations into manageable steps.
Relaxation Techniques: Practices such as deep breathing, progressive muscle relaxation, meditation,
or guided imagery can help reduce physical and emotional tension. These methods promote
relaxation, lower heart rate, and reduce muscle tension, which can help patients manage stress
effectively.
Physical Activity: Exercise is a highly effective way to reduce stress. Activities like walking, jogging,
yoga, or swimming help release endorphins, improve mood, and reduce tension. Nurses can
encourage patients to incorporate physical activity into their daily routine.
Social Support: Seeking support from friends, family, or support groups can provide emotional
comfort and practical assistance during stressful times. Social support helps individuals feel less
isolated and more resilient.
Time Management: Being organized and managing time effectively can help reduce stress caused by
feeling overwhelmed. Nurses can teach patients how to prioritize tasks, set achievable goals, and
delegate responsibilities to others when appropriate.
Cognitive Restructuring: This involves changing the way an individual thinks about a stressful
situation. Cognitive restructuring techniques focus on replacing negative thought patterns with
more positive, constructive ones, which can reduce stress and promote a sense of control.
2. Maladaptive Coping Mechanisms
Maladaptive coping strategies are unhealthy or destructive behaviors that individuals use to deal
with stress, which may offer temporary relief but ultimately lead to negative consequences. These
include:
Substance Abuse: Using alcohol, drugs, or tobacco as a means of coping with stress may provide
short-term relief but can lead to long-term addiction, physical harm, and emotional deterioration.
Denial: Refusing to acknowledge the existence of a problem or minimizing its significance can
prevent individuals from addressing the stressor, allowing it to worsen over time.
Avoidance: Avoiding or withdrawing from stressful situations instead of confronting them directly
can prolong stress and limit the ability to resolve underlying issues.
Overeating or Undereating: Emotional eating or eating disorders such as anorexia or bulimia can
develop as maladaptive ways of coping with stress, leading to serious health issues.
Nurses should be able to identify maladaptive coping mechanisms and guide patients toward
healthier alternatives, while also addressing any underlying issues such as substance abuse or eating
disorders.
Stress Management Interventions: Helping Patients Manage Stress Effectively
Nurses can implement various interventions to assist patients in managing stress and improving
their coping mechanisms. These interventions aim to reduce the physiological, emotional, and
psychological impact of stress on patients.
1. Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy is an evidence-based intervention that helps patients recognize and
modify negative thought patterns that contribute to stress and anxiety. Through CBT, patients
learn to reframe their thoughts, develop healthier coping strategies, and build resilience. Nurses
can educate patients on the benefits of CBT and, if applicable, refer them to a licensed therapist
for further assistance.
2. Mindfulness and Meditation
Mindfulness-based interventions, including mindfulness meditation, focus on being present in the
moment and accepting stressors without judgment. Nurses can teach patients simple mindfulness
techniques, such as focusing on the breath or performing a body scan, to promote relaxation and
reduce stress.
Mindful Breathing: Deep, slow breathing exercises help activate the body’s parasympathetic nervous
system, which induces a state of calmness. Nurses can guide patients through deep breathing
exercises to manage acute stress.
3. Progressive Muscle Relaxation (PMR)
Progressive muscle relaxation is a relaxation technique in which patients systematically tense and
relax different muscle groups in their bodies. This process helps release physical tension and
promotes overall relaxation. Nurses can teach patients how to perform PMR, which can be used
as a tool for stress management, especially during periods of acute anxiety or stress.
4. Biofeedback
Biofeedback is a technique that helps individuals become aware of physiological processes, such
as heart rate, muscle tension, or breathing, and learn to control them through relaxation
techniques. By using sensors that measure physiological responses, patients can see how their
body reacts to stress and practice managing it. Biofeedback can help patients gain better control
over stress responses and improve relaxation skills.
5. Support Groups
Support groups provide patients with the opportunity to connect with others facing similar
challenges. These groups can help reduce feelings of isolation, offer emotional support, and
provide practical advice for coping with stress. Nurses should educate patients about the
availability of community or online support groups and encourage them to participate.
6. Physical Exercise Programs
Exercise is a proven stress reducer and mood enhancer. Nurses can educate patients on the
benefits of physical activity, encourage them to engage in regular exercise, and recommend
activities such as walking, yoga, or swimming. Group exercise programs or fitness classes can
provide a social outlet as well as a physical one, further contributing to stress relief.
7. Sleep Hygiene Education
Chronic stress often leads to sleep disturbances, and poor sleep exacerbates stress. Nurses should
provide sleep hygiene education, emphasizing the importance of maintaining a consistent sleep
schedule, creating a restful sleep environment, and avoiding stimulants such as caffeine or
electronics before bedtime. Good sleep habits contribute significantly to stress reduction.
8. Relaxation Training and Visualization
Visualization techniques involve imagining oneself in a peaceful, calming environment. Nurses
can guide patients through visualization exercises to help them relax and reduce stress. Relaxation
training can be combined with guided imagery, where patients envision themselves in a serene
place, such as a beach or forest, to evoke a sense of calm.
The Nurse’s Role in Stress Management
As healthcare providers, nurses have a unique opportunity to guide patients through effective
stress management techniques. Nurses should:
Assess stress levels: By observing physical symptoms of stress and listening to patients' concerns,
nurses can assess how stress is affecting patients and determine appropriate interventions.
Educate patients: Nurses can teach patients about the physiological effects of stress, explain healthy
coping mechanisms, and introduce stress management techniques such as relaxation and
mindfulness.
Provide emotional support: Nurses should offer a compassionate and non-judgmental listening ear,
helping patients express their emotions and find effective ways to manage their stress.
Monitor progress: Nurses should track patients' stress levels and coping abilities over time, making
adjustments to care plans and interventions as needed.
NCLEX Considerations for Stress Management
The NCLEX-RN exam will test your ability to apply stress management interventions and
recognize different coping mechanisms. It may include questions on:

 Identifying adaptive and maladaptive coping strategies in various patient scenarios.

 Choosing the most appropriate stress management intervention for a specific patient.
 Understanding the physiological and psychological effects of stress on health.

8.2 Mental Health Disorders: Diagnosis and Nursing

Interventions
Mental health disorders are conditions that affect a person’s thoughts, feelings, emotions, and
behaviors. These conditions can disrupt daily life, causing difficulties in work, relationships, and
even basic self-care. They can stem from various causes, including genetic predisposition,
environmental factors, trauma, and substance use. The following are some common mental health
disorders, along with their diagnostic criteria and nursing interventions.
1. Anxiety Disorders
Anxiety disorders are among the most common mental health conditions, affecting millions of
people worldwide. These disorders are characterized by excessive worry, fear, or anxiety that can
interfere with normal activities. Anxiety disorders can include generalized anxiety disorder (GAD),
panic disorder, social anxiety disorder, and specific phobias.
Diagnosis: Anxiety disorders are diagnosed based on the criteria set out in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5). Symptoms typically include excessive fear or
worry, difficulty controlling anxiety, and physical manifestations such as increased heart rate,
sweating, and restlessness.
Nursing Interventions:
Cognitive Behavioral Therapy (CBT): A key intervention for anxiety, CBT helps patients identify and
challenge distorted thinking patterns that contribute to anxiety. Nurses can encourage patients to
seek therapy and use CBT techniques in daily life.
Relaxation Techniques: Nurses can teach patients relaxation methods such as deep breathing,
progressive muscle relaxation, and mindfulness meditation to reduce physical symptoms of
anxiety.
Medication: In some cases, patients may require medications like selective serotonin reuptake
inhibitors (SSRIs), benzodiazepines, or beta-blockers to manage anxiety symptoms. Nurses
should educate patients about the benefits and risks of medication.
Supportive Care: Nurses should provide reassurance, offer a nonjudgmental listening ear, and
encourage patients to discuss their feelings and fears openly.
2. Mood Disorders
Mood disorders, including depression and bipolar disorder, involve significant disturbances in a
person’s emotional state. These disorders can cause persistent sadness, irritability, or extreme
mood swings that affect daily functioning.
Depression:
Diagnosis: Depression is diagnosed when a patient experiences a persistent low mood for at least
two weeks, along with symptoms such as loss of interest in activities, fatigue, sleep disturbances,
changes in appetite, and thoughts of death or suicide.
Nursing Interventions:
Therapeutic Communication: Nurses should provide a safe space for patients to express their feelings.
Open, empathetic communication helps patients feel heard and validated.
Cognitive Behavioral Therapy (CBT): CBT can help patients challenge negative thinking patterns and
develop healthier coping strategies.
Medication: Antidepressant medications, such as SSRIs, SNRIs, or tricyclic antidepressants, are
commonly prescribed. Nurses should monitor for side effects and encourage adherence to
medication regimens.
Support Systems: Encouraging patients to engage in social activities, seek family support, and
participate in group therapy can be beneficial in treating depression.
Bipolar Disorder:
Diagnosis: Bipolar disorder is characterized by extreme mood swings, including episodes of mania
(elevated mood, impulsive behavior) and depression. The disorder is diagnosed based on clinical
criteria for manic and depressive episodes.
Nursing Interventions:
Medication Management: Lithium and anticonvulsants are commonly used to stabilize mood. Nurses
should monitor blood levels of lithium and educate patients on the potential side effects and risks
of these medications.
Patient Education: Teaching patients about the nature of their disorder and the importance of
medication adherence helps prevent relapse.
Cognitive Behavioral Therapy (CBT): CBT can be effective in helping patients understand their triggers
and manage their emotions.
Stabilizing Routine: Nurses can help patients establish a structured routine for sleep, nutrition, and
physical activity to help regulate mood swings.
3. Psychotic Disorders
Psychotic disorders, such as schizophrenia, involve a disconnection from reality, which can
manifest as delusions, hallucinations, and disorganized thinking.
Diagnosis: Schizophrenia is diagnosed when patients experience symptoms like delusions (false
beliefs), hallucinations (seeing or hearing things that are not there), and disorganized speech or
behavior. Symptoms typically need to be present for at least six months for a diagnosis.
Nursing Interventions:
Medication: Antipsychotic medications, both typical and atypical, are prescribed to manage
symptoms. Nurses must ensure that patients understand the importance of taking their
medications as prescribed and monitor for side effects like weight gain, sedation, or tardive
dyskinesia.
Therapeutic Communication: Nurses should establish trust and rapport with patients by engaging in
clear, consistent, and non-judgmental communication. During periods of psychosis, nurses should
provide reassurance and attempt to refocus the patient’s attention on reality.
Reality Orientation: Nurses should use grounding techniques to help patients distinguish between
reality and hallucinations or delusions. This could include reminding the patient of the date, place,
and people involved in their care.
Supportive Care: Nurses can encourage patients to engage in therapy, join support groups, and
receive family education to better manage their condition and improve their quality of life.
4. Obsessive-Compulsive Disorder (OCD)
Obsessive-Compulsive Disorder is characterized by intrusive thoughts (obsessions) and repetitive
behaviors (compulsions) performed to reduce anxiety. Patients may feel the need to wash their
hands repeatedly, check things multiple times, or follow rigid routines.
Diagnosis: OCD is diagnosed when the obsessions and compulsions significantly interfere with the
person’s daily life. The obsessions cause distress, and the compulsive behaviors are performed to
prevent harm or reduce anxiety.
Nursing Interventions:
Cognitive Behavioral Therapy (CBT): One of the most effective therapies for OCD, CBT helps
patients identify and challenge irrational thoughts and compulsive behaviors. Exposure and
response prevention (ERP) is a specific type of CBT for OCD, where patients are gradually
exposed to their fears and prevented from performing compulsive rituals.
Medication: SSRIs like fluoxetine or sertraline are commonly prescribed to reduce OCD symptoms.
Nurses should educate patients about the potential side effects and encourage medication
adherence.
Stress Management: Nurses can teach relaxation techniques such as deep breathing or progressive
muscle relaxation to reduce the anxiety that fuels compulsive behaviors.
5. Post-Traumatic Stress Disorder (PTSD)
PTSD occurs after an individual experiences or witnesses a traumatic event, such as combat,
natural disasters, or violent assaults. Symptoms may include flashbacks, nightmares, hyperarousal,
and avoidance of trauma-related triggers.
Diagnosis: PTSD is diagnosed when symptoms occur for more than a month after exposure to a
traumatic event, and they significantly impair the person’s ability to function.
Nursing Interventions:
Cognitive Behavioral Therapy (CBT): CBT for PTSD helps patients reframe the trauma-related
thoughts and reduce avoidance behaviors. Nurses should encourage patients to engage in therapy
and provide a supportive environment.
Eye Movement Desensitization and Reprocessing (EMDR): EMDR is a therapeutic technique that helps
individuals process and reframe traumatic memories.
Medication: SSRIs and SNRIs are commonly used to treat the symptoms of PTSD. Nurses should
monitor for any side effects and provide guidance on how medications can help reduce intrusive
symptoms.
Support Groups: Nurses can recommend that patients join support groups for individuals with
PTSD, where they can share experiences and coping strategies.
6. Substance Use Disorders
Substance use disorders (SUDs) involve the harmful or hazardous use of substances like alcohol,
drugs, and prescription medications. This can lead to physical dependence, psychological
addiction, and significant disruptions in a person’s life.
Diagnosis: SUDs are diagnosed when an individual continues to use a substance despite negative
consequences, experiences cravings, or has difficulty controlling their use.
Nursing Interventions:
Medication-Assisted Treatment (MAT): Medications like methadone, buprenorphine, or naltrexone
can be used to help patients manage withdrawal symptoms and reduce cravings. Nurses should
monitor the patient’s response to medications and encourage participation in therapy.
Behavioral Therapy: Nurses should help patients access counseling, group therapy, and other
behavioral interventions to address the psychological aspects of addiction.
Support Groups: Nurses can recommend that patients participate in support groups like Alcoholics
Anonymous (AA) or Narcotics Anonymous (NA), which provide peer support and promote
sobriety.
The Nurse’s Role in Mental Health
Nurses provide essential care for patients with mental health disorders through:
Assessment: Nurses assess patients’ mental health through interviews, screening tools, and
observation of behavior, identifying early signs of mental illness or exacerbations of chronic
conditions.
Therapeutic Communication: Building a trusting relationship through empathetic listening, validation,
and providing a safe space for patients to express their concerns is essential in mental health
nursing.
Patient Education: Nurses educate patients about their conditions, available treatments, and coping
strategies. This education empowers patients to take an active role in their recovery.
Collaboration: Nurses collaborate with other healthcare providers, including psychiatrists,
psychologists, and social workers, to create comprehensive care plans for patients.
NCLEX Considerations for Mental Health Disorders
The NCLEX-RN exam tests nurses’ ability to apply their knowledge of mental health disorders
and provide appropriate nursing interventions. Nurses must:

 Understand the symptoms and diagnostic criteria for common mental health disorders.
 Identify the appropriate nursing interventions, including therapeutic communication,
medication management, and referrals to mental health professionals.
 Be able to recognize when a mental health crisis is occurring and know the steps to take to
ensure patient safety and well-being.

8.3 Supporting Patients with Chronic Conditions

A chronic condition is defined as a health condition that persists for a long period, often for the
remainder of a person’s life. These conditions are typically characterized by periods of
exacerbation and remission, requiring ongoing care and management. Chronic conditions can
have a profound impact on a patient’s overall health, leading to physical limitations, psychological
distress, and a reduced ability to perform activities of daily living.
The most common chronic conditions include:

 Diabetes mellitus (Type 1 and Type 2)

 Hypertension (High Blood Pressure)
 Asthma and chronic obstructive pulmonary disease (COPD)
 Osteoarthritis and rheumatoid arthritis
 Heart disease
 Chronic kidney disease (CKD)
 Obesity
 Mental health conditions, such as depression and anxiety
 Cancer (when diagnosed at a later stage and requiring long-term management)
Many chronic conditions share common risk factors, including poor diet, lack of physical activity,
smoking, and alcohol use. Nurses must work with patients to address these risk factors and
support them in managing their conditions to prevent further complications.
The Nurse’s Role in Supporting Patients with Chronic Conditions
Nurses provide crucial support to patients with chronic conditions through assessments,
education, monitoring, and patient advocacy. The nurse-patient relationship is vital in ensuring
that patients feel supported and empowered to manage their conditions effectively.
1. Comprehensive Assessment
The first step in supporting patients with chronic conditions is conducting a thorough and
ongoing assessment. Nurses should assess the following aspects of the patient's health:
Physical assessment: Nurses assess the physical status of patients with chronic conditions, monitoring
for symptoms, complications, or changes in vital signs that indicate exacerbation of the condition.
This includes checking blood pressure, glucose levels, weight, and respiratory status.
Medication adherence: Chronic conditions often require multiple medications, and adherence to the
prescribed treatment regimen is critical. Nurses should regularly assess patients for any issues
related to medication adherence, such as forgetfulness, side effects, or financial barriers to
purchasing medications.
Psychosocial assessment: Chronic conditions often affect a patient's emotional and psychological well-
being. Nurses should assess for signs of depression, anxiety, or stress, as these can negatively
impact the patient's ability to manage their health.
Health literacy: Assessing a patient’s understanding of their condition, treatment plan, and lifestyle
modifications is crucial. Nurses should ensure that patients have the necessary knowledge to
manage their condition effectively.
2. Patient Education
Patient education is one of the most powerful tools for managing chronic conditions. Nurses
must educate patients about their condition, the importance of treatment adherence, lifestyle
changes, and the potential consequences of neglecting their health.
Chronic Disease Education: Nurses should provide patients with information about their chronic
condition, including its causes, symptoms, treatment options, and potential complications. This
empowers patients to make informed decisions and actively engage in their care.
Self-Management Strategies: Chronic conditions require patients to make long-term lifestyle changes,
such as diet modification, exercise, and stress management. Nurses should teach patients practical
self-management skills, such as blood glucose monitoring for diabetic patients or how to use an
inhaler for patients with asthma or COPD.
Medication Education: It is important for nurses to educate patients on how to take their medications
correctly. This includes explaining the purpose, side effects, dosage, timing, and potential drug
interactions. Nurses should also address any concerns or misconceptions patients may have about
their medications.
Behavioral Strategies: Nurses should help patients set realistic goals for managing their chronic
condition, such as reducing sodium intake for those with hypertension or increasing physical
activity for patients with diabetes. Behavioral strategies that encourage small, achievable changes
are more likely to be successful in the long term.
3. Chronic Condition Management
Chronic conditions often involve complex management strategies, which may require coordinated
care from multiple healthcare providers. Nurses can assist patients in managing their conditions
by:
Coordinating Care: Nurses can help patients navigate the healthcare system, ensuring they receive
the necessary services, such as regular check-ups, laboratory tests, physical therapy, or mental
health counseling. Coordinated care reduces the risk of complications and improves patient
outcomes.
Encouraging Adherence: One of the most significant challenges in managing chronic conditions is
ensuring that patients adhere to their prescribed treatments. Nurses should regularly check in with
patients about their medications, encourage timely follow-up appointments, and provide
encouragement to stay on track.
Monitoring Symptoms: Chronic conditions are often unpredictable, with patients experiencing flare-
ups or exacerbations. Nurses should help patients recognize early signs of worsening symptoms
and know when to seek medical attention. For example, a patient with asthma should know how
to use their inhaler at the first sign of shortness of breath, or a diabetic patient should monitor
for signs of hypoglycemia.
Lifestyle Modifications: Nurses can help patients make lifestyle changes to manage their chronic
conditions effectively. For example, helping a patient with hypertension create a low-sodium diet,
encouraging patients with obesity to join a weight loss program, or assisting a patient with diabetes
in developing an exercise routine.
4. Addressing Complications
Chronic conditions can lead to complications that significantly affect a patient’s quality of life.
Nurses must monitor for common complications and intervene early to prevent further health
issues.
Diabetes: Diabetes is associated with complications such as diabetic retinopathy, neuropathy, and
kidney disease. Nurses should regularly monitor blood glucose levels, encourage eye exams, and
educate patients on proper foot care to prevent complications like ulcers and amputations.
Cardiovascular Disease: Patients with chronic heart disease may experience complications such as
heart failure, stroke, or myocardial infarction. Nurses should monitor vital signs, educate patients
on symptom management, and provide guidance on medication adherence and lifestyle
modifications to reduce the risk of complications.
Chronic Respiratory Conditions: Conditions like COPD and asthma can lead to severe respiratory
distress, which may require hospitalization. Nurses should teach patients proper inhaler technique,
monitor lung function, and provide education on recognizing signs of exacerbations.
Chronic Kidney Disease (CKD): CKD can progress to end-stage renal disease (ESRD), requiring
dialysis. Nurses should monitor kidney function, educate patients on fluid restrictions, and
provide emotional support for patients facing dialysis.
Arthritis: Arthritis can cause joint pain, inflammation, and decreased mobility. Nurses can assist
patients by providing education on joint protection techniques, encouraging physical therapy, and
recommending appropriate assistive devices for mobility.
5. Psychosocial Support
Living with a chronic condition can take an emotional toll, leading to feelings of frustration,
anxiety, and depression. Nurses play a significant role in providing emotional support and
addressing the psychological needs of patients.
Empathy and Supportive Care: Nurses should provide emotional support by actively listening,
acknowledging the patient's feelings, and validating their experiences. Offering a compassionate
and understanding approach can help patients feel more comfortable discussing their concerns.
Mental Health Referrals: Chronic conditions often lead to mental health struggles such as depression,
anxiety, or stress. Nurses should screen for these conditions and make referrals to mental health
professionals if needed.
Family Support: Nurses can also provide education and support to the families of patients with
chronic conditions. Family members may play a significant role in caregiving and managing the
patient’s health. Providing family counseling or directing them to support groups can help alleviate
the emotional burden and improve overall care.
6. Health Promotion and Preventive Care
Preventive care is vital in reducing the burden of chronic diseases and promoting long-term
health. Nurses should encourage patients with chronic conditions to take proactive steps in
maintaining their health:
Health Screenings: Regular screenings for complications related to chronic conditions (e.g.,
cholesterol levels, kidney function, eye exams) are essential for early detection and intervention.
Vaccinations: Patients with chronic conditions, especially those with weakened immune systems
(e.g., diabetes, heart disease), should receive recommended vaccinations, including flu shots,
pneumococcal vaccines, and hepatitis vaccinations.
Diet and Exercise: Nurses should continue to stress the importance of a balanced diet and regular
physical activity in managing chronic conditions. This includes emphasizing portion control,
promoting heart-healthy foods, and encouraging regular exercise.
Stress Reduction: Chronic conditions can be exacerbated by stress, so nurses should incorporate
stress management techniques such as relaxation exercises, mindfulness, and counseling into their
care plans.
The Nurse’s Role in Chronic Condition Management
The nurse’s role in managing chronic conditions goes beyond clinical care. Nurses should:

 Collaborate with multidisciplinary teams to ensure comprehensive care for patients with
chronic conditions.
 Assess physical, emotional, and psychosocial needs, ensuring that patients receive
individualized care plans.
 Provide ongoing education on self-care techniques, symptom management, and
medication adherence.
 Monitor patient progress, adjusting care plans as needed to address complications or
changes in the patient's condition.
 Encourage patient autonomy, supporting patients in taking ownership of their health.
NCLEX Considerations for Chronic Conditions

 The NCLEX-RN exam will test your ability to manage patients with chronic conditions
effectively. Nurses must:
 Recognize the signs and symptoms of chronic conditions.
 Apply appropriate nursing interventions to manage chronic conditions and prevent
complications.
 Educate patients on self-management techniques and the importance of adherence to
prescribed treatment regimens.

8.4 End-of-Life Care and Family Support

End-of-life care is defined as the care provided to individuals who are nearing the end of their
life. It focuses on comfort and quality of life rather than curative treatments. The goal of end-of-
life care is to ensure that the patient’s remaining time is as comfortable and meaningful as possible,
while also supporting their loved ones. This care often involves managing pain, addressing
emotional and psychological issues, and preparing the family for the impending death.
Palliative Care vs. Hospice Care
Palliative care and hospice care are both types of end-of-life care, but they are distinct in terms of
timing and focus:
Palliative Care: Palliative care focuses on providing relief from the symptoms and stress of a serious
illness. It can be provided at any stage of a serious illness, alongside curative treatments, with the
goal of improving quality of life. The care is holistic, addressing physical, emotional, and spiritual
aspects of the patient’s condition.
Hospice Care: Hospice care, on the other hand, is a specialized type of palliative care provided when
a patient is no longer receiving curative treatments, and death is expected within six months. It
focuses on comfort and quality of life, offering services such as pain management, emotional
support, and bereavement services for the family.
The Nurse’s Role in End-of-Life Care
Nurses play an integral role in ensuring that end-of-life care is provided with respect, dignity, and
compassion. They are involved in symptom management, providing emotional support, educating
patients and families, and assisting with decision-making. Nurses should be well-versed in the
physical, emotional, and spiritual needs of patients at the end of life and possess the necessary
skills to communicate effectively with patients and their families during this difficult time.
1. Symptom Management
Pain: Pain is one of the most significant concerns for patients nearing the end of life. Nurses assess
pain using appropriate pain scales and provide pain relief through pharmacologic and non-
pharmacologic interventions. Medications such as opioids (morphine, fentanyl) are often used to
manage moderate to severe pain, with appropriate monitoring for side effects such as respiratory
depression or sedation.
Dyspnea (Shortness of Breath): Dyspnea is common in patients with advanced diseases such as cancer,
heart failure, and chronic obstructive pulmonary disease (COPD). Nurses can help manage
dyspnea with medications such as opioids (to reduce the sensation of breathlessness), oxygen
therapy, and non-pharmacologic measures like positioning the patient for optimal airflow.
Nausea and Vomiting: Nausea and vomiting can occur due to medications or the progression of a
disease. Nurses can administer antiemetics to control these symptoms and provide comfort. They
should also assess for causes such as bowel obstruction or metabolic imbalances that may require
further intervention.
Agitation and Confusion: Agitation or confusion, particularly in the final stages of life, may be caused
by pain, metabolic disturbances, or medications. Nurses should assess the underlying cause and
provide interventions such as anti-anxiety medications or sedatives to help the patient relax and
avoid unnecessary distress.
Constipation: Many patients at the end of life experience constipation due to decreased mobility,
medications (especially opioids), and poor fluid intake. Nurses should assess bowel function
regularly and provide appropriate interventions, including laxatives, stool softeners, and increased
fluid intake when possible.
2. Communication with the Patient and Family
Effective communication is a cornerstone of end-of-life care. Nurses must be skilled in providing
clear, honest, and compassionate communication with both the patient and their family.
Discussing Prognosis: Nurses should ensure that patients and families have a clear understanding of
the patient's condition, prognosis, and available options. This involves conveying information in
a sensitive and supportive manner. Nurses should avoid giving false hope while maintaining a
compassionate approach that respects the patient's and family's emotional state.
Active Listening: At the end of life, patients and families often have unresolved feelings or concerns.
Nurses must actively listen to their concerns, validate their emotions, and provide appropriate
responses. Empathy and reassurance are key components in building trust and offering comfort.
Providing Emotional Support: Emotional and psychological distress is common for both patients and
families. Nurses should be prepared to offer emotional support by providing a safe space for
patients and families to express their fears, sadness, or regrets. Nurses should also assess for signs
of depression or anxiety, which are prevalent in patients and families dealing with end-of-life
issues.
Facilitating Family Decision-Making: The decision-making process at the end of life can be difficult
and complex. Nurses should assist families in understanding treatment options, including whether
to continue or discontinue curative treatments. They should support the family in making
decisions that align with the patient’s wishes, values, and goals.
Advance Directives and Living Wills: Nurses should encourage patients to have discussions about
advance directives, which specify their preferences for end-of-life care. This can include living
wills and durable power of attorney for healthcare. Nurses can provide information on the legal
aspects of advance directives and help families understand the patient’s wishes.
3. Cultural and Spiritual Sensitivity
End-of-life care is deeply influenced by cultural and spiritual beliefs. Nurses should be sensitive
to these factors and incorporate them into the care plan.
Cultural Considerations: Different cultures have unique beliefs and practices regarding death and
dying. Nurses should understand the cultural practices of their patients and families, including
funeral customs, rituals, and the role of family in decision-making.
Spiritual Care: Spirituality is a vital part of the end-of-life experience for many patients. Nurses
should provide spiritual support by respecting the patient’s religious beliefs and practices. They
may collaborate with chaplains or spiritual advisors to provide more specific spiritual care. Nurses
should also be attentive to the spiritual concerns of the family and provide a supportive
environment for them to find meaning during this time.
4. Ethical and Legal Considerations
End-of-life care often involves ethical and legal issues that nurses must navigate carefully. These
can include decisions about withholding or withdrawing life-sustaining treatments, palliative
sedation, and physician-assisted suicide.
Autonomy and Respect for Patient Wishes: A fundamental ethical principle in end-of-life care is respect
for the patient’s autonomy. Nurses must advocate for the patient’s rights to make decisions about
their care, ensuring that the patient’s wishes are respected.
Do Not Resuscitate (DNR) Orders: Nurses must understand the legal implications of DNR orders
and ensure that these are documented and communicated clearly among the healthcare team.
Nurses should advocate for patients who wish to forgo resuscitation efforts, ensuring that the
order is respected.
Palliative Sedation: In cases where patients experience intractable suffering that cannot be controlled
by other means, palliative sedation may be used. Nurses should understand the ethical
considerations and the appropriate protocols for this practice.
Physician-Assisted Suicide and Euthanasia: In some regions, physician-assisted suicide or euthanasia
may be legal, but it remains a highly controversial and ethically charged issue. Nurses must be
aware of the legal frameworks in their jurisdiction and be prepared to address ethical dilemmas
while respecting the patient's and family’s wishes.
Providing Family Support
The family plays an integral role in end-of-life care, and the nurse must provide not only care for
the patient but also emotional and logistical support for the family. The dying process can be
emotionally draining, and families often need guidance as they deal with grief and decision-
making.
Supporting Grief and Bereavement: Nurses should assess the family’s emotional state and provide grief
support. This may include helping the family cope with anticipatory grief (the grief experienced
before the patient’s death) and offering counseling or support group referrals for post-death grief.
Providing Information: Families often need information about what to expect as the patient nears the
end of life. Nurses should educate the family about the physical signs of dying, such as changes
in breathing patterns, reduced consciousness, and loss of appetite, to help them prepare for the
patient's death.
Involving the Family in Care: Nurses should encourage family members to participate in the care
process, including providing physical care, emotional support, and offering comfort to the patient.
This involvement can foster a sense of closure and help the family feel more in control during a
difficult time.
Handling Difficult Conversations: Nurses may need to facilitate difficult conversations between
patients and families, particularly around topics like death and end-of-life wishes. It is important
for nurses to provide guidance and support during these conversations, helping families make
decisions that align with the patient’s values.
NCLEX Considerations for End-of-Life Care
The NCLEX-RN exam includes questions related to end-of-life care, which may involve:

 Recognizing signs and symptoms of impending death.

 Identifying appropriate nursing interventions for managing physical symptoms such as
pain, dyspnea, and nausea.
 Supporting patients and families through communication, education, and emotional
support.
 Understanding ethical and legal principles related to end-of-life care, including advance
directives and DNR orders.
 Chapter 9: Basic Care and
Comfort (6%-12%)
9.1 Assisting with Activities of Daily Living (ADLs)
ADLs are the basic functions that a person needs to be able to carry out in order to live
independently and maintain their well-being. These activities include bathing, dressing, feeding,
mobility, toileting, and personal hygiene. Nurses play a significant role in assisting patients with
ADLs, especially when patients experience physical, cognitive, or emotional limitations that
impair their ability to perform these tasks on their own. ADLs can be divided into two categories:
basic ADLs (BADLs) and instrumental ADLs (IADLs).
Basic ADLs (BADLs): These are the essential activities that an individual must perform to care
for themselves daily. These include:

 Bathing and showering: Personal hygiene tasks that promote cleanliness and comfort.
 Dressing: The ability to choose and wear appropriate clothing.
 Feeding: The ability to eat independently or with assistance.
 Toileting: Managing the need to go to the bathroom, including self-toileting and managing
continence.
 Ambulation (mobility): The ability to move independently from one place to another, such
as walking or using mobility aids like a walker or wheelchair.
 Instrumental ADLs (IADLs): These are more complex tasks that support independent
living but are not required for basic survival. IADLs include:
 Managing finances: Handling personal finances, paying bills, and budgeting.
 Shopping: The ability to purchase groceries or other essential items.
 Housekeeping: Cleaning and maintaining a safe living environment.
 Transportation: The ability to use public transportation or drive a car.
 Medication management: Taking prescribed medications correctly, including organizing
medications and adhering to schedules.
While BADLs are generally more fundamental, both BADLs and IADLs are important for
maintaining independence and promoting a patient’s quality of life. The level of support required
for each activity varies, depending on the individual patient's condition.
2. Nurses’ Role in Assisting with ADLs
Nurses are involved in providing direct assistance or guidance to patients with ADLs, as well as
in evaluating the need for further support or rehabilitation. The goal is always to promote
independence and self-care, whenever possible. Nurses are responsible for assessing the patient’s
abilities, ensuring that appropriate support is provided, and identifying any potential safety risks.
The role can include:
Assessment of ADLs: The nurse performs a comprehensive assessment to determine the patient's
level of independence in performing ADLs. This includes evaluating the patient's physical,
cognitive, and emotional abilities to perform these tasks.
Providing Direct Assistance: In cases where a patient is unable to complete ADLs independently, the
nurse can provide direct assistance. This might include helping a patient bathe, dress, or move
from the bed to a wheelchair. Nurses should use proper body mechanics to ensure both patient
and nurse safety during these activities.
Promoting Independence: Nurses encourage patients to perform ADLs as independently as possible,
providing assistance only when necessary. For example, if a patient has a disability that affects
their ability to dress, a nurse may assist with complicated tasks but encourage the patient to dress
themselves as much as possible. The goal is to promote self-esteem and confidence by maximizing
independence.
Assisting with Mobility: Nurses help patients maintain or improve their ability to move
independently. This could include assisting with walking, transferring from a bed to a chair, or
using mobility devices such as wheelchairs or walkers. Proper techniques should be followed to
ensure the safety of both the patient and the nurse.
Implementing Safety Measures: Assisting with ADLs may involve addressing safety concerns,
especially for patients who are at risk of falls or other injuries. Nurses should make sure that the
environment is free from hazards, such as loose rugs or poor lighting, and that the patient has
adequate support to prevent accidents. Fall prevention strategies, including the use of bed rails,
non-slip mats, and proper footwear, should be part of the care plan.
Providing Emotional Support: Many patients, particularly those with chronic conditions or disabilities,
may feel frustrated, embarrassed, or depressed about needing assistance with ADLs. Nurses
should provide emotional support by offering reassurance, listening to concerns, and promoting
a sense of dignity and respect for the patient.
3. Challenges in Assisting with ADLs
There are several challenges that nurses may face when assisting patients with ADLs. These
challenges may stem from the patient's physical, cognitive, or emotional limitations, or they may
be related to the nurse's ability to provide effective care while maintaining the patient’s autonomy.
Physical Limitations: Patients with mobility impairments or physical limitations due to conditions
such as arthritis, stroke, or spinal cord injuries may require significant assistance with ADLs. In
these cases, nurses must assess the patient’s physical abilities and help them use mobility aids or
adaptive equipment to enhance their independence.
Cognitive Impairment: Patients with dementia, Alzheimer's disease, or other cognitive disorders may
struggle to remember the steps involved in performing ADLs. Nurses may need to assist with or
supervise the performance of these tasks while also offering supportive reminders or verbal cues.
Emotional and Psychological Barriers: Some patients may feel a sense of loss or frustration due to their
inability to perform ADLs independently. This can be especially true for patients who are
recovering from surgery or illness. Nurses should approach these situations with empathy,
providing emotional support and encouraging patients to participate in their care as much as
possible.
Family Involvement: In some cases, family members may be involved in helping patients with ADLs.
Nurses should educate family members on safe techniques and strategies for providing assistance.
This might include demonstrating how to help with bathing, dressing, or mobility to ensure the
patient's safety and well-being.
Resource Limitations: In some healthcare settings, there may be limited resources or staffing to assist
patients with ADLs. Nurses need to be efficient in managing time and resources to ensure that
all patients receive the necessary care. Additionally, nurses may advocate for more resources or
staffing when the workload exceeds capacity.
4. Patient Education and ADLs
Patient education plays a crucial role in supporting ADLs. By teaching patients how to care for
themselves and adapt to physical changes, nurses empower patients to maintain their
independence and improve their quality of life. Some key educational strategies include:
Teaching Adaptive Strategies: Nurses can teach patients adaptive techniques to perform ADLs more
independently. For example, a nurse can teach a patient with arthritis how to use specialized tools
to dress, cook, or manage personal hygiene without straining their joints.
Training on Assistive Devices: Patients who require mobility aids (e.g., canes, walkers, wheelchairs)
should receive proper training in using these devices. Nurses can demonstrate how to use these
devices safely and effectively to prevent falls and increase mobility.
Providing Instructions on Home Modifications: Nurses can educate patients and families about potential
home modifications to make ADLs easier and safer. This might include installing grab bars in the
bathroom, using raised toilet seats, or rearranging furniture to create more space for mobility aids.
Promoting Healthy Lifestyle Choices: Nurses can educate patients on maintaining or improving their
physical health to support ADLs. This may include recommendations for regular exercise,
balanced nutrition, and maintaining a healthy weight to prevent or manage chronic conditions
that may affect the ability to perform ADLs.
5. Documenting ADL Assistance
Proper documentation of ADL assistance is critical in ensuring that patient care is well-
coordinated and safe. Nurses must document:

 The level of assistance provided for each ADL.

 Any changes in the patient’s abilities to perform ADLs independently.
 Specific interventions, such as the use of assistive devices or modifications to the care plan.
 Any complications or concerns related to the patient’s ability to perform ADLs (e.g., falls,
skin breakdown).
Clear and accurate documentation helps communicate the patient's needs to the entire healthcare
team and ensures continuity of care.
6. NCLEX Considerations for Assisting with ADLs
The NCLEX exam will test your ability to recognize the importance of ADLs in nursing care.
Key areas to focus on include:

 Assessing a patient’s ability to perform ADLs and identifying when assistance is needed.
 Understanding the impact of physical, cognitive, and emotional factors on ADL
performance.
 Demonstrating safe and efficient techniques for assisting with ADLs, including proper
body mechanics and the use of adaptive devices.
 Educating patients and families about how to perform ADLs independently or with
assistance.
 Promoting patient dignity and autonomy while providing necessary assistance.
In NCLEX questions, you may be asked to prioritize which ADLs to address first, how to assist
a patient in a specific ADL, or how to educate a patient or family member about performing
ADLs safely.
9.2 Pain Management Strategies for Acute and Chronic Pain
Pain is one of the most common and distressing symptoms experienced by patients in healthcare
settings, and effective pain management is a key component of nursing care. Pain can be classified
into two main types: acute pain and chronic pain. Each type requires specific assessment and
management strategies to ensure that the patient’s pain is controlled, and their quality of life is
improved. The nurse’s role in pain management involves assessing the intensity, location, and
nature of pain, implementing interventions, and educating the patient about pain relief options.
1. Acute Pain Management
Acute pain is often the result of injury, surgery, or an underlying health condition that is sudden
in onset and typically short-term. Acute pain serves as a warning sign for tissue damage or injury,
and it usually resolves once the underlying cause is treated or healed. Effective management of
acute pain aims to reduce discomfort, promote healing, and prevent the development of chronic
pain.
a. Assessment of Acute Pain
The first step in managing acute pain is a thorough assessment. Nurses must gather information
about the patient’s pain using both subjective and objective data. This can be done through:
Pain Scales: Tools like the Numeric Rating Scale (NRS), Visual Analog Scale (VAS), and the Wong-
Baker Faces Pain Rating Scale are commonly used to quantify pain intensity. This helps the nurse
assess the severity of the pain and determine the effectiveness of interventions.
Pain History: A comprehensive pain history should include the onset, location, duration, quality,
intensity, and aggravating or alleviating factors. The nurse should also inquire about any previous
pain episodes or treatments.
Physical Examination: Observing the patient’s behavior and physiological responses to pain (e.g.,
increased heart rate, sweating, grimacing) can provide additional insight into the level of
discomfort and guide management decisions.
b. Pharmacologic Pain Management for Acute Pain
The cornerstone of acute pain management is pharmacological intervention. Nurses should
collaborate with the healthcare team to administer the appropriate medications based on the
severity of the pain.
Non-Opioid Analgesics: For mild to moderate acute pain, non-opioid analgesics such as
acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are often used. These drugs
help reduce pain and inflammation and are typically the first-line treatment for many types of
acute pain, including musculoskeletal pain or mild postoperative pain.
Opioids: For moderate to severe acute pain, opioids like morphine, fentanyl, hydromorphone, and
oxycodone may be necessary. Opioids work by binding to opioid receptors in the brain and spinal
cord to block pain transmission. These medications should be prescribed and administered with
caution due to the risk of addiction, sedation, and respiratory depression.
Adjuvant Medications: Certain medications that are not primarily intended for pain relief can be used
as adjuvants in acute pain management. These may include anticonvulsants like gabapentin for
nerve-related pain or corticosteroids for inflammation-related pain.
Patient-Controlled Analgesia (PCA): PCA pumps allow patients to self-administer a controlled dose
of pain medication, typically an opioid, at predetermined intervals. This gives the patient more
control over their pain management and can improve patient satisfaction.
c. Non-Pharmacologic Pain Management for Acute Pain
In addition to medications, nurses should employ non-pharmacological interventions to enhance
pain relief and promote comfort.
Heat and Cold Therapy: Heat (e.g., warm packs or heating pads) can be used to relax muscles and
improve blood circulation, while cold therapy (e.g., ice packs) can reduce inflammation and numb
the area of pain. Both techniques are commonly used for musculoskeletal injuries.
Physical Therapy and Movement: Gentle exercises or physical therapy may help reduce pain in
conditions such as muscle strain or joint pain. However, the nurse must ensure that movement
does not aggravate the injury.
Cognitive Behavioral Therapy (CBT): CBT techniques such as relaxation exercises, deep breathing,
and guided imagery can help patients manage pain by focusing their attention away from
discomfort and reducing anxiety.
Distraction Techniques: Diverting the patient’s attention from pain through activities such as
watching TV, listening to music, or engaging in conversation can be an effective way to reduce
pain perception, particularly in patients with acute pain.
Massage: Gentle massage may reduce muscle tension and help relieve pain in some cases, such as
with back or neck pain.
2. Chronic Pain Management
Chronic pain persists over time, often lasting for months or even years, and may result from
conditions such as arthritis, fibromyalgia, or neuropathic pain. Chronic pain is typically more
complex to manage than acute pain because it often has no identifiable, treatable cause and may
be associated with psychological and social factors.
a. Assessment of Chronic Pain
The assessment of chronic pain requires careful evaluation to identify the underlying cause and
determine the impact on the patient’s quality of life.
Pain Duration: Chronic pain typically lasts for longer than three months, and it may result from
conditions like osteoarthritis, cancer, neuropathy, or fibromyalgia. Nurses should assess the
duration, intensity, and quality of the pain, as well as how it affects the patient’s daily activities.
Impact on Functionality: Nurses should assess how chronic pain affects the patient’s ability to
perform activities of daily living (ADLs) and their emotional well-being. Chronic pain can lead to
limitations in mobility, decreased ability to work, and social isolation, which can contribute to
depression and anxiety.
Psychosocial Factors: Chronic pain is often associated with emotional distress, and nurses must assess
for symptoms of depression, anxiety, or stress that may exacerbate the pain. Identifying and
addressing these factors can be crucial in the management of chronic pain.
b. Pharmacologic Pain Management for Chronic Pain
Managing chronic pain typically requires a multimodal approach that combines medications from
different classes to achieve optimal pain relief.
Non-Opioid Analgesics: Acetaminophen and NSAIDs are frequently used in chronic pain
management for conditions like osteoarthritis or back pain. These medications are often used as
part of an ongoing pain management plan.
Opioids: While opioids are sometimes necessary for chronic pain management, they are typically
used with caution due to the potential for tolerance, dependence, and misuse. Extended-release
formulations (e.g., oxycodone ER or morphine sulfate ER) may be prescribed for patients with
severe, persistent pain. Opioid therapy should be continuously reevaluated and used at the lowest
effective dose.
Antidepressants and Anticonvulsants: Medications like tricyclic antidepressants (TCAs), serotonin-
norepinephrine reuptake inhibitors (SNRIs), and anticonvulsants (e.g., gabapentin) can be used in
chronic pain management, particularly for neuropathic pain. These medications help modulate
pain transmission in the nervous system and can be effective for conditions like diabetic
neuropathy or fibromyalgia.
Topical Medications: Topical treatments such as lidocaine patches or capsaicin cream can be used
for localized chronic pain. These treatments provide pain relief with fewer systemic side effects
compared to oral medications.
c. Non-Pharmacologic Pain Management for Chronic Pain
Non-pharmacological interventions are essential components of chronic pain management,
especially for patients seeking to reduce reliance on medications or experiencing medication-
related side effects.
Physical Therapy and Exercise: Regular physical activity can help maintain mobility, reduce stiffness,
and improve overall function in patients with chronic pain. Tailored exercise programs designed
by a physical therapist can help improve strength, flexibility, and endurance.
Cognitive Behavioral Therapy (CBT): CBT is particularly effective in chronic pain management by
helping patients change the way they think about pain, reduce anxiety, and develop coping
strategies. Pain catastrophizing (exaggerated negative thoughts about pain) can be reduced with
CBT techniques, improving pain tolerance.
Mindfulness and Relaxation Techniques: Techniques such as guided imagery, deep breathing exercises,
and meditation can help patients manage chronic pain by promoting relaxation and reducing stress,
which can, in turn, alleviate pain.
Acupuncture and Massage: Acupuncture and massage therapy have been shown to reduce pain and
improve quality of life for some individuals with chronic pain. These therapies can help relax
muscles, improve blood flow, and release endorphins, which are natural pain relievers.
Biofeedback: Biofeedback is a technique that teaches patients how to control physiological
functions, such as muscle tension or heart rate, with the goal of reducing pain. It involves using
electronic devices to provide real-time feedback to the patient, allowing them to learn relaxation
techniques.
3. Multidisciplinary Approach to Pain Management
Effective pain management, particularly for chronic pain, often requires a multidisciplinary
approach. Nurses should collaborate with physicians, physical therapists, psychologists, and other
healthcare providers to develop an individualized treatment plan that addresses the patient’s
specific needs. This approach can include:
Patient Education: Nurses should educate patients about their pain condition, treatment options,
and the importance of self-management strategies. Education should also address any
misconceptions or fears the patient may have about pain medications, side effects, and the long-
term management of their condition.
Support Systems: Providing support for patients and their families is crucial for successful pain
management. Nurses should facilitate open communication about the challenges of living with
chronic pain and offer emotional support to help patients cope with the physical and
psychological impact of pain.
4. NCLEX Considerations for Pain Management
On the NCLEX, pain management questions may ask about:

 The appropriate use of pharmacologic and non-pharmacologic pain management

techniques for both acute and chronic pain.
 Assessing and monitoring pain in patients with different types of pain.
 The importance of educating patients on pain management options, including the risks and
benefits of different treatments.
 Managing pain in patients with specific conditions, such as post-operative pain, cancer
pain, or neuropathic pain.
Recognizing signs of opioid misuse or dependency and providing appropriate interventions.

9.3 Comfort and Palliative Care Principles

Palliative care is based on a few fundamental principles that guide the nursing care of individuals
experiencing serious illness or nearing the end of life. These principles are focused on alleviating
suffering, maintaining dignity, and providing support for patients and their families.
a. Patient-Centered Care
At the heart of comfort and palliative care is patient-centered care. This means that care is tailored
to meet the unique needs, preferences, and values of each patient. Nurses assess the patient’s
physical, emotional, spiritual, and psychological needs, ensuring that all aspects of their well-being
are considered.
Patient-centered care involves:

 Respecting patient autonomy by involving them in decision-making.

 Providing emotional and psychological support to help patients cope with the challenges
of their illness.
  Offering comfort and dignity throughout the disease progression.
b. Holistic Approach
Palliative care takes a holistic approach to treating the patient, addressing not only physical
symptoms but also emotional, social, and spiritual aspects. This involves collaborating with a
multidisciplinary team that may include doctors, social workers, chaplains, and psychologists to
ensure that the patient’s overall needs are met.
A holistic approach to care includes:

 Managing physical symptoms such as pain, nausea, and breathlessness.

 Providing emotional support for anxiety, depression, and fear.
 Offering spiritual care for those who may need support with existential concerns.
 Engaging family members to provide a support system during this difficult time.
c. Symptom Management
Effective symptom management is a cornerstone of palliative care. Nurses assess the patient’s
symptoms regularly and use both pharmacologic and non-pharmacologic methods to relieve
discomfort. The goal is to alleviate symptoms to a level where the patient can maintain a good
quality of life, rather than attempting to cure the illness itself.
Key symptoms often managed in palliative care include:
Pain: Pain is the most common symptom in palliative care, and its management is crucial to
improving quality of life. Nurses use a variety of strategies to manage pain, including opioids,
NSAIDs, and adjunctive therapies such as anticonvulsants or antidepressants. Non-
pharmacologic interventions, such as relaxation techniques and guided imagery, can also be
helpful.
Nausea and Vomiting: These symptoms are common in patients with advanced cancer or other
serious illnesses. Antiemetic medications, along with positioning and diet modifications, can help
alleviate nausea and vomiting.
Dyspnea (Shortness of Breath): Patients with respiratory conditions, such as COPD or end-stage
cancer, may experience dyspnea. Oxygen therapy, bronchodilators, and positioning techniques
can help alleviate breathlessness.
Fatigue: Many patients in palliative care experience profound fatigue. Nurses work with patients
to manage energy levels and encourage rest, while also promoting activities that provide mental
stimulation and comfort.
Constipation: Opioid medications, while effective for pain management, can cause constipation.
Nurses monitor bowel movements and provide appropriate interventions, such as laxatives or
stool softeners, to address this common issue.
d. Communication and Shared Decision-Making
Effective communication is essential in palliative care, as it helps ensure that the patient’s wishes
and goals are respected. Nurses must foster open, empathetic communication with the patient
and their family, particularly when discussing sensitive topics such as prognosis, treatment
options, and end-of-life decisions.
Shared decision-making involves:

 Having honest discussions with the patient and family about the illness, prognosis, and
available options.
 Helping the patient express their preferences for care, including whether they want to
pursue aggressive treatments or focus on comfort measures.
 Encouraging family members to be part of the decision-making process, providing
emotional support, and respecting cultural or religious beliefs that may influence the
patient's choices.
e. Caregiver Support and Education
In palliative care, caregivers—often family members—play a vital role in providing day-to-day
support to the patient. Nurses educate caregivers on how to assist with activities of daily living,
manage symptoms, and provide emotional and spiritual support. Nurses also help caregivers
navigate the emotional and physical challenges of caring for a loved one at the end of life, and
they provide resources for respite care if needed.
Caregiver support includes:

 Teaching family members how to administer medications, manage symptoms, and provide
physical care.
 Offering emotional support to help caregivers cope with the stress and emotional burden
of caring for a loved one.
 Referring family members to support groups, counseling, or respite care services to ensure
they have the resources needed to cope.
2. Pain Management in Palliative Care
Pain is one of the most important symptoms to address in palliative care, as uncontrolled pain
significantly affects a patient's quality of life. Effective pain management is achieved through a
combination of pharmacological treatments, non-pharmacological interventions, and holistic care
approaches.
a. Pharmacological Pain Management
Pain relief in palliative care often requires opioid medications, such as morphine, hydromorphone,
and fentanyl, which are effective for managing moderate to severe pain. These medications are
titrated to the patient’s needs, and the nurse ensures that doses are adjusted regularly to maintain
comfort.
Opioids: These are the primary class of drugs used for pain relief in palliative care. They work by
binding to opioid receptors in the brain and spinal cord to block pain signals. Nurses must
monitor for side effects, such as constipation, sedation, and respiratory depression.
NSAIDs: Non-steroidal anti-inflammatory drugs like ibuprofen and naproxen can be used for
mild to moderate pain, especially if inflammation is contributing to the pain.
Adjuvant Medications: Medications such as anticonvulsants (e.g., gabapentin) and antidepressants
(e.g., amitriptyline) may be used to manage specific types of pain, such as neuropathic pain.
b. Non-Pharmacologic Pain Management
While medications are crucial in palliative care, non-pharmacological approaches should also be
incorporated to manage pain effectively.
Massage Therapy: Gentle massage can reduce muscle tension and promote relaxation. It can be
particularly helpful for patients with chronic pain, such as those with cancer or arthritis.
Relaxation Techniques: Techniques like deep breathing, progressive muscle relaxation, and guided
imagery can help patients manage pain by reducing stress and increasing feelings of control over
their bodies.
Heat and Cold Therapy: Heat (e.g., heating pads) can help relieve musculoskeletal pain, while cold
therapy (e.g., ice packs) can reduce inflammation and swelling.
Music Therapy: Music has been shown to have a calming effect and can help distract the patient
from pain or distress.
3. End-of-Life Considerations in Palliative Care
Palliative care often transitions into end-of-life care, which focuses on providing comfort to
patients who are nearing the end of their lives. The primary goals of end-of-life care are to ensure
the patient is free from pain and discomfort, support the emotional and spiritual needs of both
the patient and their family, and allow the patient to die with dignity.
a. End-of-Life Conversations
Nurses should be prepared to engage in conversations with patients and families about end-of-
life care. These discussions should be handled with sensitivity and respect, allowing the patient
and family members to express their wishes for the final stage of life. Nurses help facilitate these
conversations and ensure that the patient’s wishes regarding life-sustaining treatments, organ
donation, and other matters are respected.
b. Comfort Measures
In the final stages of life, the focus shifts entirely to comfort care. Nurses play an integral role in
managing symptoms that cause discomfort, including pain, dyspnea (shortness of breath), nausea,
and agitation. Palliative care interventions, including medication adjustments and emotional
support, are used to ensure that the patient is as comfortable as possible in their last days.
c. Family Support
End-of-life care involves supporting the family as much as the patient. Nurses should provide
emotional support, educate family members about what to expect during the dying process, and
help them prepare for grief. Nurses may also offer guidance on creating lasting memories with
the patient, including through “legacy work,” such as writing letters or creating mementos.
4. Nurses’ Role in Comfort and Palliative Care
Nurses are at the forefront of delivering comfort and palliative care, using their clinical expertise
and compassionate communication skills to provide holistic care to patients and families. Nurses
are responsible for:
Assessment and Monitoring: Continuously assessing pain, symptoms, and emotional well-being, and
adjusting care plans accordingly.
Collaborating with the Care Team: Working with other healthcare providers, such as physicians, social
workers, and chaplains, to address the comprehensive needs of the patient.
Providing Education and Support: Educating the patient and family about palliative care options,
symptom management, and the end-of-life process.
5. NCLEX Considerations for Comfort and Palliative Care
In the NCLEX, comfort and palliative care questions may focus on:
  Assessing and managing pain and other symptoms in patients with advanced illness.
 Communicating with patients and families about end-of-life care and respecting patient
preferences.
 Implementing strategies to manage physical and emotional symptoms in palliative care
settings.
 Recognizing the role of the nurse in providing holistic, compassionate care to improve
patient quality of life.

8.4 Ensuring Patient Safety in Routine Care

Patient safety in routine care is the proactive effort to prevent harm and minimize risk factors that
could compromise patient outcomes. It is about creating an environment where patients can
receive care without unnecessary risk, ensuring that the necessary steps are taken to safeguard
their well-being. Ensuring safety requires not only adherence to established protocols and
guidelines but also the application of critical thinking, vigilance, and collaboration among
healthcare teams.
a. Risk Assessment and Identification
Risk assessment is a fundamental step in ensuring patient safety. Nurses must be able to recognize
and address any potential risks to patient safety in routine care. This includes being aware of
factors that could lead to falls, medication errors, infection transmission, or patient
misidentification. Through comprehensive patient assessments and careful observation, nurses
are equipped to identify risks early and take the appropriate measures to mitigate them.
Patient History: Gathering a thorough medical history, including current medications, allergies, and
previous health conditions, is essential for identifying potential risks. Nurses must also be aware
of any history of falls or other complications that could affect patient safety.
Environmental Factors: The physical environment where care is delivered must also be considered.
Hazards such as clutter, inadequate lighting, or poor ergonomics can all increase the risk of harm.
Nurses should assess and address these environmental factors to ensure patient safety during
routine activities.
b. Effective Communication
Effective communication is vital to patient safety. Miscommunication or lack of communication
between healthcare providers, patients, and families can result in preventable errors and harm.
Nurses must ensure clear, concise, and accurate communication at all times, whether they are
passing on information during handoff reports, explaining procedures to patients, or relaying
critical information to the healthcare team.
SBAR Communication: One of the key tools for ensuring clear communication in healthcare is the
SBAR (Situation, Background, Assessment, and Recommendation) method. This standardized
approach ensures that information is conveyed in an organized and systematic way, reducing the
likelihood of important details being missed or misunderstood.
Patient and Family Education: Nurses must also communicate effectively with patients and their
families, explaining procedures, risks, and the rationale behind certain interventions. Educating
patients on their care plans, medications, and safety precautions empowers them to take an active
role in their own safety.
2. Infection Control and Prevention
Infection control is a critical aspect of patient safety, as healthcare-associated infections (HAIs)
can significantly impact patient outcomes. Nurses are responsible for ensuring that infection
prevention and control measures are followed meticulously to prevent the spread of pathogens in
healthcare settings.
a. Hand Hygiene
Proper hand hygiene is one of the simplest and most effective ways to prevent the transmission
of infections. Nurses should adhere to the "5 Moments of Hand Hygiene" as recommended by
the World Health Organization (WHO):
Before patient contact.
Before performing an aseptic task.
After body fluid exposure risk.
After patient contact.
After contact with patient surroundings.
Frequent hand washing with soap and water, as well as the use of alcohol-based hand sanitizers,
can prevent the transmission of germs that may be passed from patient to patient or from
healthcare worker to patient.
b. Use of Personal Protective Equipment (PPE)
PPE, such as gloves, masks, gowns, and eye protection, is essential in preventing the spread of
infections, particularly in high-risk situations such as handling bodily fluids or caring for patients
with contagious conditions. Nurses must ensure they are properly equipped with the appropriate
PPE for each clinical scenario.
Gloves: Should be used when handling any material or body fluid that could be contaminated, such
as blood, urine, or wound drainage.
Masks and Eye Protection: These are critical when providing care for patients with respiratory
illnesses or when there is a risk of splashes or sprays of body fluids.
c. Aseptic Techniques
Aseptic techniques are used to prevent the introduction of harmful microorganisms during
medical procedures. For instance, when performing wound care, inserting catheters, or
administering injections, it is crucial to maintain sterile fields and use sterile equipment to avoid
infection.
3. Medication Safety and Error Prevention
Medication errors are one of the most common causes of harm in healthcare. Ensuring
medication safety is a fundamental aspect of patient safety in routine care, and nurses are at the
forefront of preventing medication-related errors.
a. Five Rights of Medication Administration
The Five Rights of Medication Administration is a foundational guideline that nurses use to ensure
safe medication practices. These rights help ensure that the right medication is given to the right
patient at the right time, in the right dose, and by the right route. The Five Rights are:
Right Medication: The nurse must verify the medication by checking the order against the
medication label.
Right Dose: Nurses must confirm the dose prescribed matches the dose on the label and is
appropriate for the patient’s age and condition.
Right Time: The medication should be given at the correct time, and the nurse must be mindful of
the timing relative to meals or other medications.
Right Route: The nurse must administer the medication via the correct route (oral, intravenous,
intramuscular, etc.).
Right Patient: The nurse must verify the patient’s identity using two identifiers, such as name and
date of birth, to ensure that the medication is administered to the correct person.
b. Bar Code Medication Administration (BCMA)
Many healthcare facilities now use barcode scanning technology as an additional safeguard to
prevent medication errors. Nurses scan both the patient’s wristband and the medication before
administration to verify that the right drug is being given to the right patient.
c. Monitoring for Adverse Effects
After medication administration, nurses are responsible for monitoring the patient for any adverse
effects, including allergic reactions, side effects, or signs of toxicity. Immediate intervention may
be required if a patient experiences an adverse reaction, and nurses must be prepared to take
action swiftly.
4. Patient Safety in Physical Care
Patient safety is not only about medication and infection control; it also extends to the physical
environment and activities of daily living (ADLs). Nurses ensure patient safety by closely
monitoring patients during routine care and ensuring that any activities do not pose unnecessary
risks.
a. Fall Prevention
Falls are a leading cause of injury, particularly in older adults and patients with compromised
mobility. Nurses should assess fall risk using standardized tools, such as the Morse Fall Scale, and
implement appropriate interventions to prevent falls.
Environmental Modifications: Ensuring that patient rooms are free of obstacles, clutter, or items that
could cause tripping hazards is key to preventing falls.
Assistive Devices: Patients who have difficulty walking may require assistive devices such as walkers
or canes. Nurses should ensure that these devices are used correctly and are in good working
condition.
Patient Education: Educating patients on the importance of asking for assistance when moving, and
encouraging them to call for help before attempting to get out of bed, can help reduce fall risk.
b. Positioning and Pressure Ulcer Prevention
Patients who are bedridden or have limited mobility are at risk for developing pressure ulcers, also
known as bedsores. Nurses must follow protocols to ensure that patients are repositioned
regularly to alleviate pressure on vulnerable areas like the back, heels, and sacrum.
Repositioning: Patients should be turned or repositioned at least every two hours to prevent pressure
from building up on any one part of the body.
Pressure-Relieving Devices: Use of specialized mattresses, cushions, and pads can help reduce the risk
of pressure ulcers.
c. Safety during Activities of Daily Living (ADLs)
Ensuring that patients are safe during ADLs—such as bathing, dressing, eating, and toileting—
requires close monitoring and support. For example:
Bathing: If a patient is at risk of slipping in the shower, the nurse may need to assist with bathing
or provide bath rails to ensure stability.
Eating: Patients with swallowing difficulties, such as those with dysphagia, should be closely
monitored during meals to prevent choking.
5. The Role of Nurses in Ensuring Patient Safety
Nurses are at the center of ensuring patient safety. Their role encompasses many tasks, including
risk assessment, communication, medication management, and patient education. They are
responsible for ensuring that safety protocols are followed, that patients are properly monitored,
and that any risks to safety are addressed immediately.
a. Advocacy
Nurses act as patient advocates, ensuring that the patient’s best interests are represented at all
times. This may involve advocating for safer practices, ensuring that the patient is informed of
potential risks, and supporting the patient’s autonomy in decision-making.
b. Continuous Education
Patient safety is an evolving field, and nurses must stay informed about the latest safety protocols,
technologies, and best practices. Ongoing education, including participation in safety drills,
workshops, and professional development courses, ensures that nurses are equipped with the
knowledge and skills to maintain patient safety in all care settings.
6. NCLEX Considerations for Patient Safety in Routine Care
On the NCLEX, questions related to patient safety in routine care may cover various topics,
including:

 The five rights of medication administration.

 Strategies for preventing falls, pressure ulcers, and other adverse events.
 Effective infection control practices, including hand hygiene and the use of PPE.
 Monitoring for adverse medication effects and implementing appropriate interventions.
 Assessing and managing environmental hazards to ensure patient safety.
 Communicating effectively with the healthcare team to promote patient safety.
 Chapter 10: Pharmacological
and Parenteral Therapies (13%-
19%)
10.1 Understanding Drug Classifications and Actions
Medications can be classified in various ways, including by their therapeutic effect, mechanism of
action, or chemical structure. Here are some of the major drug classifications and examples:

Drug Example Mechanism of Action Nursing

Classification Medications Implications

Antibiotics Penicillin, Kill or inhibit the growth of Monitor for allergic

Amoxicillin, microorganisms like bacteria. reactions, monitor
Vancomycin CBC for signs of
infection or adverse
effects.

Analgesics Acetaminophen, Block pain pathways, either by Assess for pain relief,
Ibuprofen, inhibiting inflammation monitor for side
Morphine (NSAIDs) or modulating pain effects like respiratory
receptors (opioids). depression (opioids).

Antidiabetic Metformin, Lower blood glucose by Monitor blood

Agents Insulin, Glipizide different mechanisms (insulin glucose levels, assess
promotes glucose uptake, for hypoglycemia in
others improve insulin insulin therapy.
sensitivity).
 Antihypertensive Lisinopril, Lower blood pressure through Monitor blood
Amlodipine, various mechanisms: pressure, assess for
Metoprolol vasodilation, diuresis, or signs of hypotension,
reducing heart rate. especially after the
first dose.

Anticoagulants Warfarin, Heparin, Inhibit blood clotting Monitor for signs of

Enoxaparin mechanisms to prevent bleeding, check INR
thromboembolism. (Warfarin) or aPTT
(Heparin).

Corticosteroids Prednisone, Suppress inflammation by Monitor for signs of

Hydrocortisone inhibiting the release of pro- infection, elevated
inflammatory mediators. blood sugar, and long-
term bone health
issues.

Diuretics Furosemide, Increase urine output by Monitor electrolytes

Spironolactone promoting renal excretion of (especially
sodium and water. potassium), assess for
signs of dehydration.

2. Understanding the Mechanism of Action

The mechanism of action (MOA) of a drug refers to the specific biochemical interaction through
which a drug produces its effect. This can vary widely across drug classifications, and
understanding MOA helps nurses recognize potential therapeutic effects and side effects.
Analgesics: For example, morphine binds to opioid receptors in the brain and spinal cord to block
the transmission of pain signals. In contrast, NSAIDs like ibuprofen work by inhibiting
cyclooxygenase enzymes (COX-1 and COX-2), which reduces the production of prostaglandins
that cause pain and inflammation.
Antibiotics: The MOA of antibiotics like penicillin involves inhibiting bacterial cell wall synthesis,
leading to cell death. Vancomycin, on the other hand, inhibits bacterial cell wall synthesis but is
more commonly used for Gram-positive infections, especially those resistant to other antibiotics.
3. Side Effects and Adverse Reactions
Each drug classification has common side effects, but nurses must also be vigilant for adverse
reactions, which are more severe and less common.
Opioids (e.g., Morphine, Hydrocodone): Common side effects include nausea, constipation, and
sedation. However, nurses should monitor for respiratory depression, a potentially life-
threatening adverse effect, especially in high doses.
Antibiotics (e.g., Amoxicillin, Penicillin): Common side effects include GI disturbances, such as nausea
or diarrhea. Serious reactions may include anaphylaxis or Stevens-Johnson syndrome, especially
with sulfonamides or penicillin.
Diuretics (e.g., Furosemide, Spironolactone): These drugs can lead to electrolyte imbalances, including
hypokalemia (low potassium) with loop diuretics (e.g., furosemide) or hyperkalemia (high
potassium) with potassium-sparing diuretics (e.g., spironolactone).
4. Monitoring Parameters
Proper drug administration goes hand in hand with monitoring key parameters to prevent adverse
effects and optimize therapeutic outcomes. These include:

Drug Class Monitoring Parameters Reason for Monitoring

Anticoagulants PT/INR (Warfarin), aPTT To ensure proper anticoagulation and prevent

(Heparin), platelet count bleeding or clotting complications.

Diuretics Serum electrolytes, BP, weight To monitor for dehydration, electrolyte

imbalances, and blood pressure control.

Corticosteroids Blood glucose, electrolytes, To assess for hyperglycemia, fluid retention,

weight and changes in potassium levels.

Opioids Respiratory rate, sedation To detect signs of overdose (e.g., respiratory

level, pain level depression) and evaluate effectiveness.

5. Special Considerations for Drug Classes

a. Antihypertensive Drugs
Antihypertensive drugs lower blood pressure by various mechanisms, including vasodilation,
diuresis, and heart rate reduction. Nurses must monitor patients for hypotension and orthostatic
hypotension, especially with medications like ACE inhibitors (e.g., Lisinopril), ARBs (e.g.,
Losartan), and calcium channel blockers (e.g., Amlodipine). These drugs can also increase
potassium levels, so monitoring electrolytes is necessary.
b. Diuretics
Diuretics, commonly prescribed for conditions like hypertension and heart failure, help the body
remove excess fluid. However, they can lead to electrolyte imbalances such as hypokalemia with
loop diuretics (e.g., furosemide) or hyperkalemia with potassium-sparing diuretics (e.g.,
spironolactone). Nurses should monitor potassium levels, renal function, and vital signs to
manage these risks.
c. Antidepressants and Antipsychotics
Many antidepressants, such as SSRIs (e.g., fluoxetine) and TCAs (e.g., amitriptyline), and
antipsychotics, such as clozapine, work by altering neurotransmitter levels in the brain. For
instance, SSRIs increase serotonin levels, which can improve mood and anxiety. However, they
carry the risk of sexual dysfunction, nausea, and, in some cases, serotonin syndrome when
combined with other medications. It is essential to monitor patients for these side effects.
d. Cardiac Medications
Drugs like beta-blockers (e.g., metoprolol) and calcium channel blockers (e.g., verapamil) are
crucial for managing conditions like hypertension, angina, and arrhythmias. These medications
can lower heart rate and cause hypotension, so nursing assessments should include heart rate,
blood pressure, and electrolyte levels. Digoxin, used for heart failure and arrhythmias, has a
narrow therapeutic range, so monitoring serum levels is necessary to avoid toxicity.
6. Special Drug Considerations for High-Risk Populations
Certain populations, such as the elderly, pregnant women, and those with renal or hepatic
impairments, require special consideration when prescribing and administering medications. For
example:

 Elderly patients may experience altered drug metabolism, leading to increased drug levels
and risk of toxicity.
 Pregnant women must avoid drugs like ACE inhibitors, which can be teratogenic and
harmful to the fetus.
  Renal and hepatic dysfunction may impair drug clearance, so dosage adjustments are often
needed for medications like digoxin, antibiotics, and antihypertensives.
7. Commonly Used Drug Examples and Nursing Implications
Here are some specific drug examples and the nursing implications associated with them:

Drug Indication Side Effects Nursing Implications

Name

Amlodipine Hypertension, angina Peripheral edema, Monitor BP, assess for edema,
dizziness, headache and educate on orthostatic
hypotension.

Furosemide Edema, hypertension Hypokalemia, Monitor electrolytes, BP, and

hypotension, renal function.
dehydration

Metformin Type 2 diabetes GI upset, lactic Hold before contrast

acidosis (rare) procedures, monitor blood
glucose levels.

Amoxicillin Bacterial infections Nausea, diarrhea, Monitor for signs of an allergic

allergic reactions reaction, educate on completing
the full course.

Prednisone Inflammation, Hyperglycemia, fluid Monitor glucose levels, weight,

autoimmune diseases retention, osteoporosis and for signs of infection.

Warfarin Anticoagulation Bleeding, GI upset, Monitor INR, educate on

purple toes (rare) avoiding high-vitamin K foods,
and bleeding precautions.

10.2 Medication Administration: Dosage Calculations and Routes

Dosage calculations ensure that the right amount of a medication is administered to a patient.
Nurses must be proficient in calculating dosages based on various units of measurement (e.g.,
milligrams, milliliters, units) and patient-specific factors (e.g., weight, age, condition). Common
types of dosage calculations include:

 Basic Dosage Calculations: These involve the calculation of a dose based on a known
concentration of a medication.
Formula for Basic Dosage Calculation:
𝐷𝑒𝑠𝑖𝑟𝑒𝑑 𝐷𝑜𝑠𝑒 × 𝑉𝑜𝑙𝑢𝑚𝑒 𝑜𝑛 𝐻𝑎𝑛𝑑
𝐷𝑜𝑠𝑒 𝑡𝑜 𝐴𝑑𝑚𝑖𝑛𝑖𝑠𝑡𝑒𝑟 =
𝐴𝑚𝑜𝑢𝑛𝑡 𝑜𝑛 𝐻𝑎𝑛𝑑
Example:
A doctor prescribes 50 mg of a medication, and the medication comes in a concentration of 100
mg/2 mL. To calculate the correct volume to administer:
50 𝑚𝑔 × 2 𝑚𝐿
𝐷𝑜𝑠𝑒 𝑡𝑜 𝐴𝑑𝑚𝑖𝑛𝑖𝑠𝑡𝑒𝑟 = = 1 mL
100 𝑚𝑔

Thus, the nurse would administer 1 mL of the medication.

 Weight-Based Dosage Calculations: Some medications are dosed based on the patient's weight.
For example, pediatric medications are often dosed by weight.
Formula for Weight-Based Dosage:
𝐷𝑜𝑠𝑎𝑔𝑒 = 𝐷𝑜𝑠𝑎𝑔𝑒 𝑝𝑒𝑟 𝑘𝑔 × 𝑃𝑎𝑡𝑖𝑒𝑛𝑡’𝑠 𝑊𝑒𝑖𝑔ℎ𝑡 (𝑘𝑔)
Example:
If a medication is prescribed as 10 mg/kg for a child weighing 15 kg:
𝐷𝑜𝑠𝑎𝑔𝑒 = 10 𝑚𝑔/𝑘𝑔 × 15 𝑘𝑔 = 150 𝑚𝑔
So, the child would receive 150 mg of the medication.

 IV Flow Rate Calculations: IV medications are often given by infusion, and nurses must be
able to calculate the rate at which the IV fluid should be infused.
Formula for IV Flow Rate:
𝑉𝑜𝑙𝑢𝑚𝑒 𝑡𝑜 𝑏𝑒 𝐼𝑛𝑓𝑢𝑠𝑒𝑑 (𝑚𝐿)
𝐼𝑉 𝐹𝑙𝑜𝑤 𝑅𝑎𝑡𝑒 (𝑚𝐿/ℎ𝑜𝑢𝑟) =
𝑇𝑖𝑚𝑒 (ℎ𝑜𝑢𝑟𝑠)
Example:
If a patient is to receive 500 mL of IV fluid over 4 hours:
 500 𝑚𝐿
IV Flow Rate = = 125 𝑚𝐿/ℎ𝑜𝑢𝑟
4 ℎ𝑜𝑢𝑟𝑠

Thus, the nurse should set the IV drip to 125 mL/hour.

2. Common Units of Measurement
In medication administration, different units are used to express medication dosages. Some
common units include:

Unit Equivalent Used For

Milligrams 1 mg = 1000 micrograms (mcg) Common for oral medications and

(mg) injectable solutions.

Milliliters 1 mL = 1 cubic centimeter (cc) Volume measurement, used for liquid

(mL) medications.

Grams (g) 1 g = 1000 mg Used for larger dosages or compounded

medications.

Units Varies by medication (e.g., insulin, Used for medications like insulin or
heparin) anticoagulants.

3. Routes of Medication Administration

Medications can be administered via various routes, each of which affects the absorption and
action of the drug. The most common routes include:
a. Oral (PO) Administration
Description: Medications taken by mouth are absorbed through the gastrointestinal (GI) tract.
Examples: Tablets, capsules, liquid suspensions.
Nursing Considerations:
Ensure the patient is able to swallow and alert.
Some medications should be taken with food to minimize gastric irritation (e.g., ibuprofen,
aspirin), while others are taken on an empty stomach to enhance absorption (e.g., levothyroxine).
Certain medications should not be crushed (e.g., enteric-coated tablets, extended-release
formulations).
b. Intravenous (IV) Administration
Description: Medications are injected directly into the bloodstream via the vein, providing rapid
onset of action.
Examples: IV push (bolus), IV infusion.
Nursing Considerations:
Ensure the IV site is patent and free of complications like infiltration or phlebitis.
Calculate the correct infusion rate using IV flow rate calculations.
For IV medications, confirm the appropriate dilution and infusion times.
c. Intramuscular (IM) Administration
Description: Medications are injected into a muscle, where they are absorbed into the
bloodstream.
Examples: Vaccines, hormones.
Nursing Considerations:
Select the appropriate muscle (e.g., ventrogluteal, deltoid).
Use the correct needle size based on the medication and patient’s muscle mass.
Rotate injection sites to minimize tissue irritation and damage.
d. Subcutaneous (SubQ) Administration
Description: Medications are injected into the fatty tissue just beneath the skin.
Examples: Insulin, anticoagulants.
Nursing Considerations:
Proper needle size is crucial (usually 25-31 gauge, 3/8 to 5/8 inch).
Rotate sites to avoid tissue damage or lipodystrophy.
Absorption may be slower than IM or IV routes, so expect a delayed onset of action.
e. Topical Administration
Description: Medications are applied directly to the skin or mucous membranes.
Examples: Creams, ointments, patches.
Nursing Considerations:
Ensure skin is clean and dry before application.
If using a patch (e.g., Nitroglycerin patch), place it on a hairless area and remove the previous
patch to prevent overdose.
f. Inhalation Administration
Description: Medications are delivered directly to the respiratory system via the lungs.
Examples: Inhalers (e.g., albuterol), nebulizers.
Nursing Considerations:
Educate patients on proper inhaler technique to ensure medication reaches the lungs.
Rinse the mouth after steroid inhalers to reduce the risk of oral fungal infections.
g. Rectal Administration
Description: Medications are administered via the rectum.
Examples: Suppositories, enemas.
Nursing Considerations:
Ensure the patient is in a comfortable position.
For suppositories, insert deeply into the rectum for optimal absorption.
Be aware of potential side effects such as rectal irritation.
4. Special Considerations for Routes of Administration
Oral Administration: Ensure patient is not NPO (nothing by mouth) before giving medications. For
patients with swallowing difficulties, consider liquid forms or crushed tablets (only if not
contraindicated).
IV Administration: Never administer medications through IV lines that are already being used for
other infusions unless specified by a doctor, as this may lead to incompatibilities.
SubQ and IM Administration: Rotate injection sites to minimize pain, irritation, and tissue damage.
Always check for allergic reactions after administering injections.
5. Common Calculations Involving Routes of Administration

Drug Route Calculation Example Nursing Implications

Oral Dose required = Desired dose × Administer based on the patient's

(Volume on hand / Amount on ability to swallow. Monitor for GI side
hand) effects.

IV (Volume/Flow Flow rate (mL/hour) = Total Monitor for extravasation or

Rate) volume (mL) ÷ Time (hr) infiltration. Adjust flow rates
accordingly.

SubQ/IM Dose required = (Dose per kg) × Rotate injection sites, monitor for
(Weight-based) Patient’s weight (kg) reactions at the injection site.

Topical Area of application = (Total Ensure correct amount is applied and

amount prescribed) ÷ Area of monitor for skin irritation.
coverage

10.3 Managing Side Effects, Contraindications, and Drug

Interactions
1. Side Effects
Side effects are unwanted or harmful reactions that occur when taking a medication. While not
all side effects are serious, some can significantly affect a patient's health or the overall
effectiveness of a treatment. Managing side effects involves careful monitoring, patient education,
and sometimes modifying the treatment plan to minimize discomfort or harm.
Types of Side Effects
Common side effects: These are expected or frequently encountered reactions. For example,
antihistamines may cause drowsiness, while antibiotics like penicillin may cause gastrointestinal
upset.
Serious side effects: These may indicate an allergic reaction, organ toxicity, or life-threatening
complications. Common serious side effects include anaphylaxis, liver damage, renal failure,
severe bleeding, or respiratory depression. Immediate action should be taken to prevent further
harm, such as discontinuing the drug and providing antidotes (e.g., Naloxone for opioid
overdose).
Delayed side effects: Some side effects do not appear immediately after medication administration
but may show up after prolonged use. For example, long-term use of corticosteroids may cause
osteoporosis or gastrointestinal ulcers.
Nursing Considerations for Managing Side Effects
Monitoring: Keep track of side effects and document any changes in the patient’s condition.
Patient Education: Inform patients about the potential side effects of their medications, including
how to recognize early signs of severe reactions (e.g., rash, swelling, difficulty breathing).
Managing side effects: Adjust dosages, switch medications, or implement symptomatic treatments
like antihistamines for rashes, antiemetics for nausea, or analgesics for pain.
2. Contraindications
Contraindications refer to situations where a specific medication should not be used because it
could be harmful to the patient. These may be absolute contraindications, where a drug should
never be used under any circumstances, or relative contraindications, where the benefits of using
the drug may outweigh the risks in certain situations.
Common Contraindications
Allergic reactions: Patients who have known allergies to a medication or class of medications (e.g.,
penicillin or sulfa drugs) should avoid those drugs to prevent severe reactions like anaphylaxis.
Pregnancy: Certain medications, like teratogenic drugs (e.g., thalidomide, isotretinoin), should never
be used during pregnancy as they can cause birth defects or harm to the fetus.
Pre-existing conditions: Patients with certain health conditions may not be able to safely use some
medications. For instance:

 Beta-blockers should be avoided in patients with bradycardia (slow heart rate).

 NSAIDs (e.g., ibuprofen) should not be given to patients with peptic ulcer disease due to
the risk of bleeding.
 ACE inhibitors should be avoided in pregnancy or for patients with angioedema.
Managing Contraindications
Screening: Nurses should assess a patient’s medical history and current condition before
administering medications.
Consultation: Always consult with the prescribing healthcare provider if any contraindications are
identified, especially for serious conditions like renal failure, hepatic impairment, or heart disease.
Alternative medications: If a medication is contraindicated for a patient, look for alternatives that do
not pose a risk to their health.
3. Drug Interactions
Drug interactions occur when one medication affects the activity of another, either enhancing or
inhibiting its effects. Interactions can result in increased toxicity, decreased therapeutic effect, or
new harmful effects. Nurses must be familiar with common drug interactions to prevent
complications and optimize treatment outcomes.
Types of Drug Interactions
Pharmacokinetic interactions: These occur when one drug alters the absorption, distribution,
metabolism, or excretion of another drug.
Absorption: For example, antacids can interfere with the absorption of tetracycline antibiotics,
decreasing their effectiveness.
Metabolism: Certain drugs, like antifungals (e.g., ketoconazole), can inhibit cytochrome P450
enzymes, which metabolize many medications, potentially leading to drug toxicity.
Excretion: Medications that affect renal function (e.g., diuretics) may alter the excretion rate of
other drugs, leading to increased or decreased drug levels.
Pharmacodynamic interactions: These occur when two drugs have additive, synergistic, or antagonistic
effects on the body.
Additive effects: Two drugs with similar effects can result in an enhanced therapeutic effect. For
example, using aspirin and clopidogrel together may increase the anticoagulant effect.
Synergistic effects: When the combination of two drugs leads to a greater effect than the sum of their
individual effects (e.g., amoxicillin and clavulanate in the treatment of bacterial infections).
Antagonistic effects: When one drug reduces the effect of another (e.g., naloxone reversing the effects
of opioids).
Common Drug Interactions and Their Management

Drug Interaction Drugs Involved Resulting Effect Nursing Action

 Warfarin and Warfarin, Increased risk of Monitor for signs of
NSAIDs Ibuprofen bleeding bleeding, avoid NSAIDs,
recommend alternative pain
relief.

ACE Inhibitors and Lisinopril, Increased risk of Monitor potassium levels,

Potassium Sparing Spironolactone hyperkalemia (high avoid high-potassium foods,
Diuretics potassium levels) educate patient about
symptoms of hyperkalemia.

Cimetidine and Cimetidine, Increased sedative Monitor for excessive

Diazepam Diazepam effects of diazepam sedation, adjust dose, and
educate patient.

Digoxin and Digoxin, Increased risk of Monitor potassium levels,

Diuretics Furosemide digoxin toxicity (due teach patient to recognize
to hypokalemia) signs of digoxin toxicity (e.g.,
nausea, vision changes).

Antibiotics and Oral Amoxicillin, Oral Reduced Recommend additional

Contraceptives Contraceptives effectiveness of oral contraceptive methods
contraceptives during antibiotic use.

Managing Drug Interactions

Assess patient history: Always take a complete medication history to identify any possible
interactions.
Consult with healthcare providers: If an interaction is suspected, consult the healthcare provider
to adjust the treatment regimen, change medications, or adjust dosages.
Patient education: Teach patients about the potential risks of drug interactions, how to recognize
symptoms, and what to do if they experience side effects or complications.
4. Nursing Interventions for Drug Interactions, Contraindications, and Side Effects
Nurses play a key role in preventing and managing medication-related issues. Here are some
strategies for handling side effects, contraindications, and drug interactions:
Patient Monitoring: Keep track of vital signs, laboratory results, and any physical signs of adverse
effects. For example, monitor renal function when administering ACE inhibitors or diuretics, and
watch for signs of infection when giving immunosuppressive agents like methotrexate.
Patient Education: Ensure patients understand their medications, the potential side effects, and
when to seek medical help. Encourage patients to inform all healthcare providers about all
medications, including over-the-counter drugs, herbal supplements, and vitamins.
Medication Adjustments: If a drug interaction or contraindication is discovered, it may be necessary
to change the medication, adjust the dosage, or switch to an alternative therapy.
Prevention: To prevent serious side effects, educate patients on lifestyle changes, dietary restrictions
(e.g., avoid foods high in vitamin K with warfarin), and how to properly take medications (e.g.,
take with food to avoid gastric upset).
5. Reporting Adverse Events
If a patient experiences severe side effects or drug interactions, it is essential to report the event.
This can be done through:
Reporting to the healthcare provider: Immediate action should be taken, including stopping the
drug and potentially using antidotes or supportive therapy.
FDA MedWatch program: Nurses are encouraged to report any adverse events, product defects,
or quality issues related to medications through the MedWatch program.

10.4 Parenteral Medications, IV Therapy, and Infusions

1. Parenteral Medications:
Parenteral medications are drugs administered by routes other than the digestive system, typically
via injections or infusions. This includes medications given subcutaneously, intramuscularly,
intravenously, or intradermally. Parenteral drug administration is often used for rapid onset or
when oral administration is not possible (e.g., nausea, vomiting, unconsciousness, or when the
drug is not available in oral form).
Types of Parenteral Administration
Subcutaneous (SubQ):

 Medications are injected into the subcutaneous tissue beneath the skin.
  Common drugs administered via this route include insulin, heparin, and some vaccines.
 Sites: Outer aspect of the upper arm, anterior thigh, and abdomen.
 Needle size: Usually a 25-27 gauge, 5/8 inch needle.
 Injection technique: Pinch the skin to create a "tent" and inject at a 45 to 90-degree angle.
Intramuscular (IM):

 Medications are injected into the muscle tissue, allowing for faster absorption than
subcutaneous injections.
 Common drugs: Vaccines (e.g., flu), antibiotics (e.g., penicillin), and vitamin B12.
 Sites: Deltoid, vastus lateralis (thigh), and gluteus medius (hip).
 Needle size: 20-23 gauge, 1-1.5 inch needle (depending on patient size).
 Injection technique: Inject at a 90-degree angle with a quick, steady motion to minimize
discomfort.
Intravenous (IV):

 Direct administration of medication into a vein, allowing for immediate absorption and
rapid therapeutic effects.
 Common medications: Pain relievers (e.g., morphine), antibiotics (e.g., ceftriaxone), and
fluids (e.g., saline, lactated Ringer's).
 Venous access: Peripheral IV lines, central lines (e.g., PICC lines, central venous catheters),
and implantable ports.
 Needle/catheter size: 20-22 gauge for peripheral IV, 18-20 gauge for central venous access.
 Injection technique: Administer medication slowly via IV push or via infusion pump if a
prolonged effect is required.
Intradermal (ID):

 Medication injected into the dermis just under the epidermis, used primarily for allergy
testing or tuberculosis screening.
 Needle size: 25-27 gauge, ½ inch needle.
 Injection technique: Insert the needle at a 10-15 degree angle, just beneath the skin surface.
Nursing Considerations for Parenteral Medications:
Site selection: Choose an appropriate site based on the drug and patient condition (e.g., use the thigh
for IM injections in children and the upper arm for adults).
Injection technique: Ensure proper technique to minimize pain, prevent complications (e.g.,
hematoma, infection), and ensure the medication is absorbed correctly.
Aseptic technique: Always follow aseptic technique to prevent infection. Use sterile equipment and
ensure the injection site is clean.
Patient monitoring: Observe the patient for immediate reactions after administration, especially for
signs of allergic reactions or adverse effects.
Documentation: Record the site of injection, medication administered, dosage, and any patient
reactions to the medication.
2. IV Therapy and Infusions:
Intravenous (IV) therapy involves the infusion of fluids, medications, or blood products directly
into the patient's bloodstream. IV therapy is used for maintaining fluid and electrolyte balance,
providing medications, and offering nutritional support. It is also essential for patients undergoing
surgery, those with dehydration, or those who are critically ill.
IV Therapy Types:
Continuous IV Infusion:

 Used for medications that require constant administration over a prolonged period, such
as antibiotics, chemotherapy, or insulin.
 Common fluids: Normal saline (0.9% NaCl), Lactated Ringer’s solution, or Dextrose in
water.
 The infusion rate is often controlled using an IV pump or drip factor (measured in drops
per minute).
Intermittent IV Infusion (IVPB):
Medications are administered in periodic doses, often over 30-60 minutes. This is typically used
for antibiotics and other short-term medications.
The IV is disconnected after the medication infusion is completed.
IV push: A rapid injection of a medication directly into the bloodstream, usually done for
medications that require fast onset (e.g., morphine or benzodiazepines).
Total Parenteral Nutrition (TPN):
A form of IV therapy that provides complete nutritional support, including proteins, fats,
carbohydrates, vitamins, and minerals for patients who cannot eat by mouth or whose digestive
system is nonfunctional.
TPN is usually delivered through a central venous catheter (CVC) or a PICC line.
Blood and Blood Products Infusion:
Blood transfusions are typically done via IV lines using Y-set tubing with a filter to remove clots
or other debris.
Commonly used for patients with anemia, trauma, or surgery.
Components of IV Fluids:
Crystalloids: These are fluids that contain small molecules, such as saline or lactated Ringer’s
solution, and are used for fluid replacement, maintaining electrolyte balance, and hydration.
Colloids: These fluids contain large molecules like proteins (e.g., albumin) and are used to expand
blood volume or treat conditions like hypovolemia or shock.
Blood Products: Includes red blood cells, plasma, platelets, and cryoprecipitate, used for patients
who need a blood volume boost due to blood loss.
IV Therapy Complications:
Phlebitis: Inflammation of the vein due to irritation from the IV catheter or medication. Symptoms
include redness, swelling, and pain at the insertion site.
Management: Remove the IV, apply warm compresses, and monitor for signs of infection.
Infiltration: Occurs when the IV fluid or medication leaks out of the vein and into the surrounding
tissue. Signs include swelling, coolness, and pain at the site.
Management: Stop the infusion, elevate the extremity, and apply a warm compress.
Extravasation: A more severe form of infiltration that occurs when a vesicant (medication that can
damage tissue) leaks into the tissue. This can cause tissue necrosis.
Management: Stop the infusion immediately, notify the healthcare provider, and administer
antidotes or other treatments if available (e.g., phentolamine for dopamine extravasation).
Air Embolism: Air entering the bloodstream, which can be caused by loose connections, improper
priming of IV tubing, or disconnection.
Management: Clamp the IV line, place the patient in the Trendelenburg position, and monitor vital
signs closely.
Infection: A serious complication caused by poor aseptic technique or contamination during
insertion or care of the IV line.
Management: Remove the IV catheter, start antibiotics if needed, and ensure proper aseptic
technique for future insertions.
Nursing Responsibilities in IV Therapy:
Selection of IV Site: Choose the appropriate site for the catheter, considering patient factors (e.g.,
veins available, condition of the skin, and the type of fluid or medication to be administered).
IV Insertion: Perform proper hand hygiene and follow aseptic technique. Insert the IV catheter at
the correct angle (usually 15-30 degrees) to access the vein.
IV Maintenance: Monitor the IV site for any complications (e.g., infiltration, phlebitis), and ensure
the IV is patent and flowing freely. Change IV sites according to institutional protocols (usually
every 72-96 hours).
Rate Control: Ensure the infusion rate is correctly set according to the prescribed rate (mL/hr), and
adjust as necessary. Use IV pumps for more accurate control, especially with medications that
have a narrow therapeutic range.
Patient Education: Teach patients about the IV therapy process, the importance of keeping the site
clean and dry, and when to notify healthcare providers (e.g., signs of infection, swelling).

10.5 Cardiology Medications and Nursing Interventions

Cardiology medications are a class of drugs used to treat cardiovascular diseases, including
hypertension, heart failure, arrhythmias, and coronary artery disease. Nurses must understand the
different classes of cardiology medications, their mechanisms of action, side effects, and nursing
interventions to ensure safe and effective patient care. This section will cover common cardiology
medications and provide essential nursing interventions.
1. Common Cardiology Medications:
1.1 Antihypertensive Medications
Hypertension (high blood pressure) is a major risk factor for cardiovascular diseases like stroke,
heart failure, and kidney disease. Various classes of antihypertensive medications are used to
manage blood pressure.
ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors):
Examples: Lisinopril, Enalapril, Ramipril.
Mechanism of Action: ACE inhibitors block the enzyme that converts angiotensin I to
angiotensin II, a potent vasoconstrictor. This reduces blood pressure by relaxing blood vessels.
Nursing Considerations:
Monitor for cough, a common side effect due to the accumulation of bradykinin.
Monitor potassium levels, as ACE inhibitors can cause hyperkalemia.
Assess for angioedema, a severe allergic reaction that can occur, particularly in African American
patients.
Monitor renal function (BUN, creatinine) as ACE inhibitors can cause kidney dysfunction in
susceptible individuals.
Angiotensin II Receptor Blockers (ARBs):
Examples: Losartan, Valsartan, Olmesartan.
Mechanism of Action: ARBs block the effects of angiotensin II at the receptor site, which causes
vasodilation and lowers blood pressure.
Nursing Considerations:
ARBs do not typically cause the persistent cough associated with ACE inhibitors.
Monitor for hyperkalemia and renal function.
Educate patients to avoid potassium-rich foods or potassium supplements unless advised
otherwise.
Calcium Channel Blockers (CCBs):
Examples: Amlodipine, Diltiazem, Verapamil.
Mechanism of Action: CCBs inhibit calcium entry into vascular smooth muscle and the heart,
leading to vasodilation and a decrease in heart rate.
Nursing Considerations:
Monitor for bradycardia, hypotension, and peripheral edema.
Be cautious in patients with heart failure, especially with non-dihydropyridine CCBs (e.g.,
Verapamil, Diltiazem) as they can reduce cardiac contractility.
Encourage patients to rise slowly to prevent orthostatic hypotension.
Beta-Blockers:
Examples: Metoprolol, Atenolol, Carvedilol.
Mechanism of Action: Beta-blockers reduce heart rate and myocardial contractility by blocking
beta receptors in the heart. They are used to manage hypertension and arrhythmias, and to reduce
the workload on the heart in conditions like heart failure and post-myocardial infarction.
Nursing Considerations:
Monitor heart rate and blood pressure before administering. Withhold if heart rate is below 60
bpm or systolic BP is below 90 mmHg.
Caution with asthmatic patients, as beta-blockers can cause bronchoconstriction.
Assess for fatigue and dizziness, which can occur due to the drug’s action on the heart.
1.2 Diuretics
Diuretics help remove excess fluid from the body, which is beneficial in conditions like heart
failure, hypertension, and edema.
Loop Diuretics:
Examples: Furosemide (Lasix), Bumetanide.
Mechanism of Action: Loop diuretics work by inhibiting sodium, chloride, and potassium
reabsorption in the loop of Henle in the kidneys, leading to increased urine output.
Nursing Considerations:
Monitor for electrolyte imbalances, particularly hypokalemia, hyponatremia, and
hypomagnesemia.
Monitor renal function (BUN, creatinine).
Assess for orthostatic hypotension and encourage fluid intake unless contraindicated.
Thiazide Diuretics:
Examples: Hydrochlorothiazide, Chlorthalidone.
Mechanism of Action: Thiazide diuretics work by inhibiting sodium reabsorption in the distal
tubules of the kidneys, leading to increased excretion of sodium and water.
Nursing Considerations:
Monitor for hypokalemia, hyponatremia, and hyperglycemia.
Educate the patient to increase potassium intake, as thiazides can lead to potassium loss.
Assess for renal function and urinary output.
1.3 Anticoagulants and Antiplatelets
These medications are used to prevent blood clots, which are common in conditions like atrial
fibrillation, deep vein thrombosis (DVT), and coronary artery disease.
Warfarin (Coumadin):
Mechanism of Action: Warfarin inhibits vitamin K-dependent clotting factors in the liver,
reducing the ability of blood to clot.
Nursing Considerations:
Monitor INR regularly to ensure therapeutic levels (2.0-3.0 for most indications).
Educate the patient on dietary restrictions, especially foods rich in vitamin K (e.g., leafy greens),
as they can affect the efficacy of warfarin.
Warn about potential bleeding complications, including signs of internal bleeding like dark stools
or unexplained bruising.
Direct Oral Anticoagulants (DOACs):
Examples: Apixaban (Eliquis), Rivaroxaban (Xarelto).
Mechanism of Action: DOACs directly inhibit clotting factors (Factor Xa or thrombin), providing
a more predictable anticoagulant effect.
Nursing Considerations:
Monitor renal function as DOACs are cleared by the kidneys.
Educate patients that these medications do not require routine blood monitoring like warfarin,
but they should be taken at the same time each day.
Instruct patients on the risk of bleeding and the importance of regular follow-ups.
Antiplatelets (Aspirin, Clopidogrel):
Mechanism of Action: Antiplatelet medications inhibit platelet aggregation, preventing the
formation of blood clots.
Nursing Considerations:
Monitor for gastrointestinal bleeding, especially with aspirin.
Educate patients to avoid over-the-counter NSAIDs unless approved by a healthcare provider, as
they can increase the risk of bleeding.
1.4 Antiarrhythmic Medications
Antiarrhythmic drugs are used to treat abnormal heart rhythms by regulating the electrical
impulses of the heart.
Class I: Sodium Channel Blockers:
Examples: Quinidine, Procainamide, Lidocaine.
Mechanism of Action: These drugs block sodium channels, reducing the excitability of the cardiac
cell and preventing arrhythmias.
Nursing Considerations:
Monitor ECG for any signs of prolonged QT interval or arrhythmias.
Lidocaine should be given intravenously and is typically used in emergency settings.
Class II: Beta-Blockers:
Examples: Metoprolol, Atenolol.
Mechanism of Action: Beta-blockers reduce heart rate and myocardial contractility, useful in
managing arrhythmias like atrial fibrillation.
Nursing Considerations:
Monitor heart rate and blood pressure regularly, and withhold the medication if the heart rate is
less than 60 bpm.
Monitor for hypotension and bradycardia.
Class III: Potassium Channel Blockers:
Examples: Amiodarone, Sotalol.
Mechanism of Action: Potassium channel blockers lengthen the repolarization phase of the
cardiac cycle, preventing abnormal rhythms.
Nursing Considerations:
Monitor liver and thyroid function due to the risk of long-term toxicity with amiodarone.
Amiodarone can cause pulmonary toxicity, so monitor for signs of respiratory distress.
Class IV: Calcium Channel Blockers:
Examples: Diltiazem, Verapamil.
Mechanism of Action: CCBs block calcium entry into the heart muscle and vascular smooth
muscle, slowing the heart rate and controlling arrhythmias.
Nursing Considerations:
Monitor for bradycardia and hypotension.
Avoid in patients with heart failure or AV block without a pacemaker.
1.5 Heart Failure Medications
Medications used in heart failure aim to reduce symptoms and improve quality of life by
improving the heart's ability to pump blood and reducing fluid overload.
ACE Inhibitors and ARBs: As discussed, these medications reduce afterload and help prevent the
progression of heart failure.
Beta-Blockers: These drugs also reduce heart rate and myocardial oxygen demand, improving
cardiac output.
Diuretics: Reduce fluid retention and pulmonary congestion, improving symptoms like shortness
of breath and edema.
2. Nursing Interventions for Cardiology Medications:
Monitor Vital Signs: Blood pressure, heart rate, respiratory rate, and oxygen saturation levels are
crucial in assessing the effectiveness of cardiology medications.
Assess for Side Effects: Common side effects include dizziness, hypotension, electrolyte imbalances,
and arrhythmias. Regular monitoring of lab results (e.g., potassium, renal function, liver enzymes)
is important.
Patient Education: Educate patients on the importance of medication adherence, the proper use of
medications (e.g., sublingual nitroglycerin), and signs of complications like bleeding (in
anticoagulants), or dizziness (in antihypertensives).
Adjust Dosages Based on Patient Response: For drugs like ACE inhibitors and beta-blockers,
ensure the dosage is titrated according to the patient’s blood pressure and heart rate.
Monitor for Drug Interactions: Some medications can interact with each other (e.g., beta-blockers with
calcium channel blockers, or warfarin with NSAIDs), increasing the risk of adverse effects. Ensure
there are no contraindicated drug combinations.

10.6 Oncology Medications and Therapies

Immune System and Cancer Development
The immune system is integral to recognizing and defending against abnormal or cancerous cells.
It operates through a series of defense lines:
Immune System Defense Mechanisms
First Line of Defense: White blood cells (WBC), particularly neutrophils, play a crucial role in
neutralizing foreign bodies, including cancer cells.
Second Line of Defense: B cells (including killer and helper cells) are involved in identifying and
destroying foreign bodies and abnormal cells, including cancer cells.
Third Line of Defense: Helper T cells (CD4) and macrophages clean up dead cells and foreign
invaders. The immune system's failure to properly recognize and destroy these abnormal cells can
lead to cancer progression.
Cancer cells share similarities with normal cells but exhibit key differences that allow them to
replicate uncontrollably. They can be promoted and spread through carcinogenesis, which
involves initiation, promotion, and metastasis stages:
Carcinogenesis is driven by carcinogens such as preservatives, artificial sweeteners, nicotine, and
stress.
Stage 1: Initiation occurs when cancer cells are first exposed to carcinogens.
Stage 2: Promotion involves continuous exposure to these carcinogens, leading to changes in cell
metabolism and DNA alterations.
Stage 3: Metastasis is when cancer cells spread to other organs, and detectable cancer forms.
Chemotherapy Medications and Nursing Considerations
Chemotherapy remains one of the most widely used treatments for cancer. Chemotherapy drugs
are categorized based on their mechanisms of action and their impact on cancer cells.
1. Chemotherapy Drugs

 Alkylating Agents (e.g., Cyclophosphamide, Ifosfamide)

Mechanism: Alkylating agents damage the DNA of cancer cells, preventing their replication and
leading to cell death.
Side Effects: Myelosuppression, nausea, vomiting, hemorrhagic cystitis, alopecia.
Nursing Considerations: Hydration is crucial to prevent bladder toxicity, and blood counts should be
monitored regularly to detect myelosuppression.

 Antimetabolites (e.g., Methotrexate, Fluorouracil)

Mechanism: These drugs interfere with DNA and RNA production by mimicking their building
blocks, halting cancer cell division.
Side Effects: Myelosuppression, mucositis, hepatotoxicity, nausea, vomiting.
Nursing Considerations: Monitor liver function tests (LFTs) and renal function. Encourage
mouth rinses for mucositis and hydrate patients well to avoid kidney damage.

 Plant Alkaloids (e.g., Vincristine, Paclitaxel)

Mechanism: These medications disrupt cell division during mitosis, effectively preventing cancer
cells from dividing.
Side Effects: Peripheral neuropathy, alopecia, myelosuppression, extravasation injury.
Nursing Considerations: Monitor for signs of extravasation, and assess for neurological symptoms
such as numbness or tingling.
Targeted Therapy Medications
Targeted therapies are designed to block specific molecules involved in cancer cell growth,
offering a more precise treatment than traditional chemotherapy.
1. Tyrosine Kinase Inhibitors (TKIs)
Examples: Imatinib (Gleevec), Dasatinib, Erlotinib
Mechanism: TKIs inhibit tyrosine kinases, enzymes that promote cancer cell growth, thereby
slowing or stopping the proliferation of cancer cells.
Side Effects: Fatigue, rash, nausea, liver toxicity, fluid retention.
Nursing Considerations: Monitor liver function tests, watch for signs of fluid retention, and
ensure patients understand the importance of adhering to medication schedules.
2. Monoclonal Antibodies
Examples: Trastuzumab (Herceptin), Rituximab, Bevacizumab
Mechanism: Monoclonal antibodies target specific proteins on cancer cells, blocking their ability to
grow and divide.
Side Effects: Infusion reactions, cardiotoxicity (with trastuzumab), immunosuppression.
Nursing Considerations: Pre-medicate to reduce the risk of infusion reactions, and monitor heart
function, particularly with trastuzumab.
Immunotherapy in Oncology
Immunotherapy is an innovative treatment modality that harnesses the body’s immune system to
fight cancer. It has become an essential part of cancer treatment regimens.
1. Checkpoint Inhibitors
Examples: Pembrolizumab (Keytruda), Nivolumab (Opdivo)
Mechanism: Checkpoint inhibitors work by blocking the checkpoints that prevent immune cells
from attacking cancer cells, allowing the immune system to recognize and destroy the cancer.
Side Effects: Immune-related adverse effects such as pneumonitis, colitis, hepatitis, and thyroid
dysfunction.
Nursing Considerations: Monitor for autoimmune symptoms, provide thyroid function tests, and
manage any organ-specific toxicities with appropriate interventions.
2. Cytokine Therapy
Examples: Interleukin-2 (IL-2), Interferons
Mechanism: Cytokines boost the immune system by stimulating immune cells, enhancing the body's
ability to target and destroy cancer cells.
Side Effects: Flu-like symptoms, hypotension, edema, hepatotoxicity.
Nursing Considerations: Monitor vital signs, especially blood pressure, and assess for signs of flu-like
symptoms. Hydrate the patient to manage hypotension and edema.
Radiation Therapy in Oncology
Radiation therapy uses high-energy rays to destroy or damage cancer cells. It can be delivered
externally or internally, depending on the type of cancer and its location.
1. External Beam Radiation (Teletherapy)
Mechanism: External radiation delivers focused beams of radiation from outside the body to the
cancerous area.
Side Effects: Nausea, fatigue, skin irritation, bone marrow suppression.
Nursing Considerations: Protect the skin from sun exposure, encourage mild soap for skin care, and
provide comfort measures for fatigue.
2. Internal Radiation (Brachytherapy)
Types: Sealed (pellets placed inside the body) and Unsealed (radioactive liquid).
Mechanism: Sealed radiation delivers radiation directly to the tumor site, while unsealed radiation
involves intravenous or oral radioactive medications.
Side Effects: Radiation burns, mucositis, fatigue, risk of infection.
Nursing Considerations: Follow safety protocols for handling radioactive materials, such as wearing
lead aprons and maintaining appropriate distances. Monitor for infection and skin reactions.
Chemotherapy Drugs and Nursing Management
Chemotherapy drugs, while effective, can also cause significant side effects, requiring nursing
interventions to manage these complications and minimize patient discomfort.
Chemotherapy Drugs and Their Side Effects
Vincristine: Neurotoxic, causing paresthesia and increased intracranial pressure.
5-Fluorouracil (5-FU): Can cause oral thrush and stomatitis, which can be managed with oral
antifungals like Nystatin.
Doxorubicin (Adriamycin): Cardiotoxic, potentially causing arrhythmias and heart failure.
Busulfan: Pulmonary toxicity, requiring monitoring of lung function.
Methotrexate: Used for rheumatoid arthritis, ectopic pregnancy, and cancer treatment. It can cause
immunosuppression and requires careful monitoring of liver function and renal function.
Management of Side Effects
Neutropenic Precautions: Due to bone marrow suppression, patients are at high risk for infections.
Ensure proper hand hygiene, limit exposure to crowds, and monitor for fever.
Hair Loss: Alopecia is common with many chemotherapy drugs. Encourage patients to prepare
for hair loss and explore options like wigs or scarves.
Mucositis: Manage with mouth rinses, soft toothbrushes, and avoiding acidic or spicy foods.
Nausea and Vomiting: Administer antiemetics as prescribed, and encourage small, frequent meals.
Superinfection: Because chemotherapy can compromise the immune system, the patient is at
increased risk for infections such as oral thrush. Monitor for signs of infection and report them
promptly.
 Chapter 11: Reduction of Risk
Potential (9%-15%)
11.1 Identifying Risk Factors in Patient Assessments
Risk factors are characteristics or behaviors that increase the likelihood of a person developing a
particular disease or health condition. Identifying these factors during an assessment helps
healthcare providers take appropriate preventive measures, modify care plans, and educate
patients on how to manage their risks.
In oncology, for example, certain genetic mutations, lifestyle choices, and environmental
exposures can significantly increase the likelihood of developing cancer. By assessing a patient's
medical history and environmental factors, nurses can help tailor interventions that may prevent
or mitigate these risks.
Types of Risk Factors
Risk factors can be classified into several categories:
Genetic and Hereditary Factors
Family history of chronic illnesses, particularly hereditary conditions such as breast cancer, heart
disease, or diabetes, plays a significant role in assessing risk.
Genetic mutations, such as the BRCA1 and BRCA2 genes, are linked to an increased risk of breast
and ovarian cancers.
Inherited conditions like sickle cell anemia, cystic fibrosis, or Huntington's disease must also be
carefully monitored for specific risk factors in affected patients.
Age-Related Risks
Age is one of the most significant risk factors for many chronic diseases and conditions, including
heart disease, cancer, and diabetes.
As individuals age, the risk for conditions like osteoporosis, hypertension, and cognitive decline
increases. Elderly patients also face a higher risk of developing complications from common
illnesses or surgical procedures.
Lifestyle and Behavioral Risk Factors
Smoking is a leading cause of preventable diseases such as lung cancer, emphysema, and chronic
obstructive pulmonary disease (COPD). In patient assessments, it is crucial to ask about smoking
habits and provide resources for smoking cessation.
Poor dietary habits, including high-fat, high-sugar diets, increase the risk of obesity, hypertension,
diabetes, and certain cancers. Nurses should assess eating habits and encourage healthier lifestyle
choices.
Physical inactivity is another significant risk factor for cardiovascular diseases, obesity, and
musculoskeletal disorders. Nurses should assess physical activity levels and promote exercise as
part of a balanced lifestyle.
Alcohol consumption also increases the risk of liver diseases, hypertension, and certain cancers.
A history of alcohol use should be included in routine assessments.
Substance abuse and high-risk sexual behavior can contribute to conditions like HIV, hepatitis,
and sexually transmitted infections (STIs). These behaviors need to be addressed with appropriate
interventions.
Environmental and Occupational Exposures
Exposure to hazardous substances in the environment or at the workplace can lead to serious
health conditions. For example, long-term exposure to asbestos increases the risk of
mesothelioma, and exposure to certain chemicals can lead to leukemia or other cancers.
Nurses should inquire about patients' work environments, hobbies, and travel history to assess
potential environmental exposures that may pose a risk to health.
Psychosocial Factors
Mental health issues, such as stress, anxiety, and depression, can affect physical health by
weakening the immune system, disrupting sleep patterns, and contributing to poor decision-
making regarding health behaviors.
Social determinants of health, including socioeconomic status, education, and access to
healthcare, can also influence health outcomes. Individuals with low income or inadequate access
to healthcare are more likely to experience delayed diagnoses and inadequate disease management.
Chronic Conditions and Comorbidities
Existing chronic conditions, such as diabetes, hypertension, or heart disease, place patients at
higher risk for developing complications. For instance, diabetes increases the risk of developing
cardiovascular diseases, while hypertension may lead to kidney failure or stroke.
Nurses should assess for comorbidities, ensuring that care plans account for the management of
multiple conditions concurrently.
Tools and Techniques for Identifying Risk Factors
Effective identification of risk factors requires the use of various assessment tools and techniques.
Some of the key methods include:
Health History and Patient Interviews
Gathering detailed health histories is essential for identifying risk factors. During patient
interviews, nurses should ask about family history, personal health history, lifestyle choices, and
exposures to potential environmental hazards.
Nurses should also explore psychosocial aspects, such as stress levels, support systems, and mental
health status, as these can provide important clues to overall health risks.
Physical Examinations
During physical assessments, nurses should look for signs or symptoms that could indicate an
underlying risk factor. For example, obesity, high blood pressure, or irregular heart rhythms can
signal cardiovascular risks.
Skin assessments are particularly important for detecting signs of skin cancer or other
dermatological conditions.
Screening and Diagnostic Tests
Regular screening and diagnostic tests are critical for identifying risk factors early. Examples
include:

 Mammograms for breast cancer

 Pap smears for cervical cancer
 Colonoscopies for colon cancer
 Blood pressure checks for hypertension
 Blood glucose testing for diabetes
Nurses should educate patients on the importance of regular screenings and help facilitate access
to these services.
Laboratory and Imaging Studies
Laboratory tests, such as cholesterol levels, liver function tests, and renal function tests, can
provide valuable information about a patient's risk factors for various conditions.
Imaging studies, such as CT scans, MRIs, and ultrasounds, can help detect abnormalities in organs
or structures that may indicate an increased risk of disease.
Risk Factor Modification and Management
Once risk factors are identified, nurses play a pivotal role in helping patients modify their
behaviors and manage their risks. This involves:
Education and Counseling
Nurses should provide clear and concise education to patients about the risk factors they face.
This may involve discussing the link between lifestyle choices and chronic diseases and offering
practical advice on how to make healthier choices.
Lifestyle changes, such as smoking cessation, adopting a healthier diet, increasing physical activity,
and reducing alcohol consumption, should be emphasized.
Collaborating with Healthcare Teams
Nurses must work collaboratively with other healthcare providers, including dietitians, physical
therapists, and physicians, to develop a comprehensive care plan that addresses the patient's
specific risk factors.
Nurses can facilitate referrals for specialty care, such as cardiology, oncology, or endocrinology,
to ensure patients receive appropriate screening, diagnosis, and treatment.
Behavioral Support and Monitoring
Ongoing monitoring of patients' risk factors is necessary to track progress and detect any changes
in health status. This could include regular follow-ups to monitor weight loss, blood pressure, or
glucose levels.
Nurses can offer behavioral support, such as motivational interviewing, to encourage patients to
make lasting changes and stay on track with their health goals.
Ethical and Cultural Considerations
When assessing risk factors, nurses must be aware of cultural, social, and ethical considerations.
These factors may influence how patients perceive their risks, make health decisions, or adhere to
recommended interventions. Nurses should ensure that their care is culturally sensitive and that
they respect patients' values and beliefs while encouraging health-promoting behaviors.
11.2 Preventive Measures and Health Surveillance
Preventive healthcare aims to prevent illness and promote general well-being by encouraging
lifestyle changes, regular screenings, immunizations, and early interventions. The goal of
preventive care is to stop diseases from occurring, identify them early when treatment is most
effective, and improve long-term health outcomes.
There are three primary levels of prevention:
Primary Prevention
Primary prevention focuses on preventing the onset of disease before it occurs. This includes
efforts to reduce exposure to risk factors and promote behaviors that promote good health.
Examples of primary prevention strategies include vaccination programs, public health education
campaigns (e.g., anti-smoking campaigns), and lifestyle counseling for physical activity, healthy
eating, and stress management.
Secondary Prevention
Secondary prevention aims to detect diseases early, especially before symptoms appear. Early
diagnosis and intervention allow for prompt treatment to prevent further complications.
This includes routine screenings, such as mammograms for breast cancer, colonoscopies for
colorectal cancer, and blood tests for cholesterol levels. Nurses assist in organizing and providing
these screenings for at-risk populations.
Tertiary Prevention
Tertiary prevention focuses on reducing the impact of a disease that is already diagnosed,
preventing complications, and improving quality of life for patients with chronic conditions or
those who have experienced serious illnesses.
This includes rehabilitation programs, medication management for chronic conditions, and
supportive care for patients undergoing treatments like chemotherapy or dialysis.
Key Preventive Health Measures
Health Education and Promotion
Health education is a vital component of preventive care. Nurses should educate patients and
communities on the importance of healthy lifestyle choices, including regular exercise, balanced
nutrition, proper sleep, and stress management.
Nurses can also promote smoking cessation, safe alcohol consumption, and safe sexual practices
as part of public health campaigns.
Vaccination and Immunization
Vaccines are one of the most effective preventive measures for reducing the spread of infectious
diseases. Immunization helps prevent the onset of diseases like measles, polio, influenza, and
hepatitis.
Nurses play a critical role in educating patients about the importance of vaccinations,
administering vaccines, and tracking immunization schedules, especially for children and
vulnerable adults (e.g., elderly or immunocompromised patients).
Screening Programs
Screening programs are essential for detecting diseases in their early stages, even before symptoms
appear. By identifying conditions early, healthcare providers can initiate treatments and
interventions that can delay disease progression or prevent complications.
Routine screenings are critical for conditions such as hypertension, diabetes, high cholesterol, and
cancer. Nurses may be involved in conducting screenings, educating patients about the
importance of regular check-ups, and following up on abnormal results.
Common screenings include:

 Blood pressure screenings for hypertension

 Mammograms for breast cancer
 Pap smears for cervical cancer
 Prostate exams for prostate cancer
 Colonoscopy for colon cancer
Lifestyle Modifications and Behavioral Interventions
Nurses must encourage and guide patients in making behavioral changes that reduce health risks,
such as adopting healthy eating habits, increasing physical activity, reducing stress, and quitting
smoking.
Behavioral interventions may involve motivational interviewing, goal setting, and offering
resources for health improvement programs. Nurses may collaborate with dietitians, mental health
counselors, and fitness trainers to provide holistic care.
Chronic Disease Management
For patients with chronic diseases, preventive care involves managing the condition to prevent
complications and improve the patient's quality of life. Nurses assist in coordinating care,
educating patients on managing their conditions (e.g., diabetes, asthma, or heart disease), and
providing support for medication adherence and lifestyle changes.
For example, patients with diabetes may need regular blood glucose monitoring, dietary
adjustments, and medication management. Nurses may also educate patients on recognizing the
early signs of complications like diabetic neuropathy or retinopathy.
Environmental and Occupational Health Monitoring
Nurses assess environmental and occupational risk factors to minimize exposure to toxins,
pollutants, and hazardous conditions. This includes advising patients on safety measures in the
workplace, such as using protective equipment, avoiding exposure to harmful chemicals, and
ensuring adequate ventilation.
Environmental factors like air quality, water contamination, and pesticide exposure can
significantly affect health, so monitoring and education about these factors are essential.
Health Surveillance: The Role of Monitoring and Tracking
Health surveillance involves the continuous collection, analysis, and interpretation of health data
to track the health status of populations and identify emerging health trends. Surveillance helps
detect outbreaks of infectious diseases, monitor the effectiveness of preventive interventions, and
identify areas where public health strategies can be improved.
Types of Health Surveillance
Active Surveillance
Active surveillance requires healthcare providers to actively seek out information about patient
conditions, such as regularly contacting patients to assess their health status or monitoring health
trends in specific populations.
For example, healthcare workers might check for early signs of disease outbreaks by actively
monitoring patients in high-risk areas (e.g., flu clinics during flu season).
Passive Surveillance
Passive surveillance relies on healthcare providers to report cases of certain diseases or conditions
to public health authorities. This type of surveillance is less resource-intensive but depends on
healthcare professionals’ voluntary reporting of cases.
Passive surveillance is commonly used for monitoring communicable diseases like tuberculosis,
hepatitis, and influenza.
Sentinel Surveillance
Sentinel surveillance involves monitoring specific high-risk groups or locations that may provide
an early warning for emerging health problems. For example, hospitals or clinics in high-risk
regions may serve as sentinel sites for tracking infectious diseases or environmental hazards.
Syndromic Surveillance
Syndromic surveillance involves tracking health data based on symptoms or syndromes rather
than specific diagnoses. For example, if a sudden increase in cases of fever, cough, or shortness
of breath is observed, it could suggest the early stages of a respiratory illness or flu outbreak.
Key Tools for Health Surveillance
Health Records and Databases
Patient health records are a valuable tool for monitoring individual and population health.
Electronic health records (EHRs) allow healthcare providers to access comprehensive patient
information quickly, helping identify at-risk individuals or groups.
Data Collection and Reporting Systems
Surveillance systems, such as national disease reporting systems or specialized registries (e.g.,
cancer registries), track trends in disease prevalence and help public health authorities monitor
health risks at local, national, and international levels.
Health Risk Assessments (HRAs)
Health risk assessments are questionnaires or tools that assess an individual's lifestyle, health
behaviors, and risk factors for chronic diseases. Nurses can use HRAs to evaluate patients' health
risk profiles and recommend targeted interventions.
Patient Monitoring Devices
Devices such as blood glucose monitors, blood pressure cuffs, and wearable fitness trackers are
essential tools for continuous monitoring of patients with chronic conditions or those at risk of
developing diseases. These devices allow for real-time tracking of patient health metrics and
enable nurses to adjust care plans accordingly.
Role of Nurses in Preventive Measures and Health Surveillance
Nurses play a crucial role in both preventive care and health surveillance. They are at the front
lines of patient education, risk assessment, and disease prevention. By integrating preventive
measures into patient care and conducting regular health surveillance, nurses help reduce the risk
of disease development and improve patient outcomes.
Patient Education
Nurses are responsible for educating patients on the importance of preventive care, including
screenings, immunizations, and lifestyle changes. Educating patients on the benefits of prevention
empowers them to take an active role in their health and make informed decisions.
Screening and Early Detection
Nurses often administer screenings, provide counseling on early detection practices, and refer
patients to appropriate specialists for further evaluation. By identifying high-risk individuals early,
nurses can facilitate interventions that can prevent the progression of diseases.
Health Promotion and Advocacy
Nurses advocate for policies and initiatives that promote health and well-being, including public
health campaigns, community health programs, and initiatives to reduce health disparities.
Monitoring and Reporting
Nurses monitor patient status and health outcomes, ensuring that health data is accurately
reported for surveillance and tracking. By collaborating with public health agencies, nurses
contribute to identifying health trends and outbreaks.
Follow-Up Care
Nurses ensure that patients are properly followed up after screenings, immunizations, or
interventions. This follow-up care is essential to assess the effectiveness of preventive measures
and make adjustments if necessary.

11.3 Monitoring Patient Status and Vital Signs

Vital signs are a set of measurements taken to assess a patient's general physical health. They
include:
Temperature
Body temperature provides information about the body’s ability to regulate its internal
environment. The average normal body temperature is approximately 98.6°F (37°C), but this can
vary slightly depending on the individual, time of day, and method of measurement.
Elevated temperature (fever) can indicate infection, inflammation, or an immune response, while
hypothermia can result from exposure to cold, sepsis, or shock.
Clinical significance:
Fever may indicate infection, dehydration, or inflammatory conditions.
Low body temperature (hypothermia) may result from sepsis, shock, or exposure to cold.
Fever management includes cooling measures and antipyretic medications such as acetaminophen
or ibuprofen.
Heart Rate (Pulse)
Heart rate refers to the number of times the heart beats per minute. The normal range for an adult
at rest is between 60 and 100 beats per minute (bpm).
Tachycardia (a heart rate greater than 100 bpm) may indicate fever, anxiety, pain, anemia, or
hypovolemia.
Bradycardia (a heart rate less than 60 bpm) may be seen in athletes, during sleep, or due to
conditions like hypothyroidism, heart block, or certain medications (e.g., beta-blockers).
Clinical significance:
A rapid heart rate may suggest stress, infection, or cardiac arrhythmia.
A slow heart rate may indicate a need for an ECG to evaluate for conduction issues.
Blood Pressure
Blood pressure measures the force exerted by circulating blood on the walls of blood vessels. It
is recorded as two numbers: systolic (the pressure when the heart beats) and diastolic (the pressure
when the heart is at rest between beats).
Normal blood pressure is typically around 120/80 mmHg.
Hypertension (systolic > 130 mmHg or diastolic > 80 mmHg) increases the risk of heart disease,
stroke, and kidney damage.
Hypotension (low blood pressure) may cause dizziness, fainting, or shock. It is often seen in cases
of blood loss, dehydration, or sepsis.
Clinical significance:
Elevated blood pressure may require lifestyle changes or pharmacological intervention, while low
blood pressure could indicate inadequate perfusion and require further investigation.
Respiratory Rate
Respiratory rate is the number of breaths a person takes per minute. The normal rate for adults is
between 12 and 20 breaths per minute.
Tachypnea (rapid breathing) can indicate fever, anxiety, hypoxia, or respiratory conditions like
pneumonia.
Bradypnea (slow breathing) can occur in head injuries, opioid overdose, or during sleep.
Clinical significance:
A high respiratory rate may indicate respiratory distress, hypoxia, or infection.
A low respiratory rate may be a result of opioid use or neurological issues.
Oxygen Saturation (SpO2)
Oxygen saturation is a measure of the percentage of hemoglobin in the blood that is saturated
with oxygen. It is typically measured using a pulse oximeter.
The normal SpO2 level is typically 95-100%. A level below 90% is considered hypoxemia, and
the patient may require supplemental oxygen.
Clinical significance:
Low oxygen saturation indicates poor oxygen delivery to tissues, which may be caused by
respiratory or cardiac conditions like COPD, pneumonia, or congestive heart failure.
Methods of Monitoring Vital Signs
Manual Measurements
Temperature: Body temperature can be measured orally, rectally, axillary (underarm), tympanic (ear),
or using an infrared scanner. The most accurate methods are typically rectal and tympanic.
Pulse: The pulse can be checked by palpating the radial pulse on the wrist, the carotid pulse in the
neck, or the femoral pulse in the groin. The pulse rate can be determined by counting the beats
over a 60-second period.
Blood Pressure: Blood pressure is typically measured using a sphygmomanometer (blood pressure
cuff) and a stethoscope. It can be measured manually or with an automated machine. When using
the manual method, the nurse inflates the cuff, listens for Korotkoff sounds, and records the
systolic and diastolic pressures.
Respiratory Rate: Respiratory rate is monitored by observing the rise and fall of the chest, or by
using an electronic monitoring device. The rate is counted over a 30-second period and multiplied
by two to get the rate per minute.
Oxygen Saturation: Oxygen saturation is measured using a non-invasive pulse oximeter, which is
typically placed on the patient's finger or earlobe. The reading is available within seconds.
Continuous Monitoring
For patients in critical care or those with serious conditions, vital signs may be continuously
monitored using advanced monitoring systems. These systems can provide real-time data on heart
rate, blood pressure, respiratory rate, and oxygen saturation.
Continuous monitoring is essential in intensive care units (ICUs) and emergency departments,
where rapid interventions may be needed.
Nursing Role in Monitoring Vital Signs
Nurses play a critical role in assessing, monitoring, and interpreting vital signs as part of patient
care. The following are key nursing responsibilities in monitoring patient status:
Baseline Assessment
On admission, nurses should establish baseline vital signs for each patient. These readings provide
a reference point for detecting deviations from normal values and help identify trends over time.
Routine Monitoring
Vital signs should be measured at regular intervals, depending on the patient's condition and the
type of care they are receiving. Routine monitoring is essential for patients with chronic
conditions, post-operative patients, and those receiving certain medications that can affect vital
signs.
Assessment of Trends
Nurses should assess trends in vital signs over time. For example, a gradual increase in blood
pressure over several days or a consistent decrease in oxygen saturation may indicate the
development of a problem. Documenting these trends can help in early identification of
complications.
Interpreting Abnormal Vital Signs
Abnormal vital signs should always be interpreted in the context of the patient's overall clinical
condition. For example, an elevated heart rate in a febrile patient may be a normal response to
fever, but in a patient with heart disease, it may indicate potential cardiac distress.
If vital signs fall outside the acceptable range, nurses must notify the physician or healthcare
provider immediately and take appropriate action, such as administering medications, providing
oxygen therapy, or initiating resuscitation protocols as needed.
Patient Education
Nurses should educate patients on the importance of monitoring vital signs, especially for those
with chronic conditions like hypertension, diabetes, and respiratory diseases. Patients should be
taught how to take their own vital signs at home and understand the significance of maintaining
them within normal ranges.
Monitoring and Recognizing Critical Changes
Critical changes in vital signs can indicate life-threatening conditions and require immediate
intervention. For example:
Severe Tachycardia or Bradycardia
If a patient's heart rate becomes excessively high or low, it could indicate severe arrhythmia, blood
loss, or other serious conditions that require emergency treatment.
Hypotension
A sudden drop in blood pressure, especially if accompanied by dizziness, fainting, or confusion,
may indicate shock, dehydration, or hemorrhage. Early identification and treatment are critical.
Severe Respiratory Distress
A marked increase or decrease in respiratory rate, along with signs of difficulty breathing (such as
use of accessory muscles, cyanosis, or gasping), may indicate respiratory failure, a blocked airway,
or severe hypoxia.
Hypoxemia
Oxygen saturation levels below 90% should prompt immediate action. Patients with poor oxygen
saturation may require supplemental oxygen or other interventions to improve lung function and
oxygen delivery.
Interventions for Abnormal Vital Signs
Temperature
For fever, antipyretics (e.g., acetaminophen or ibuprofen) may be administered, and cooling
measures like tepid baths or cooling blankets may be used. If the fever is due to an infection,
antibiotics or antivirals may be needed.
Heart Rate
Tachycardia may be treated by addressing the underlying cause (e.g., fluid resuscitation for
hypovolemia, medication for arrhythmias). Bradycardia may require atropine or pacemaker
therapy depending on the severity.
Blood Pressure
Hypertension may require antihypertensive medications, while hypotension may be managed with
intravenous fluids, vasopressors, or other interventions to stabilize blood pressure.
Respiratory Rate
For abnormal respiratory rates, interventions may include administering oxygen therapy,
bronchodilators, or mechanical ventilation for severe respiratory distress.
Oxygen Saturation
Oxygen therapy should be provided if oxygen saturation drops below 90%, and further
diagnostics should be performed to identify the cause of hypoxemia (e.g., chest X-ray, blood
gases).

11.4 Early Detection of Complications and Health Deterioration

Early detection refers to the identification of signs, symptoms, or changes in a patient's condition
before it progresses into a more severe issue or complication. Identifying health deterioration
early allows for timely interventions that can prevent or minimize the severity of complications.
Early detection has been linked to reduced mortality, improved recovery times, and overall better
outcomes for patients.
Some benefits of early detection include:

 Preventing the progression of acute issues into chronic conditions.

 Reducing the need for invasive interventions.
 Reducing hospital stays and healthcare costs.
 Decreasing patient morbidity and mortality rates.
 Common Complications to Monitor for Early Detection
As part of comprehensive patient assessments, nurses must be vigilant in monitoring for a variety
of complications across different systems of the body. These complications can be related to the
underlying medical condition or arise due to treatment interventions. Below are common areas
where early detection is vital:
1. Cardiovascular Complications
Signs of Cardiac Complications
Chest pain, palpitations, shortness of breath, dizziness, and fatigue are common signs of
cardiovascular issues.
Early warning signs: These symptoms can indicate ischemia, arrhythmias, or heart failure.
Monitoring vital signs like blood pressure, heart rate, and oxygen saturation is essential.
Early Detection of Heart Failure
Symptoms such as sudden weight gain, edema (especially in the legs), and shortness of breath are
often early signs of heart failure.
Nursing actions: Monitoring for pulmonary edema, maintaining accurate intake and output
records, and educating patients on managing sodium intake are vital.
Myocardial Infarction (MI)
Early signs of MI: Patients may complain of chest discomfort, nausea, shortness of breath, or pain
radiating to the arm or jaw.
Nurses should be aware of these symptoms, especially in high-risk patients, and ensure timely
electrocardiograms (ECGs) and cardiac enzyme tests are performed.
2. Respiratory Complications
Signs of Respiratory Deterioration
Increased respiratory rate, shallow breathing, use of accessory muscles, cyanosis, and wheezing
can indicate respiratory compromise.
Early Detection of Pulmonary Embolism (PE)
Symptoms: Sudden shortness of breath, chest pain, or hemoptysis (coughing up blood) are signs
of a PE.
Interventions: Oxygen therapy, anticoagulation therapy, or fibrinolytics may be necessary to treat
a PE.
Pneumonia
Symptoms like fever, cough, and difficulty breathing can be early signs of pneumonia. Nurses
should monitor oxygen levels and ensure patients are properly hydrated and receiving appropriate
antibiotics.
Acute Respiratory Distress Syndrome (ARDS)
Patients with ARDS will experience rapid breathing, hypoxia, and bilateral lung infiltrates. Early
identification and ventilation support are crucial to preventing further deterioration.
3. Renal Complications
Signs of Renal Complications
Decreased urine output, edema, electrolyte imbalances (especially potassium), and elevated blood
urea nitrogen (BUN) levels can indicate renal complications such as acute kidney injury (AKI).
Early Detection of AKI
Nurses should monitor fluid balance, renal function tests (creatinine, GFR), and signs of oliguria
or anuria. Prompt treatment and adjustments in medications (e.g., diuretics) are necessary.
Electrolyte Imbalance
Monitoring serum electrolyte levels is essential in detecting imbalances. For example,
hyperkalemia (elevated potassium) or hyponatremia (low sodium) can lead to severe cardiac
arrhythmias and need immediate attention.
4. Gastrointestinal Complications
Signs of Gastrointestinal Bleeding
Vomiting blood (hematemesis), black stools (melena), and hypotension can be signs of GI
bleeding. Immediate attention is required to prevent shock and organ failure.
Early Detection of Peritonitis
Abdominal pain, tenderness, fever, and changes in bowel movements could indicate peritonitis.
Early intervention with antibiotics and possibly surgery may be necessary.
Bowel Obstruction
Symptoms include abdominal bloating, constipation, nausea, and vomiting. Immediate action,
including imaging studies and possibly surgical intervention, is necessary to avoid perforation and
sepsis.
5. Infectious Complications
Signs of Infection
Fever, chills, increased white blood cell (WBC) count, and localized redness or swelling at the
surgical site can be signs of infection.
Early Detection of Sepsis
Sepsis can present with fever, tachycardia, tachypnea, and hypotension. Early identification and
initiation of broad-spectrum antibiotics are vital to reducing the mortality associated with sepsis.
Wound Infection
The presence of pus, swelling, and pain at the wound site may indicate infection. Nurses should
assess wounds regularly and monitor for signs of systemic infection.
6. Neurological Complications
Signs of Neurological Deterioration
Sudden confusion, speech difficulties, changes in mental status, or focal weakness may indicate a
stroke or other neurological issue.
Early Detection of Stroke
Symptoms: Sudden numbness or weakness, confusion, trouble speaking, or sudden vision
problems should prompt immediate evaluation with imaging studies, such as a CT scan or MRI.
Intracranial Pressure (ICP) Increase
Symptoms like headache, nausea, vomiting, and changes in consciousness may signal rising
intracranial pressure. Nurses should monitor for these signs, and interventions like head elevation
and osmotic diuretics may be necessary.
7. Endocrine Complications
Signs of Hypoglycemia
Shaking, sweating, confusion, and dizziness are symptoms of low blood glucose. Nurses should
assess blood glucose levels and provide immediate interventions like administering glucose.
Hyperglycemia and Diabetic Ketoacidosis (DKA)
Symptoms such as increased thirst, frequent urination, fruity breath, and confusion could indicate
hyperglycemia or DKA. Early intervention with insulin and hydration is crucial to prevent further
complications.
Thyroid Dysfunction
Early symptoms of thyroid issues such as fatigue, weight changes, and changes in skin condition
should be monitored, particularly in patients receiving thyroid replacement therapy or anti-thyroid
medications.
Tools for Early Detection
Effective monitoring and assessment tools are crucial for detecting complications early. Some
commonly used tools include:
Early Warning Scoring Systems
NEWS2 (National Early Warning Score): A scoring system used to track the physiological changes
in patients and alert healthcare professionals to deteriorating conditions. This system takes into
account respiratory rate, oxygen saturation, systolic blood pressure, heart rate, level of
consciousness, and temperature.
MEWS (Modified Early Warning Score): This is another scoring system designed to detect the
early signs of clinical deterioration in patients based on vital signs and clinical indicators.
Frequent Monitoring of Vital Signs
Continuous or frequent measurement of blood pressure, heart rate, temperature, oxygen
saturation, and respiratory rate allows for the early identification of abnormal trends and potential
complications.
Laboratory Tests
Regular laboratory tests, including complete blood counts (CBC), electrolyte levels, renal function
tests (creatinine, BUN), and liver function tests, help identify complications such as infection,
kidney injury, or metabolic disturbances.
Imaging Studies
Imaging, including X-rays, CT scans, and MRIs, can assist in detecting complications such as
gastrointestinal perforations, lung infiltrates, or strokes. These should be used when clinical signs
suggest a possible deterioration.
Nursing Interventions for Early Detection
Nurses play a crucial role in early detection and intervention. Some nursing interventions include:
Routine Assessments and Reassessments
Perform frequent assessments of vital signs, mental status, and physical appearance. Changes in
mental status or behavior should be promptly reported to the healthcare provider.
Use of Monitoring Equipment
Utilize monitoring equipment (e.g., pulse oximeters, ECG monitors, blood pressure cuffs) to
assess vital signs and detect early signs of deterioration. Nurses should also ensure the proper
calibration and functioning of this equipment.
Patient Education
Educate patients on the importance of reporting any changes in symptoms or new discomforts,
especially in high-risk patients. Provide instructions on managing chronic conditions and
recognizing early signs of complications.
Collaboration with the Healthcare Team
Work closely with physicians, respiratory therapists, dietitians, and other healthcare professionals
to create a comprehensive care plan that includes preventive measures, early detection strategies,
and timely interventions.
 Chapter 12: Physiological
Adaptation (11%-17%)
12.1 Managing Acute and Chronic Physiological Conditions
Acute physiological conditions are sudden, severe, and short-lived. They often require immediate
intervention and can lead to life-threatening complications if not treated promptly. Common
acute conditions include myocardial infarction (heart attack), stroke, acute respiratory distress
syndrome (ARDS), sepsis, and trauma-related injuries.
Key Aspects of Managing Acute Conditions
Early Recognition
Early identification of acute conditions is essential for successful management. Nurses are
responsible for monitoring patients’ vital signs, reviewing lab results, and noting any subtle
changes in a patient’s condition. This vigilance allows for rapid response to emerging
complications.
For instance, in the case of a myocardial infarction (MI), recognizing the early signs such as chest
pain, shortness of breath, or irregular heartbeats can prompt immediate intervention (e.g.,
administration of aspirin, oxygen therapy, or anticoagulants).
Priority Nursing Interventions
Interventions should focus on stabilizing the patient, preventing further deterioration, and
addressing underlying causes.
Airway Management: In acute conditions like asthma or anaphylaxis, ensuring an open airway is
the priority. Nurses may administer bronchodilators or antihistamines, as appropriate.
Pain Management: Pain control, often a significant component in managing acute conditions,
should be prioritized. For example, in cases of MI, administering morphine or nitroglycerin can
reduce pain, control blood pressure, and improve oxygenation.
Monitoring: Continuous monitoring of vital signs (e.g., blood pressure, heart rate, respiratory rate,
oxygen saturation) helps identify any signs of deterioration. For instance, monitoring blood
glucose levels is crucial in acute diabetic crises such as diabetic ketoacidosis (DKA).
Rapid Response to Emergencies
Nurses must be prepared to implement emergency protocols, such as cardiopulmonary
resuscitation (CPR) for cardiac arrest, or initiating rapid fluid resuscitation in cases of hypovolemic
shock.
Multidisciplinary Collaboration: Acute conditions often require the involvement of multiple
healthcare professionals. For example, a stroke patient may need input from a neurologist,
respiratory therapist, physical therapist, and dietitian for comprehensive care.
Patient and Family Education
Educating patients and families about the condition, treatment options, and necessary lifestyle
changes is essential in both the short and long term.
For example, after an acute myocardial infarction, patients should be educated on smoking
cessation, diet modifications, and the importance of regular follow-up care.
Examples of Acute Conditions
Acute Myocardial Infarction (MI)
MI requires immediate assessment and intervention to restore blood flow to the heart and prevent
further damage. Key interventions include administering aspirin, nitroglycerin, and monitoring
for arrhythmias. Nurses are responsible for assessing for signs of heart failure, shock, and ensuring
that medications are administered promptly.
Acute Respiratory Distress Syndrome (ARDS)
ARDS can occur due to trauma, infection, or other causes, leading to severe hypoxemia and
respiratory failure. Management includes mechanical ventilation, administering oxygen, and
monitoring for fluid overload. Nurses monitor ABG levels, respiratory rate, and oxygen saturation
to assess treatment effectiveness.
Sepsis
Sepsis is a life-threatening response to infection and requires immediate antibiotic administration,
fluid resuscitation, and supportive care. Nurses monitor vital signs for signs of systemic infection
(fever, elevated heart rate, and low blood pressure) and provide critical care interventions such as
IV fluids, oxygen, and medications.
Chronic Physiological Conditions
Chronic conditions are long-lasting and may be managed but not cured. Common chronic
conditions include hypertension, diabetes mellitus, chronic obstructive pulmonary disease
(COPD), and heart failure. These conditions require ongoing care to prevent complications and
improve quality of life.
Key Aspects of Managing Chronic Conditions
Ongoing Monitoring and Assessment
Nurses play a key role in the ongoing assessment of chronic conditions. Regular check-ups and
monitoring are necessary to evaluate the effectiveness of treatment plans and make adjustments
as needed.
For instance, in diabetes management, nurses monitor blood glucose levels regularly and teach
patients how to manage their insulin or oral hypoglycemic medications. They also assess for
potential complications such as diabetic neuropathy, retinopathy, and nephropathy.
Patient Education
Educating patients about their condition is crucial for empowering them to manage their health.
For example, patients with hypertension should understand the importance of medication
adherence, dietary modifications, stress management, and regular exercise.
Chronic conditions often require lifestyle changes, and nurses must provide resources and support
to help patients incorporate these changes into their daily routines.
Collaboration with Other Healthcare Providers
Chronic conditions often involve a multidisciplinary approach, including physicians, dietitians,
physical therapists, and social workers. Nurses work collaboratively to ensure comprehensive care
that addresses all aspects of the patient’s condition, including physical, emotional, and social
needs.
For instance, a patient with chronic heart failure may require input from cardiologists, respiratory
therapists, and social workers to ensure that all aspects of the patient’s care are managed
effectively.
Management of Exacerbations
Many chronic conditions have periods of exacerbation, where symptoms worsen and require
intensified treatment. Nurses should be proactive in recognizing the early signs of exacerbation,
such as increased shortness of breath in a COPD patient or elevated blood sugar levels in a
diabetic patient.
Prompt intervention during these exacerbations, including adjusting medications, providing
supportive care, or referring to specialists, can prevent hospitalization and improve long-term
outcomes.
Examples of Chronic Conditions
Hypertension
Hypertension, if not well managed, can lead to serious complications such as stroke, heart failure,
and kidney damage. Nurses must educate patients on the importance of adhering to prescribed
antihypertensive medications, monitoring their blood pressure at home, and implementing
lifestyle changes like reducing sodium intake and increasing physical activity.
Diabetes Mellitus
Diabetes requires ongoing management of blood glucose levels to prevent complications such as
diabetic neuropathy, kidney disease, and vision problems. Nurses assist patients in monitoring
their blood sugar levels, administering insulin or oral medications, and ensuring proper foot care.
They also provide education on diet and exercise, which are integral to managing the condition.
Chronic Obstructive Pulmonary Disease (COPD)
COPD is a progressive lung disease that requires ongoing care to manage symptoms and slow
progression. Nurses educate patients on proper inhaler techniques, the importance of smoking
cessation, and breathing exercises. Regular monitoring of oxygen saturation and pulmonary
function tests are essential to track disease progression.
Heart Failure
Nurses monitor for signs of fluid retention, such as edema and weight gain, and ensure that heart
failure patients adhere to medication regimens, dietary restrictions (e.g., low sodium), and exercise
programs. Nurses also provide education on managing symptoms, recognizing early signs of
exacerbation, and when to seek medical help.
Strategies for Managing Both Acute and Chronic Conditions
Holistic Approach
Regardless of whether the condition is acute or chronic, a holistic approach to care is essential.
This approach considers the patient’s physical, emotional, and social needs. Nurses assess the
whole patient, provide emotional support, and ensure that care is tailored to the individual’s
circumstances and preferences.
Regular Assessments and Reassessments
Acute and chronic conditions both require ongoing monitoring. Regular assessments help identify
changes in the patient’s condition and guide treatment adjustments. Nurses use various tools, such
as vital signs, lab results, and patient feedback, to assess progress and make informed decisions.
Patient-Centered Care
Nurses should ensure that care plans are developed collaboratively with patients, taking into
account their preferences, goals, and lifestyle. In chronic conditions, patient-centered care also
includes empowering patients to take an active role in managing their health.
Early Identification of Complications
Nurses should always be alert to the signs of complications, especially in patients with chronic
conditions. Regular monitoring, patient education, and timely interventions can help reduce the
risk of complications. For example, educating diabetic patients on proper wound care can prevent
infections, while monitoring heart failure patients for weight gain can catch fluid retention early.

12.2 Response to Trauma, Shock, and Infection

Trauma refers to any injury to the body caused by an external force. It can be classified as physical
or psychological, but most commonly, it involves physical injury resulting from accidents, falls,
violence, or other causes. The body's response to trauma is immediate and requires prompt and
comprehensive management.
Physiological Response to Trauma
The body’s response to trauma typically follows a predictable sequence:
Hemorrhagic Response: Bleeding is the primary immediate consequence of trauma. Blood vessels
may rupture, leading to blood loss. The body initiates the clotting process and constricts blood
vessels in an attempt to reduce the bleeding. However, if the bleeding is severe or prolonged, it
may lead to hypovolemic shock.
Inflammatory Response: The immune system responds by sending white blood cells (leukocytes) to
the site of injury to clear damaged tissue and prevent infection. This response also causes swelling,
pain, and redness.
Neuroendocrine Response: The body releases stress hormones such as adrenaline (epinephrine) and
cortisol to increase heart rate, blood pressure, and energy production. This helps the body deal
with the immediate effects of the trauma.
Pain Response: Trauma often triggers a pain response that can lead to significant discomfort and
anxiety. Pain can be localized (e.g., from a broken bone) or more widespread (e.g., in cases of
severe burns or internal bleeding).
Nursing Interventions in Trauma
Initial Assessment (Primary Survey)
A - Airway: Ensure the airway is open and clear. In cases of severe trauma, especially in head or
neck injuries, airway management is the priority.
B - Breathing: Assess the patient’s respiratory rate and effectiveness of breathing. Administer
oxygen if necessary, and ensure ventilation is not compromised.
C - Circulation: Control bleeding and assess circulation. Apply pressure to external wounds,
elevate limbs if appropriate, and monitor for signs of shock.
D - Disability (Neurological Status): Check the patient’s level of consciousness using the Glasgow
Coma Scale (GCS). Assess pupil reaction to light and limb movements to check for neurological
impairment.
E - Exposure and Environment Control: Remove clothing to assess for hidden injuries but keep
the patient warm to prevent hypothermia.
Monitoring and Ongoing Assessment
Continuous monitoring of vital signs, including heart rate, blood pressure, oxygen saturation, and
temperature, is essential to track changes in the patient's condition. Nurses should be vigilant for
signs of shock, internal bleeding, or organ failure.
Pain Management
Administer pain medication as ordered and based on the patient's condition. Pain relief helps
reduce stress and improve comfort, which can positively influence the healing process.
Wound Care and Infection Prevention
Clean wounds thoroughly to reduce the risk of infection and apply appropriate dressings. If the
trauma involves internal injuries or fractures, be prepared for potential surgical intervention.
Shock Response
Shock is a life-threatening condition that occurs when there is inadequate perfusion of oxygen
and nutrients to the body’s tissues and organs. It can result from various causes, including trauma,
hemorrhage, sepsis, or severe allergic reactions. Shock is classified into different types based on
the underlying cause: hypovolemic, cardiogenic, obstructive, and distributive shock.
Physiological Response to Shock
Initial Stage (Compensatory Phase)
In the early stages of shock, the body compensates for the lack of perfusion by constricting blood
vessels and increasing heart rate to maintain blood pressure. The body also activates the renin-
angiotensin-aldosterone system (RAAS) to retain sodium and water, helping to increase blood
volume.
However, these compensatory mechanisms are not sustainable and can lead to organ dysfunction
if not addressed promptly.
Progressive Stage (Decompensated Shock)
As shock progresses, compensatory mechanisms become overwhelmed. Blood pressure drops,
tissues become hypoxic, and organs begin to fail. The body starts to show signs of multisystem
dysfunction, including altered mental status, low urine output, and metabolic acidosis.
Refractory Stage (Irreversible Shock)
In this final stage, the damage to vital organs becomes irreversible, and death is imminent. Despite
interventions, the body’s systems shut down, and organ failure progresses.
Nursing Interventions in Shock
Fluid Resuscitation
The first line of treatment in hypovolemic shock (caused by blood loss or fluid loss) is the
administration of intravenous fluids. Normal saline or lactated Ringer’s solution is commonly
used to restore intravascular volume.
Blood products, such as packed red blood cells, may be needed in cases of significant hemorrhage
to restore oxygen-carrying capacity.
Monitoring Hemodynamic Status
Nurses must monitor hemodynamic parameters such as heart rate, blood pressure, central venous
pressure (CVP), and urine output. Invasive monitoring, such as an arterial line, may be required
in severe cases.
Oxygen Therapy
Oxygen should be administered to ensure adequate oxygenation. In severe cases, mechanical
ventilation or intubation may be necessary.
Medication Administration
Medications such as vasopressors (e.g., norepinephrine, dopamine) are used to support blood
pressure in cases of distributive or cardiogenic shock. Medications to address the underlying cause
(e.g., antibiotics for septic shock or antihistamines for anaphylactic shock) should be administered
promptly.
Infection Response
Infection occurs when harmful microorganisms invade the body and trigger an immune response.
Infections can range from mild to life-threatening and are a common cause of morbidity and
mortality, especially in critically ill patients.
Physiological Response to Infection
Local Immune Response
The body’s immune system responds to infection by increasing blood flow to the infected area,
which brings white blood cells to fight off the pathogens. This results in inflammation, redness,
heat, and pain at the site of infection.
In cases of severe infection, the body may produce pus as a result of dead white blood cells and
bacteria.
Systemic Immune Response
If the infection spreads, it can lead to systemic symptoms such as fever, chills, and increased heart
rate. The body’s response to sepsis (widespread infection) can cause widespread inflammation,
leading to shock, organ failure, and death if untreated.
Nursing Interventions in Infection
Antibiotic Administration
In bacterial infections, antibiotics are the cornerstone of treatment. Nurses must ensure that the
appropriate antibiotic is administered based on the culture and sensitivity results. Broad-spectrum
antibiotics may be started while awaiting culture results in severe cases.
Monitoring for Sepsis
Nurses should monitor patients for signs of sepsis, including fever, hypotension, tachycardia, and
altered mental status. Early recognition and prompt treatment with fluids, antibiotics, and
vasopressors are critical to prevent progression to septic shock.
Wound Care and Infection Control
Proper wound care and hygiene are essential in preventing the spread of infection. Nurses must
follow standard precautions and use personal protective equipment (PPE) to protect themselves
and other patients from infection.
Fluid and Electrolyte Management
Infection can lead to fluid and electrolyte imbalances, especially in cases of severe infection or
sepsis. Nurses should closely monitor fluid intake and output and administer IV fluids as needed
to maintain hydration and electrolyte balance.
Patient Education
Educating patients on infection prevention, such as proper hand hygiene and wound care, is
crucial in both hospital and home care settings. Nurses should also provide information about
completing the full course of antibiotics to prevent antibiotic resistance.

12.3 Fluid and Electrolyte Imbalances: Management and

Interventions
The human body is composed of approximately 60% water, with the distribution of this water
divided into intracellular and extracellular compartments. Fluid balance is regulated by the
kidneys, endocrine system (including hormones like aldosterone and antidiuretic hormone), and
the cardiovascular system.
Electrolytes such as sodium, potassium, calcium, magnesium, chloride, phosphate, and
bicarbonate play vital roles in various physiological processes, including nerve conduction, muscle
contraction, fluid balance, and acid-base homeostasis. When the levels of these electrolytes deviate
from their normal ranges, it can lead to serious clinical manifestations and complications.
Common Causes of Fluid and Electrolyte Imbalances
Fluid and electrolyte imbalances can result from a variety of conditions and interventions:
Dehydration:
Causes: Excessive fluid loss (e.g., vomiting, diarrhea, fever, sweating), inadequate fluid intake, or
fluid sequestration in third spaces.
Symptoms: Thirst, dry mucous membranes, reduced urine output, increased heart rate, and
hypotension.
Overhydration (Fluid Overload):
Causes: Excessive fluid intake (e.g., overzealous IV fluid administration), renal failure, or heart
failure.
Symptoms: Edema, weight gain, dyspnea, increased blood pressure, and decreased urine output.
Hyponatremia (Low Sodium):
Causes: Excessive water intake, inadequate sodium intake, or conditions like heart failure, liver
cirrhosis, and renal failure.
Symptoms: Nausea, vomiting, headache, confusion, muscle cramps, and seizures in severe cases.
Hypernatremia (High Sodium):
Causes: Excessive sodium intake, dehydration, or conditions like diabetes insipidus.
Symptoms: Thirst, dry skin, agitation, confusion, and seizures in severe cases.
Hypokalemia (Low Potassium):
Causes: Diuretic therapy, vomiting, diarrhea, or certain kidney conditions.
Symptoms: Muscle weakness, fatigue, cramping, and irregular heart rhythms (e.g., arrhythmias).
Hyperkalemia (High Potassium):
Causes: Renal failure, excessive potassium intake, or potassium-sparing diuretics.
Symptoms: Muscle weakness, fatigue, palpitations, and life-threatening arrhythmias.
Hypocalcemia (Low Calcium):
Causes: Hypoparathyroidism, vitamin D deficiency, or kidney disease.
Symptoms: Muscle spasms, tingling or numbness in fingers and toes, and seizures.
Hypercalcemia (High Calcium):
Causes: Hyperparathyroidism, malignancies, or excessive vitamin D intake.
Symptoms: Weakness, fatigue, confusion, constipation, and kidney stones.
Acid-Base Imbalances (pH Issues):
Causes: Respiratory or metabolic issues, such as respiratory acidosis (due to hypoventilation) or
metabolic alkalosis (due to vomiting or overuse of antacids).
Symptoms: Respiratory distress, confusion, fatigue, and changes in heart rate.
Management and Interventions for Fluid and Electrolyte Imbalances
Proper management of fluid and electrolyte imbalances involves identifying the underlying cause,
correcting the imbalance, and monitoring the patient closely. The following provides detailed
management strategies for common fluid and electrolyte imbalances.
Dehydration Management
Assessment:
Evaluate vital signs (e.g., tachycardia, hypotension).
Monitor urine output, urine specific gravity, and the presence of concentrated urine.
Check skin turgor, mucous membranes, and capillary refill.
Interventions:
IV Fluid Administration: Use isotonic solutions like Normal Saline (0.9% NaCl) for initial
rehydration. For severe dehydration, colloid solutions (e.g., albumin) may be used to restore
intravascular volume.
Oral Rehydration: In cases of mild dehydration, encourage oral fluid intake with electrolyte solutions
like Oral Rehydration Salts (ORS).
Monitoring: Keep track of intake and output (I&O), monitor for signs of overhydration, and adjust
fluid administration accordingly.
Fluid Overload (Hypervolemia) Management
Assessment:
Monitor for edema, weight gain, and lung sounds (e.g., crackles or wheezes indicating pulmonary
edema).
Check for increased central venous pressure (CVP) and monitor vital signs for signs of respiratory
distress or hypertension.
Interventions:
Fluid Restriction: Limit the intake of fluids based on the physician's orders, ensuring balance with
urine output.
Diuretics: Administer loop diuretics such as furosemide (Lasix) to promote fluid excretion.
Potassium-sparing diuretics may be used with caution to prevent hypokalemia.
Monitoring: Monitor for changes in blood pressure, heart rate, and weight. Perform daily weight
checks to assess fluid balance.
Hyponatremia Management
Assessment:
Monitor serum sodium levels and assess the patient's neurological status (e.g., mental confusion
or seizures).
Evaluate for signs of fluid overload or dehydration.
Interventions:
Sodium Replacement: Administer hypertonic saline (3% NaCl) for severe hyponatremia, or isotonic
saline for mild cases.
Fluid Restriction: In cases of dilutional hyponatremia (due to fluid overload), restrict water intake
to prevent further dilution.
Monitoring: Monitor for changes in mental status, vital signs, and laboratory values. Recheck
sodium levels frequently.
Hyperkalemia Management
Assessment:
Check serum potassium levels and assess for signs of muscle weakness, cardiac arrhythmias (e.g.,
peaked T waves), or changes in ECG.
Interventions:
Potassium Binders: Administer potassium binders such as sodium polystyrene sulfonate
(Kayexalate) to reduce potassium levels.
Calcium Gluconate: For severe hyperkalemia with ECG changes, calcium gluconate can stabilize
cardiac cell membranes.
Diuretics: Loop diuretics (e.g., furosemide) may be used to promote potassium excretion.
Insulin and Glucose: In emergency situations, insulin (regular insulin) with glucose can help
drive potassium back into cells.
Dialysis: In cases of renal failure or refractory hyperkalemia, dialysis may be necessary to remove
potassium from the bloodstream.
Hypokalemia Management
Assessment:
Monitor serum potassium levels and assess for muscle weakness, fatigue, and changes in ECG
(e.g., flattened T waves).
Monitor for signs of arrhythmias, especially in patients receiving digoxin therapy.
Interventions:
Potassium Supplementation: Administer oral or intravenous potassium chloride (KCl) to
replace lost potassium. When giving IV potassium, dilute it properly and administer it slowly to
avoid causing phlebitis or arrhythmias.
Monitor ECG: Regularly monitor the patient's ECG for signs of arrhythmias and correct
electrolyte imbalances.
Potassium-Sparing Diuretics: For patients on diuretics, consider using potassium-sparing
diuretics (e.g., spironolactone) to prevent further potassium loss.
Calcium Imbalances (Hypocalcemia and Hypercalcemia) Management
Hypocalcemia:
Assessment: Monitor serum calcium levels and watch for symptoms such as muscle cramps,
tingling, and positive Chvostek's or Trousseau's signs.
Interventions: Administer calcium supplements (oral or IV) and vitamin D to enhance calcium
absorption. Monitor for hypercalcemia during treatment.
Hypercalcemia:
Assessment: Monitor serum calcium levels and assess for signs of fatigue, confusion,
constipation, and polyuria.
Interventions: Administer IV fluids to promote calcium excretion. Bisphosphonates (e.g.,
pamidronate) or calcitonin can be used to reduce calcium levels.
Monitoring Fluid and Electrolyte Therapy
Ongoing Monitoring:
Regularly monitor serum electrolytes (e.g., sodium, potassium, calcium, magnesium) to ensure
proper correction of imbalances.
Assess I&O meticulously to track fluid balance, especially when managing conditions such as fluid
overload or dehydration.
Vital signs should be monitored frequently to detect signs of complications like arrhythmias,
hypotension, or respiratory distress.
Patient Education:
Educate patients on the importance of maintaining adequate fluid intake and balancing
electrolytes, especially if they have conditions like diabetes or kidney disease.
Instruct patients on recognizing symptoms of electrolyte imbalances, such as muscle weakness,
fatigue, or changes in heart rhythm.
Provide information on dietary modifications (e.g., increasing potassium intake for hypokalemia
or limiting sodium for hypernatremia).

12.4 Respiratory and Cardiovascular Disorders: Nursing

Interventions
Respiratory disorders range from mild conditions like asthma to life-threatening diseases such as
chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS).
The role of the nurse in managing respiratory disorders includes identifying risk factors,
administering appropriate treatments, and supporting patients in managing their condition.
Common Respiratory Disorders
Asthma:
A chronic inflammatory disease of the airways, characterized by wheezing, shortness of breath,
and coughing.
Chronic Obstructive Pulmonary Disease (COPD):
A progressive disease including chronic bronchitis and emphysema, leading to airflow
obstruction.
Pneumonia:
An infection of the lungs, which can be bacterial, viral, or fungal. It causes inflammation and fluid
buildup in the lungs.
Pulmonary Embolism (PE):
A blockage in one of the pulmonary arteries in the lungs, usually caused by a blood clot.
Acute Respiratory Distress Syndrome (ARDS):
A severe condition where fluid accumulates in the alveoli, leading to impaired oxygen exchange.
Nursing Interventions for Asthma
Assessment:
Monitor the patient's respiratory rate, pulse oximetry, and lung sounds.
Identify triggers such as allergens, irritants, or physical exertion.
Monitor peak flow meter readings to assess the severity of airflow obstruction.
Interventions:
Administer Bronchodilators: Short-acting beta-agonists (e.g., albuterol) for acute asthma attacks
and long-acting beta-agonists for maintenance.
Inhaled Corticosteroids: To reduce airway inflammation (e.g., fluticasone).
Education: Teach the patient how to use inhalers correctly (e.g., spacer use with inhalers).
Oxygen Therapy: Administer supplemental oxygen as needed to maintain SpO2 levels above 90%.
Positioning: Help the patient sit up to promote optimal lung expansion and ease breathing.
Nursing Interventions for Chronic Obstructive Pulmonary Disease (COPD)
Assessment:
Assess for symptoms like chronic cough, sputum production, and dyspnea.
Monitor respiratory rate and oxygen saturation.
Check for signs of respiratory infections or exacerbations.
Interventions:
Medications: Administer bronchodilators (e.g., beta-agonists, anticholinergics) and inhaled
corticosteroids as prescribed.
Oxygen Therapy: Provide oxygen to maintain an oxygen saturation of 88-92%.
Pulmonary Rehabilitation: Encourage participation in programs designed to improve endurance,
strength, and lung function.
Patient Education: Teach the patient breathing exercises like pursed-lip breathing and
diaphragmatic breathing to help with airflow.
Encourage Smoking Cessation: Provide resources and support for smoking cessation.
Nursing Interventions for Pneumonia
Assessment:
Monitor for signs of infection, such as fever, cough, sputum production, and chest pain.
Assess respiratory function: rate, rhythm, and depth of respiration, lung sounds, and oxygen
saturation.
Obtain sputum samples to identify the causative pathogen.
Interventions:
Antibiotics: Administer the prescribed antibiotics based on the causative agent (bacterial
pneumonia).
Oxygen Therapy: Provide supplemental oxygen to maintain adequate oxygenation.
Hydration: Encourage fluid intake to help thin secretions.
Positioning: Encourage frequent position changes to promote lung expansion and reduce the risk
of atelectasis.
Coughing and Deep Breathing Exercises: Teach the patient to perform these exercises to mobilize
secretions.
Nursing Interventions for Pulmonary Embolism (PE)
Assessment:
Monitor for signs of PE, including sudden shortness of breath, chest pain, tachypnea, and
tachycardia.
Assess for risk factors, such as a history of deep vein thrombosis (DVT), recent surgery, or
immobility.
Obtain a D-dimer test and imaging studies (CT pulmonary angiography) to confirm diagnosis.
Interventions:
Anticoagulation Therapy: Administer medications like heparin or low molecular weight heparin
(e.g., enoxaparin) to prevent further clot formation.
Thrombolytic Therapy: In severe cases, administer thrombolytics (e.g., alteplase) to dissolve the
clot.
Oxygen Therapy: Provide supplemental oxygen to maintain adequate oxygen levels.
Patient Education: Educate the patient on signs of bleeding (from anticoagulation) and the
importance of follow-up care.
Nursing Interventions for Acute Respiratory Distress Syndrome (ARDS)
Assessment:
Monitor for sudden onset of dyspnea, hypoxia, and signs of respiratory distress.
Assess for underlying causes such as trauma, infection, or aspiration.
Monitor arterial blood gases (ABGs) to assess the severity of respiratory impairment.
Interventions:
Mechanical Ventilation: Provide mechanical ventilation to support oxygenation, with settings
adjusted for ARDS management (e.g., low tidal volume).
Prone Positioning: In some cases, positioning the patient prone can improve oxygenation.
Sedation: Provide sedatives and pain management to ease discomfort and reduce oxygen
consumption.
Fluid Management: Monitor and manage fluid balance, as excessive fluids can exacerbate
pulmonary edema.
Nutritional Support: Provide adequate nutrition to support healing and recovery.
Cardiovascular Disorders: Nursing Interventions
Cardiovascular diseases include conditions such as heart failure, coronary artery disease,
hypertension, and arrhythmias. These conditions require timely and appropriate nursing
interventions to optimize heart function, prevent complications, and improve patient outcomes.
Common Cardiovascular Disorders
Heart Failure (HF):
A condition where the heart is unable to pump sufficient blood to meet the body's needs, leading
to symptoms such as shortness of breath, edema, and fatigue.
Coronary Artery Disease (CAD):
A condition characterized by the narrowing of coronary arteries due to plaque buildup, which can
lead to angina and myocardial infarction (heart attack).
Hypertension:
High blood pressure, often asymptomatic, but a significant risk factor for heart disease, stroke,
and kidney failure.
Arrhythmias:
Abnormal heart rhythms, such as atrial fibrillation, ventricular tachycardia, and bradycardia.
Nursing Interventions for Heart Failure
Assessment:
Monitor for signs of fluid retention, including edema, jugular vein distension, and weight gain.
Assess lung sounds for crackles indicating pulmonary congestion.
Monitor vital signs, including heart rate, blood pressure, and oxygen saturation.
Interventions:
Diuretics: Administer loop diuretics (e.g., furosemide) to reduce fluid overload.
ACE Inhibitors/ARBs: Use medications like enalapril or losartan to reduce afterload and improve
heart function.
Beta-Blockers: Administer beta-blockers (e.g., metoprolol) to reduce heart rate and improve
myocardial efficiency.
Oxygen Therapy: Provide oxygen as needed to maintain oxygen saturation levels.
Low-Sodium Diet: Encourage the patient to reduce sodium intake to prevent fluid retention.
Nursing Interventions for Coronary Artery Disease (CAD)
Assessment:
Assess for chest pain, discomfort, or tightness, especially after physical activity.
Monitor ECG for signs of ischemia (e.g., ST-segment depression).
Check for risk factors such as smoking, diabetes, hypertension, and family history.
Interventions:
Medications: Administer antiplatelet drugs (e.g., aspirin) and statins (e.g., atorvastatin) to reduce
cholesterol and prevent clot formation.
Nitroglycerin: Administer nitroglycerin for chest pain relief by promoting vasodilation.
Lifestyle Modifications: Encourage smoking cessation, weight loss, and increased physical activity.
Patient Education: Teach the patient about the importance of adherence to medication regimens
and dietary changes.
Nursing Interventions for Hypertension
Assessment:
Monitor blood pressure regularly and assess for signs of target organ damage, such as retinal
changes or kidney dysfunction.
Interventions:
Medications: Administer antihypertensive drugs, including ACE inhibitors, beta-blockers, calcium
channel blockers, or diuretics as prescribed.
Lifestyle Modifications: Encourage weight loss, salt reduction, regular exercise, and stress
management techniques.
Patient Education: Instruct the patient on the importance of regular blood pressure monitoring
and medication adherence.
Nursing Interventions for Arrhythmias
Assessment:
Monitor the ECG for abnormal rhythms, assess pulse, and look for signs of poor perfusion (e.g.,
dizziness, chest pain).
Assess the patient for symptoms such as palpitations, fainting, or shortness of breath.
Interventions:
Antiarrhythmic Medications: Administer medications like amiodarone or digoxin to stabilize the
heart rhythm.
Electrolyte Correction: Correct electrolyte imbalances (e.g., potassium or magnesium) that may
trigger arrhythmias.
Cardioversion: For certain arrhythmias like atrial fibrillation, electrical cardioversion may be
necessary to restore normal rhythm.

12.5 Oncology and Cardiology Nursing Interventions and Care

Oncology nursing focuses on the care of patients with cancer, which can include a wide range of
disease types, from solid tumors (e.g., breast cancer, lung cancer) to hematologic cancers (e.g.,
leukemia, lymphoma). These patients often require medical interventions like chemotherapy,
radiation therapy, immunotherapy, and surgery, along with symptom management and
psychosocial support.
Common Cancer Types
Breast Cancer
One of the most common cancers, often treated with surgery, radiation, chemotherapy, and
hormone therapy.
Lung Cancer
A leading cause of cancer death, treated with surgery, radiation, and chemotherapy. It can also be
managed with immunotherapy and targeted therapies.
Leukemia
Cancer of the blood or bone marrow, requiring chemotherapy, stem cell transplants, and
supportive care.
Colorectal Cancer
Often diagnosed through screening tests like colonoscopy and managed with surgery,
chemotherapy, and radiation.
Nursing Interventions for Oncology Patients
Assessment:
Pain Management: Monitor for pain associated with cancer and its treatment. Use appropriate
pain scales and assess for breakthrough pain.
Nutritional Status: Many oncology patients experience weight loss, nausea, or difficulty eating.
Regularly assess for signs of malnutrition or dehydration.
Psychosocial Support: Cancer diagnosis can lead to anxiety, depression, and fear. Nurses should
provide emotional support and referrals to support groups or counselors as necessary.
Chemotherapy Nursing Interventions:
Pre-Chemotherapy:
Assess baseline lab values, including blood counts (e.g., WBC, hemoglobin, platelets), kidney and
liver function tests, and electrolytes.
Ensure patients are educated about possible side effects, including nausea, vomiting, hair loss, and
fatigue.
Provide antiemetics as ordered to manage chemotherapy-induced nausea and vomiting (CINV).
Ensure the patient understands the importance of hand hygiene and infection control due to
immunosuppression.
During Chemotherapy:
Administer chemotherapy as prescribed, ensuring correct dosage and method (IV, oral, etc.).
Monitor for allergic reactions, including anaphylaxis. Prepare emergency medications (e.g.,
epinephrine) as needed.
Monitor vital signs closely for any changes during infusion, especially in the first few minutes.
Assess for signs of extravasation (e.g., redness, swelling, pain) during IV infusion.
Post-Chemotherapy:
Continue monitoring for adverse reactions such as fever, signs of infection, and gastrointestinal
distress.
Encourage fluid intake to flush out chemotherapy agents and prevent dehydration.
Educate the patient about managing side effects at home, such as nausea, mouth sores, and
fatigue.
Radiation Therapy Nursing Interventions:
Pre-Radiation:
Educate patients about the procedure and the importance of staying still during treatment.
Provide skincare education, especially around radiation sites, to prevent irritation or burns.
During Radiation:
Monitor skin integrity around the site of radiation, ensuring it is protected from heat and friction.
Administer medications to control side effects like nausea or fatigue.
Post-Radiation:
Monitor for late side effects, such as tissue fibrosis or lung damage, depending on the type of
radiation.
Encourage the patient to follow up regularly with their healthcare provider to assess for long-term
effects.
Pain Management in Cancer Care:
Pain Assessment: Regularly assess pain using pain scales and evaluate the impact of pain on the
patient’s quality of life.
Medications: Administer prescribed analgesics, including opioids, NSAIDs, or adjuvant therapies
like anticonvulsants or antidepressants for neuropathic pain.
Non-Pharmacologic Interventions: Provide comfort measures such as positioning, massage,
relaxation techniques, or guided imagery.
Cardiology Nursing Interventions and Care
Cardiology nursing focuses on managing patients with cardiovascular conditions such as coronary
artery disease (CAD), heart failure (HF), arrhythmias, and hypertension. Cardiovascular disorders
require ongoing management to optimize heart function, prevent complications, and improve
quality of life. Nursing interventions play a vital role in ensuring patients receive appropriate
treatment, education, and care.
Common Cardiovascular Conditions
Coronary Artery Disease (CAD):
Caused by atherosclerotic plaque buildup in the coronary arteries, leading to angina and
myocardial infarction (MI).
Heart Failure (HF):
A condition where the heart is unable to pump enough blood to meet the body's needs, causing
symptoms such as shortness of breath, fluid retention, and fatigue.
Arrhythmias:
Abnormal heart rhythms, such as atrial fibrillation (AF), ventricular tachycardia, and bradycardia,
which can affect cardiac output and blood pressure.
Hypertension:
A condition of elevated blood pressure, which is a significant risk factor for heart disease, stroke,
and kidney failure.
Nursing Interventions for Cardiology Patients
Assessment:
Vital Signs: Regularly monitor blood pressure, heart rate, respiratory rate, and oxygen saturation
to assess cardiac function.
Cardiac Monitoring: Use telemetry to monitor the patient’s heart rhythm, especially after
myocardial infarction or during arrhythmias.
Assess for Complications: Monitor for signs of heart failure (e.g., edema, lung crackles, weight
gain) or arrhythmias (e.g., palpitations, dizziness, fainting).
Interventions for Coronary Artery Disease (CAD):
Medications: Administer antiplatelet agents (e.g., aspirin), statins to lower cholesterol, and
nitrates for chest pain relief.
Monitor for Chest Pain: Administer nitroglycerin as prescribed for chest pain, monitoring the
patient’s blood pressure regularly due to the risk of hypotension.
Lifestyle Modifications: Educate the patient on smoking cessation, dietary changes (low-
sodium, low-fat diet), and the importance of regular physical activity.
Interventions for Heart Failure:
Diuretics: Administer diuretics like furosemide to reduce fluid overload and improve breathing.
ACE Inhibitors/ARBs: Use medications like enalapril to reduce afterload and improve heart
function.
Beta-Blockers: Administer beta-blockers (e.g., metoprolol) to improve heart function and reduce
the risk of arrhythmias.
Oxygen Therapy: Provide oxygen as needed to ensure adequate oxygenation, particularly during
episodes of acute heart failure exacerbation.
Patient Education: Instruct the patient on managing fluid intake, daily weight monitoring, and
recognizing symptoms of worsening heart failure (e.g., increased edema, shortness of breath).
Interventions for Arrhythmias:
Medications: Administer antiarrhythmic drugs (e.g., amiodarone) or beta-blockers to regulate
heart rhythm.
Electrolyte Management: Monitor potassium, magnesium, and calcium levels to prevent
arrhythmias caused by electrolyte imbalances.
Cardioversion: For patients with atrial fibrillation, synchronized cardioversion may be necessary
to restore a normal rhythm.
Interventions for Hypertension:
Medications: Administer antihypertensive drugs such as ACE inhibitors, diuretics, beta-blockers,
or calcium channel blockers as prescribed.
Lifestyle Modifications: Encourage weight loss, sodium reduction, and regular exercise to
manage blood pressure.
Monitor for Organ Damage: Regularly assess for signs of target organ damage, such as changes
in vision (retinopathy) or kidney function.
Part 4: Practice Questions &
Model Exams
 Chapter 13: High-Yield Practice
Questions
A. Safe and Effective Care Environment
1. A nurse is planning to delegate tasks to a nursing assistant. Which of the following tasks is
appropriate for the nurse to delegate?
a) Assessing a patient’s lung sounds
b) Monitoring a patient post-op for complications
c) Assisting a patient with feeding
d) Administering medications to a patient
2. A nurse is preparing to administer a medication to a patient with a known allergy to sulfa
drugs. Which medication is contraindicated for this patient?
a) Furosemide
b) Lorazepam
c) Acetaminophen
d) Vitamin C
3. The nurse is reviewing the ethical principles involved in patient care. Which principle
focuses on ensuring fairness in providing care to all patients?
a) Autonomy
b) Justice
c) Beneficence
d) Nonmaleficence
4. A patient is being discharged from the hospital after a stroke. Which action by the nurse
demonstrates effective case management?
a) Referring the patient to physical therapy for ongoing rehabilitation
b) Providing the patient with a list of exercises to perform at home
c) Asking the patient to follow up with the doctor in 1 month
d) Writing a prescription for the patient’s medications
5. A nurse is caring for a patient with a low white blood cell count due to chemotherapy.
Which of the following should the nurse prioritize to reduce the patient’s risk of infection?
a) Monitoring the patient’s blood pressure every 4 hours
b) Encouraging deep breathing and coughing every hour
c) Implementing strict hand hygiene and using isolation precautions
d) Encouraging the patient to drink fluids every 2 hours
6. A nurse is preparing a patient for surgery. Which of the following should be included in
the preoperative teaching?
a) The patient should refrain from eating or drinking for 12 hours before surgery
b) The patient will need to provide a stool sample after surgery
c) The patient’s vital signs will not be monitored after surgery
d) The patient should avoid coughing or deep breathing after surgery
7. Which of the following safety protocols is most important when caring for a patient who is
receiving intravenous potassium?
a) Monitor the patient’s blood glucose levels every 2 hours
b) Ensure the IV potassium is given via an infusion pump
c) Assess the patient’s lung sounds for congestion every 4 hours
d) Check the patient’s blood pressure every 4 hours
8. The nurse is assessing a postoperative patient and notices the patient has a rapid, weak
pulse, hypotension, and confusion. Which condition is the nurse most concerned about?
a) Infection
b) Acute renal failure
c) Hypovolemic shock
d) Hypertensive crisis
9. A nurse is educating a patient about the importance of hand hygiene in preventing
healthcare-associated infections (HAIs). Which statement made by the patient indicates
understanding?
a) "I should wash my hands only if they are visibly dirty."
b) "I should wash my hands before touching food and after using the restroom."
c) "Hand hygiene is only necessary if I am in the hospital."
d) "Hand hygiene is not important if I wear gloves."
10. A nurse is caring for a patient who is immunocompromised due to chemotherapy. Which
of the following is the most important intervention to prevent the spread of infection?
a) Maintain the patient’s room temperature at 72°F (22°C)
b) Provide the patient with a high-fiber diet
c) Use strict hand hygiene and isolation precautions
d) Encourage the patient to remain in a sitting position at all times
11. When delegating tasks to a nursing assistant, which of the following is the nurse’s
responsibility?
a) To evaluate the patient’s response to the delegated task
b) To perform the delegated task
c) To ensure the nursing assistant completes the task independently
d) To ignore the task if it is outside the scope of the nursing assistant’s abilities
12. A nurse is caring for a patient in the ICU who is on mechanical ventilation. Which of the
following interventions is essential to prevent ventilator-associated pneumonia (VAP)?
a) Encourage the patient to speak every hour
b) Administer antibiotics prophylactically every 6 hours
c) Elevate the head of the bed to 30–45 degrees
d) Sedate the patient to prevent agitation
13. Which of the following would the nurse identify as a primary source of infection in a
healthcare setting?
a) A patient’s Foley catheter
b) A nurse’s stethoscope
c) The hospital’s cafeteria
d) The patient’s family members
14. A nurse is observing a newly hired nurse perform a sterile procedure. The newly hired
nurse places a sterile instrument on a non-sterile surface. What is the nurse’s next step?
a) Remind the nurse to correct the mistake immediately
b) Allow the nurse to continue and correct the error later
c) Continue the procedure, as the mistake is not critical
d) Call for help and delay the procedure
15. The nurse is planning care for a patient with an infectious disease. Which of the following
actions should the nurse include in the care plan to reduce the risk of transmission?
a) Place the patient in a private room and use standard precautions
b) Restrict visitors to the patient’s room
c) Administer a prophylactic antibiotic
d) Have the patient wear a mask when leaving the room
16. A nurse is working with a team to manage a patient’s care following a stroke. Which of the
following demonstrates effective resource management by the nurse?
a) Coordinating with physical therapy for the patient’s rehabilitation needs
b) Assigning the patient’s entire care to one nurse
c) Ignoring the family’s concerns about the patient’s progress
d) Referring the patient for additional diagnostic testing without consulting the healthcare
provider
17. A nurse is caring for a patient in an isolation room who requires assistance with feeding.
Which action demonstrates the nurse’s understanding of patient rights?
a) The nurse provides assistance with feeding while following proper precautions
b) The nurse refuses to provide assistance due to isolation protocols
c) The nurse allows family members to feed the patient without any precautions
d) The nurse leaves the patient alone during mealtime due to the isolation status
18. A nurse is caring for a patient who requires both surgical intervention and post-operative
pain management. Which of the following actions should the nurse take to coordinate
care?
a) Contact the anesthesiologist to discuss pain management options
b) Inform the patient to expect pain relief in 24 hours
c) Administer all prescribed pain medications at once
d) Ask the patient to wait for a pain management plan until after surgery
19. When supervising a nursing assistant, the nurse observes that the assistant is not using
proper infection control techniques while cleaning the patient’s wound. What should the
nurse do first?
a) Reprimand the assistant for not following proper procedures
b) Correct the assistant’s technique and explain the rationale
c) Report the assistant to the manager
d) Ignore the issue, as the assistant is new to the unit
20. A nurse is discussing informed consent with a patient scheduled for surgery. Which of the
following is the most important point for the nurse to convey?
a) The surgeon will explain the procedure in detail
b) The patient must sign the consent form before any information is provided
c) The patient can change their mind at any time during the procedure
d) The nurse is responsible for obtaining the patient’s consent
21. A nurse is preparing a sterile field for a procedure. The nurse realizes that one of the sterile
items has been contaminated. What should the nurse do next?
a) Continue the procedure and ignore the contamination
b) Remove the contaminated item and replace it with a sterile item
c) Call the doctor to report the contamination
d) Discard the entire sterile field and start over
22. A nurse is supervising a nursing assistant who is providing care to a patient on contact
precautions. Which action by the nursing assistant requires the nurse’s intervention?
a) The nursing assistant wears gloves when entering the room
b) The nursing assistant places used linens in a plastic bag without gloves
c) The nursing assistant washes hands before and after patient care
d) The nursing assistant wears a mask when entering the patient’s room
23. A patient who has undergone a surgical procedure is being prepared for discharge. Which
action is most important for the nurse to take to ensure continuity of care?
a) Schedule a follow-up appointment with the surgeon
b) Provide the patient with instructions for physical therapy
 c) Review the patient’s medication regimen and potential side effects
d) Ask the patient to rest and avoid strenuous activities for 2 weeks
24. A nurse is preparing to delegate the task of bathing a patient to a nursing assistant. Which
patient situation would make this delegation inappropriate?
a) A patient who is able to sit up and move their arms
b) A patient who is recovering from surgery and requires assistance with mobility
c) A patient who has a pressure ulcer on their sacrum and requires frequent dressing
changes
d) A patient who is confused and needs assistance with communication
25. A nurse is caring for a patient who is at risk for aspiration. Which of the following actions
should the nurse take to promote patient safety during meals?
a) Encourage the patient to eat quickly to reduce the chance of aspiration
b) Place the patient in a supine position to promote swallowing
c) Ensure the patient is sitting upright at a 90-degree angle during meals
d) Provide the patient with soft, pureed foods only
26. The nurse is caring for a patient receiving a blood transfusion. The patient develops chills,
fever, and back pain during the infusion. What is the nurse’s priority action?
a) Continue the transfusion and notify the physician after the procedure
b) Stop the transfusion immediately and notify the healthcare provider
c) Administer acetaminophen to relieve the fever
d) Monitor vital signs and document the event in the medical record
27. A nurse is providing preoperative teaching to a patient scheduled for surgery. Which
statement made by the patient indicates an understanding of the teaching regarding
postoperative activity restrictions?
a) "I will be able to walk around the day after my surgery."
b) "I will avoid any physical activity for 4-6 weeks after my surgery."
c) "I should not bend over or lift anything heavy for the next 3 months."
d) "I can resume all normal activities within a week after surgery."
28. Which of the following interventions would the nurse perform to minimize the risk of a
healthcare-associated infection in a patient undergoing surgery? (Select all that apply.)
a) Administer prophylactic antibiotics before surgery
b) Maintain the patient’s temperature at 36°C (96.8°F)
c) Encourage the patient to cough and deep breathe postoperatively
d) Perform hand hygiene before and after patient contact
e) Remove hair from the surgical area using clippers
29. A nurse is caring for a patient in an isolation room. Which of the following actions by the
nurse demonstrates proper infection control?
 a) Entering the room without wearing a gown or gloves
b) Leaving the patient’s door open to facilitate ventilation
c) Using proper hand hygiene before and after patient contact
d) Avoiding wearing a mask when caring for the patient
30. A patient is at high risk for developing deep vein thrombosis (DVT) post-surgery. Which
of the following interventions should the nurse prioritize to reduce this risk?
a) Applying a heating pad to the patient’s legs
b) Encouraging the patient to remain in bed with the legs elevated
c) Administering anticoagulant therapy as prescribed
d) Providing the patient with a soft diet to avoid constipation
31. A nurse is administering an intravenous medication to a patient. The nurse notices the
patient’s IV site is swollen and red. What is the nurse’s next step?
a) Continue the infusion and monitor the site every 15 minutes
b) Remove the IV and apply a warm compress to the area
c) Reassure the patient and document the findings in the medical record
d) Contact the healthcare provider to request a change of the medication
32. A patient who is receiving chemotherapy is at risk for neutropenia. Which of the following
interventions should the nurse implement to reduce the risk of infection?
a) Administer a prophylactic antibiotic
b) Restrict visitors to only immediate family members
c) Ensure the patient wears a mask when leaving their room
d) Encourage the patient to rest and limit physical activity
33. A nurse is preparing a medication for a patient with renal impairment. The patient’s
laboratory results show a serum creatinine level of 3.5 mg/dL. Which action should the
nurse take before administering the medication?
a) Increase the medication dose to ensure effectiveness
b) Administer the medication as prescribed, without any adjustments
c) Notify the healthcare provider to adjust the medication dose
d) Hold the medication and ask the patient to report any side effects
34. A nurse is working in a clinic and receives a report of a patient with a suspected infectious
disease. What is the nurse’s first priority when caring for this patient?
a) Ensure the patient is placed in a private room
b) Begin the patient’s treatment protocol immediately
c) Assess the patient for signs and symptoms of the infection
d) Start the patient on broad-spectrum antibiotics
35. A nurse is providing education on the prevention of healthcare-associated infections
(HAIs). Which statement by the patient indicates understanding of the teaching?
 a) "I should wash my hands only when they look dirty."
b) "Hand hygiene is important after using the bathroom and before eating."
c) "I should wash my hands after touching any equipment in the room."
d) "I don’t need to wash my hands if I’m wearing gloves."
36. A nurse is monitoring a postoperative patient for signs of hypovolemic shock. Which of
the following findings would indicate the patient is in the early stages of shock?
a) Rapid, weak pulse and hypotension
b) Increased urine output and confusion
c) Warm, flushed skin and decreased heart rate
d) Decreased respiratory rate and increased blood pressure
37. A nurse is caring for a patient who is at risk for developing a healthcare-associated
infection (HAI) due to a prolonged catheterization. Which of the following is a priority
intervention to prevent infection in this patient?
a) Encourage the patient to drink plenty of fluids
b) Ensure that the catheter is securely taped and remains sterile
c) Clean the catheter insertion site with an antiseptic solution daily
d) Remove the catheter as soon as it is no longer needed
38. A nurse is caring for a patient who has been placed on transmission-based precautions for
a respiratory infection. Which of the following actions should the nurse take to prevent the
spread of infection?
a) Discard used equipment in the regular trash
b) Wear a surgical mask when entering the patient’s room
c) Keep the patient’s room door closed at all times
d) Refrain from performing hand hygiene after patient contact
39. A nurse is caring for a patient with a central venous catheter. The patient suddenly
develops shortness of breath and chest pain. What is the nurse’s priority action?
a) Notify the healthcare provider immediately
b) Check the catheter for signs of dislodgment or kinking
c) Position the patient in a semi-Fowler’s position and assess vital signs
d) Administer supplemental oxygen and monitor respiratory status
40. A nurse is caring for a patient who is receiving chemotherapy and is experiencing fatigue.
What is the nurse’s priority intervention to address this patient’s fatigue?
a) Encourage the patient to rest and limit physical activity
b) Administer a blood transfusion to increase hemoglobin levels
c) Provide the patient with a high-calorie, high-protein diet
d) Encourage the patient to perform light exercises throughout the day
41. A nurse is caring for a patient who has been prescribed physical restraints. Which of the
following interventions is required when caring for this patient?
a) Checking the restraints and assessing the patient every 4 hours
b) Documenting the continued need for restraints at least every 24 hours
c) Removing the restraints at least every 2 hours to perform skin assessment and range of
motion
d) Obtaining a new physician order every 48 hours
42. A nurse is caring for several patients on a medical-surgical unit. Which situation requires the
most immediate nursing intervention?
a) A patient who is due for a scheduled antibiotic in 10 minutes
b) A patient who reports pain at 6/10 and is due for pain medication
c) A patient whose blood glucose reading is 58 mg/dL
d) A patient who needs assistance to use the bathroom
43. A nurse discovers an unconscious person in the hospital parking lot. Place the following
actions in the correct order of priority.
a) Check for breathing and pulse
b) Call for help and activate the emergency response system
c) Begin chest compressions if no pulse is detected
d) Ensure the scene is safe before approaching
e) Open the airway using head tilt-chin lift
44. A patient with dementia frequently attempts to leave the nursing unit. Select all appropriate
interventions for this patient.
a) Apply a wrist restraint to prevent wandering
b) Place the patient in a room near the nursing station
c) Use an electronic tracking device with family consent
d) Administer sedatives as needed to decrease wandering behavior
e) Establish a routine for regular physical activity
f) Implement an hourly rounding schedule
45. A nurse is working in a long-term care facility during a power outage. The nurse's priority
action should be to:
a) Contact family members to pick up residents
b) Identify residents on oxygen or other electricity-dependent treatments
c) Begin transfer of all residents to the nearest hospital
d) Complete documentation of the incident
46. A patient's advance directive states that she does not want cardiopulmonary resuscitation.
Under which of the following circumstances would the nurse be justified in not following
these wishes?
 a) When the patient's condition suddenly deteriorates
b) When the family requests that everything be done to save the patient
c) When the healthcare provider orders resuscitation despite the directive
d) When the patient experiences a suicide attempt
47. A nurse is planning care for multiple patients. For which patient should the nurse implement
transmission-based precautions in addition to standard precautions?
a) A patient with a draining wound infected with Pseudomonas
b) A patient diagnosed with active pulmonary tuberculosis
c) A patient with a urinary tract infection
d) A patient with a history of MRSA colonization two years ago
48. What is the maximum number of consecutive hours recommended for a nurse to work to
maintain patient safety?
49. A patient asks the nurse to explain the meaning of "informed consent." The nurse's best
response is that informed consent means the patient:
a) Has been informed of the statistical success rate of the procedure
b) Understands the risks, benefits, and alternatives of the proposed treatment
c) Consents to anything the healthcare provider deems necessary
d) Has signed the hospital's standard consent form
50. A charge nurse discovers that the unit is short-staffed for the upcoming shift. Which of the
following actions by the charge nurse would best address this situation?
a) Calling in additional staff even if it means paying overtime
b) Requesting that nurses work a double shift
c) Redistributing patient assignments based on acuity and available staff
d) Closing the unit to new admissions without administrative approval
51. A nurse is caring for a patient who is receiving blood products. The patient develops chills,
hives, and complains of lower back pain 15 minutes after the transfusion started. Select all
appropriate nursing interventions.
a) Slow the transfusion rate to reduce symptoms
b) Immediately stop the transfusion
c) Maintain venous access with normal saline
d) Document the patient's reactions
e) Continue to monitor vital signs
f) Administer acetaminophen for fever control
52. A nurse witnesses a visitor verbally abusing a patient. Which of the following is the most
appropriate initial response?
a) Call security immediately
b) Ask the visitor to leave the facility
 c) Separate the visitor from the patient and assess the situation
d) Document the incident without intervening
53. A nurse manager needs to improve staff compliance with hand hygiene protocols. Arrange
the following interventions from most to least effective in creating sustainable change.
a) Posting signs reminding staff to wash hands
b) Implementing peer observation and feedback
c) Providing education on healthcare-associated infections
d) Installing automatic hand sanitizer dispensers
e) Disciplining staff who fail to comply with protocols
54. A patient who speaks limited English requires discharge instructions. What is the best
approach for the nurse to take?
a) Speak slowly and loudly to help the patient understand
b) Use a certified medical interpreter
c) Ask a bilingual family member to translate
d) Provide written instructions in English and ask the patient to have them translated later
55. The nurse is reviewing a patient's medication list and notes that the patient is taking warfarin
(Coumadin) 5 mg daily. What critical information should the nurse include when teaching this
patient about medication safety? Select all that apply.
a) The importance of consistent vitamin K intake in diet
b) The need for regular INR monitoring
c) Signs of bleeding to report immediately
d) That over-the-counter pain relievers can be taken as needed
e) To avoid alcohol while taking this medication
f) That missed doses should be doubled the next day
56. A nurse-manager is implementing a quality improvement project on a medical-surgical unit.
Which of the following best describes a component of the "Plan" phase in the PDCA (Plan-
Do-Check-Act) cycle?
a) Collecting data to evaluate if the change resulted in improvement
b) Identifying the problem and analyzing relevant data
c) Implementing the planned change on a small scale
d) Standardizing the successful approach and monitoring results
57. A nurse observes a coworker repeatedly coming to work appearing impaired, with slurred
speech and unsteady gait. The nurse's most appropriate action is to:
a) Confront the coworker about suspected substance abuse
b) Report observations to the nursing supervisor immediately
c) Ask other colleagues if they have noticed similar behaviors
d) Document observations for future reference if needed
58. A patient is admitted with a disorder requiring strict airborne isolation. Which of the
following rooms would be most appropriate for this patient?
a) A private room with the door closed
b) A negative pressure room with an anteroom
c) A positive pressure room with HEPA filtration
d) A semi-private room with another patient who has the same condition
59. A nurse receives a new order to administer 1000 mL of normal saline over 8 hours. If the
administration set delivers 15 drops per mL, at what rate should the nurse set the intravenous
infusion in drops per minute?
a) 21 drops/minute
b) 31 drops/minute
c) 42 drops/minute
d) 125 drops/minute
60. A nurse is aware that a medication error occurred on the unit but did not report it because
no harm came to the patient. This action is an example of which of the following?
a) Risk management
b) Failure to rescue
c) Incident concealment
d) Professional judgment
61. A nurse is using the SBAR technique when calling a healthcare provider about a change in a
patient's condition. What information should the nurse include in the "Background"
component?
a) The patient's name, room number, and reason for admission
b) The patient's vital signs and assessment findings
c) What the nurse thinks is happening with the patient
d) The specific request or recommendation for the provider
62. A patient tells the nurse, "I don't want my daughter to know about my cancer diagnosis."
Later, the daughter asks the nurse directly about her father's diagnosis. The most appropriate
response by the nurse is:
a) "Your father has been diagnosed with stage 3 lung cancer."
b) "I can't share that information without your father's permission."
c) "You should speak with your father about his health condition."
d) "I'm not sure of the exact diagnosis yet."
63. A nurse is assessing a confused patient who has a history of falls. Select all appropriate
interventions to prevent falls in this patient.
a) Apply a vest restraint while the patient is in bed
b) Ensure the bed is in the lowest position with brakes locked
 c) Place a fall mat beside the bed
d) Sedate the patient during the night to prevent wandering
e) Implement hourly rounding to assess patient needs
f) Use an electronic bed alarm system
64. A hospital is implementing a new computerized provider order entry (CPOE) system.
Arrange the following implementation steps in the most appropriate order.
a) Schedule staff training sessions on using the new system
b) Form a multidisciplinary team to evaluate system requirements
c) Conduct post-implementation evaluation and make necessary adjustments
d) Conduct a pilot test on one unit before hospital-wide implementation
e) Analyze workflow processes to identify potential issues
65. A nurse is preparing to administer an IV medication and realizes the pharmacy has sent a
concentration different from what is usually stocked on the unit. The nurse's most
appropriate action is to:
a) Calculate a new administration rate for the different concentration
b) Return the medication to the pharmacy and request the usual concentration
c) Verify with pharmacy that the concentration is appropriate before administering
d) Ask another nurse to check the calculation before administration
66. A nurse discovers a discrepancy in the controlled substance count at the end of the shift.
The next appropriate action is to:
a) Complete an incident report and notify the nurse manager
b) Conduct a thorough search of all areas where medications might be stored
c) Ask all nursing staff who had access to the controlled substances about the discrepancy
d) Assume the previous shift miscounted and correct the count
67. The nurse is planning care for a patient with a central venous catheter. Which intervention
is most important for preventing central line-associated bloodstream infections (CLABSI)?
a) Changing the central line dressing every day
b) Using chlorhexidine for skin antisepsis during dressing changes
c) Wearing sterile gloves when accessing the catheter
d) Flushing the catheter with heparin after each use
68. The healthcare facility is updating its policy on patient identification. The most reliable
method for identifying patients prior to procedures or treatments is:
a) Checking the patient's room number and bed assignment
b) Asking the patient to state their name
c) Using two patient identifiers and comparing to medical record
d) Confirming identity with family members or caregivers
69. On a medical-surgical unit, identify the areas in the room where hand hygiene should be
performed to prevent healthcare-associated infections.
70. A nurse is prioritizing care for several patients. Which patient should the nurse assess first?
a) A patient who reports a sudden onset of chest pain radiating to the left arm
b) A patient who has not had a bowel movement in two days
c) A patient whose scheduled pain medication is due in 15 minutes
d) A patient who needs assistance with ambulation to the bathroom
71. During a code blue situation, the role of the primary nurse caring for the patient includes:
a) Directing the resuscitation efforts
b) Administering medications as ordered
c) Providing patient history and information to the code team
d) Performing chest compressions
72. A nurse is planning to administer a blood transfusion. Select all nursing actions that must be
completed before initiating the transfusion.
a) Obtain baseline vital signs
b) Verify blood product with another licensed nurse
c) Administer a prescribed antipyretic
d) Have the patient empty their bladder
e) Ensure informed consent is documented
f) Start an IV with 0.9% sodium chloride solution
73. A patient's family member becomes verbally aggressive toward nursing staff. The nurse's
best initial action is to:
a) Call security immediately
b) Respond firmly that such behavior will not be tolerated
c) Move to a private area and listen to the family member's concerns
d) Ask another staff member to take over care of the patient
74. The nurse manager is evaluating the unit's compliance with regulatory requirements. The
minimum time interval at which a patient's pain should be reassessed after administration of
IV pain medication is:
75. A nurse needs to calculate the correct dose of medication. The order reads "morphine sulfate
4 mg IV." The medication is supplied as 10 mg/mL. How many milliliters should the nurse
administer?
a) 0.4 mL
b) 0.8 mL
c) 2.5 mL
d) 4 mL
76. A nurse is participating in a disaster triage situation. Match each patient to the appropriate
triage category. Patients:
o 67-year-old with respiratory rate of 32, altered mental o Triage Categories:
status, and SpO2 82%
o 24-year-old with open femur fracture, stable vital signs, o Immediate (Red)
and moderate pain
o Delayed (Yellow)
o 45-year-old with minor lacerations and abrasions,
ambulatory o Minimal (Green)
o 5-year-old with no pulse or respirations after prolonged
submersion o Expectant (Black)
o 35-year-old with chest pain, diaphoresis, BP 90/60,
anxiety
77. A nurse is caring for a patient who requires contact precautions. Which of the following
statements about contact precautions is accurate?
a) Contact precautions are required for patients with MRSA colonization only
b) Gloves and gown should be worn when entering the room of a patient on contact
precautions
c) N95 respirators must be worn when caring for patients on contact precautions
d) Contact precautions are only necessary during direct patient care activities
78. A nurse witnesses a colleague making an error while programming an IV pump. The nurse
should:
a) Report the colleague to the nursing supervisor for disciplinary action
b) Intervene immediately to prevent potential harm to the patient
c) Wait until after the shift to discuss the error with the colleague
d) Document the incident in the chart without addressing it directly
79. A nurse is reviewing the following nursing interventions for a post-operative patient. Select
all that are appropriate to include in the plan of care.
a) Encourage coughing and deep breathing exercises every 4 hours
b) Maintain NPO status until bowel sounds return
c) Keep the head of bed flat to reduce stress on the incision
d) Assess the surgical site with each vital sign check
e) Administer pain medication around the clock for the first 24 hours
f) Encourage early ambulation as ordered
80. A nurse manager is reviewing unit performance data and notes an increase in hospital-
acquired pressure injuries. Which quality improvement approach would be most appropriate
to address this issue?
 a) Conduct a root cause analysis to identify contributing factors
b) Implement a new skin care protocol without analyzing current practices
c) Discipline staff members who have had patients develop pressure injuries
d) Increase documentation requirements to monitor compliance
81. A nurse is obtaining informed consent for a surgical procedure. Which of the following
statements indicates the patient has an accurate understanding of informed consent?
a) "Once I sign this form, I cannot change my mind about having the procedure."
b) "This form means the doctor cannot be held responsible if something goes wrong."
c) "I understand the risks and benefits, and I can withdraw consent at any time."
d) "The hospital requires this form before any treatment can begin."
82. A nurse is caring for a patient who has an implanted venous access port. To maintain patency
of the port, the nurse should:
a) Flush with normal saline after each use
b) Irrigate with hydrogen peroxide monthly
c) Access the port weekly even if not in use
d) Flush with heparinized saline per facility protocol
83. A healthcare facility is implementing a new electronic health record system. Arrange the
following implementation steps in the most appropriate order.
a) Provide ongoing technical support and address user issues
b) Conduct comprehensive staff training sessions
c) Perform a readiness assessment of current processes
d) Run parallel paper and electronic systems during transition
e) Evaluate system effectiveness and make necessary adjustments
84. A nurse is monitoring a post-operative patient who received morphine 2 hours ago. Which
assessment finding requires immediate intervention?
a) Blood pressure 110/70 mmHg, down from 128/84 mmHg
b) Respiratory rate 8 breaths per minute, down from 16
c) Pain level 3/10, down from 7/10
d) Urinary output 50 mL over the past hour
85. Select all appropriate interventions to prevent surgical site infections.
a) Maintain normothermia during the perioperative period
b) Ensure proper hand hygiene before wound care
c) Apply antibiotic ointment to all surgical incisions regardless of surgeon's orders
d) Discontinue antibiotics 24 hours after surgery unless otherwise indicated
e) Use sterile technique when changing surgical dressings
f) Clip hair at the surgical site immediately before the procedure
86. A nurse suspects that a colleague is diverting narcotics for personal use. The most
appropriate initial action is to:
a) Confront the colleague privately about the suspicion
b) Report the suspicion to the charge nurse or supervisor
c) Monitor the colleague's behavior for additional evidence
d) Document patterns of medication discrepancies for future reference
87. A patient with limited English proficiency needs education about a new medication. The
nurse should:
a) Speak louder and use simple words to ensure understanding
b) Ask a family member to translate the medical information
c) Use a professional interpreter service for the education
d) Provide written materials in English and suggest translation later
88. During a rapid response situation, which nursing intervention should be performed first?
a) Administer oxygen and assess vital signs
b) Review the patient's recent laboratory results
c) Prepare emergency medications
d) Document the sequence of events
89. A nurse is caring for a patient with a history of violence. Identify the areas in the image where
the nurse should position themselves to maintain safety while providing care
90. A nurse must safely transfer a 250-pound patient from the bed to a chair. Which of the
following is the best approach?
a) Use a mechanical lift with appropriate staff assistance
b) Ask two colleagues to help manually transfer the patient
c) Encourage the patient to move independently with minimal assistance
d) Postpone the transfer until more staff are available
91. A nurse discovers that a healthcare worker has accessed the medical record of a celebrity
patient not under their care. The nurse should:
a) Discuss the privacy breach directly with the healthcare worker
b) Report the HIPAA violation according to facility policy
c) Advise the healthcare worker to self-report the violation
d) Monitor the situation to see if it happens again
92. A facility is conducting a fire drill. The nurse's primary responsibility during a fire drill is to:
a) Assist with evacuation of ambulatory patients first
b) Know the location and operation of fire extinguishers
c) Protect patients by closing doors and windows
d) Account for all staff members in the area
93. Match each scenario with the appropriate ethical principle being applied.
 Scenarios: Ethical Principles:
o A nurse respects a patient's informed refusal of treatment o Autonomy
o A nurse ensures all patients on the unit receive equal o Beneficence
access to care o Non-maleficence
o A nurse administers pain medication to relieve suffering o Justice
o A nurse avoids performing a procedure they're not
competent to perform

94. A nurse is caring for a patient who requires isolation due to Clostridioides difficile infection.
When exiting the isolation room, in what order should the following items be removed?
a) Mask
b) Gloves
c) Gown
d) Perform hand hygiene
95. A central venous catheter dressing is due to be changed. The nurse should:
a) Apply sterile gloves immediately before touching the dressing materials
b) Prepare all supplies, perform hand hygiene, then apply sterile gloves
c) Perform hand hygiene, apply sterile gloves, then prepare supplies
d) Apply clean gloves, remove old dressing, then apply sterile gloves
96. A nurse is working on an oncology unit when a hazardous medication spill occurs. Select all
appropriate actions.
a) Immediately wipe up the spill with paper towels
b) Notify environmental services to clean the spill
c) Use the hazardous drug spill kit according to protocol
d) Evacuate patients from the immediate area
e) Document the incident according to facility policy
f) Continue patient care while waiting for the spill to be addressed
97. A nurse is administering medications to multiple patients. For which patient should the nurse
question the medication order?
a) A patient with a penicillin allergy ordered cephalexin
b) A patient with a heart rate of 52 ordered digoxin
c) A patient with a creatinine of 1.0 mg/dL ordered gentamicin
d) A patient with a systolic blood pressure of 136 ordered lisinopril
98. A healthcare facility is developing a new disaster preparedness plan. During a natural disaster,
the primary responsibility of the charge nurse is to:
a) Coordinate patient care and allocate staff appropriately
 b) Communicate with patients' families about their condition c) Document all actions taken
during the disaster
d) Oversee evacuation of the entire facility
99. The "Five Rights" of medication administration are commonly known as the right patient,
medication, dose, route, and time. Identify the "Sixth Right" that has been added to these
principles.
a) Right technique
b) Right education
c) Right monitoring
d) Right documentation
100. A 32-year-old female patient asks the nurse about breast cancer screening. According to
current guidelines, the nurse should recommend that the patient:
a) Begin annual mammograms immediately
b) Have a clinical breast exam every 3 years
c) Begin annual mammograms at age 40
d) Have a baseline mammogram now and then begin regular screening at age 50
101. When providing anticipatory guidance to parents of a 15-month-old child, which safety
recommendation should the nurse emphasize?
a) Using a forward-facing car seat in the back seat of the car
b) Installing safety gates at the top and bottom of stairs
c) Allowing supervised swimming in a kiddie pool
d) Introducing honey into the child's diet
102. A nurse is teaching a group of adolescents about healthy lifestyle choices. Which teaching
approach would be most effective for this age group?
a) Providing factual information with emphasis on long-term health consequences
b) Using peer-led discussion groups focusing on real-life scenarios
c) Having parents present during the session to reinforce learning
d) Using simple language and frequent repetition of key points
103. A 60-year-old male with no family history of colorectal cancer asks the nurse about
appropriate screening. Based on current guidelines, the nurse should recommend:
a) Annual fecal occult blood testing
b) Colonoscopy every 10 years
c) Annual digital rectal examination
d) Sigmoidoscopy every 5 years only
104. A nurse is conducting a developmental assessment on a 4-year-old child. Which behavior
would be considered age-appropriate? Select all that apply.
a) Copying a circle and square
 b) Counting to 20
c) Riding a bicycle without training wheels
d) Using plural words
e) Tying shoelaces independently
f) Identifying primary colors
105. A 28-year-old female who is 8 weeks pregnant asks the nurse about appropriate weight
gain during pregnancy. Based on her pre-pregnancy BMI of 24, the nurse should recommend
a total weight gain of:
a) 11-20 pounds
b) 15-25 pounds
c) 25-35 pounds
d) 28-40 pounds
106. A nurse is providing education about immunizations to a parent who is hesitant about
vaccinating their child. Which statement by the nurse is most appropriate?
a) "If you choose not to vaccinate, your child will not be able to attend public school."
b) "I understand you have concerns. What specific questions can I address about vaccine
safety?"
c) "The risks of not vaccinating far outweigh any potential side effects from vaccines."
d) "Most parents choose to follow the recommended vaccination schedule."
107. Place the following developmental milestones in the correct chronological order in which
they typically appear.
a) Says first word
b) Sits without support
c) Walks independently
d) Rolls from back to stomach
e) Crawls on hands and knees
108. A school nurse is planning a health screening program. Which of the following screenings
is most appropriate for elementary school children?
a) Depression screening
b) Vision and hearing screening
c) Sexually transmitted infection screening
d) Osteoporosis screening
109. A 45-year-old male with a family history of cardiovascular disease asks about preventive
measures. Which recommendation should the nurse include in the teaching plan? Select all
that apply.
a) Taking a daily aspirin without consulting a healthcare provider
b) Maintaining a blood pressure below 120/80 mmHg
 c) Participating in moderate exercise for at least 150 minutes per week
d) Having cholesterol levels checked every 5 years
e) Limiting dietary sodium intake
f) Annual electrocardiogram (ECG) screening
110. A nurse is providing education to a 55-year-old female patient about menopause. Which
statement by the patient indicates a need for further teaching?
a) "Hot flashes and night sweats are common symptoms during menopause."
b) "Menopause occurs when I haven't had a menstrual period for 12 consecutive months."
c) "Hormone therapy will completely prevent all symptoms of menopause."
d) "I should continue to use birth control for at least one year after my last period."
111. A prenatal nurse is assessing a pregnant woman's nutritional status. Identify the area on
the image where the nurse should place the measuring tape to obtain an accurate mid-upper
arm circumference (MUAC) measurement.
112. A school nurse is developing a healthy eating program for teenagers. The most effective
approach would focus on:
a) Calorie counting and portion control
b) Following a specific diet plan
c) Making balanced food choices and enjoying physical activity
d) Avoiding all processed foods and sugar
113. A nurse is teaching a patient who is 14 weeks pregnant about fetal development. Which of
the following statements is accurate regarding fetal development at this stage?
a) The fetus can hear sounds from outside the uterus
b) All major organs have formed and are functioning
c) The sex of the fetus can be determined by ultrasound
d) The fetus is approximately 16 inches in length
114. During a well-child visit for a 2-year-old, which of the following findings requires further
evaluation?
a) The child uses 15 single words
b) The child cannot pedal a tricycle
c) The child has a vocabulary of 50 words but doesn't combine words
d) The child prefers to play alone rather than with other children
115. A nurse is providing education to a family about genetic screening. What is the primary
purpose of genetic screening?
a) To determine the exact cause of a genetic disorder
b) To identify individuals who carry genes for specific disorders
c) To cure genetic diseases before they manifest
d) To prevent all birth defects through early intervention
116. A nurse is teaching a class on contraception methods. Match each contraceptive method
with its typical effectiveness rate with perfect use.
Contraceptive Methods: Effectiveness Rates:
o Combined oral contraceptive pills o >99% effective
o Male condoms o 98% effective
o Copper IUD o 99.2% effective
o Withdrawal method o 96% effective
o Contraceptive implant o 78% effective
117. A nurse is providing health promotion education to a 70-year-old patient. Which of the
following interventions should be included in the teaching plan?
a) Beginning a high-intensity exercise program
b) Limiting fluid intake after dinner to prevent nocturia
c) Annual influenza vaccination
d) Taking calcium supplements regardless of dietary intake
118. A mother asks the nurse about her 6-month-old infant's nutritional needs. Which
recommendation should the nurse provide?
a) Begin introducing solid foods, starting with iron-fortified cereals
b) Start giving whole cow's milk as a supplement to breast milk
c) Introduce fruit juices to provide additional vitamins
d) Continue exclusive breastfeeding for another 6 months
119. A public health nurse is planning a community health fair focused on cancer prevention.
Which of the following screening recommendations should be included for the general
population? Select all that apply.
a) Annual full-body skin examinations for everyone over age 18
b) HPV vaccination for eligible individuals ages 9-26
c) Low-dose CT scan for lung cancer screening in asymptomatic adults
d) Cervical cancer screening with Pap tests starting at age 21
e) Prostate-specific antigen (PSA) testing for all men over age 40
f) Colonoscopy beginning at age 45 for those at average risk
B. Health Promotion and Maintenance
1. A nurse is providing education about smoking cessation to a 35-year-old patient who
smokes one pack of cigarettes daily. Which statement by the nurse is most appropriate?
a) "Quitting cold turkey is the most effective method for long-term success."
b) "Most smokers need multiple attempts before successfully quitting."
c) "Smoking cessation medications are only effective for heavy smokers."
d) "You should gradually reduce your smoking over a six-month period."
2. A nurse is teaching a class on osteoporosis prevention. Which of the following
recommendations should the nurse include? Select all that apply.
a) Regular weight-bearing exercise
b) Calcium intake of 1000-1200 mg daily for adults
c) Limited sun exposure to protect skin
d) Vitamin D supplementation if dietary intake is insufficient
e) Avoiding dairy products to reduce inflammation
f) Limiting caffeine consumption
3. A nurse is conducting a health assessment for a 55-year-old male patient. Based on current
recommendations, which of the following screenings should be included?
a) Annual prostate-specific antigen (PSA) testing
b) Bone density scanning
c) Hepatitis C testing if born between 1945 and 1965
d) Annual chest X-ray
4. A parent brings in a 4-month-old infant for a well-baby check. The nurse should
recommend that the parent:
a) Place the infant to sleep on their stomach to prevent choking
b) Begin introducing solid foods to improve sleep patterns
c) Place the infant on their back for sleep in a crib with a firm mattress
d) Allow the infant to sleep with soft toys and blankets for comfort
5. A nurse is teaching a first-time pregnant woman about fetal movement monitoring during
the third trimester. The nurse should instruct the patient to:
a) Count fetal movements once weekly for routine monitoring
b) Call the healthcare provider if she feels fewer than 10 movements in 2 hours
c) Expect more fetal activity in the evening than in the morning
d) Record only strong movements that cause discomfort
6. Arrange the following immunizations in the order they are typically first administered
according to the CDC recommended childhood immunization schedule.
a) Measles, Mumps, Rubella (MMR) vaccine
 b) Hepatitis B vaccine
c) Pneumococcal conjugate vaccine (PCV13)
d) Rotavirus vaccine
e) Influenza vaccine
7. A school nurse is teaching adolescents about human papillomavirus (HPV) vaccination.
Which of the following statements is accurate?
a) The vaccine is recommended only for females before sexual activity begins
b) The vaccine provides protection against all sexually transmitted infections
c) The vaccine is recommended for both males and females ages 11-12 years
d) One dose of the vaccine provides lifetime immunity against HPV
8. A nurse is conducting a vision screening for a 3-year-old child. The most appropriate
method for this age group is:
a) Snellen eye chart
b) Picture or symbol chart
c) Random dot E stereogram
d) Confrontation visual field testing
9. A 42-year-old female with a family history of breast cancer in her mother (diagnosed at age
48) asks the nurse about genetic testing. The nurse's most appropriate response is:
a) "Genetic testing isn't necessary since your mother was over 45 when diagnosed."
b) "You should meet with a genetic counselor to discuss your risk and testing options."
c) "You should definitely get tested since you have a first-degree relative with breast
cancer."
d) "Wait until you're 45 to consider genetic testing since that's when your risk increases."
10. Identify the area on the image where the nurse should focus health promotion efforts to
reduce the risk of skin cancer.
11. A nurse is providing preconception counseling to a 27-year-old woman planning
pregnancy. Which of the following recommendations should the nurse include?
a) Begin taking folic acid when pregnancy is confirmed
b) Maintain normal body weight before conception
c) Restrict all medication use including prescribed medications
d) Postpone pregnancy until completing all dental work
12. A nurse is teaching a class about preventing cardiovascular disease. What is the
recommended amount of moderate-intensity aerobic physical activity for adults according
to current guidelines?
a) At least 30 minutes daily, 3 days per week
b) At least 30 minutes daily, 5 days per week
c) At least 60 minutes daily, 3 days per week
 d) At least 60 minutes daily, 7 days per week
13. A 68-year-old patient asks the nurse about fall prevention strategies. Which of the
following should the nurse recommend? Select all that apply.
a) Removing throw rugs from the home
b) Installing grab bars in the bathroom
c) Limiting physical activity to prevent injury
d) Having regular vision and hearing checks
e) Minimizing fluid intake in the evening
f) Reviewing medications with healthcare provider
14. A parent of a 12-month-old child asks the nurse about appropriate developmental
activities. Which activity is most appropriate for this age?
a) Coloring with crayons
b) Playing with building blocks
c) Using scissors to cut paper
d) Reading independently
15. A nurse is teaching a patient with a family history of diabetes about preventive measures.
Which of the following is the most effective strategy for preventing type 2 diabetes?
a) Taking prophylactic metformin
b) Following a high-protein, low-carbohydrate diet
c) Maintaining a healthy weight through diet and exercise
d) Monitoring blood glucose daily
16. Match each stage of pregnancy with the appropriate health promotion activity.
Stages: Health Promotion Activities:
o First trimester (weeks 1-12) o Begin fetal movement counting
o Second trimester (weeks 13-26) o Start pelvic floor exercises
o Third trimester (weeks 27-40) o Receive Tdap vaccination
o Postpartum period o Prepare for breastfeeding
o Undergo screening for gestational diabetes

17. A nurse is conducting a health assessment of a 16-year-old adolescent. Which of the

following questions is most appropriate for assessing risk behaviors?
a) "Do you ever drink alcohol or use drugs?"
b) "Tell me about how you spend time with your friends."
c) "Have your friends ever pressured you to do something you didn't want to do?"
d) "Do your parents know what you do when you're not at home?"
18. A school nurse is developing a program to prevent childhood obesity. Which of the
following interventions should be included?
a) Restricting caloric intake based on BMI percentile
b) Promoting 60 minutes of daily physical activity
c) Eliminating all sugar-containing foods from the diet
d) Weighing children weekly to monitor progress
19. A 75-year-old patient asks about cognitive health maintenance. The nurse should
recommend:
a) Complete retirement from all work and volunteer activities
b) Engaging in mentally stimulating activities and social interaction
c) Taking ginkgo biloba supplements to enhance memory
d) Limiting physical activity to conserve mental energy
20. An infant has just received their 2-month immunizations. The nurse should instruct the
parents to:
a) Give acetaminophen every 4 hours for the next 24 hours regardless of symptoms
b) Apply warm compresses to injection sites to reduce discomfort
c) Contact the healthcare provider if the infant develops a fever above 104°F (40°C)
d) Monitor for fever and give acetaminophen as needed for discomfort
21. A nurse is educating parents of a 9-month-old infant about nutrition. Which of the
following foods is not appropriate to introduce at this age?
a) Soft cooked vegetables
b) Honey
c) Mashed beans
d) Small pieces of soft fruits
22. A 50-year-old female patient asks the nurse about perimenopause. Which of the following
symptoms is most characteristic of perimenopause?
a) Complete cessation of menstruation
b) Increased menstrual regularity
c) Irregular menstrual cycles
d) Decreased vaginal secretions
23. A nurse is conducting a fall risk assessment for an older adult. Which of the following
factors increases the risk of falls? Select all that apply.
a) History of previous falls
b) Use of four or more medications
c) Lower body weakness
d) Daily stretching exercises
e) Well-lit living areas
 f) Normal blood pressure readings
24. A father asks the nurse about normal speech development for his 3-year-old son. The nurse
should inform him that a typical 3-year-old should be able to:
a) Use 3-4 word sentences and be understood by strangers
b) Name all letters of the alphabet
c) Speak without any grammatical errors
d) Follow 5-step verbal commands
25. A nurse is teaching a community class on heart-healthy diets. Which of the following
dietary patterns is most supported by research for cardiovascular health?
a) Low-carbohydrate, high-protein diet
b) Mediterranean diet
c) Strict vegetarian diet
d) High-protein, low-fat diet
26. A nurse is providing education about sunscreen use. Arrange the following steps in the
correct order for proper sunscreen application.
a) Reapply every two hours and after swimming or sweating
b) Apply to all exposed skin areas including ears and back of neck
c) Apply 15-30 minutes before sun exposure
d) Use a broad-spectrum sunscreen with SPF 30 or higher
e) Use approximately one ounce (a shot glass full) for full body coverage
27. A school nurse is assessing a 14-year-old for scoliosis. Identify the area on the image where
the nurse should focus the assessment to detect early signs of scoliosis.
28. A 28-year-old woman who is planning to become pregnant asks about folic acid
supplementation. The nurse should recommend:
a) Taking 400 mcg of folic acid daily beginning at least one month before conception
b) Starting folic acid only after pregnancy is confirmed
c) Taking 1000 mcg of folic acid only during the first trimester
d) Using folic acid supplements only if dietary intake is inadequate
29. A public health nurse is planning an influenza vaccination campaign. For which of the
following groups is annual influenza vaccination most strongly recommended?
a) Healthy adults ages 25-40
b) Children 6 months and older
c) Adults who received the vaccine last year
d) Individuals with egg allergies
30. A nurse is teaching about testicular self-examination. How frequently should men perform
this examination? ________________
31. A nurse is providing anticipatory guidance to parents of a 2-year-old child. Which guidance
about toilet training is most appropriate?
a) Begin training as soon as the child can walk to promote early independence
b) Use punishment techniques to discourage accidents and encourage success
c) Look for signs of readiness such as staying dry for longer periods
d) Expect night-time dryness to occur simultaneously with daytime training
32. Match each nutrient with the appropriate food source that is particularly high in that
nutrient.
Nutrients: Food Sources:
o Iron o Leafy greens and dairy products
o Calcium o Bell peppers and citrus fruits
o Omega-3 fatty acids o Fatty fish and flaxseeds
o Vitamin C o Legumes and red meat
o Fiber o Whole grains and legumes

33. A nurse is teaching a patient newly diagnosed with hypertension about the DASH diet.
Which of the following foods should be limited on this diet?
a) Fresh fruits
b) Low-fat dairy products
c) Processed foods high in sodium
d) Whole grains
34. A nurse is providing education about cancer prevention. Which of the following is the
most modifiable risk factor for multiple types of cancer?
a) Family history
b) Tobacco use
c) Age
d) Gender
35. A parent asks the nurse about appropriate physical activity for their 5-year-old child. The
nurse should recommend:
a) Structured sports training for at least 30 minutes daily
b) At least 60 minutes of active play daily
c) Limiting physical activity to prevent injuries
d) Focus on developing specific athletic skills
36. A nurse is providing guidance to a 45-year-old patient about maintaining bone health.
Which of the following activities best promotes bone density?
a) Swimming laps for 30 minutes
 b) Cycling on flat terrain
c) Walking on a treadmill
d) Yoga and weight-bearing exercises
37. A nurse is providing education about preventing type 2 diabetes. Which of the following
statements indicates the patient understands the teaching? Select all that apply.
a) "I should eliminate all carbohydrates from my diet."
b) "Regular physical activity will help control my weight."
c) "I need to lose at least 5-7% of my body weight if I'm overweight."
d) "I should avoid all sugar to prevent diabetes."
e) "Regular screening is important if I have risk factors."
f) "Diabetes prevention means I need to follow a very low-calorie diet."
38. A nurse is educating a pregnant woman about environmental hazards. Which of the
following should the woman avoid during pregnancy?
a) Microwave cooking
b) Cell phone use
c) Changing cat litter
d) Using household cleaners with gloves
39. A nurse is conducting a developmental assessment of a 12-month-old child. Which of the
following findings indicates potential developmental delay requiring further evaluation?
a) The child does not walk independently
b) The child does not say any recognizable words
c) The child does not respond to their name
d) The child does not feed themselves with a spoon
40. A nurse is providing discharge teaching to a postpartum patient. Which of the following
instructions about exercise after vaginal delivery is most appropriate?
a) Avoid all physical activity for six weeks
b) Resume pre-pregnancy exercise routine after the first week
c) Begin with gentle walking and gradually increase activity
d) Focus on abdominal strengthening exercises
41. A nurse is planning a health education session for adolescents about preventing sexually
transmitted infections. Which teaching strategy would be most effective?
a) Emphasizing abstinence as the only acceptable choice
b) Using peer educators to discuss safe sexual practices
c) Providing detailed information about disease pathophysiology
d) Having parents present during the education session
42. A nurse is teaching a 55-year-old patient about age-appropriate health screenings. Which
screening recommendation is appropriate for this patient? Select all that apply.
 a) Annual mammogram for women
b) Colorectal cancer screening
c) Prostate-specific antigen (PSA) test for men after discussion of risks and benefits
d) Annual chest X-ray
e) Skin examination for suspicious lesions
f) Annual electrocardiogram (ECG)
43. A 30-year-old patient asks about recommendations for physical activity. The nurse's
response should include that healthy adults should engage in:
a) Vigorous aerobic activity for at least 15 minutes daily
b) Light to moderate exercise for 20 minutes, three times weekly
c) Strength training of all major muscle groups at least twice weekly
d) High-intensity interval training daily to maximize cardiovascular benefits
44. A nurse is teaching about the prevention of osteoporosis. When should calcium intake be
optimized to achieve peak bone mass?
a) During childhood and adolescence
b) During pregnancy and lactation
c) Between ages 35-50
d) After menopause
45. A school nurse is assessing a 10-year-old child for signs of puberty. Which finding would
indicate the earliest stage of puberty in a female child?
a) Development of breast buds
b) Growth of pubic hair
c) Onset of menstruation
d) Increase in height
46. A nurse is counseling a patient with a body mass index (BMI) of 28 kg/m². Which of the
following statements about weight management is most appropriate?
a) "You need to lose at least 50 pounds to reach a healthy weight."
b) "Even a modest weight loss of 5-10% can improve health outcomes."
c) "You should follow a very low-calorie diet to achieve rapid weight loss."
d) "You need to eliminate all carbohydrates from your diet to lose weight."
47. A 65-year-old patient has never received the shingles vaccine. According to current
recommendations, the nurse should advise:
a) The vaccine is no longer beneficial after age 60
b) A single dose of the vaccine is sufficient
c) Two doses of the recombinant zoster vaccine given 2-6 months apart
d) Annual vaccination, similar to influenza vaccine
48. A parent asks the nurse about normal gross motor development for a 6-month-old infant.
The nurse should explain that a typical 6-month-old can:
a) Pull to standing position using furniture
b) Roll from back to stomach and stomach to back
c) Walk with one hand held
d) Climb stairs with alternating feet
49. A nurse is providing information about the ABCDE rule for skin cancer detection. Which
feature is represented by the letter "E" in this acronym?
a) Elevation of the skin lesion
b) Evolution or change in the lesion over time
c) Eczema surrounding the lesion
d) Excoriation of the skin around the lesion
50. Place the following events of normal pregnancy in the correct chronological order.
a) Quickening (maternal perception of fetal movement)
b) Fetal heartbeat detectable by Doppler
c) Fertilization and implantation
d) Fetal heartbeat detectable by fetoscope e) Positive pregnancy test (urine hCG)
51. A nurse is counseling a 40-year-old female patient about alcohol consumption. According
to current guidelines, what is the recommended maximum alcohol intake for women to
reduce health risks?
a) No more than 1 drink per day and no more than 7 drinks per week
b) No more than 2 drinks per day and no more than 10 drinks per week
c) No more than 3 drinks per day and no more than 12 drinks per week
d) No more than 4 drinks on any single occasion
52. Identify the area on the image where the nurse should instruct women to begin breast self-
examination.
53. A nurse is teaching about factors that reduce the risk of developing type 2 diabetes. Which
of the following statements is most accurate?
a) "Complete avoidance of all carbohydrates prevents diabetes."
b) "Moderate weight loss can significantly reduce diabetes risk in overweight individuals."
c) "Type 2 diabetes risk is determined solely by genetic factors."
d) "Daily blood glucose monitoring is necessary to prevent diabetes."
54. A nurse is providing nutrition counseling to reduce the risk of neural tube defects. Which
of the following foods is the best natural source of folate?
a) Citrus fruits
b) Dairy products
c) Leafy green vegetables
 d) Lean meats
55. Match each age group with the most appropriate health promotion focus.
Age Groups: Health Promotion Focus:
o Toddlers (1-3 years) o Safety measures and immunizations
o School-age children (6-12 years) o Identity development and risk behavior
o Adolescents (13-18 years) prevention
o Adults (30-50 years) o Chronic disease prevention and stress
o Older adults (65+ years) management
o Fall prevention and medication management
o Physical activity and health education

56. A nurse is teaching a community class on stress management. Which of the following
techniques has the strongest evidence for reducing physiological stress responses?
a) Watching television
b) Regular physical exercise
c) Increased caffeine consumption
d) Working longer hours to complete tasks
57. A primary care nurse is discussing cervical cancer screening with a healthy 35-year-old
woman with no history of abnormal results. The current recommendation for screening
frequency is:
a) Annual Pap test
b) Pap test every 3 years or HPV co-testing every 5 years
c) HPV testing only every 10 years
d) No further screening needed if three consecutive tests are normal
58. A nurse is educating parents about vaccine-preventable diseases. Which of the following
diseases has been successfully eradicated worldwide through vaccination efforts? Select all
that apply.
a) Smallpox
b) Polio
c) Measles
d) Diphtheria
e) Rubella
f) Tetanus
59. A nurse is developing a health promotion plan for a 70-year-old patient with osteoarthritis.
Which of the following exercises would be most appropriate to recommend?
a) High-impact aerobics
 b) Long-distance running
c) Water-based exercise program
d) Competitive sports
60. A nurse is counseling an expectant mother about breastfeeding. Which of the following
statements about the benefits of breastfeeding is accurate?
a) Breastfeeding guarantees that the infant will not develop allergies
b) Formula-fed babies gain developmental milestones faster than breastfed babies
c) Breastfeeding reduces the mother's risk of breast and ovarian cancer
d) Breastfed infants never experience digestive issues such as colic
61. A nurse is educating a pregnant woman about nutrition during pregnancy. The
recommended daily folic acid intake for pregnant women is ________ micrograms.
62. A nurse is providing discharge instructions to parents of a newborn. According to the
American Academy of Pediatrics, the safest position for infant sleep is:
a) Side-lying position
b) Prone position
c) Supine position
d) Semi-Fowler's position
63. A nurse is counseling a patient about methods to help quit smoking. Which of the
following smoking cessation aids requires a prescription? Select all that apply.
a) Nicotine gum
b) Varenicline (Chantix)
c) Nicotine patches
d) Bupropion (Zyban)
e) Nicotine lozenges
f) Nicotine nasal spray
64. A nurse is teaching parents about developmental milestones. The typical age when most
children begin to use a mature pincer grasp (thumb and forefinger) to pick up small objects
is ________ months.
65. A nurse is providing education about non-pharmacological pain management techniques.
Which technique is based on the stimulation of specific points along energy pathways?
a) Guided imagery
b) Acupressure
c) Progressive muscle relaxation
d) Biofeedback
66. The nurse is teaching a patient with hypertension about the DASH diet. The maximum
recommended daily sodium intake on this diet is ________ milligrams.
67. A nurse in a pediatric clinic is preparing to administer immunizations to a 4-year-old child.
Place the following interventions in the order they should be implemented to minimize the
child's distress.
a) Apply a topical anesthetic to the injection sites
b) Distract the child during the injections
c) Explain the procedure using age-appropriate language
d) Position the child securely on the parent's lap
e) Administer the most painful vaccine last
68. A school nurse is conducting vision screening for first-grade students. A child is considered
to have failed the screening if visual acuity is worse than:
a) 20/30
b) 20/40
c) 20/50
d) 20/70
69. A nurse is teaching about risk factors for cardiovascular disease. Which of the following is
considered a major modifiable risk factor for cardiovascular disease?
a) Age
b) Family history
c) Hypertension
d) Gender
70. A nurse is teaching a pregnant woman about the importance of prenatal visits. The
recommended schedule for prenatal visits during an uncomplicated pregnancy includes
visits every ________ weeks during the first and second trimesters.
71. A nurse is providing guidance on childhood obesity prevention. Identify the area on the
image where parents should focus their attention when reading food labels to make
healthier choices.
72. A 25-year-old female patient asks about the HPV vaccine. The nurse explains that the
maximum age for routine HPV vaccination recommendation is:
a) 18 years
b) 21 years
c) 26 years
d) 45 years
73. A nurse is teaching a patient with a family history of skin cancer about prevention
strategies. Which of the following statements about sunscreen is accurate?
a) SPF 30 blocks twice as many UV rays as SPF 15
b) Sunscreen should be applied immediately before sun exposure
c) A water-resistant sunscreen remains effective for up to 80 minutes while swimming
 d) One application of sunscreen provides protection for an entire day outdoors
74. Match each vitamin with its primary function in the body.
Vitamins: Functions:
o Vitamin A o Blood clotting
o Vitamin C o Collagen formation and iron absorption
o Vitamin D o Bone health and calcium absorption
o Vitamin E o Vision and immune function
o Vitamin K o Antioxidant protection of cells

75. A nurse is counseling a patient about healthy sleep habits. The recommended amount of
sleep for adults is ________ hours per night.
76. A nurse is conducting a health assessment of a 16-year-old adolescent. Which of the
following screening tools is specifically designed to identify substance abuse in adolescents?
a) PHQ-9
b) CRAFFT
c) CAGE
d) AUDIT
77. A nurse is providing anticipatory guidance to parents of a 4-year-old child. Which of the
following safety recommendations is most appropriate? Select all that apply.
a) Using a booster seat in the car
b) Allowing the child to ride a bicycle without a helmet on quiet streets
c) Teaching the child how to swim
d) Storing cleaning products in a locked cabinet
e) Allowing the child to use the stove with supervision
f) Teaching the child how to cross the street safely
78. A nurse is discussing exercise recommendations with a pregnant patient in her second
trimester. In the absence of contraindications, pregnant women should engage in
moderate-intensity physical activity for at least ________ minutes per week.
79. A nurse is providing education about oral health. The recommended frequency for
replacing a toothbrush is every:
a) 1-2 months
b) 3-4 months
c) 6 months
d) 12 months
80. A nurse is conducting a health history with a 55-year-old male patient. Which of the
following questions would be most appropriate for assessing the patient's prostate health?
 a) "Do you have a family history of prostate cancer?"
b) "Have you noticed any changes in your urinary pattern?"
c) "Do you perform monthly testicular self-examinations?"
d) "Have you experienced any rectal bleeding?"
81. A patient diagnosed with major depressive disorder tells the nurse, "I'm such a burden to
everyone. My family would be better off without me." The nurse's most appropriate
response is:
a) "You have so much to live for. Think about your family."
b) "Are you having thoughts of hurting yourself?"
c) "Everyone feels down sometimes. It will get better."
d) "I'll let your doctor know you're feeling this way."
82. A nurse is caring for a patient who is experiencing anxiety prior to surgery. Which of the
following non-pharmacological interventions would be most appropriate? Select all that
apply.
a) Deep breathing exercises
b) Providing detailed information about surgical complications
c) Guided imagery
d) Limiting visitors
e) Progressive muscle relaxation
f) Telling the patient not to worry
83. A nurse is admitting a patient with bipolar disorder who is experiencing mania. Which of
the following assessment findings would the nurse expect to observe? Select all that apply.
a) Decreased need for sleep
b) Slowed psychomotor activity
c) Rapid, pressured speech
d) Flight of ideas
e) Flat affect
f) Grandiose delusions
84. A nurse is caring for a patient experiencing alcohol withdrawal. The priority nursing
intervention is to:
a) Encourage the patient to attend an Alcoholics Anonymous meeting
b) Provide a quiet, dimly lit environment with minimal stimulation
c) Administer benzodiazepines as prescribed
d) Restrict visitors to reduce emotional stress
85. A patient tells the nurse, "I'm hearing voices telling me to harm myself." The nurse's initial
response should be:
a) "That must be very frightening for you."
 b) "Can you describe what the voices are saying?"
c) "Do the voices tell you specific ways to harm yourself?"
d) "Are you currently having thoughts of harming yourself?"
86. A nurse is caring for a patient who has been diagnosed with post-traumatic stress disorder
(PTSD). Which intervention would be most appropriate to include in the care plan?
a) Encouraging the patient to avoid discussing the traumatic event
b) Teaching grounding techniques to use during flashbacks
c) Suggesting the patient watch movies about similar traumatic events
d) Recommending the patient focus on forgetting what happened
87. The nurse observes that a patient has been isolating in their room, refusing to attend group
therapy sessions. The most therapeutic approach would be to:
a) Insist that the patient attend group sessions to comply with the treatment plan
b) Inform the patient that privileges will be restricted if they don't participate
c) Document the patient's non-compliance and wait for their readiness to engage
d) Spend time with the patient to explore reasons for not wanting to attend
88. A nurse is assessing a patient with anorexia nervosa. Which of the following physical
findings would the nurse expect to observe?
a) Hypertension
b) Bradycardia
c) Elevated body temperature
d) Increased bowel sounds
89. A nurse is providing care for a patient who has been diagnosed with schizophrenia. The
patient refuses to eat, stating, "The food is poisoned." The most appropriate nursing
intervention is to:
a) Explain that the food is not poisoned and encourage the patient to eat
b) Allow the patient's family to bring food from home
c) Offer to eat a small portion of the food to demonstrate it is safe
d) Document the refusal and notify the healthcare provider
90. Identify the statements that indicate a patient is using a defense mechanism. Place each
statement next to the corresponding defense mechanism.
 Statements: Defense Mechanisms:
o "I didn't get the promotion because my boss hates me, not o Denial
because of my performance." o Displacement
o "I'm not angry at my spouse; I'm just irritated with my
o Projection
coworker."
o "I know the diagnosis is serious, but everything will be fine."
o Repression
o "I forgot all about my appointment with the therapist." o Rationalization
o "I'm not afraid of needles; they just make me feel
uncomfortable."
91. A nurse is caring for a patient who is experiencing a panic attack. The priority nursing
intervention is to:
a) Administer an antipsychotic medication
b) Place the patient in a quiet room with minimal stimulation
c) Stay with the patient and maintain a calm, reassuring approach
d) Contact the patient's family members for support
92. The therapeutic communication technique that encourages a patient to elaborate on a topic
is:
a) Reflecting
b) Asking why questions
c) Giving advice
d) Using open-ended questions
93. A nurse is caring for a patient who has been diagnosed with obsessive-compulsive disorder
(OCD). The patient spends 3 hours each morning performing hand-washing rituals. The
most appropriate initial nursing intervention is to:
a) Prevent the patient from washing their hands more than once
b) Acknowledge the patient's anxiety and provide support during rituals
c) Tell the patient that excessive hand-washing is irrational
d) Distract the patient when they attempt to perform rituals
94. A nurse suspects a patient may be experiencing domestic violence. The most appropriate
screening question would be:
a) "Does your partner ever hit you when they get angry?"
b) "Why do you stay in a relationship that is harmful to you?"
c) "Do you feel safe in your current relationship?"
d) "Have you considered leaving your abusive partner?"
95. A 16-year-old patient is exhibiting signs of substance abuse. The nurse knows that
adolescents who abuse substances frequently exhibit which of the following behaviors?
Select all that apply.
a) Declining academic performance
 b) Changes in peer group
c) Increased interest in family activities
d) Mood swings
e) Improved personal hygiene
f) Secrecy about activities and whereabouts
96. The nursing intervention most likely to be effective for a patient experiencing delusions is:
a) Arguing with the patient about the false belief
b) Validating the emotional content without reinforcing the delusion
c) Agreeing with the delusion to gain the patient's trust
d) Challenging the logic of the patient's belief system
97. A nurse is caring for a patient who has attempted suicide. Upon assessment, what is the
most important information for the nurse to obtain?
a) The patient's current level of suicidal ideation and plan
b) Whether the family has a history of mental illness
c) The patient's religious beliefs about suicide
d) Whether the patient has medical insurance for psychiatric treatment
98. A family member of a patient with schizophrenia asks about the genetic risk for their
children. The nurse's best response would be:
a) "Schizophrenia is directly inherited, so your children will develop the disorder."
b) "There is no genetic component to schizophrenia; it's caused by environmental factors."
c) "Schizophrenia has both genetic and environmental factors, but having a relative with
the disorder increases risk."
d) "You should consider genetic testing before having children to determine their risk."
99. A nurse is caring for a patient experiencing grief after the death of a spouse. Which
statement by the patient indicates complicated grief requiring additional intervention?
a) "I still think about my spouse every day after six months."
b) "I've started volunteering at the hospital where my spouse died."
c) "I've kept everything exactly as it was when my spouse was alive. Nothing can be
moved."
d) "Some days are better than others, but holidays are especially difficult."
100. A nurse is developing a care plan for a patient with generalized anxiety disorder.
What is the most appropriate nursing diagnosis?
a) Ineffective coping related to inadequate psychological resources
b) Anxiety related to threat to self-concept
c) Social isolation related to altered thought processes
d) Disturbed sleep pattern related to psychological stress
C. Psychosocial Integrity
1. A client diagnosed with major depressive disorder states, "Nothing matters anymore. I just
want it all to end." Which nursing intervention has the highest priority? A. Encourage the
client to participate in unit activities B. Complete a suicide risk assessment C. Administer
prescribed antidepressant medication D. Contact the client's family members for support
2. A nurse is caring for a client who has been diagnosed with schizophrenia and is
experiencing auditory hallucinations. The client states, "The voices are telling me to hurt
myself." Which response by the nurse would be most therapeutic? A. "Try to ignore the
voices; they aren't real." B. "I understand you're hearing voices. I don't hear them, but I
believe that you do. Let's focus on keeping you safe." C. "Let's talk about something else
to distract you from those thoughts." D. "The medication should start working soon to
make the voices go away."
3. A client with generalized anxiety disorder is using deep breathing techniques to manage
symptoms. Which of the following observations would indicate that the technique is
effective? Select all that apply. A. Decreased respiratory rate B. Decreased blood pressure
C. Dilated pupils D. Increased concentration E. Increased muscle tension
4. During a group therapy session, a client shares feelings of worthlessness and hopelessness.
The other group members sit silently. Which action by the nurse group leader would be
most appropriate? A. Acknowledge the client's feelings and encourage group discussion B.
Change the topic to something more positive C. Suggest the client discuss these feelings
privately with their psychiatrist D. Allow the silence to continue until someone else speaks
5. A nurse is assessing a client who has been admitted following a sexual assault. Which of
the following nursing interventions should receive priority? A. Teaching coping strategies
B. Encouraging the client to talk about the experience C. Providing for physical and
psychological safety D. Administering prescribed anxiolytic medication
6. A client is admitted to the psychiatric unit with symptoms of alcohol withdrawal. The nurse
observes that the client is diaphoretic, tremulous, and reports seeing spiders on the wall.
The client's vital signs are BP 168/94, HR 112, RR 24, and temperature 38.1°C. Arrange
the following nursing interventions in order of priority: A. Administer prescribed
benzodiazepine B. Place the client in a quiet, well-lit room C. Reorient the client to reality
D. Monitor vital signs every 15 minutes E. Assess for seizure activity
7. During an initial assessment, a client states, "I've been using cocaine for about five years,
but I can stop anytime I want." Which stage of change is the client demonstrating? A.
Precontemplation B. Contemplation C. Preparation D. Action
8. A 16-year-old client is admitted with anorexia nervosa. The client's BMI is 16.2. Which
nursing intervention is most appropriate? A. Allow the client to choose their own meals to
 promote autonomy B. Implement a behavioral contract regarding expected weight gain C.
Restrict physical activity and monitor during and after meals D. Focus primarily on positive
body image education
9. A nurse is caring for a client who has recently been diagnosed with terminal cancer. The
client states, "This can't be happening to me. The doctors must have mixed up my test
results." Which stage of grief is the client experiencing? A. Denial B. Anger C. Bargaining
D. Depression
10. The nurse is participating in a crisis intervention for a community following a natural
disaster. Which of the following represents an appropriate tertiary prevention strategy? A.
Distributing information about normal reactions to trauma B. Offering psychological first
aid at evacuation centers C. Providing long-term counseling for those with persistent
symptoms D. Screening for high-risk individuals
11. A client with bipolar disorder in the manic phase is demonstrating hyperactive behavior,
rapid speech, and grandiose thinking. Which nursing intervention would be most effective
in managing this client's current symptoms? A. Encouraging participation in stimulating
group activities B. Providing a quiet environment with minimal stimulation C. Engaging
the client in complex problem-solving tasks D. Allowing the client to lead unit activities
12. A nurse is conducting an assessment on a client with suspected post-traumatic stress
disorder (PTSD). Identify the area on the image below where the nurse should click to
indicate the part of the brain most associated with the fear response in PTSD. [IMAGE:
Brain cross-section showing hippocampus, amygdala, prefrontal cortex, and cerebellum]
13. A client who has been in therapy for depression states, "I've been thinking that maybe my
problems aren't all my fault." This statement most clearly represents progress in which
therapeutic area? A. Development of insight B. Medication compliance C. Symptom
management D. Social skills training
14. A nurse is assessing a client who reports "feeling down" for the past month following the
death of a spouse. Which of the following assessment findings would indicate normal grief
rather than complicated grief or depression? A. Persistent inability to accept the death after
six months B. Waves of sadness that come and go, with periods of positive memories C.
Preoccupation with feelings of worthlessness D. Suicidal ideation with a specific plan
15. A nurse is facilitating a therapy group for clients with substance use disorders. Which of
the following group norms would be most important to establish first? A. Maintaining
confidentiality B. Starting and ending on time C. Active participation by all members D.
Completion of homework assignments
16. The parents of a 14-year-old client with oppositional defiant disorder ask the nurse how
they should respond when their child refuses to follow household rules. Which response
by the nurse is most appropriate? A. "You should remove all privileges until the behavior
 improves." B. "Try to understand that this is just a phase that will pass with time." C. "Set
clear, consistent consequences and follow through while acknowledging positive
behaviors." D. "Consider a more strict parenting approach to establish your authority."
17. A nurse observes that a client diagnosed with paranoid schizophrenia is sitting alone,
appears suspicious, and refuses to eat hospital food. Which approach would be best to use
initially with this client? A. Explain that all hospital food is prepared under strict safety
guidelines B. Offer prepackaged food options and gradually build trust C. Insist that the
client eat to maintain nutritional status D. Recommend an order for nutritional
supplements
18. A nurse is working with a client who has social anxiety disorder. The client consistently
avoids social situations and reports intense fear of embarrassment. Which cognitive
distortion is this client most likely experiencing? A. Catastrophizing B. All-or-nothing
thinking C. Mind reading D. Emotional reasoning
19. The nurse is assessing a client who reports using multiple substances, including alcohol,
marijuana, and opioids. Which assessment finding would indicate the need for immediate
medical intervention? A. Reports of insomnia and irritability B. Pupil constriction and
drowsiness C. Respiratory rate of 8 breaths per minute D. Expressed desire to discontinue
substance use
20. A client who survived a serious car accident three weeks ago reports nightmares,
hypervigilance, and avoiding driving. The nurse recognizes these as symptoms of acute
stress disorder. Which statement by the client would indicate a positive coping mechanism?
A. "I'm increasing my alcohol intake to help me sleep through the night." B. "I've been
talking with a support group of other accident survivors." C. "I've decided never to ride in
a car again to stay safe." D. "I'm keeping busy with work to avoid thinking about what
happened."
21. A client with borderline personality disorder threatens self-harm after learning their
primary nurse will be on vacation for a week. Which response by the nurse is most
therapeutic? A. "You're only saying that to get attention." B. "I understand you're upset
about my absence. Let's discuss coping strategies you can use during this time." C. "I'll ask
if I can delay my vacation if that will help you." D. "You've made progress in therapy; you
should be able to handle this separation."
22. The nurse is providing care for a client who has been diagnosed with schizophrenia. The
client states, "The government has implanted a device in my brain to monitor my
thoughts." Which response is most appropriate? A. "That's not possible. No one can
monitor your thoughts." B. "I don't believe that's true, but I understand you're concerned
about your privacy." C. "Let's talk about something else more positive." D. "I understand
that feels real to you. How does having these thoughts make you feel?"
23. A nurse is leading a stress management group and is teaching progressive muscle
relaxation. Place the following steps in the correct sequence: A. Tense the muscles in the
feet B. Release the tension in the feet C. Provide instruction on deep breathing D. Ask
clients to identify areas of tension E. Move progressively up the body
24. A client recovering from alcohol use disorder states, "I can probably have one beer at my
brother's wedding. I've been sober for six months." Which nursing response is most
appropriate? A. "One beer probably won't hurt as long as you stop there." B. "You should
avoid your brother's wedding altogether to prevent relapse." C. "Let's discuss the risks of
that decision and explore alternatives for celebrating without alcohol." D. "You shouldn't
even consider drinking again after all your hard work."
25. A nurse is planning care for a 67-year-old client who was recently widowed and reports
difficulty sleeping, decreased appetite, and feeling "empty." The client attends church
regularly and mentions that faith has always been important. Which nursing intervention
would be most appropriate to include in the plan of care? A. Recommend the client start
antidepressant medication immediately B. Suggest the client move in with adult children
for support C. Encourage the client to connect with their religious community for support
D. Advise the client to focus on hobbies rather than dwelling on their loss
26. A nurse observes a 15-year-old client in an inpatient psychiatric unit exhibiting self-
harming behavior by scratching their arms. Which of the following represents the best
initial nursing intervention? A. Immediately apply restraints to prevent further self-harm
B. Approach calmly, assess safety, and engage the client in conversation about their feelings
C. Inform the client that privileges will be restricted if the behavior continues D. Call for
additional staff to help manage the situation
27. A client who experienced a traumatic event one month ago reports nightmares, flashbacks,
and avoiding situations that remind them of the trauma. The nurse recognizes these
symptoms may be consistent with which diagnosis? A. Adjustment disorder B. Major
depressive disorder C. Post-traumatic stress disorder D. Acute stress disorder
28. The nurse is caring for a client with severe anxiety who is experiencing a panic attack.
Which of the following interventions should the nurse implement first? A. Administer
PRN anxiolytic medication B. Guide the client through slow, deep breathing exercises C.
Remove the client from stimulating environments D. Encourage the client to identify the
triggers of the panic attack
29. A client with antisocial personality disorder becomes argumentative with staff members
after being denied a special request. Which approach would be most effective in managing
this situation? A. Explain that the behavior is inappropriate and must stop immediately B.
Set clear limits while remaining calm and non-confrontational C. Allow the client to
 continue expressing feelings to prevent escalation D. Call for security personnel to
demonstrate consequences
30. A nurse is caring for a client who is experiencing hallucinations. Which of the following
assessment questions would provide the most useful information about the hallucinations?
Select all that apply. A. "What voices are you hearing right now?" B. "Do you always have
these hallucinations when you feel stressed?" C. "Are the hallucinations telling you to harm
yourself or others?" D. "Can you identify what makes the hallucinations better or worse?"
E. "Do you believe these hallucinations are real?"
31. The family of a client with moderate dementia reports that the client becomes agitated and
combative during evening hours. Which nursing intervention would be most appropriate
to include in the care plan? A. Administer PRN antipsychotic medication at the first sign
of agitation B. Implement a structured routine with calming activities during peak periods
of sundowning C. Minimize all stimulation by keeping the client in a quiet room during
evening hours D. Use mild restraints during evening hours to prevent injury
32. A client attends group therapy and remains silent throughout the session. Which nursing
intervention would be most appropriate? A. Ask the client direct questions to encourage
participation B. Respect the client's silence while offering opportunities to contribute C.
Suggest the client might benefit more from individual therapy D. Require verbal
participation as a condition of remaining in the group
33. A client with depression has been prescribed sertraline (Zoloft). Which of the following
statements by the client indicates understanding of the medication teaching? A. "I should
start feeling better within 2-3 days after starting the medication." B. "I can stop taking the
medication once I start feeling better." C. "I should avoid alcohol while taking this
medication." D. "If I miss a dose, I should take double the amount the next day."
34. A nurse is planning care for a client with anorexia nervosa who has a BMI of 17.1. Which
of the following outcomes would be most appropriate to prioritize initially? A. Client will
verbalize positive statements about body image B. Client will identify distorted thoughts
about food and weight C. Client will maintain adequate nutritional intake to support weight
restoration D. Client will demonstrate healthy coping mechanisms when feeling anxious
35. A client is brought to the emergency department after a suicide attempt. After medical
stabilization, the nurse conducts a risk assessment. Which of the following factors would
indicate the highest risk for a future suicide attempt? A. The client has a history of previous
suicide attempts B. The client reports current financial problems C. The client lives alone
D. The client has been diagnosed with depression
36. A nurse is facilitating a group therapy session for clients with substance use disorders. One
client dominates the conversation and frequently interrupts others. Which intervention by
the nurse would be most appropriate? A. Ask the client to leave the group to maintain a
 therapeutic environment B. Ignore the behavior to avoid confrontation in the group setting
C. Address the behavior privately with the client after the session D. Tactfully redirect by
acknowledging the client's input and inviting others to share
37. A nurse is caring for a client experiencing psychosis who refuses to take prescribed
medication. Which approach would be most appropriate initially? A. Request an order for
injectable antipsychotic medication B. Explore the client's concerns about medication and
provide education C. Inform the client that medication can be court-ordered if necessary
D. Ask family members to convince the client to take the medication
38. A nurse is planning care for a client with bulimia nervosa. Which nursing intervention
addresses the core psychological issue underlying this disorder? A. Monitoring for
electrolyte imbalances B. Observing for 30 minutes after meals C. Exploring issues related
to control, self-esteem, and body image D. Maintaining a food diary to track intake
39. An older adult client who recently moved to a long-term care facility reports feeling
"useless" and "like a burden." Which nursing intervention would be most therapeutic in
addressing these feelings? A. Encourage reminiscence and life review B. Suggest the client
focus on making new friends C. Reassure the client that everyone feels this way at first D.
Recommend increased visits from family members
40. A client with bipolar disorder who is experiencing a manic episode approaches the
medication window but then becomes suspicious and refuses medication. The client states,
"You're trying to poison me." Which approach by the nurse would be most effective? A.
"You need to take your medication as prescribed by your doctor." B. "I can see you're
concerned about the medication. Can you tell me more about your concerns?" C. "I'll need
to inform your doctor that you're refusing your medication." D. "Would you prefer to take
your medication later when you feel more comfortable?"
41. A nurse is caring for a client with obsessive-compulsive disorder (OCD) who spends three
hours each morning performing hand-washing rituals. Which therapeutic approach would
be most appropriate for helping this client? A. Preventing the client from washing their
hands to break the cycle B. Providing gloves to protect skin integrity while allowing the
ritual C. Implementing exposure and response prevention techniques D. Encouraging the
client to substitute another activity for hand washing
42. A 72-year-old client is admitted to the hospital following a stroke that has left them with
partial paralysis. The client states, "I'm useless now. My family would be better off without
me." Which response by the nurse would be most therapeutic? A. "Don't say that. You
have a lot to live for." B. "I'm concerned about what you're saying. Are you having thoughts
of harming yourself?" C. "Your family loves you and wouldn't feel that way at all." D. "This
is just temporary. You'll feel better once rehabilitation starts."
43. A nurse is caring for a client with schizophrenia who has been experiencing command
hallucinations. Which assessment finding would require immediate intervention? A. The
client reports hearing voices that criticize their appearance B. The client states the voices
are telling them to harm staff C. The client appears distracted during conversation D. The
client believes the television is sending special messages
44. During a psychiatric emergency, a client becomes physically aggressive toward staff. After
the situation is safely managed, which of the following represents the nurse's priority? A.
Documenting the incident in detail B. Processing the event with the client when calm C.
Notifying security to increase unit surveillance D. Administering PRN medication to
prevent recurrence
45. A client who recently experienced a miscarriage at 16 weeks gestation tells the nurse, "I
keep hearing my baby crying at night." Which response by the nurse is most appropriate?
A. "That must be very distressing. Would you like to talk more about your experience?" B.
"I'll request an order for a sleep medication to help you rest better." C. "These auditory
hallucinations indicate you need a psychiatric evaluation." D. "Try to keep busy during the
day so you'll be too tired to think about it at night."
46. A nurse is conducting a group for clients with eating disorders. Which therapeutic factor
would be most important to emphasize in the early stages of the group? A. Catharsis B.
Universality C. Interpersonal learning D. Installation of hope
47. A client with anxiety reports using benzodiazepines obtained from a family member.
Which statement by the nurse provides accurate information about this practice? A. "Using
family members' medications is acceptable as long as the symptoms are similar." B.
"Benzodiazepines are safe to use occasionally without a prescription." C. "Using
unprescribed benzodiazepines can be dangerous due to potential interactions with other
medications and risk of dependence." D. "You should continue using the medication until
you can get your own prescription."
48. The nurse is assessing a client with major depressive disorder who has started taking
sertraline (Zoloft) one week ago. The client reports no improvement in symptoms. Which
response by the nurse is most appropriate? A. "We should request that your doctor switch
you to a different medication." B. "Let's discuss doubling your dose to see faster results."
C. "It usually takes 2-4 weeks before you'll notice the full benefits of this medication." D.
"Perhaps depression medication isn't right for your condition."
49. A nurse is developing a care plan for a client with a history of physical abuse. The client
becomes anxious when unfamiliar male staff enter the room. Which nursing intervention
should be included in the care plan? A. Assign only female staff to care for the client B.
Gradually introduce male staff members with the client's permission C. Teach the client
 that not all men are abusive D. Administer PRN anxiolytic medication before male staff
interactions
50. A nurse is conducting an assessment on a client with suspected depression. From the
screening tools below, select the one most appropriate for initial depression screening in a
general adult population. A. Hamilton Rating Scale for Depression (HAM-D) B. Beck
Depression Inventory (BDI) C. Patient Health Questionnaire-9 (PHQ-9) D. Children's
Depression Inventory (CDI)
51. A client with post-traumatic stress disorder (PTSD) is using guided imagery for symptom
management. During a session, the client becomes increasingly agitated and
hyperventilates. Which nursing action would be most appropriate initially? A. Stop the
guided imagery immediately and implement grounding techniques B. Continue with the
guided imagery to work through the traumatic memory C. Administer PRN anxiolytic
medication D. Encourage the client to discuss the traumatic event in detail
52. A nurse has been caring for a client with borderline personality disorder for several weeks.
The client gives the nurse an expensive gift and says, "You're the only one who really
understands me." Which response by the nurse is most appropriate? A. "Thank you for
the kind gesture, but I cannot accept expensive gifts as it would be unethical." B. "I
appreciate your thanks, but helping you is just part of my job." C. "Your progress is the
best gift you could give me." D. "Giving gifts to staff could be a sign of your fear of
abandonment."
53. The nurse is caring for a client who has been diagnosed with anorexia nervosa. Which of
the following cognitive distortions is most common in clients with this disorder? A.
Personalization B. Catastrophizing C. All-or-nothing thinking D. Mind reading
54. A nurse is planning care for a client with alcohol use disorder who is currently in
detoxification. Which of the following nursing diagnoses would have the highest priority?
A. Risk for Injury related to altered sensory perception B. Disturbed Sleep Pattern related
to anxiety C. Ineffective Coping related to denial of problem D. Imbalanced Nutrition:
Less Than Body Requirements related to poor intake
55. A client with bipolar disorder has been stable on lithium therapy for two years. Which
laboratory value would be most important for the nurse to monitor regularly? A. Complete
blood count B. Liver function tests C. Serum lithium level D. Thyroid function tests
56. A nurse is leading a stress management session and is teaching the "4-7-8" breathing
technique. Place the following instructions in the correct sequence: A. Hold the breath for
a count of 7 B. Exhale completely through the mouth C. Inhale quietly through the nose
for a count of 4 D. Exhale with a whooshing sound for a count of 8 E. Close the lips and
inhale through the nose
57. A nurse is caring for a client who has been admitted following a suicide attempt. Upon
entering the client's room, the nurse notices the client attempting to hide objects under the
bed covers. Which action should the nurse take first? A. Confront the client about hiding
potentially dangerous items B. Immediately search the bed without discussing it with the
client C. Ask another staff member to stay with the client while obtaining assistance D.
Respect the client's privacy and leave the room
58. A client with social anxiety disorder is preparing for a job interview. Which cognitive-
behavioral strategy would be most helpful for the nurse to teach? A. Systematic
desensitization B. Thought stopping C. Cognitive restructuring D. Operant conditioning
59. A nurse is working in a substance abuse treatment facility. Which statement by a client
indicates understanding of the concept of enabling? A. "My spouse kept giving me money
even though they knew I would spend it on drugs." B. "My family encouraged me to attend
treatment after my DUI." C. "My friends stopped inviting me to events where alcohol
would be served." D. "My parents set clear boundaries about not using substances in their
home."
60. A client with generalized anxiety disorder states, "I feel like something terrible is going to
happen to my family while I'm in the hospital." The nurse recognizes this as which type of
cognitive distortion? A. Fortune telling B. Labeling C. Minimization D. Emotional
reasoning
61. A nurse is assessing a client with schizophrenia who states, "The CIA has implanted a
microchip in my tooth that's broadcasting my thoughts." This statement is an example of
a: A. Hallucination B. Delusion C. Illusion D. Loose association
62. The nurse is caring for a client experiencing acute alcohol withdrawal. During assessment,
the client reports seeing insects crawling on the wall. This symptom is most consistent
with: A. Delirium tremens B. Korsakoff's syndrome C. Alcoholic hallucinosis D.
Wernicke's encephalopathy
63. A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder, manic
episode. The priority nursing intervention for this client would be to: A. Encourage
participation in group activities B. Provide a highly stimulating environment C. Establish
a structured, low-stimulation routine D. Allow the client to direct their own care
64. A client with depression who has been taking fluoxetine (Prozac) for three weeks tells the
nurse, "I've been feeling more energetic lately, and I finally feel like I can solve all my
problems." The nurse should: A. Document that the medication is having the desired effect
B. Assess for suicidal ideation, as increased energy may increase suicide risk C. Recommend
that the physician increase the medication dosage D. Suggest that the client begin
psychotherapy since they're feeling better
65. A hospice nurse is caring for a client in the terminal stage of cancer. The client's spouse
states, "I don't know how I'll go on without them." Which response by the nurse would
be most therapeutic? A. "You need to be strong for your family." B. "Tell me more about
what you're feeling right now." C. "Many people feel that way at first, but it gets better with
time." D. "Have you considered joining a support group after your spouse passes?"
66. A nurse is conducting an admission assessment for a client with anorexia nervosa. Fill in
the blank with the physiological adaptation that would most likely be observed in this
client.
The nurse would expect to find ________________ as a compensatory mechanism for
chronic malnutrition.
67. A client with post-traumatic stress disorder (PTSD) is practicing mindfulness meditation.
Which statement by the client indicates understanding of this technique? A. "I focus on
blocking out all thoughts about my trauma." B. "I practice replacing negative thoughts with
positive ones." C. "I notice my thoughts and feelings without judgment." D. "I imagine
myself in a safe place away from triggers."
68. A nurse is implementing therapeutic communication techniques with a client who has
depression. Fill in the blank with the most appropriate technique to use when the client
makes vague statements about their symptoms.
When the client states, "Things just aren't right," the nurse should use ________________
to gather more specific information about the client's experience.
69. A client with obsessive-compulsive disorder (OCD) has been prescribed clomipramine
(Anafranil). The nurse should monitor this client for which side effect that is most
concerning with tricyclic antidepressants? A. Hypertension B. Cardiac arrhythmias C.
Increased appetite D. Photosensitivity
70. During a home visit, a nurse assesses an older adult client who has been caring for their
spouse with Alzheimer's disease for the past five years. Which assessment finding would
most strongly indicate caregiver role strain? A. The caregiver mentions feeling tired
occasionally B. The caregiver has hired additional help twice weekly C. The caregiver
reports significant weight loss and insomnia D. The caregiver expresses frustration with
the healthcare system
71. A client is experiencing intense anxiety during a panic attack. Select the zones on the image
that correspond to the body areas where the nurse would expect to assess signs of
sympathetic nervous system activation during the panic attack.
72. The nurse is providing education to a client about managing symptoms of PTSD. Fill in
the blank with the appropriate coping strategy for the described situation.
When the client begins to experience flashbacks, the most effective immediate intervention
would be to use ________________ techniques to reconnect with the present moment.
73. A client with schizophrenia who takes risperidone (Risperdal) tells the nurse, "My muscles
feel stiff, and I can't stop moving my legs." The nurse recognizes these symptoms as: A.
Expected side effects that will diminish over time B. Signs of neuroleptic malignant
syndrome C. Extrapyramidal side effects requiring intervention D. Symptoms of
medication withdrawal
74. A nurse is caring for a client who has been admitted to the psychiatric unit after a suicide
attempt. Which client statement would indicate the highest ongoing suicide risk? A. "I feel
embarrassed about what I did." B. "I'm still sad, but I don't want to die anymore." C. "I've
let my family down by not succeeding." D. "I want to work on my depression now."
75. The nurse is conducting a family session with parents of an adolescent with an eating
disorder. Fill in the blank with the most appropriate therapeutic principle to guide this
intervention.
When working with the family, the nurse should emphasize that the most important
approach is ________________, which prevents reinforcing the eating disorder behaviors
while supporting recovery.
76. A client with generalized anxiety disorder is learning progressive muscle relaxation. Place
the following steps in the correct sequence for teaching this technique: A. Have the client
identify areas of tension in the body B. Guide the client to relax muscles completely C.
Instruct the client to tense specific muscle groups D. Teach the client to focus on the
contrast between tension and relaxation E. Begin with deep breathing exercises
77. A client with a history of sexual abuse becomes visibly anxious during a physical
examination. Which nursing intervention would be most appropriate? A. Proceed quickly
with the examination to minimize discomfort B. Ask another nurse to complete the
examination C. Offer to pause, explain each step, and obtain ongoing consent D. Suggest
rescheduling the examination for another day
78. A nursing student asks the instructor about the key difference between delusions and
overvalued ideas. Fill in the blank with the most accurate distinction.
Unlike delusions, overvalued ideas are characterized by ________________, which makes
them potentially more responsive to cognitive interventions.
79. A nurse is facilitating a group therapy session for clients with substance use disorders. The
group is in the working stage. Which of the following would be most characteristic of this
stage of group development? A. Members questioning the purpose and value of the group
B. Deep exploration of personal issues and constructive feedback between members C.
Polite interactions with minimal self-disclosure D. Concerns about the group ending and
fears of managing without group support
80. A client with bipolar disorder states, "Sometimes I get so happy I max out all my credit
cards and don't sleep for days, and other times I can barely get out of bed." The nurse
 identifies this symptom pattern as characteristic of which type of bipolar presentation? A.
Bipolar I disorder B. Bipolar II disorder C. Cyclothymic disorder D. Rapid cycling bipolar
disorder
81. A nurse is caring for a 17-year-old client admitted after a suicide attempt. The parents state,
"We had no idea our child was depressed. They always seemed happy around us." Which
assessment findings would most likely be present in an adolescent with masked depression?
Select all that apply. A. Declining academic performance B. Increased risk-taking behaviors
C. Somatic complaints without medical cause D. Expressed feelings of hopelessness E.
Social withdrawal from peers
82. A client with a history of trauma reports using alcohol to help with sleep and anxiety. The
nurse recognizes this as: A. A healthy coping mechanism B. Self-medication C. Substance-
induced anxiety D. Dual diagnosis
83. The nurse is planning care for a client experiencing an acute episode of schizophrenia with
disorganized thinking. Arrange the following nursing interventions in order of priority: A.
Encourage participation in group therapy B. Use short, simple sentences when
communicating C. Establish a therapeutic relationship D. Assess for safety risks E.
Administer prescribed antipsychotic medication
84. A client who was recently diagnosed with generalized anxiety disorder states, "I just need
to stop worrying so much. I should be able to control this." The nurse's response is based
on the understanding that the most effective approach to anxiety management involves:
85. A nurse is conducting a suicide risk assessment. Identify the area on the image below where
the nurse should document the most critical risk factor for completed suicide.
86. The nurse is providing education to a family whose teenage member has been diagnosed
with schizophrenia. The family asks about genetic factors. Which response by the nurse is
most accurate? A. "Schizophrenia is entirely genetic and will affect all siblings." B.
"Environmental factors play no role in the development of schizophrenia." C. "If one
identical twin has schizophrenia, the other has about a 50% chance of developing it." D.
"Having a first-degree relative with schizophrenia means you will definitely develop the
disorder."
87. A client with borderline personality disorder becomes angry when the nurse sets a limit on
behavior. Which statements reflect appropriate therapeutic responses? Select all that apply.
A. "I understand you're upset, but these limits are necessary for everyone's safety." B. "You
need to control your anger if you want to make progress in treatment." C. "Let's discuss
this later when you're feeling calmer." D. "Your reaction is showing why you have trouble
maintaining relationships." E. "These limits apply to all clients and aren't meant to single
you out."
 88. A nurse is screening an older adult client for depression. The client denies feeling sad but
reports loss of interest in previously enjoyed activities, sleep disturbances, and multiple
somatic complaints. Based on this assessment, the nurse should: A. Document that the
client does not have depression since sadness is absent B. Consider that depression may
present differently in older adults C. Focus on treating the somatic complaints rather than
mental health D. Refer the client only for sleep medication
89. A client who experienced a traumatic event is exhibiting which of the following symptoms?
Drag each symptom to either the Acute Stress Disorder column or the Post-Traumatic
Stress Disorder column based on diagnostic timeframe.
Symptoms: Flashbacks, Avoidance of reminders, Dissociative amnesia, Hypervigilance,
Emotional numbing, Nightmares
Acute Stress Disorder (occurs within first month Post-Traumatic Stress Disorder (persists beyond
after trauma): one month after trauma):

90. A client with alcohol use disorder has been abstinent for two weeks and tells the nurse,
"I'm cured now. I can probably have one drink at social events." The nurse identifies this
statement as indicating which stage in the recovery process? A. Maintenance B. Action C.
Contemplation D. Precontemplation
91. During a mental status examination, a nurse observes that a client is well-groomed, makes
good eye contact, and responses are relevant but come after long pauses. The client's affect
is restricted, and thoughts are logical but slow. These findings are most consistent with: A.
Schizophrenia B. Major depression C. Hypomania D. Generalized anxiety disorder
92. The nurse is preparing a client for electroconvulsive therapy (ECT). The nurse should
include which of the following in the pre-procedure teaching? Select all that apply. A. The
client will be under general anesthesia during the procedure B. Memory impairment may
occur temporarily C. The client will experience painful convulsions D. A muscle relaxant
will be administered before the procedure E. The client must discontinue all psychiatric
medications
93. A client diagnosed with agoraphobia has difficulty leaving home due to fear of having a
panic attack in public. The most effective evidence-based treatment approach would
include:
94. A nurse is caring for a client who reports hearing voices that tell the client they are
worthless. The nurse recognizes this symptom as a: A. Delusion of grandeur B. Auditory
hallucination C. Idea of reference D. Thought insertion
95. A nurse is assessing a client with an eating disorder who exercises compulsively. Which
statement by the client would indicate the most severe distortion in body image perception?
A. "I know I'm within normal weight range, but I'd like to be thinner." B. "My family says
I'm too thin, but I don't see it that way." C. "I can't stop exercising because my thighs are
huge even though I weigh 85 pounds." D. "Sometimes I worry that I focus too much on
my weight."
96. A client with bipolar disorder who takes lithium has been experiencing nausea, vomiting,
and tremors. The nurse should immediately:
97. A nurse is leading a support group for family members of clients with schizophrenia.
Which topics would be most important to include in the education plan? Select all that
apply. A. Recognition of early warning signs of relapse B. Communication strategies for
interacting with the ill family member C. Methods to cure schizophrenia through family
intervention D. The importance of medication adherence E. Techniques for maintaining
appropriate boundaries
98. A client is being treated for generalized anxiety disorder. Which findings indicate the client
is using effective coping mechanisms? Select all that apply. A. The client practices
progressive muscle relaxation daily B. The client avoids all situations that might trigger
anxiety C. The client identifies and challenges catastrophic thoughts D. The client uses
alcohol to calm down before social events E. The client schedules worry time to contain
anxious thoughts
99. A nurse assesses a client who has been diagnosed with antisocial personality disorder.
Which of the following client behaviors would be most characteristic of this disorder? A.
Extreme fear of abandonment B. Lack of remorse for hurting others C. Excessive attention
to details D. Unusual perceptual experiences
100. The nurse is teaching a client about Acceptance and Commitment Therapy (ACT) for
managing chronic pain and associated depression. Which statement by the client indicates
understanding of the core principles of ACT? A. "I need to eliminate all negative thoughts
about my pain." B. "I should accept that I'll never be happy again because of my pain." C.
"I can acknowledge my pain while still engaging in meaningful activities." D. "The goal is
to distract myself from pain by staying busy all the time."
101. A 15-year-old client is admitted to the adolescent psychiatric unit with a diagnosis of
conduct disorder. During the assessment, the nurse notices multiple scars on the client's
arms. When asked about them, the client responds, "I don't want to talk about that." Which
response by the nurse demonstrates therapeutic communication? A. "You don't have to
 talk about it now, but I'm here when you're ready." B. "It's important that you tell me about
those scars for your treatment." C. "Those look like self-inflicted wounds. Are you still
cutting yourself?" D. "I'll note in your chart that you're being non-compliant with the
assessment."
102. A client diagnosed with schizophrenia is experiencing paranoid delusions and refuses to
eat hospital food. Arrange the following nursing interventions in order of priority: A. Offer
prepackaged food options B. Explain hospital food safety protocols C. Request an order
for nutritional supplements D. Establish rapport and therapeutic relationship E. Allow
family to bring food from home
103. A nurse is conducting a group therapy session for clients with substance use disorders.
Which of the following participant behaviors indicate therapeutic group progress? Select
all that apply. A. A client challenges another group member's rationalization of continued
drug use B. A client monopolizes discussion by talking about personal achievements C. A
client offers constructive feedback to another member about recovery strategies D. A client
discusses their spiritual beliefs as superior to traditional recovery methods E. A client
shares personal experiences with relapse triggers and prevention strategies
104. The nurse is providing education to the parents of an adolescent recently diagnosed with
an eating disorder. What is the primary goal of family-based treatment (FBT) for
adolescents with eating disorders?
105. A client with post-traumatic stress disorder describes experiencing flashbacks that feel
"completely real." During these episodes, they believe they are reliving the traumatic event.
This phenomenon is best characterized as: A. Dissociative amnesia B. Depersonalization
C. Derealization D. Emotional flooding
106. A nurse is working with a client diagnosed with dependent personality disorder. Which
behavior would be most important to address in the plan of care? A. Difficulty making
everyday decisions without excessive advice from others B. Disregard for social norms and
the rights of others C. Extreme perfectionism that interferes with task completion D.
Grandiose sense of self-importance and need for admiration
107. The charge nurse observes a new nurse addressing a client with schizophrenia who is
experiencing hallucinations. Select the zones on the image that represent appropriate body
positioning when communicating with this client.
108. A client has been diagnosed with complicated grief following the death of their spouse six
months ago. Which assessment findings differentiate complicated grief from normal grief?
Select all that apply. A. Intense yearning for the deceased that hasn't diminished over time
B. Occasional sadness when reminded of the deceased C. Inability to accept the reality of
the loss D. Preoccupation with thoughts of the deceased that interferes with daily
functioning E. Finding comfort in memories of the deceased
109. A nurse is administering olanzapine (Zyprexa) to a client with schizophrenia. Which
medication side effect requires monitoring and intervention due to its long-term health
implications? A. Photosensitivity B. Dry mouth C. Metabolic syndrome D. Sedation
110. A client exhibits the following symptoms: constant worry about multiple life
circumstances, muscle tension, fatigue, irritability, and difficulty sleeping. These symptoms
have persisted for eight months and significantly impair daily functioning. The nurse
recognizes these symptoms as most consistent with:
111. The nurse is facilitating a dialectical behavior therapy (DBT) skills group. Match each DBT
skill module with its primary therapeutic focus.
DBT Skills: Mindfulness, Distress tolerance, Emotion regulation, Interpersonal effectiveness
Therapeutic Focus: A. Surviving crisis situations without making things worse B. Balancing
wants and needs in relationships C. Being aware of and present in the current moment D.
Changing or managing intense emotions
112. A nurse is caring for a client who has been diagnosed with bipolar disorder and is currently
experiencing a mixed episode. Which assessment finding would be most characteristic of
this presentation? A. Sustained period of elevated mood with increased energy B.
Simultaneous symptoms of mania and depression C. Rapid cycling between distinct manic
and depressive episodes D. Mild elevation in mood without significant functional
impairment
113. A client with obsessive-compulsive disorder (OCD) performs a hand-washing ritual 30
times per day, causing skin breakdown. Which therapeutic approach demonstrates the
correct application of exposure and response prevention (ERP)? A. Having the client touch
increasingly "contaminated" objects while preventing hand washing B. Redirecting the
client to another activity whenever hand-washing urges occur C. Providing antibacterial gel
as a substitute for hand washing D. Limiting hand washing to five times per day and
gradually reducing frequency
114. A nurse is assessing a client with a history of trauma who reports nightmares,
hypervigilance, and emotional numbing. The client states, "Sometimes I feel like I'm
outside my body, watching myself." This symptom is known as:
115. A nurse is admitting a client with anorexia nervosa who has a BMI of 15.8. Which
complication requires immediate assessment and intervention? A. Amenorrhea B.
Osteopenia C. Cardiac dysrhythmias D. Lanugo
116. A client in the psychiatric unit is experiencing an acute psychotic episode with agitation.
Which of the following interventions should the nurse implement first? A. Administer
PRN antipsychotic medication B. Place the client in seclusion C. Remove environmental
stimuli and speak in a calm, clear manner D. Request an order for physical restraints
117. A client with major depressive disorder has been prescribed a selective serotonin reuptake
inhibitor (SSRI). After two weeks of treatment, the client reports no improvement in mood
but is experiencing headaches and nausea. The most appropriate nursing action would be
to: A. Recommend that the healthcare provider change to a different class of
antidepressant B. Explain that therapeutic effects typically take 2-6 weeks while side effects
may appear earlier C. Suggest discontinuing the medication due to unfavorable side effect
profile D. Double the medication dose to achieve faster results
118. A nurse is working with parents whose child has been diagnosed with attention deficit
hyperactivity disorder (ADHD). Which parenting strategies should the nurse recommend?
Select all that apply. A. Establish consistent routines and clear expectations B. Provide
frequent, immediate feedback for positive behaviors C. Remove all structure to allow the
child's creativity to flourish D. Use time-out procedures that match the child's
developmental level E. Punish negative behaviors more severely than with other children
119. A client with schizoaffective disorder is experiencing both psychotic and mood symptoms.
Identify the assessment findings that would indicate this diagnosis rather than
schizophrenia or a mood disorder alone. A. The presence of hallucinations without mood
symptoms B. Delusions occurring only during mood episodes C. Psychotic symptoms
present for substantial periods when mood symptoms are not active D. Mood symptoms
occurring for a brief duration compared to psychotic symptoms
120. A nurse is conducting a suicide risk assessment for a client who has expressed thoughts of
self-harm. Which risk factor, if present, would most significantly increase the client's acute
suicide risk? A. History of childhood trauma B. Recent diagnosis of a chronic illness C.
Specific plan with access to lethal means D. Family history of suicide
D. Physiological Integrity
1. A nurse is caring for a patient who is receiving morphine for pain management after
surgery. Which of the following assessments should the nurse prioritize?
a) Blood pressure
b) Respiratory rate
c) Heart rate
d) Temperature
2. A patient with dehydration has been prescribed intravenous fluids. The nurse notices that
the patient’s skin turgor is poor, and the urine output is significantly reduced. Which
laboratory value should the nurse monitor to assess the severity of the dehydration?
a) Hemoglobin
b) Sodium
c) Creatinine
d) Hematocrit
3. The nurse is caring for a patient who is experiencing acute pain. Which of the following
interventions is most appropriate to provide relief?
a) Administer a nonsteroidal anti-inflammatory drug (NSAID)
b) Position the patient in a high Fowler’s position
c) Increase the patient’s fluid intake
d) Use a cold compress to the painful area
4. A patient with chronic kidney disease is being monitored for fluid and electrolyte
imbalances. Which of the following signs would the nurse expect to see in this patient?
a) Decreased sodium levels
b) Hyperkalemia
c) Hypoglycemia
d) Decreased creatinine levels
5. A nurse is administering a blood transfusion. The patient begins to experience chills,
fever, and itching. What is the nurse’s immediate action?
a) Continue the transfusion and monitor for further symptoms
b) Stop the transfusion and notify the healthcare provider
c) Administer acetaminophen and continue the transfusion
d) Administer an antihistamine and resume the transfusion
6. A patient who has been on a prolonged course of antibiotics is at risk for Clostridium
difficile infection. Which of the following actions should the nurse prioritize to reduce
this patient’s risk?
a) Administer a probiotic as prescribed
 b) Monitor for signs of sepsis
c) Ensure the patient receives a flu vaccine
d) Increase the patient's fluid intake
7. The nurse is caring for a patient with a central venous catheter (CVC) who develops a
fever and swelling at the catheter insertion site. What should the nurse do first?
a) Administer an antibiotic
b) Remove the catheter
c) Obtain blood cultures
d) Apply a warm compress to the site
8. A patient with asthma is prescribed a bronchodilator. Which of the following is the most
common side effect of this medication?
a) Dizziness
b) Tachycardia
c) Hypertension
d) Hypotension
9. A nurse is caring for a patient who is receiving total parenteral nutrition (TPN). The
nurse should monitor which of the following to evaluate the patient's tolerance to the
TPN solution?
a) Respiratory rate
b) Blood glucose levels
c) Hemoglobin levels
d) Urine specific gravity
10. A nurse is caring for a patient who is at risk for deep vein thrombosis (DVT). Which of
the following interventions is most important in preventing the development of DVT?
a) Encourage the patient to perform deep breathing exercises
b) Apply compression stockings as prescribed
c) Encourage fluid intake to promote urine output
d) Place the patient in a low Fowler’s position
11. A nurse is administering a diuretic to a patient with heart failure. Which of the following
laboratory values should the nurse monitor closely?
a) Sodium
b) Potassium
c) Glucose
d) Calcium
12. A patient with a history of hypertension is being discharged after receiving a new
prescription for an antihypertensive medication. Which of the following instructions
should the nurse include in the discharge teaching?
 a) "Take the medication with grapefruit juice."
b) "Change positions slowly to avoid dizziness."
c) "Take your blood pressure before each dose."
d) "Skip a dose if you feel fine."
13. The nurse is preparing to administer a blood transfusion to a patient. Which of the
following actions is necessary to ensure patient safety?
a) Verify the patient’s identity using two identifiers
b) Pre-medicate the patient with acetaminophen
c) Use a Y-type blood transfusion set
d) Administer the transfusion at a rapid rate
14. A nurse is caring for a patient recovering from surgery. Which of the following
interventions would be most effective to prevent atelectasis?
a) Encourage coughing and deep breathing exercises
b) Administer supplemental oxygen as prescribed
c) Reposition the patient every two hours
d) Monitor vital signs every four hours
15. A nurse is caring for a patient receiving heparin therapy. The nurse should monitor for
which of the following complications?
a) Hypertension
b) Bleeding
c) Hyperglycemia
d) Hyperkalemia
16. A patient with a history of myocardial infarction (MI) is prescribed a beta-blocker. Which
of the following assessments should the nurse prioritize for this patient?
a) Heart rate
b) Respiratory rate
c) Oxygen saturation
d) Temperature
17. The nurse is caring for a patient receiving an intravenous (IV) infusion of potassium
chloride. The nurse observes that the IV site is red, swollen, and warm to the touch.
What is the nurse’s first action?
a) Discontinue the IV and notify the healthcare provider
b) Increase the rate of the IV infusion
c) Apply a warm compress to the site
d) Change the IV site to the other arm
18. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS). Which
of the following interventions should the nurse implement to improve oxygenation?
 a) Provide supplemental oxygen via nasal cannula
b) Place the patient in a prone position
c) Administer pain medication as prescribed
d) Increase fluid intake to promote hydration
19. A patient is receiving chemotherapy and complains of nausea and vomiting. What is the
nurse’s priority intervention?
a) Administer an antiemetic as prescribed
b) Offer the patient a cool, dry cloth for their face
c) Provide clear fluids to rehydrate the patient
d) Encourage the patient to perform relaxation exercises
20. A nurse is caring for a patient who is experiencing a postoperative complication of ileus.
Which of the following interventions should the nurse include in the care plan?
a) Encourage early ambulation
b) Provide high-fiber foods
c) Administer a stool softener as prescribed
d) Increase the patient’s fluid intake
21. A nurse is caring for a patient who is receiving a blood transfusion. The patient suddenly
complains of a headache, chills, and fever. What is the nurse’s immediate action?
a) Slow down the infusion rate and notify the healthcare provider
b) Continue the transfusion at the same rate
c) Stop the transfusion immediately and administer an antihistamine
d) Stop the transfusion immediately and notify the healthcare provider
22. A patient with chronic obstructive pulmonary disease (COPD) is being treated with a
corticosteroid inhaler. Which of the following instructions should the nurse provide
regarding the use of the inhaler?
a) "Rinse your mouth after each use to prevent fungal infections."
b) "Use the inhaler only when you experience shortness of breath."
c) "Increase your fluid intake while using this medication."
d) "Do not use the inhaler if you feel lightheaded."
23. A nurse is assessing a postoperative patient who is experiencing a temperature of 101°F
(38.3°C). Which action should the nurse take first?
a) Administer an antipyretic medication
b) Encourage the patient to drink fluids
c) Obtain a blood culture
d) Increase the patient's oxygen supply
24. A patient is being prepared for a colonoscopy. The nurse should instruct the patient to:
a) Fast for at least 6 hours before the procedure
 b) Take the prescribed bowel prep medication the night before the procedure
c) Consume a light breakfast before the procedure
d) Take a laxative 24 hours before the procedure
25. A patient is receiving IV potassium chloride for hypokalemia. The nurse notices that the
infusion site is swollen and warm to the touch. What should the nurse do first?
a) Continue the infusion and apply a warm compress
b) Stop the infusion immediately and assess for infiltration
c) Administer a bolus of saline to dilute the potassium chloride
d) Apply ice to the site to reduce swelling
26. A nurse is caring for a patient with a suspected myocardial infarction (MI). Which of the
following is the priority intervention?
a) Administer aspirin as prescribed
b) Obtain an ECG
c) Prepare for cardiac catheterization
d) Administer morphine for pain relief
27. A nurse is caring for a patient with asthma who is prescribed a corticosteroid inhaler. The
nurse notices that the patient’s mucous membranes are dry and irritated. Which of the
following is the best action to take?
a) Encourage the patient to drink more fluids
b) Recommend the use of a humidifier
c) Apply a water-based lubricant to the mucous membranes
d) Increase the corticosteroid dosage
28. A patient is receiving intravenous fluids after a burn injury. The nurse should monitor for
signs of:
a) Hyperkalemia
b) Hyponatremia
c) Hyperglycemia
d) Hypokalemia
29. A nurse is administering a blood transfusion to a patient. The patient begins to develop
chills, fever, and back pain. What is the nurse’s next action?
a) Continue the transfusion and monitor the patient closely
b) Stop the transfusion immediately and administer acetaminophen
c) Slow the infusion and notify the healthcare provider
d) Stop the transfusion immediately and notify the healthcare provider
30. A nurse is caring for a patient receiving chemotherapy who is at risk for
thrombocytopenia. The nurse should monitor for which of the following symptoms?
a) Pallor
 b) Fever
c) Bruising or petechiae
d) Hypertension
31. A nurse is caring for a patient with a postoperative infection. The patient’s WBC count is
elevated. What should the nurse anticipate?
a) Increased risk for bleeding
b) Need for antibiotic therapy
c) Increased risk for hypokalemia
d) Need for fluid restriction
32. The nurse is administering a blood transfusion to a patient with anemia. Which of the
following should the nurse monitor throughout the transfusion process?
a) Oxygen saturation
b) Blood pressure
c) Respiratory rate
d) Heart rate
33. A nurse is caring for a patient diagnosed with hyperthyroidism. The nurse should
monitor the patient for which of the following symptoms?
a) Weight gain
b) Bradycardia
c) Hypothermia
d) Tremors
34. A nurse is caring for a patient with end-stage renal disease. Which of the following is the
most important to monitor in this patient?
a) Blood glucose levels
b) Serum potassium levels
c) Hemoglobin levels
d) White blood cell count
35. A nurse is caring for a patient who is recovering from surgery. The nurse notes that the
patient is restless and has a respiratory rate of 30 breaths per minute. What is the nurse’s
priority intervention?
a) Administer an anxiolytic medication
b) Encourage deep breathing exercises
c) Notify the healthcare provider
d) Administer supplemental oxygen
36. A nurse is assessing a patient who is suspected of having acute pancreatitis. Which of the
following signs is most characteristic of this condition?
a) Severe, sudden upper abdominal pain
 b) Yellowing of the skin and eyes
c) Chest pain radiating to the left arm
d) Progressive weakness and fatigue
37. The nurse is caring for a patient with heart failure who is prescribed a diuretic. Which
laboratory value should the nurse monitor to assess for potential complications?
a) Sodium
b) Potassium
c) Glucose
d) Calcium
38. A nurse is assessing a patient who is receiving IV fluids for dehydration. Which of the
following signs indicates that the patient is not responding to the treatment?
a) Increased blood pressure
b) Increased urine output
c) Decreased respiratory rate
d) Decreased skin turgor
39. A nurse is preparing a patient for a thoracentesis. Which of the following is the priority
intervention before the procedure?
a) Explain the procedure to the patient
b) Administer an analgesic medication
c) Obtain a consent form
d) Place the patient in a supine position
40. A nurse is caring for a patient who has been diagnosed with sepsis. The patient is
receiving IV antibiotics. Which of the following is the most important intervention for
the nurse to perform?
a) Monitor the patient's blood pressure and heart rate
b) Administer fluids to maintain blood pressure
c) Notify the healthcare provider if the patient’s temperature increases
d) Reposition the patient every two hours
41. A nurse is caring for a patient who is receiving a potassium infusion. The patient
suddenly complains of chest tightness, and the ECG shows peaked T waves. What
should the nurse do first?
a) Stop the infusion and notify the healthcare provider
b) Administer a diuretic to decrease potassium levels
c) Increase the infusion rate
d) Administer an antidote such as sodium bicarbonate
42. A patient has been prescribed warfarin (Coumadin) following a recent myocardial
infarction. The nurse should educate the patient to avoid:
 a) Increasing their daily vitamin K intake
b) Taking nonsteroidal anti-inflammatory drugs (NSAIDs)
c) Drinking large amounts of cranberry juice
d) Both b and c
43. A nurse is caring for a patient who is receiving a blood transfusion and begins to show
signs of a transfusion reaction, including hives and itching. What is the nurse’s first
priority?
a) Continue the transfusion at a slower rate
b) Stop the transfusion and administer antihistamines
c) Stop the transfusion immediately and keep the IV line open with saline
d) Notify the healthcare provider for further instructions
44. A patient with heart failure is prescribed digoxin. The nurse should monitor for signs of
digoxin toxicity, including:
a) Nausea, vomiting, and visual disturbances
b) Increased appetite and weight gain
c) Bradycardia and hypertension
d) Dry mouth and urinary retention
45. The nurse is caring for a patient who has just undergone a surgical procedure. Which of
the following should the nurse prioritize in the postoperative period?
a) Monitoring the patient's oxygen saturation
b) Managing the patient’s pain level
c) Promoting early ambulation to prevent deep vein thrombosis
d) All of the above
46. A patient is admitted with a diagnosis of dehydration. Which laboratory value should the
nurse monitor most closely?
a) Blood glucose
b) Hemoglobin
c) Serum sodium
d) Serum potassium
47. A nurse is caring for a patient who is recovering from surgery and is on a PCA (patient-
controlled analgesia) pump. The nurse notices that the patient is sleepy and has shallow
respirations. What is the first action the nurse should take?
a) Increase the patient’s fluid intake
b) Assess the patient’s pain level
c) Stop the PCA pump and assess the patient’s respiratory status
d) Notify the healthcare provider immediately
48. A nurse is caring for a patient with chronic kidney disease. Which of the following lab
results would be most concerning?
a) High serum calcium levels
b) High serum potassium levels
c) Low hemoglobin levels
d) High serum creatinine levels
49. The nurse is educating a patient with asthma on the proper use of a rescue inhaler.
Which instruction should the nurse provide?
a) "Use the inhaler every day, even when you feel fine."
b) "Take a deep breath and hold it for 10 seconds after inhaling."
c) "Rinse your mouth with water after using the inhaler to prevent a fungal infection."
d) "Use the inhaler only when you have wheezing or shortness of breath."
50. A nurse is caring for a patient with acute pancreatitis. Which of the following findings
would require immediate intervention?
a) Serum amylase and lipase levels elevated
b) Abdominal pain that radiates to the back
c) Decreased blood pressure and increased heart rate
d) Positive bowel sounds in all quadrants
51. A nurse is caring for a patient who is receiving IV fluids after a burn injury. The nurse
notices the patient is becoming agitated and their blood pressure is dropping. What is the
nurse's first priority?
a) Continue to administer fluids at the same rate
b) Administer a sedative to calm the patient
c) Assess for signs of shock and notify the healthcare provider
d) Increase the IV fluids and monitor for signs of fluid overload
52. A patient with liver disease is prescribed a diuretic to manage fluid retention. Which
electrolyte imbalance is the nurse most concerned about in this patient?
a) Hyperkalemia
b) Hypernatremia
c) Hypocalcemia
d) Hyponatremia
53. A nurse is caring for a patient who is receiving a blood transfusion and begins to
experience chills, fever, and hypotension. What is the most likely cause of these
symptoms?
a) Allergic reaction
b) Bacterial contamination
 c) Acute hemolytic reaction
d) Transfusion-related acute lung injury
54. A nurse is caring for a patient receiving intravenous morphine for pain management. The
patient is becoming increasingly lethargic and has a respiratory rate of 8 breaths per
minute. What is the nurse's priority action?
a) Administer an opioid antagonist, such as naloxone
b) Increase the morphine dosage to control the pain
c) Notify the healthcare provider and continue to monitor
d) Reassure the patient and provide additional oxygen
55. A nurse is caring for a patient with type 2 diabetes who has been prescribed insulin. The
patient is experiencing hypoglycemia. Which of the following should the nurse administer
to the patient?
a) Orange juice with added sugar
b) A piece of candy or glucose tablets
c) A snack with protein and carbohydrates
d) Water with honey
56. The nurse is caring for a patient with deep vein thrombosis (DVT). Which of the
following is the priority intervention?
a) Encourage the patient to walk as much as possible
b) Administer anticoagulant medication as prescribed
c) Apply heat to the affected leg
d) Keep the patient’s leg elevated above the heart
57. A patient is being prepared for discharge following abdominal surgery. Which of the
following instructions should the nurse include in the discharge teaching?
a) "You should avoid driving until you're completely pain-free."
b) "You can resume your normal activities after two days of rest."
c) "If you notice any increased swelling or redness at the incision site, contact your
healthcare provider."
d) "It's normal to have a low-grade fever for a few weeks after surgery."
58. A nurse is assessing a patient who is receiving antibiotics for an infection. The patient
reports a new-onset rash. What is the nurse’s priority action?
a) Continue administering the antibiotic and monitor the rash
b) Stop the antibiotic and notify the healthcare provider
c) Apply a topical cream to the rash
d) Reassure the patient that the rash is not serious and monitor
59. A nurse is caring for a patient with a history of seizures. Which of the following is the
most important action to take during a seizure?
 a) Administer supplemental oxygen
b) Turn the patient to their side to prevent aspiration
c) Place a bite block in the patient’s mouth to prevent injury
d) Hold the patient’s head still to prevent head trauma
60. A nurse is preparing a patient for a thoracentesis. What should the nurse instruct the
patient to do during the procedure?
a) Lie flat on the back with the arms extended overhead
b) Remain as still as possible and avoid coughing or deep breathing
c) Sit upright and lean forward on a table
d) Breathe deeply and hold their breath when instructed
61. A nurse is caring for a patient who is receiving a blood transfusion. The patient starts
showing signs of a transfusion reaction, including fever, chills, and back pain. What is the
nurse’s first priority?
a) Continue the transfusion at a slower rate
b) Stop the transfusion immediately and administer normal saline
c) Increase the rate of the transfusion to flush out the reaction
d) Contact the healthcare provider for further instructions
62. A patient with diabetes mellitus is admitted for surgery. Which of the following should
the nurse prioritize in the preoperative care?
a) Administer insulin as usual and monitor blood glucose levels
b) Discontinue the patient’s insulin regimen to prevent hypoglycemia
c) Increase the patient’s fluid intake to reduce blood glucose levels
d) Administer oral hypoglycemic agents before surgery
63. A nurse is preparing to administer a blood transfusion. Which of the following actions is
essential before starting the transfusion?
a) Check the patient's blood type and crossmatch with the donor blood
b) Ensure that the patient has eaten at least an hour before the transfusion
c) Apply a warm compress to the IV site to facilitate blood flow
d) Administer pain medications prior to the transfusion
64. A nurse is educating a patient on the proper use of a dry powder inhaler (DPI) for
asthma. Which instruction should the nurse provide?
a) "Breathe out slowly before inhaling the medication."
b) "Hold your breath for at least 10 seconds after inhaling."
c) "Use the inhaler once every 12 hours regardless of symptoms."
d) "Rinse your mouth with water after using the inhaler to prevent a fungal infection."
65. A nurse is caring for a patient with a history of hypertension and coronary artery disease.
The healthcare provider prescribes a beta-blocker. Which assessment should the nurse
 perform before administering the medication?
a) Measure the patient’s heart rate and blood pressure
b) Monitor the patient's respiratory rate and oxygen saturation
c) Assess the patient's peripheral pulses and capillary refill time
d) Check the patient's serum potassium level
66. A nurse is caring for a patient with a diagnosis of pneumonia. The nurse should expect
which of the following symptoms?
a) Bradycardia and hypotension
b) Increased white blood cell count and productive cough
c) Decreased respiratory rate and oxygen saturation
d) Fever and peripheral edema
67. The nurse is administering an intravenous (IV) medication. The patient suddenly
experiences pain at the IV site and redness and swelling begin to develop. What should
the nurse do first?
a) Stop the IV infusion and remove the IV catheter
b) Apply a warm compress to the IV site and continue the infusion
c) Call the healthcare provider immediately before stopping the infusion
d) Notify the pharmacy to prepare a new dose of medication
68. A patient with a history of asthma is prescribed a corticosteroid inhaler. The nurse
should instruct the patient to:
a) Use the inhaler only when experiencing an asthma attack
b) Rinse the mouth thoroughly after using the inhaler to prevent oral thrush
c) Take the medication at bedtime to minimize side effects
d) Avoid using the inhaler more than twice a day
69. A nurse is caring for a patient who is post-operative following abdominal surgery. The
nurse notices the patient is unable to urinate, and the bladder is distended. What is the
nurse's first intervention?
a) Insert a Foley catheter to relieve the urinary retention
b) Encourage the patient to drink fluids to stimulate urination
c) Perform bladder irrigation to relieve the obstruction
d) Position the patient in a prone position to promote urination
70. A nurse is caring for a patient who has just undergone a colonoscopy. The nurse should
expect which of the following as part of the recovery process?
a) Clear liquid diet for the first 24 hours
b) Immediate return to a normal diet
c) Monitoring for signs of constipation
d) Discharge with no restrictions on activity
71. A nurse is assessing a patient who has been receiving IV fluids for several days. The
patient is now experiencing confusion, seizures, and muscle weakness. What is the
nurse's priority action?
a) Administer a bolus of normal saline
b) Assess the patient's electrolytes, especially sodium levels
c) Increase the rate of IV fluid administration
d) Administer a potassium supplement
72. A nurse is caring for a patient who is post-operative and receiving an opioid for pain
management. The nurse should be concerned about which of the following symptoms?
a) Increased bowel sounds
b) Decreased respiratory rate and drowsiness
c) Increased urine output
d) Elevated heart rate and blood pressure
73. A nurse is educating a patient about lifestyle modifications to manage type 2 diabetes.
Which of the following statements by the patient indicates the need for further teaching?
a) "I will eat a balanced diet with regular meals and snacks."
b) "I will exercise at least 30 minutes a day, five days a week."
c) "I will skip meals occasionally to reduce my insulin needs."
d) "I will monitor my blood glucose levels regularly."
74. A nurse is caring for a patient with deep vein thrombosis (DVT). The nurse is preparing
to administer heparin. What should the nurse assess before administration?
a) Hemoglobin and hematocrit levels
b) Platelet count and activated partial thromboplastin time (aPTT)
c) Liver function and kidney function
d) Prothrombin time (PT) and international normalized ratio (INR)
75. A nurse is caring for a patient who is receiving chemotherapy. The patient is at high risk
for infection due to neutropenia. What is the nurse's priority intervention?
a) Monitor the patient’s temperature regularly and administer antipyretics as needed
b) Encourage the patient to ambulate to increase circulation
c) Keep the patient’s room well-ventilated and at a comfortable temperature
d) Avoid visitors who may have a cold or infection
76. A nurse is caring for a patient who is receiving insulin therapy. The patient’s blood
glucose level is 60 mg/dL. What should the nurse do first?
a) Administer a rapid-acting carbohydrate such as orange juice
b) Increase the insulin dosage to lower the blood glucose
c) Notify the healthcare provider immediately
d) Withhold food and fluids until the blood glucose is normalized
77. A nurse is educating a patient with hypertension on lifestyle modifications. Which of the
following is the most effective change the nurse should emphasize?
a) Decrease salt intake and increase potassium-rich foods
b) Increase fluid intake to prevent dehydration
c) Increase carbohydrate intake to improve energy levels
d) Engage in vigorous exercise at least once a week
78. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The
patient is experiencing difficulty breathing and is using accessory muscles. What is the
nurse’s first action?
a) Administer supplemental oxygen as prescribed
b) Have the patient perform pursed-lip breathing
c) Encourage the patient to rest and avoid physical activity
d) Administer a bronchodilator as prescribed
79. A nurse is caring for a patient who is receiving total parenteral nutrition (TPN). Which of
the following assessments is the priority?
a) Monitoring for signs of infection at the IV insertion site
b) Checking the patient’s weight daily
c) Monitoring blood glucose levels regularly
d) Assessing the patient for edema and fluid retention
80. A nurse is caring for a patient who is recovering from surgery. The nurse notes that the
patient's wound has a large amount of greenish drainage. What is the nurse’s priority
action?
a) Reassure the patient that this is normal after surgery
b) Notify the healthcare provider for possible wound infection
c) Apply a dressing and continue to monitor
d) Administer an antibiotic as prescribed
81. A nurse is caring for a patient who has been newly diagnosed with type 1 diabetes. Which
of the following factors would indicate the need for an adjustment in the patient’s insulin
regimen?
a) Blood glucose level remains elevated despite increased physical activity
b) The patient is experiencing frequent episodes of hypoglycemia during the night
c) The patient reports frequent thirst and urination throughout the day
d) Blood glucose levels are consistently within the target range
82. A nurse is performing a neurological assessment on a patient after a traumatic brain
injury. The nurse observes that the patient has a Glasgow Coma Scale (GCS) score of 10.
What is the next step the nurse should take?
(Select all that apply)
 a) Notify the healthcare provider and continue to monitor the patient
b) Document the findings as the patient is stable
c) Administer sedation to help relax the patient
d) Check the patient’s vitals for signs of hypotension
83. A nurse is caring for a patient receiving heparin therapy. The nurse notes the patient's
aPTT is 100 seconds (normal range: 30–40 seconds). What is the nurse’s most
appropriate action?
Answer: Hold the heparin and notify the healthcare provider immediately
84. A nurse is caring for a patient with chronic kidney disease who has been prescribed
erythropoietin. Which lab value should the nurse monitor to assess the patient’s response
to the medication?
a) White blood cell count
b) Hemoglobin and hematocrit
c) Creatinine clearance
d) Blood glucose level
85. A nurse is assessing a patient with suspected sepsis. Where should the nurse focus their
immediate assessment?
86. A nurse is caring for a patient receiving morphine for post-operative pain. The nurse
should monitor the patient for which of the following potential side effects? (Select all
that apply)
a) Decreased respiratory rate
b) Increased heart rate
c) Nausea and vomiting
d) Constipation
87. A nurse is preparing to administer an IM injection of vitamin B12 to a patient. Which of
the following is the correct procedure for administering the injection?
a) Inject the medication rapidly to minimize discomfort
b) Massage the site after injection to increase absorption
c) Use the deltoid muscle as the preferred injection site
d) Rotate injection sites to prevent tissue damage
88. Place the steps in order for managing fluid overload in a patient.
1. Elevate the patient’s legs to improve venous return
2. Administer diuretics as ordered
3. Monitor for respiratory distress and hypoxia
4. Assess urine output and vital signs
[Drag-and-Drop order: 4, 1, 3, 2]
89. A nurse is caring for a patient receiving continuous enteral feedings. The nurse should
monitor which laboratory value to assess for potential complications?
a) Serum albumin levels
b) Serum calcium levels
c) Blood glucose levels
d) Serum sodium levels
90. A nurse is preparing to administer an opioid medication for a patient experiencing severe
pain. Before administering the medication, the nurse should assess the patient for which
of the following?
Answer: A baseline pain rating
91. A nurse is caring for a patient with an indwelling urinary catheter. Which of the following
interventions is most appropriate to reduce the risk of catheter-associated urinary tract
infection (CAUTI)?
a) Use aseptic technique during catheter insertion and maintenance
b) Clean the catheter with alcohol-based solutions daily
c) Use a 22 French catheter for all patients requiring catheterization
d) Reposition the catheter tubing every 4 hours
92. A nurse is caring for a patient with a history of hypertension and hyperlipidemia. The
patient is being started on atorvastatin. The nurse should monitor for which of the
following side effects of atorvastatin?
a) Muscle pain and weakness
b) Severe headache and blurred vision
c) Increased appetite and weight gain
d) Nausea and vomiting
93. A nurse is caring for a patient receiving a blood transfusion. Which of the following is
the most important to monitor for during the first 15 minutes after the transfusion
begins?
a) Skin rash
b) Headache
c) Signs of hemolytic reaction
d) Hypotension
94. A nurse is providing education to a patient about the use of an inhaled corticosteroid.
Which of the following is a correct instruction to give to the patient?
a) "Rinse your mouth with water after using the inhaler to prevent oral thrush."
b) "Use the inhaler only during asthma attacks for quick relief."
c) "You should take the inhaler before exercise to prevent wheezing."
d) "Avoid drinking fluids while using the inhaler."
 95. A nurse is caring for a patient with hypertension who is prescribed a beta-blocker. What
is the nurse’s priority assessment before administering the medication?
a) Blood glucose levels
b) Heart rate and blood pressure
c) Serum potassium levels
d) Respiratory rate
96. A nurse is providing education to a patient about home care following a hip replacement
surgery. The nurse should include which of the following instructions?
a) "You should avoid using any assistive devices like walkers or crutches."
b) "You should not cross your legs when sitting or standing."
c) "You can resume driving after 1 week."
d) "You can shower immediately after surgery."
97. A nurse is caring for a patient who is receiving IV fluids at a rapid rate. The nurse notes
that the patient is becoming short of breath and has crackles in the lungs. What is the
nurse’s most appropriate action?
Answer: Slow the infusion rate and notify the healthcare provider
98. A nurse is assessing a patient with suspected fluid overload. What is the most important
intervention to initiate?
Answer: Monitor vital signs, especially respiratory status, and elevate the patient’s legs to
reduce fluid retention.
99. A nurse is providing education to a patient who is prescribed warfarin for anticoagulation
therapy. The nurse should instruct the patient to avoid which of the following foods
while taking warfarin?
a) Leafy green vegetables
b) Low-fat dairy products
c) Whole-grain breads
d) Fresh fruits and juices
100. A nurse is caring for a patient who is receiving a blood transfusion. Which of the
following is the most important to monitor for during the first 15 minutes after the
transfusion begins?
a) Skin rash
b) Headache
c) Signs of hemolytic reaction
d) Hypotension
 Answers and Detailed Review
A. Safe and Effective Care Environment
1. Answer: c) Assisting a patient with feeding
Rationale: Assisting with feeding is within the scope of practice for nursing assistants.
More complex tasks like medication administration and patient assessment are typically
outside their scope.
2. Answer: a) Furosemide
Rationale: Furosemide is a loop diuretic and is contraindicated in patients with a sulfa
drug allergy due to potential cross-reactivity.
3. Answer: b) Justice
Rationale: Justice in nursing focuses on ensuring fairness and equal treatment for all
patients.
4. Answer: a) Referring the patient to physical therapy for ongoing rehabilitation
Rationale: Effective case management includes arranging for continuity of care, such as
referring patients to physical therapy after a stroke.
5. Answer: c) Implementing strict hand hygiene and using isolation precautions
Rationale: Immunocompromised patients are at a higher risk of infection, so strict hand
hygiene and isolation precautions are critical.
6. Answer: a) The patient should refrain from eating or drinking for 12 hours before
surgery
Rationale: This is standard preoperative care to reduce the risk of aspiration during
anesthesia.
7. Answer: b) Ensure the IV potassium is given via an infusion pump
Rationale: Potassium should be infused slowly and never pushed as it can cause cardiac
arrhythmias. An infusion pump ensures controlled administration.
8. Answer: c) Hypovolemic shock
Rationale: The rapid, weak pulse, hypotension, and confusion are signs of hypovolemic
shock, often resulting from blood loss or fluid depletion.
9. Answer: b) "I should wash my hands before touching food and after using the restroom."
Rationale: Proper hand hygiene should be performed before eating and after using the
restroom to prevent the spread of infections.
10. Answer: c) Use strict hand hygiene and isolation precautions
Rationale: Immunocompromised patients are at a higher risk of infection, so isolation
precautions and hand hygiene are necessary to prevent infection.
11. Answer: a) To evaluate the patient’s response to the delegated task
Rationale: The nurse remains responsible for the patient’s overall care and must evaluate
the patient’s response to any tasks delegated to others.
12. Answer: c) Elevate the head of the bed to 30–45 degrees
Rationale: Elevating the head of the bed reduces the risk of VAP by preventing
aspiration and promoting lung expansion.
13. Answer: a) A patient’s Foley catheter
Rationale: A Foley catheter is a primary source of infection in healthcare settings,
particularly when not properly cared for.
14. Answer: a) Remind the nurse to correct the mistake immediately
Rationale: If a sterile instrument is placed on a non-sterile surface, it must be corrected
immediately to prevent contamination.
15. Answer: a) Place the patient in a private room and use standard precautions
Rationale: Isolation precautions depend on the patient’s condition, but standard
precautions are necessary to prevent the spread of infection.
16. Answer: a) Coordinating with physical therapy for the patient’s rehabilitation needs
Rationale: Effective resource management involves coordinating care with all relevant
healthcare professionals, including physical therapy.
17. Answer: a) The nurse provides assistance with feeding while following proper
precautions
Rationale: Even with isolation protocols, it is important to assist the patient with feeding
while adhering to infection control measures.
18. Answer: a) Contact the anesthesiologist to discuss pain management options
Rationale: Coordinating care involves contacting appropriate specialists, such as an
anesthesiologist for pain management.
19. Answer: b) Correct the assistant’s technique and explain the rationale
Rationale: It is essential to correct the assistant’s technique immediately and explain the
importance of proper infection control measures.
20. Answer: a) The surgeon will explain the procedure in detail
Rationale: Informed consent is a process where the surgeon explains the procedure, risks,
and benefits to the patient.
21. Answer: b) Remove the contaminated item and replace it with a sterile item
Rationale: If a sterile item becomes contaminated, it is essential to remove it immediately
and replace it with a new sterile item to maintain the integrity of the sterile field.
22. Answer: b) The nursing assistant places used linens in a plastic bag without gloves
Rationale: It is important for healthcare workers to wear gloves when handling
contaminated linens to prevent the spread of infection.
23. Answer: c) Review the patient’s medication regimen and potential side effects
Rationale: A thorough review of medications and their potential side effects is essential in
ensuring continuity of care, especially during discharge.
24. Answer: c) A patient who has a pressure ulcer on their sacrum and requires frequent
dressing changes
Rationale: Patients with complex wound care needs should not have tasks delegated to
nursing assistants as they require skilled nursing intervention.
25. Answer: c) Ensure the patient is sitting upright at a 90-degree angle during meals
Rationale: Sitting the patient upright during meals reduces the risk of aspiration,
especially for those at high risk.
26. Answer: b) Stop the transfusion immediately and notify the healthcare provider
Rationale: Chills, fever, and back pain are signs of a transfusion reaction. Immediate
intervention is necessary to prevent further complications.
27. Answer: b) I will avoid any physical activity for 4-6 weeks after my surgery
Rationale: Postoperative activity restrictions are important for proper healing and
preventing complications.
28. Answer: b) Administer a prophylactic antibiotic
Rationale: Prophylactic antibiotics are essential to prevent healthcare-associated
infections, especially in high-risk patients.
29. Answer: c) Using proper hand hygiene before and after patient contact
Rationale: Hand hygiene is the most effective way to prevent the spread of infections in
healthcare settings.
30. Answer: c) Use strict hand hygiene and isolation precautions
Rationale: Immunocompromised patients are at high risk for infections, and isolation
precautions help prevent exposure to harmful pathogens.
31. Answer: a) To evaluate the patient’s response to the delegated task
Rationale: The nurse remains responsible for the overall care and must evaluate the
patient’s response to any tasks delegated to others.
32. Answer: c) Elevate the head of the bed to 30–45 degrees
Rationale: Elevating the head of the bed helps reduce the risk of ventilator-associated
pneumonia (VAP) by promoting better lung expansion.
33. Answer: a) A patient’s Foley catheter
Rationale: A Foley catheter is a common source of healthcare-associated infections if not
properly cared for.
34. Answer: a) Remind the nurse to correct the mistake immediately
Rationale: Immediate correction of contamination is necessary to maintain a sterile field
and prevent the spread of infection.
35. Answer: a) Place the patient in a private room and use standard precautions
Rationale: Isolation precautions are essential to prevent the spread of infection to other
patients and healthcare workers.
36. Answer: a) Coordinating with physical therapy for the patient’s rehabilitation needs
Rationale: Effective resource management involves coordinating care with other
professionals, such as physical therapists.
37. Answer: a) The nurse provides assistance with feeding while following proper
precautions
Rationale: Patient rights must always be considered, even in isolation, and care must be
provided with strict adherence to infection control protocols.
38. Answer: a) Contact the anesthesiologist to discuss pain management options
Rationale: Effective coordination of care involves collaborating with appropriate
specialists to manage patient needs.
39. Answer: b) Correct the assistant’s technique and explain the rationale
Rationale: It is important to correct errors immediately and educate the team to ensure
the highest standards of care.
40. Answer: a) The surgeon will explain the procedure in detail
Rationale: Informed consent is a process where the surgeon must explain the details of
the procedure, including risks and benefits, to the patient.
41. Correct Answer: c) Removing the restraints at least every 2 hours to perform skin
assessment and range of motion
Rationale: When caring for a patient in restraints, the standard of care requires removal of
restraints at least every 2 hours to perform skin assessment, range of motion exercises, and
to assess continued need. This prevents complications like pressure injuries, circulatory
impairment, and contractures. Checking restraints every 4 hours (option a) is insufficient
for patient safety. Documentation of continued need (option b) and new physician orders
(option d) are required elements of restraint use but do not address the immediate physical
needs of the restrained patient.
42. Correct Answer: c) A patient whose blood glucose reading is 58 mg/dL
Rationale: A blood glucose level of 58 mg/dL indicates hypoglycemia, which can rapidly
progress to altered mental status, seizures, and loss of consciousness if not treated
promptly. This situation requires immediate intervention to prevent serious complications.
While a scheduled antibiotic (option a) is time-sensitive, a 10-minute delay poses less
immediate risk. Pain management (option b) is important but not immediately life-
threatening. Assistance with toileting (option d) is a comfort measure that can be briefly
delayed if necessary while addressing the hypoglycemic patient.
43. Correct Priority Order: d, b, a, e, c
 Rationale:
d) Ensure the scene is safe before approaching - Safety of the rescuer is always the first
priority.
b) Call for help and activate the emergency response system - Early activation of emergency
services is crucial.
a) Check for breathing and pulse - After ensuring safety and calling for help, assess the
patient's status.
e) Open the airway using head tilt-chin lift - If the patient is not breathing, open the airway.
c) Begin chest compressions if no pulse is detected - Initiate CPR if the patient is pulseless.
This order follows the current Basic Life Support (BLS) guidelines for healthcare providers.
44. Correct Answers: b, c, e, f
Rationale:
b) Placing the patient near the nursing station allows for increased observation without
restrictive measures.
c) Electronic tracking devices, with proper consent, can allow for safer mobility while
maintaining security.
e) Regular physical activity can reduce restlessness and wandering behavior.
f) Hourly rounding ensures regular assessment and can address needs before wandering
occurs.
a) Wrist restraints (incorrect) are not appropriate as they are restrictive and can increase
agitation.
d) Sedatives (incorrect) should not be used routinely to control wandering as they increase
fall risk and can worsen cognitive function.
45. Correct Answer: b) Identify residents on oxygen or other electricity-dependent treatments
Rationale: During a power outage, the priority action is to identify residents whose care
depends on electricity, such as those requiring oxygen therapy or other electrical medical
devices. These residents may need immediate intervention to prevent deterioration.
Contacting family members (option a) may be appropriate later but is not the immediate
priority. Transferring all residents to a hospital (option c) is overly disruptive and
unnecessary in most power outages, especially before assessing needs. Documentation
(option d) is important but secondary to ensuring resident safety.
46. Correct Answer: d) When the patient experiences a suicide attempt
Rationale: A DNR order does not apply in cases of suicide attempts because these are not
considered natural deaths from the progression of illness. In this situation, healthcare
providers are ethically and legally obligated to intervene. When a patient's condition
deteriorates naturally (option a), family requests (option b), or provider orders contrary to
 the advance directive (option c) are not valid reasons to override a valid advance directive
expressing the patient's wishes.
47. Correct Answer: b) A patient diagnosed with active pulmonary tuberculosis
Rationale: A patient with active pulmonary tuberculosis requires airborne precautions in
addition to standard precautions due to the risk of transmission through airborne droplet
nuclei. A draining wound with Pseudomonas (option a) requires contact precautions. A
urinary tract infection (option c) generally requires only standard precautions. A history of
MRSA colonization two years ago (option d) without current symptoms typically requires
standard precautions, though facility policy may vary.
48. Correct Answer: 12 hours
Rationale: Research indicates that the risk of errors increases significantly when nurses
work more than 12 consecutive hours. The recommended maximum is generally 12 hours
to maintain patient safety and prevent fatigue-related errors. Many healthcare facilities and
regulatory bodies have policies limiting shift length to 12 hours based on evidence linking
longer shifts to increased error rates and decreased patient safety.
49. Correct Answer: b) Understands the risks, benefits, and alternatives of the proposed
treatment
Rationale: Informed consent means the patient has been given sufficient information about
a procedure or treatment, including its risks, benefits, and alternatives, to make an educated
decision. Knowing just the success rate (option a) is only one aspect of informed consent.
Consenting to anything deemed necessary (option c) is not informed consent as it does not
specify particular procedures or risks. Signing a standard form (option d) without
understanding the content does not constitute informed consent.
50. Correct Answer: The AED pads should be placed on the upper right chest below the
clavicle and to the left of the nipple, and on the lower left ribcage.
Rationale: Proper AED pad placement is crucial for effective defibrillation. One pad
should be placed on the upper right chest, just below the clavicle and to the right of the
sternum. The second pad should be placed on the left side of the chest, below the nipple
on the lower ribcage at the left axillary line. This placement allows the electrical current to
travel through the heart effectively.
51. Correct Answer: c) Redistributing patient assignments based on acuity and available staff
Rationale: Redistributing patient assignments based on acuity and available staff is the most
appropriate immediate action to ensure patient safety when short-staffed. This approach
prioritizes higher-acuity patients while ensuring all patients receive necessary care. Calling
in additional staff (option a) may be appropriate but takes time and may not be feasible.
Requesting double shifts (option b) can lead to fatigue and errors. Closing the unit without
 approval (option d) exceeds the charge nurse's authority and may create problems
elsewhere in the facility.
52. Correct Answers: b, c, d, e
Rationale:
b) Immediately stopping the transfusion is essential when signs of a transfusion reaction
appear.
c) Maintaining venous access with normal saline allows for medication administration if
needed.
d) Documenting reactions is necessary for appropriate follow-up and reporting.
e) Continued monitoring of vital signs is essential to detect worsening or improvement.
a) Slowing the transfusion (incorrect) is inappropriate; the transfusion must be stopped
completely.
f) Administering acetaminophen (incorrect) requires a provider's order and may mask
symptoms of the reaction.
53. Correct Answer: c) Separate the visitor from the patient and assess the situation
Rationale: The most appropriate initial response is to separate the visitor from the patient
to stop the abuse and then assess the situation further. This approach protects the patient
while allowing the nurse to gather information needed to determine next steps.
Immediately calling security (option a) or asking the visitor to leave (option b) may escalate
the situation unnecessarily before understanding context. Documenting without
intervening (option d) fails to protect the patient from ongoing abuse.
54. Correct Priority Order: b, c, d, e, a
Rationale:
b) Peer observation and feedback - Most effective due to real-time reinforcement and
accountability.
c) Education on healthcare-associated infections - Builds understanding of rationale and
importance.
d) Automatic dispensers - Reduces barriers to compliance through environmental
modification.
e) Disciplinary measures - Less effective for sustainable change but may be necessary in
some cases.
a) Signs and reminders - Least effective due to "sign blindness" over time.
This order reflects evidence-based approaches to behavior change in healthcare settings, prioritizing active
engagement and education over passive reminders or punitive measures.
55. Correct Answer: b) Use a certified medical interpreter
Rationale: A certified medical interpreter is the best approach for communicating
important discharge instructions to patients with limited English proficiency. This ensures
 accurate translation of medical terminology and concepts. Speaking slowly and loudly
(option a) does not overcome language barriers and may seem disrespectful. Using family
members (option c) is problematic as they may lack medical vocabulary and patient
confidentiality could be compromised. Providing English instructions for later translation
(option d) is inappropriate for critical health information.
56. Correct Answers: a, b, c, e
Rationale:
a) Maintaining consistent vitamin K intake is important as fluctuations can affect
warfarin's effectiveness.
b) Regular INR monitoring is essential to ensure therapeutic anticoagulation and
prevent complications.
c) Patients must recognize and report signs of bleeding immediately to prevent serious
complications.
d) Alcohol can interact with warfarin and affect its metabolism, potentially increasing
bleeding risk.
e) Over-the-counter pain relievers (incorrect), particularly NSAIDs, can increase
bleeding risk and should be avoided.
f) Doubling missed doses (incorrect) is dangerous and can lead to excessive
anticoagulation and bleeding.
57. Correct Answer: b) Identifying the problem and analyzing relevant data
Rationale: The "Plan" phase of the PDCA cycle involves identifying problems, analyzing
data, and developing an improvement plan. Collecting data to evaluate improvement
(option a) belongs to the "Check" phase. Implementing changes on a small scale (option
c) is part of the "Do" phase. Standardizing successful approaches (option d) belongs to the
"Act" phase of the cycle.
58. Correct Answer: b) Report observations to the nursing supervisor immediately
Rationale: When a nurse observes signs of possible impairment in a colleague, patient safety
requires immediate reporting to a supervisor. Impaired practice endangers patients and
requires prompt intervention. Confronting the coworker directly (option a) may be
counterproductive and doesn't ensure patient safety. Asking other colleagues (option c)
delays action and may violate the coworker's privacy. Documenting for future reference
(option d) endangers current patients by allowing potentially impaired practice to continue.
59. Correct Answer: b) A negative pressure room with an anteroom
Rationale: Airborne isolation requires a negative pressure room to prevent contaminated
air from flowing into hallways or other patient areas. An anteroom provides an additional
barrier for donning and doffing personal protective equipment safely. A private room with
the door closed (option a) is insufficient for airborne pathogens. A positive pressure room
 (option c) would push contaminated air outward, increasing transmission risk. A semi-
private room (option d) unnecessarily exposes another patient to risk.
60. Correct Answer: b) 31 drops/minute
Rationale: The calculation for IV drip rate in drops per minute is:
Volume (mL) × Drop factor (drops/mL) ÷ Time (minutes) = Drops/minute
1000 mL × 15 drops/mL ÷ 480 minutes (8 hours × 60 minutes) = 31.25 drops/minute
This rounds to 31 drops/minute for practical administration.
61. Correct Answer: c) Incident concealment
Rationale: Not reporting a medication error, regardless of whether harm occurred, is
considered incident concealment. All medication errors should be reported according to
facility policy to identify system issues and prevent future errors. This is not risk
management (option a), which involves strategies to minimize risk. Failure to rescue
(option b) refers to the inability to recognize and respond to patient deterioration.
Professional judgment (option d) would involve making clinically sound decisions, whereas
concealing an error violates professional standards and ethical obligations.
62. Correct Answer: a) The patient's name, room number, and reason for admission
Rationale: The "Background" component of SBAR (Situation, Background, Assessment,
Recommendation) communication includes relevant patient information such as name,
room number, reason for admission, diagnosis, and pertinent medical history. Vital signs
and assessment findings (option b) belong in the "Assessment" component. What the
nurse thinks is happening (option c) also falls under the "Assessment" component. Specific
requests or recommendations (option d) belong in the "Recommendation" component of
SBAR.
63. Correct Answer: b) "I can't share that information without your father's permission."
Rationale: Patient confidentiality is protected by HIPAA regulations, which prohibit
sharing health information without the patient's consent. Since the patient explicitly stated
he doesn't want his daughter to know about his diagnosis, the nurse must respect this wish.
Sharing the diagnosis (option a) violates patient confidentiality and the patient's expressed
wishes. Suggesting the daughter speak with her father (option c) implies there is
information to share, potentially violating confidentiality. Claiming uncertainty about the
diagnosis (option d) is dishonest and unprofessional.
64. Correct Answers: b, c, e, f
Rationale:
b) Keeping the bed in the lowest position with brakes locked reduces injury risk if the
patient attempts to get out of bed.
c) Fall mats beside the bed can reduce injury risk if the patient falls.
 e) Hourly rounding proactively addresses patient needs, reducing reasons for the patient
to get up unassisted.
f) Bed alarm systems alert staff when patients attempt to exit the bed, allowing for timely
intervention.
a) Vest restraints (incorrect) are not considered best practice for fall prevention and
may increase agitation in confused patients.
d) Sedation (incorrect) is not appropriate for fall prevention as it may increase fall risk due
to drowsiness and impaired cognition.
65. Correct Priority Order: b, e, a, d, c
Rationale:
b) Forming a multidisciplinary team ensures all stakeholders are involved from the
beginning.
e) Analyzing workflow processes identifies potential issues before implementation.
a) Training staff is necessary after requirements and workflows are established but
before implementation.
d) Pilot testing on one unit allows for troubleshooting before hospital-wide
implementation.
c) Post-implementation evaluation occurs after the system is implemented to identify
needed adjustments.
This order follows a logical implementation sequence for a major system change that minimizes disruption
and maximizes success.
66. Correct Answer: c) Verify with pharmacy that the concentration is appropriate before
administering
Rationale: When a medication concentration differs from what is usually stocked, the nurse
should first verify with pharmacy that the concentration is appropriate before proceeding.
This ensures patient safety by confirming that the different concentration is intentional
rather than an error. Calculating a new administration rate (option a) without verification
could perpetuate an error. Returning the medication (option b) may be unnecessary if the
concentration is appropriate. Asking another nurse to check (option d) is good practice
but should occur after pharmacy verification.
67. Correct Answer: a) Complete an incident report and notify the nurse manager
Rationale: When discrepancies in controlled substance counts are discovered, the
appropriate action is to document the discrepancy through an incident report and notify
the nurse manager according to facility policy. This ensures proper investigation and
compliance with regulatory requirements. Conducting a search (option b) may be part of
the process but comes after formal reporting. Questioning staff (option c) should be done
 through proper channels after reporting. Assuming a previous error and correcting the
count (option d) is inappropriate and potentially illegal.
68. Correct Answer: b) Using chlorhexidine for skin antisepsis during dressing changes
Rationale: Evidence-based guidelines for preventing central line-associated bloodstream
infections (CLABSI) strongly recommend using chlorhexidine gluconate for skin antisepsis
during central line insertion and dressing changes. Changing dressings daily (option a) is
not recommended unless soiled or loose; routine changes are typically done every 7 days
for transparent dressings. Sterile gloves (option c) are recommended for central line
insertion but clean gloves may be sufficient for routine access. Heparin flushes (option d)
may prevent occlusion but are not primarily for infection prevention.
69. Correct Answer: c) Using two patient identifiers and comparing to medical record
Rationale: The most reliable method for patient identification is using at least two patient
identifiers (such as name and date of birth or medical record number) and comparing them
to the medical record or treatment documentation. This process is required by The Joint
Commission to prevent errors. Room number and bed assignment (option a) can change
and are not reliable identifiers. Asking patients to state their name (option b) alone is
insufficient and unreliable for confused patients. Confirmation with family members
(option d) is not always possible and may not be reliable.
70. Correct Answer: Hand hygiene should be performed at the entrance/exit to the room,
before and after patient contact at the bedside, at the medication preparation area, before
using the computer station, and before and after using the bathroom.
Rationale: Hand hygiene is required upon entering and leaving a patient room, before and
after direct patient contact, before preparing medications, before using shared equipment
like computers, and before and after using the bathroom. These "moments for hand
hygiene" are critical for preventing healthcare-associated infections by interrupting the
transmission of pathogens.
71. Correct Answer: a) A patient who reports a sudden onset of chest pain radiating to the left
arm
Rationale: The patient with sudden onset chest pain radiating to the left arm has symptoms
suggestive of a possible myocardial infarction, which is a life-threatening emergency
requiring immediate assessment. Constipation (option b) is uncomfortable but not
immediately life-threatening. Pain medication due in 15 minutes (option c) is important
but less urgent than potential cardiac issues. Assistance with ambulation (option d) can be
briefly delayed while addressing the potentially critical situation.
72. Correct Answer: c) Providing patient history and information to the code team
Rationale: During a code blue, the primary nurse's most important role is to provide the
code team with the patient's history, events leading to the code, medications given, and
 other relevant information. This information is crucial for making appropriate treatment
decisions. Directing resuscitation efforts (option a) is typically the role of the code leader
(usually a physician). Administering medications (option b) is often assigned to another
nurse. Performing compressions (option d) is usually assigned to various team members
who rotate to maintain effective CPR.
73. Correct Answers: a, b, e, f
Rationale:
a) Baseline vital signs must be obtained to allow comparison for detecting transfusion
reactions.
b) Two licensed nurses must verify blood product information against the patient's
identity.
e) Informed consent must be documented before administering blood products.
f) An IV with 0.9% sodium chloride must be established for blood administration.
c) Administering an antipyretic (incorrect) is not routinely required before transfusion.
d) Having the patient empty their bladder (incorrect) is not required, though it may increase
comfort.
74. Correct Answer: c) Move to a private area and listen to the family member's concerns
Rationale: The best initial approach to a verbally aggressive family member is to move to
a private area and listen to their concerns. This de-escalates the situation, shows respect,
and allows for addressing the underlying issues. Calling security immediately (option a) may
escalate the situation and should be reserved for when aggression continues despite de-
escalation attempts. Responding firmly about intolerance of behavior (option b) may be
perceived as confrontational. Asking another staff member to take over (option d) fails to
address the family member's concerns.
75. Correct Answer: 30 minutes
Rationale: The minimum time interval for reassessing pain after administering IV pain
medication is 30 minutes, which corresponds to the expected onset of action for most IV
medications. This timeframe allows the nurse to evaluate the effectiveness of the
medication and determine if additional interventions are needed. More frequent
assessments may be required based on the patient's condition and facility policy.
76. Correct Answer: a) 0.4 mL
Rationale: The dose calculation formula is:
Desired dose (4 mg) ÷ Available concentration (10 mg/mL) = Volume to administer
4 mg ÷ 10 mg/mL = 0.4 mL
77. Correct Matching:
67-year-old with respiratory rate of 32, altered mental status, and SpO2 82% → Immediate
(Red)
 24-year-old with open femur fracture, stable vital signs, and moderate pain → Delayed
(Yellow)
45-year-old with minor lacerations and abrasions, ambulatory → Minimal (Green)
5-year-old with no pulse or respirations after prolonged submersion → Expectant (Black)
35-year-old with chest pain, diaphoresis, BP 90/60, anxiety → Immediate (Red)
Rationale: In disaster triage, patients are categorized by severity and likelihood of survival.
Immediate (Red) category includes patients with life-threatening conditions who need
immediate intervention and have a high likelihood of survival, such as the 67-year-old with
respiratory distress and the 35-year-old with likely cardiac issues. Delayed (Yellow) includes
serious injuries that require medical attention but can wait, like the stabilized femur
fracture. Minimal (Green) includes walking wounded with minor injuries. Expectant
(Black) includes those unlikely to survive given available resources, such as the child with
prolonged absence of vital signs.
78. Correct Answer: b) Gloves and gown should be worn when entering the room of a patient
on contact precautions
Rationale: Contact precautions require wearing gloves and a gown when entering the
patient's room to prevent transmission of pathogens through direct or indirect contact.
Contact precautions are required for multiple conditions beyond MRSA colonization
(option a), including C. difficile, multi-drug resistant organisms, and certain viral infections.
N95 respirators (option c) are required for airborne precautions, not contact precautions.
Contact precautions must be maintained for all entries to the room (option d), not just
during direct care, as environmental contamination can occur.
79. Correct Answer: b) Intervene immediately to prevent potential harm to the patient
Rationale: Patient safety is the priority. When witnessing a potential error, the nurse should
intervene immediately to prevent harm to the patient. Reporting for disciplinary action
(option a) without first preventing the error fails to prioritize patient safety. Waiting until
after the shift (option c) allows potential harm to occur. Documenting without addressing
(option d) is inappropriate and places the patient at risk.
80. Correct Answers: a, d, f
Rationale:
a) Coughing and deep breathing exercises help prevent pulmonary complications and
are appropriate interventions.
d) Assessing the surgical site with vital signs is important to monitor for complications like
infection or dehiscence.
f) Early ambulation, as ordered, helps prevent complications like DVT and atelectasis.
b) Maintaining NPO status until bowel sounds return (incorrect) is not always necessary;
current practice often encourages early feeding.
 c) Keeping the head of bed flat (incorrect) may increase aspiration risk; semi-Fowler's
position is often preferred.
e) Administering pain medication around the clock (incorrect) should be based on
assessment rather than automatic administration.
81. Correct Answer: a) Conduct a root cause analysis to identify contributing factors
Rationale: When addressing an increase in hospital-acquired pressure injuries, a root cause
analysis is the most appropriate first step in quality improvement. This systematic process
helps identify underlying factors contributing to the problem, allowing for targeted
interventions. Implementing a new protocol without analysis (option b) fails to address
specific causes of the current problem. Disciplining staff (option c) creates a punitive
culture that discourages reporting and fails to address systemic issues. Increasing
documentation requirements (option d) adds to workload without necessarily addressing
the root causes of pressure injuries.
82. Correct Answer: c) "I understand the risks and benefits, and I can withdraw consent at any
time."
Rationale: This statement demonstrates an accurate understanding of informed consent,
which includes comprehension of the procedure's risks and benefits and the right to
withdraw consent at any time. The statement in option a is incorrect because patients can
withdraw consent at any time before the procedure. Option b is incorrect because consent
forms do not absolve healthcare providers of responsibility. Option d is incomplete as it
doesn't reflect understanding of the procedure, risks, benefits, and alternatives, which are
essential components of informed consent.
83. Correct Answer: d) Flush with heparinized saline per facility protocol
Rationale: Implanted venous access ports typically require flushing with heparinized saline
according to facility protocol to maintain patency, usually monthly when not in use and
after each use. Normal saline alone (option a) may be insufficient to prevent clot formation
in a port. Hydrogen peroxide (option b) is not appropriate for port irrigation as it can
damage the port. Weekly access (option c) is unnecessary and increases infection risk
through frequent needle insertions.
84. Correct Priority Order: c, b, d, a, e
Rationale:
c) Performing a readiness assessment identifies current workflows and potential issues
before implementation.
b) Staff training should occur after assessment but before implementation.
d) Running parallel systems during transition ensures continuity of care and provides a
safety backup.
a) Ongoing technical support addresses issues that arise during implementation.
 e) Evaluation and adjustments occur after implementation to improve system
performance.
85. Correct Answer: b) Respiratory rate 8 breaths per minute, down from 16
Rationale: A respiratory rate of 8 breaths per minute indicates respiratory depression, a
serious side effect of opioids like morphine that requires immediate intervention to prevent
respiratory arrest. A decrease in blood pressure (option a) from 128/84 to 110/70 mmHg
is within normal range and doesn't require immediate intervention. A decrease in pain level
(option c) from 7/10 to 3/10 indicates effective pain management. Urinary output of 50
mL/hour (option d) is adequate and within normal range (30-50 mL/hour).
86. Correct Answers: a, b, d, e
Rationale:
a) Maintaining normothermia during the perioperative period reduces surgical site
infection risk.
b) Proper hand hygiene before wound care is essential for infection prevention.
c) Discontinuing antibiotics within 24 hours after surgery (unless otherwise indicated)
follows evidence-based guidelines for preventing antibiotic resistance.
d) Using sterile technique for surgical dressing changes prevents contamination.
c) Applying antibiotic ointment (incorrect) to all surgical incisions regardless of orders is
not evidence-based and may contribute to antibiotic resistance.
f) Clipping hair immediately before surgery (incorrect) is not recommended; if hair removal
is necessary, it should be done as close to the procedure time as possible, but not in the
operating room.
87. Correct Answer: b) Report the suspicion to the charge nurse or supervisor
Rationale: When a nurse suspects narcotic diversion, the appropriate initial action is to
report the suspicion to leadership according to facility policy. This allows for proper
investigation while protecting patients and the suspected colleague. Confronting the
colleague directly (option a) may be ineffective or lead to denial, and places the reporting
nurse in a difficult position. Monitoring for additional evidence (option c) or documenting
patterns (option d) delays intervention and potentially puts patients at risk while allowing
impaired practice to continue.
88. Correct Answer: c) Use a professional interpreter service for the education
Rationale: Professional interpreter services should be used when providing education to
patients with limited English proficiency to ensure accurate translation of medical
information. Speaking louder or using simple words (option a) does not overcome
language barriers and may seem disrespectful. Using family members as interpreters
(option b) is problematic due to potential breaches in confidentiality, emotional
 involvement, and lack of medical terminology knowledge. Providing English materials
(option d) fails to meet the patient's immediate educational needs.
89. Correct Answer: a) Administer oxygen and assess vital signs
Rationale: During a rapid response situation, the priority is to stabilize the patient,
beginning with assessing vital signs and administering oxygen as needed. This provides
immediate intervention and critical data for the rapid response team. Reviewing laboratory
results (option b), while important, is secondary to assessment and stabilization. Preparing
emergency medications (option c) should follow assessment to determine which
medications are needed. Documentation (option d) is necessary but should not take
precedence over direct patient care during an emergency.
90. Correct Answer: The nurse should position themselves between the patient and the door,
maintaining a safe distance from the patient while ensuring an unobstructed exit path.
Rationale: When caring for a patient with a history of violence, the nurse should always
position themselves between the patient and the exit, ensuring they have an unobstructed
escape route if the patient becomes aggressive. The nurse should maintain a safe distance
(at least arm's length) from the patient to allow reaction time if needed. Never allow the
patient to block access to the door, and avoid positioning that places the nurse in a corner
or confined space.
91. Correct Answer: a) Use a mechanical lift with appropriate staff assistance
Rationale: For safely transferring a 250-pound patient, a mechanical lift with appropriate
staff assistance is the best approach to prevent injury to both the patient and staff. This
follows safe patient handling guidelines. Manually transferring a heavy patient with two
colleagues (option b) increases risk of injury to staff. Encouraging independent movement
with minimal assistance (option c) may be unsafe given the patient's weight. Postponing
the transfer (option d) delays necessary care and mobility.
92. Correct Answer: b) Report the HIPAA violation according to facility policy
Rationale: When a nurse discovers a potential HIPAA violation, such as unauthorized
access to a patient's medical record, the appropriate action is to report it according to
facility policy. This ensures proper investigation and protection of patient confidentiality.
Discussing the breach directly with the healthcare worker (option a) may interfere with the
investigation process. Advising self-reporting (option c) is insufficient to meet reporting
requirements. Monitoring the situation (option d) fails to address the current violation and
puts patient confidentiality at continued risk.
93. Correct Answer: c) Protect patients by closing doors and windows
Rationale: During a fire drill, the nurse's primary responsibility is to protect patients by
containing potential fire and smoke through closing doors and windows, following the
RACE protocol (Rescue, Alarm, Contain, Extinguish/Evacuate). While evacuation
 knowledge (option a) and fire extinguisher operation (option b) are important, containment
is the priority action for staff not directly involved in rescue. Accounting for staff (option
d) is typically the responsibility of unit leadership rather than individual nurses.
94. Correct Matching:
A nurse respects a patient's informed refusal of treatment → Autonomy
A nurse ensures all patients on the unit receive equal access to care → Justice
A nurse administers pain medication to relieve suffering → Beneficence
A nurse avoids performing a procedure they're not competent to perform → Non-
maleficence
Rationale: Autonomy refers to respecting patients' rights to make their own healthcare
decisions. Justice involves fair and equal distribution of healthcare resources. Beneficence
means acting to promote patients' well-being. Non-maleficence is the principle of avoiding
harm ("first, do no harm"), which includes not performing procedures beyond one's
competence.
95. Correct Order: b, c, a, d
Rationale:
b) Gloves should be removed first because they are the most contaminated.
c) The gown should be removed next, being careful to fold it with the contaminated side
inward.
a) The mask should be removed last, touching only the ties or elastics.
d) Hand hygiene should be performed immediately after removing all PPE.
This sequence follows standard precautions for doffing personal protective equipment
(PPE) to minimize contamination risk.
96. Correct Answer: b) Prepare all supplies, perform hand hygiene, then apply sterile gloves
Rationale: The correct sequence for a central venous catheter dressing change is to prepare
all supplies first, perform hand hygiene, and then apply sterile gloves immediately before
the procedure. This maximizes sterility and efficiency. Applying sterile gloves before
preparing supplies (option a) increases the risk of contaminating the gloves. Performing
hand hygiene and applying sterile gloves before preparing supplies (option c) may lead to
contamination during preparation. Removing the old dressing with clean gloves and then
applying sterile gloves (option d) is an unnecessary double-gloving process that increases
contamination risk.
97. Correct Answers: c, d, e
Rationale:
c) Using the hazardous drug spill kit according to protocol is the appropriate response for
containing and cleaning a hazardous medication spill.
d) Evacuating patients from the immediate area protects them from exposure.
 e) Documenting the incident is required for risk management and improvement.
a) Immediately wiping with paper towels (incorrect) increases exposure risk and
inadequately contains hazardous material.
b) Notifying environmental services (incorrect) is insufficient; specially trained staff
using proper equipment must handle hazardous spills.
f) Continuing patient care in the area (incorrect) exposes patients and staff to hazardous
substances.
98. Correct Answer: b) A patient with a heart rate of 52 ordered digoxin
Rationale: The nurse should question digoxin administration to a patient with a heart rate
of 52 beats per minute, as bradycardia (HR < 60) is a contraindication for digoxin, which
could further slow the heart rate to dangerous levels. Cephalexin for a patient with
penicillin allergy (option a) may be appropriate as most patients with penicillin allergies can
tolerate cephalosporins, though cross-reactivity is possible in some cases. Gentamicin with
normal creatinine (option c) is appropriate as renal function appears normal. Lisinopril
with a systolic BP of 136 (option d) is within normal range and not a contraindication.
99. Correct Answer: a) Coordinate patient care and allocate staff appropriately
Rationale: During a disaster, the charge nurse's primary responsibility is to coordinate
patient care and allocate staff appropriately to ensure all patients receive necessary care
based on priority needs. While family communication (option b) is important, it is often
delegated to a designated staff member or team. Documentation (option c) is necessary
but should not take precedence over coordinating care. Overseeing facility evacuation
(option d) is typically the responsibility of the incident commander or emergency
management team, not individual charge nurses.
100. Correct Answer: c) Right documentation
Rationale: The "Sixth Right" commonly added to the five rights of medication administration is
"Right documentation," which ensures that medication administration is properly recorded
to maintain continuity of care and legal protection. While right technique (option a), right
education (option b), and right monitoring (option c) are all important aspects of
medication administration, "Right documentation" is most commonly recognized as the
sixth element in the medication administration rights framework.
101. Correct Answer: b) Have a clinical breast exam every 3 years
Rationale: For average-risk women in their 30s with no family history or genetic predisposition
to breast cancer, clinical breast exams every 3 years are recommended. Annual
mammograms (options a and c) are not typically recommended for women under 40 with
average risk. A baseline mammogram (option d) is not part of standard screening
recommendations for a 32-year-old woman with no risk factors. Current guidelines from
 major organizations recommend beginning mammography between ages 40-50, with
varying recommendations on frequency.
102. Correct Answer: b) Installing safety gates at the top and bottom of stairs
Rationale: Safety gates at the top and bottom of stairs are important for a 15-month-old child
who is likely walking and climbing but lacks judgment about safety hazards. A forward-
facing car seat (option a) is not recommended for a 15-month-old; children should remain
in rear-facing car seats until at least age 2 or until they reach the maximum height and
weight for their rear-facing seat. Supervised swimming (option c) still presents drowning
risks for a 15-month-old. Honey (option d) is safe for children over 12 months, so this is
no longer a concern at 15 months.
103. Correct Answer: b) Using peer-led discussion groups focusing on real-life scenarios
Rationale: Adolescents are heavily influenced by their peers and respond well to realistic
scenarios that they can relate to their own lives. Peer-led discussions allow for sharing of
experiences and problem-solving in a relevant context. Factual information with emphasis
on long-term consequences (option a) is less effective because adolescents tend to focus
on immediate outcomes rather than future risks. Having parents present (option c) may
inhibit open discussion about sensitive topics. Simple language and repetition (option d)
may be perceived as talking down to adolescents, who have the cognitive ability to
understand more complex concepts.
104. Correct Answer: b) Colonoscopy every 10 years
Rationale: Current colorectal cancer screening guidelines for average-risk individuals
recommend beginning screening at age 45-50, with colonoscopy every 10 years being one
of the primary recommended options. Annual fecal occult blood testing (option a) is
another acceptable screening method but needs to be done yearly rather than every 10
years. Digital rectal examination alone (option c) is not considered adequate for colorectal
cancer screening. Sigmoidoscopy (option d) is typically recommended every 5 years but is
often combined with annual fecal occult blood testing for comprehensive screening.
105. Correct Answers: a, b, c, f
Rationale:
a) Copying a circle and square is appropriate for a 4-year-old's fine motor and cognitive
development.
b) Counting to 20 is typical for a 4-year-old's cognitive and language development.
c) Riding a bicycle without training wheels is an appropriate gross motor skill for many
4-year-olds.
f) Identifying primary colors is an age-appropriate cognitive milestone for a 4-year-old.
d) Using plural words (incorrect) typically occurs around age 2, so would not be a new
development for a 4-year-old.
e) Tying shoelaces independently (incorrect) is typically mastered between ages 5-7, making it
advanced for a 4-year-old.
106. Correct Answer: c) 25-35 pounds
Rationale: For a woman with a pre-pregnancy BMI of 24 (which falls within the normal range
of 18.5-24.9), the recommended total weight gain during pregnancy is 25-35 pounds.
Women with underweight pre-pregnancy BMI (<18.5) should gain 28-40 pounds (option
d). Women with overweight pre-pregnancy BMI (25-29.9) should gain 15-25 pounds
(option b). Women with obesity pre-pregnancy BMI (≥30) should gain 11-20 pounds
(option a). These guidelines aim to support optimal maternal and fetal outcomes.
107. Correct Answer: b) "I understand you have concerns. What specific questions can I address
about vaccine safety?"
Rationale: This approach acknowledges the parent's concerns and opens a dialogue, allowing
the nurse to address specific questions with factual information. This person-centered
approach builds trust and promotes informed decision-making. Stating that unvaccinated
children cannot attend public school (option a) may be inaccurate depending on state
exemption policies and creates an adversarial relationship. Making declarative statements
about risks (option c) without first understanding the parent's specific concerns may seem
dismissive. Appealing to what most parents do (option d) uses peer pressure rather than
education to influence decision-making.
108. Correct Priority Order: d, b, e, a, c
Rationale:
d) Rolls from back to stomach - typically occurs around 3-5 months
b) Sits without support - typically occurs around 6-7 months
e) Crawls on hands and knees - typically occurs around 8-10 months
a) Says first word - typically occurs around 10-14 months
b) Walks independently - typically occurs around 12-15 months
109. Correct Answer: b) Vision and hearing screening
Rationale: Vision and hearing screenings are appropriate and recommended for elementary
school children, as deficits can significantly impact learning and development. These
screenings can identify problems early when intervention is most effective. Depression
screening (option a) is more commonly recommended for adolescents rather than
elementary-age children. STI screening (option c) is not age-appropriate for elementary
school children. Osteoporosis screening (option d) is recommended for older adults, not
children.
110. Correct Answers: b, c, e
Rationale:
b) Maintaining blood pressure below 120/80 mmHg is recommended for cardiovascular health.
c) Participating in moderate exercise for at least 150 minutes per week follows current physical
activity guidelines for adults.
e) Limiting sodium intake helps control blood pressure and reduces cardiovascular risk.
a) Taking daily aspirin (incorrect) without consulting a healthcare provider is not
recommended, as aspirin therapy has risks and benefits that should be individually
assessed.
d) Checking cholesterol every 5 years (incorrect) may be insufficient for someone with a family
history of cardiovascular disease; more frequent monitoring may be recommended.
f) Annual ECG screening (incorrect) is not routinely recommended for asymptomatic
individuals, even with family history, unless specifically indicated by a healthcare provider.
111. Correct Answer: c) "Hormone therapy will completely prevent all symptoms of
menopause."
Rationale: This statement indicates a need for further teaching because hormone therapy does
not completely prevent all menopausal symptoms, though it can reduce the frequency and
severity of some symptoms like hot flashes and vaginal dryness. The statements about hot
flashes and night sweats (option a) and the definition of menopause (option b) are accurate.
The recommendation to continue contraception for a year after the last period (option d)
is also correct, as pregnancy is still possible during the perimenopausal transition until
menopause is confirmed.
112. Correct Answer: The nurse should place the measuring tape at the midpoint between the
acromion process (shoulder) and the olecranon process (elbow), with the arm hanging
relaxed at the side.
Rationale: The mid-upper arm circumference (MUAC) is measured at the midpoint between the
shoulder (acromion process) and the elbow (olecranon process) with the arm relaxed and
hanging at the side. This measurement helps assess nutritional status and is particularly
useful during pregnancy when weight gain may not accurately reflect nutritional adequacy.
MUAC remains relatively stable during pregnancy and can help identify malnutrition.
113. Correct Answer: c) Making balanced food choices and enjoying physical activity
Rationale: For teenagers, focusing on balanced food choices and enjoying physical activity
promotes a healthy relationship with food and exercise, supporting overall health without
emphasizing weight or restrictive practices. This approach acknowledges the importance
of nutrient-dense foods while allowing flexibility. Calorie counting and portion control
(option a) may lead to unhealthy food relationships or disordered eating in adolescents.
Following a specific diet plan (option b) is often unsustainable and doesn't teach adaptable
healthy eating habits. Avoiding all processed foods and sugar (option d) is unrealistic and
may promote an all-or-nothing mentality toward eating.
114. Correct Answer: c) The sex of the fetus can be determined by ultrasound
Rationale: At 14 weeks gestation, the sex of the fetus can often be determined by ultrasound as
the external genitalia have developed sufficiently to be visualized. The fetus cannot yet hear
sounds from outside the uterus (option a) until around 18-20 weeks when the auditory
system becomes functional. While most major organs have formed by 14 weeks, they are
not all fully functioning (option b) and will continue to develop throughout pregnancy. At
14 weeks, the fetus is approximately 3.5 inches (9 cm) long, not 16 inches (option d), which
would be closer to a full-term measurement.
115. Correct Answer: c) The child has a vocabulary of 50 words but doesn't combine words
Rationale: By age 2, most children have a vocabulary of at least 50 words and have begun to
combine words into short phrases (e.g., "more milk," "daddy go"). A 2-year-old with 50
words who isn't combining words may be showing signs of a language delay that warrants
further evaluation. Using 15 single words (option a) would be concerning, as a 2-year-old
should have a minimum vocabulary of about 50 words. Not being able to pedal a tricycle
(option b) is developmentally appropriate, as this skill typically develops between ages 2-3.
Preferring to play alone (option d) is common for 2-year-olds, who often engage in parallel
play rather than cooperative play.
116. Correct Answer: b) To identify individuals who carry genes for specific disorders
Rationale: The primary purpose of genetic screening is to identify individuals who carry genes
associated with specific disorders, which can inform reproductive decisions, health
monitoring, and early intervention strategies. Genetic screening does not necessarily
determine the exact cause of a genetic disorder (option a), which would require more
comprehensive genetic testing. Genetic screening cannot cure genetic diseases (option c);
it only identifies the presence of certain genes. While genetic screening can help in
prevention strategies, it cannot prevent all birth defects (option d), as many have
multifactorial or unknown causes.
117. Correct Matching:
Combined oral contraceptive pills → 99.2% effective
Male condoms → 98% effective
Copper IUD → >99% effective
Withdrawal method → 78% effective
Contraceptive implant → >99% effective
Rationale: With perfect use, combined oral contraceptive pills are about 99.2% effective, male
condoms are about 98% effective, copper IUDs and contraceptive implants are both
>99% effective (long-acting reversible contraceptives are the most effective reversible
methods), and the withdrawal method is about 78% effective even with perfect use. It's
important to note that typical use effectiveness rates are lower than perfect use rates for
methods that require consistent and correct use, such as pills and condoms.
118. Correct Answer: c) Annual influenza vaccination
Rationale: Annual influenza vaccination is recommended for adults of all ages but is particularly
important for older adults (≥65 years) who are at higher risk for serious complications
from influenza. High-intensity exercise programs (option a) may not be appropriate for all
70-year-olds, especially those with underlying health conditions; moderate exercise with
strength training is typically recommended. Limiting fluid intake after dinner (option b) is
not a general recommendation for older adults and may lead to dehydration; management
of nocturia should be tailored to individual needs and underlying causes. Taking calcium
supplements regardless of dietary intake (option d) is not recommended; supplementation
should be based on individual needs and current calcium intake.
119. Correct Answer: a) Begin introducing solid foods, starting with iron-fortified cereals
Rationale: At 6 months of age, infants should begin the introduction of complementary foods
while continuing breastfeeding or formula feeding. Iron-fortified cereals are often
recommended as a first food due to their iron content, which becomes increasingly
important at this age. Whole cow's milk (option b) should not be introduced until 12
months of age, as it lacks necessary nutrients and may cause intestinal bleeding in infants.
Fruit juices (option c) are not recommended for infants under 12 months due to their high
sugar content and minimal nutritional value. Exclusive breastfeeding (option d) is
recommended for the first 6 months but should be complemented with solid foods after
this age to meet the infant's growing nutritional needs.
120. Correct Answers: b, d, f
Rationale:
b) HPV vaccination for eligible individuals ages 9-26 is a recommended primary prevention
strategy for cervical, anal, and other HPV-related cancers.
d) Cervical cancer screening with Pap tests starting at age 21 follows current guidelines for
early detection.
f) Colonoscopy beginning at age 45 for those at average risk reflects updated guidelines
from the American Cancer Society for colorectal cancer screening.
a) Annual full-body skin examinations (incorrect) for everyone over 18 is not a
standard recommendation; skin cancer screening guidelines vary by risk factors.
b) Low-dose CT scan (incorrect) is only recommended for lung cancer screening in
high-risk individuals (e.g., heavy smokers), not the general asymptomatic
population.
e) PSA testing for all men over 40 (incorrect) is not a blanket recommendation; decisions
about prostate cancer screening should be individualized based on risk factors and shared
decision-making.
B. Health Promotion and Maintenance
1. Correct Answer: b) "Most smokers need multiple attempts before successfully quitting."
Rationale: Research shows that most smokers make multiple quit attempts (often 8-10 or
more) before achieving long-term cessation. This statement acknowledges the challenge of
quitting and normalizes the need for repeated efforts, which can encourage the patient to
persist even after relapses. The "cold turkey" approach (option a) is not statistically the
most effective method; a combination of behavioral support and pharmacotherapy often
yields better results. Smoking cessation medications (option c) can be effective for light,
moderate, and heavy smokers. Gradual reduction over six months (option d) is not
necessarily supported by evidence as more effective than other approaches.
2. Correct Answers: a, b, d, f
Rationale:
a) Regular weight-bearing exercise stimulates bone formation and helps maintain bone
density.
b) Adequate calcium intake (1000-1200 mg daily for adults) is essential for bone health.
c) Vitamin D is necessary for calcium absorption and bone health, and
supplementation may be needed if dietary intake is insufficient.
f) Limiting caffeine consumption is recommended as excessive caffeine can interfere with
calcium absorption.
c) Limited sun exposure (incorrect) may reduce vitamin D production, which is important
for bone health; safe sun exposure (with appropriate protection) is beneficial.
e) Avoiding dairy products (incorrect) is not recommended for osteoporosis prevention,
as dairy is a primary source of calcium; dairy alternatives with calcium can be used for those
who cannot consume dairy.
3. Correct Answer: c) Hepatitis C testing if born between 1945 and 1965
Rationale: The CDC and U.S. Preventive Services Task Force recommend one-time
Hepatitis C testing for all adults born between 1945 and 1965 (Baby Boomers), regardless
of risk factors, due to the higher prevalence in this population. Annual PSA testing (option
a) is not universally recommended; decisions about prostate cancer screening should be
individualized based on shared decision-making. Bone density scanning (option b) is
typically recommended for women over 65 and men over 70, not for a 55-year-old male
without specific risk factors. Annual chest X-rays (option d) are not recommended as a
screening tool for the general population due to radiation exposure and lack of proven
benefit.
4. Correct Answer: c) Place the infant on their back for sleep in a crib with a firm mattress
 Rationale: The American Academy of Pediatrics recommends placing infants on their
backs for sleep on a firm, flat surface (such as a crib mattress covered by a fitted sheet) to
reduce the risk of Sudden Infant Death Syndrome (SIDS). Stomach sleeping (option a)
increases the risk of SIDS and is not recommended. Introducing solid foods (option b) is
not recommended until around 6 months of age and should not be used to improve sleep
patterns. Soft toys and blankets (option d) pose suffocation hazards and should not be
placed in an infant's sleep environment.
5. Correct Answer: b) Call the healthcare provider if she feels fewer than 10 movements in 2
hours
Rationale: The standard recommendation for fetal movement monitoring in the third
trimester is to contact the healthcare provider if there are fewer than 10 movements in a
2-hour period after eating or drinking something sweet to stimulate fetal activity. Weekly
monitoring (option a) is insufficient for detecting potential problems. While fetal activity
may naturally vary throughout the day, instructing that there is more activity in the evening
(option c) is an overgeneralization. Only counting strong movements (option d) would
miss many normal fetal movements and could lead to false concerns about decreased
movement.
6. Correct Priority Order: b, d, c, e, a
Rationale:
b) Hepatitis B vaccine - First dose given at birth
d) Rotavirus vaccine - First dose given at 2 months
c) Pneumococcal conjugate vaccine (PCV13) - First dose given at 2 months
e) Influenza vaccine - First dose given at 6 months
a) Measles, Mumps, Rubella (MMR) vaccine - First dose given at 12-15 months
7. Correct Answer: c) The vaccine is recommended for both males and females ages 11-12
years
Rationale: The HPV vaccine is recommended for routine vaccination of both males and
females at ages 11-12 years (can be started as early as age 9). This recommendation aims to
provide protection before potential exposure through sexual activity. The vaccine is not
recommended only for females (option a); both males and females benefit from protection
against HPV-related cancers and conditions. The vaccine does not protect against all
sexually transmitted infections (option b), only those caused by the HPV types included in
the vaccine. Multiple doses are required for full protection (option d), not a single dose.
8. Correct Answer: b) Picture or symbol chart
Rationale: For a 3-year-old child, a picture or symbol chart (such as the LEA Symbols or
Allen Picture cards) is the most appropriate vision screening method. These charts use
simple, recognizable symbols that young children can identify without knowing letters. The
 Snellen eye chart (option a) requires knowledge of letters and is more appropriate for
school-age children. Random dot E stereograms (option c) assess depth perception but are
difficult for young children to comprehend. Confrontation visual field testing (option d)
assesses peripheral vision but is not a primary screening method for visual acuity in
children.
9. Correct Answer: b) "You should meet with a genetic counselor to discuss your risk and
testing options."
Rationale: Referring to a genetic counselor is the most appropriate response for someone
with a family history of breast cancer. A genetic counselor can provide comprehensive risk
assessment, discuss the benefits and limitations of genetic testing, and help the patient
make an informed decision based on their specific situation. Dismissing the need for
genetic testing based on the mother's age at diagnosis (option a) oversimplifies risk
assessment. Recommending testing based solely on having a first-degree relative with
breast cancer (option c) does not consider other important factors. Suggesting waiting until
age 45 (option d) may delay potentially valuable information that could inform screening
and prevention strategies.
10. Correct Answer: The nurse should focus on areas with the highest sun exposure, including
the face, ears, neck, and back of hands, as well as the scalp for those with thinning hair.
Rationale: These areas receive the most sun exposure and are common sites for skin cancer
development. The nurse should educate the patient about the importance of applying
sunscreen to these areas, wearing protective clothing (wide-brimmed hats, long sleeves),
seeking shade, and performing regular skin self-examinations. The back and shoulders are
also high-risk areas, particularly for melanoma, and are often neglected during self-
application of sunscreen.
11. Correct Answer: b) Maintain normal body weight before conception
Rationale: Maintaining a normal body weight before conception promotes better maternal
and fetal outcomes by reducing risks of complications such as gestational diabetes,
hypertension, and difficult deliveries. Folic acid supplementation (option a) should begin
before conception, not when pregnancy is confirmed, to reduce the risk of neural tube
defects which develop in the first few weeks of pregnancy. Restricting all medications
(option c) is not appropriate; some medications are necessary for maternal health, and
discontinuation should be evaluated on a case-by-case basis with healthcare provider
guidance. Postponing pregnancy until completing all dental work (option d) is
unnecessarily restrictive; routine dental care can be performed safely during pregnancy.
12. Correct Answer: b) At least 30 minutes daily, 5 days per week
Rationale: Current guidelines from the American Heart Association and American College
of Sports Medicine recommend at least 150 minutes of moderate-intensity aerobic physical
 activity per week for adults, which can be achieved through 30 minutes daily, 5 days per
week. Three days per week (options a and c) would not meet the recommended total of
150 minutes unless the duration was extended. While 60 minutes daily, 7 days per week
(option d) exceeds the minimum recommendation and would provide additional health
benefits, it is not the standard recommendation for general cardiovascular health
promotion.
13. Correct Answers: a, b, d, f
Rationale:
a) Removing throw rugs eliminates a common tripping hazard in the home.
b) Installing grab bars in the bathroom provides support during transfers and reduces
fall risk in a high-risk area.
c) Regular vision and hearing checks can identify sensory deficits that contribute to
falls.
f) Reviewing medications with a healthcare provider can identify those that may increase
fall risk through side effects like dizziness or sedation.
c) Limiting physical activity (incorrect) may lead to deconditioning and actually increase
fall risk; appropriate exercise programs can improve strength and balance.
e) Minimizing fluid intake in the evening (incorrect) could lead to dehydration, which
increases fall risk; while managing fluids to reduce nighttime bathroom trips is reasonable,
general fluid restriction is not recommended.
14. Correct Answer: b) Playing with building blocks
Rationale: Building blocks are developmentally appropriate for a 12-month-old child,
promoting fine motor skills, spatial awareness, and cause-and-effect understanding
through stacking and knocking down. Coloring with crayons (option a) requires more
advanced fine motor skills typically seen in children 18-24 months and older. Using scissors
(option c) is appropriate for preschool-age children (3-4 years) due to the complex fine
motor coordination required. Reading independently (option d) is a skill developed in early
elementary school years, not during infancy.
15. Correct Answer: c) Maintaining a healthy weight through diet and exercise
Rationale: Research consistently shows that maintaining a healthy weight through balanced
diet and regular physical activity is the most effective strategy for preventing type 2
diabetes, reducing risk by up to 58% in high-risk individuals. Prophylactic metformin
(option a) may be recommended for high-risk individuals but is not the first-line approach
for the general population with family history alone. A high-protein, low-carbohydrate diet
(option b) has not been established as the optimal approach for diabetes prevention;
balanced nutrition with appropriate carbohydrate intake is recommended. Daily blood
 glucose monitoring (option d) is not recommended for diabetes prevention in otherwise
healthy individuals with a family history alone.
16. Correct Matching:
First trimester (weeks 1-12) → Start pelvic floor exercises
Second trimester (weeks 13-26) → Undergo screening for gestational diabetes
Third trimester (weeks 27-40) → Receive Tdap vaccination, Begin fetal movement
counting
Postpartum period → Prepare for breastfeeding
Rationale: Pelvic floor exercises should begin early in pregnancy to strengthen muscles
supporting the uterus and bladder. Gestational diabetes screening typically occurs between
24-28 weeks (second trimester). Tdap vaccination is recommended between 27-36 weeks
of each pregnancy to provide passive antibody transfer to the fetus. Fetal movement
counting begins in the third trimester when movements are more consistent. While
breastfeeding preparation can begin during pregnancy, the actual practice of breastfeeding
occurs in the postpartum period.
17. Correct Answer: b) "Tell me about how you spend time with your friends."
Rationale: This open-ended question creates a non-threatening opportunity for the
adolescent to discuss peer relationships and activities, potentially revealing risk behaviors
without direct questioning that might create defensiveness. Asking directly about alcohol
or drug use (option a) may prompt denial or defensiveness. Asking about peer pressure
(option c) assumes negative influence and may seem judgmental. Inquiring about parental
knowledge of activities (option d) may suggest suspicion and hinder open communication.
Open-ended questions are more effective for establishing rapport and gathering
information from adolescents.
18. Correct Answer: b) Promoting 60 minutes of daily physical activity
Rationale: The CDC and American Academy of Pediatrics recommend that children and
adolescents participate in 60 minutes or more of physical activity daily as part of healthy
development and weight management. Restricting caloric intake based on BMI percentile
(option a) is not recommended for growing children and may lead to nutritional
deficiencies or unhealthy relationships with food. Eliminating all sugar-containing foods
(option c) is unnecessarily restrictive and difficult to maintain; moderation and balanced
nutrition are more sustainable approaches. Weekly weighing (option d) could create
unhealthy body image concerns and is not recommended for childhood obesity prevention
programs.
19. Correct Answer: b) Engaging in mentally stimulating activities and social interaction
Rationale: Research supports that engaging in mentally stimulating activities (reading,
puzzles, learning new skills) and maintaining social connections help preserve cognitive
 function in older adults. Complete retirement from all work and volunteer activities (option
a) may reduce cognitive stimulation and social interaction, potentially accelerating cognitive
decline. Ginkgo biloba supplements (option c) have not been consistently proven effective
for enhancing memory or preventing cognitive decline in clinical studies. Limiting physical
activity (option d) is counterproductive; regular physical exercise is associated with better
cognitive health in older adults.
20. Correct Answer: d) Monitor for fever and give acetaminophen as needed for discomfort
Rationale: After immunizations, parents should monitor for fever and discomfort and
administer acetaminophen as needed according to weight-based dosing guidelines.
Prophylactic administration of acetaminophen regardless of symptoms (option a) is not
currently recommended as some research suggests it may reduce immune response to
vaccines. Warm compresses (option b) may increase discomfort at injection sites; cool
compresses are typically recommended for localized reactions. While parents should
contact the healthcare provider for concerning symptoms, a specific threshold of 104°F
(option c) is too high; most providers recommend calling for persistent fever over 101-
102°F or for fever lasting more than 48 hours after vaccination.
21. Correct Answer: b) Honey
Rationale: Honey should not be given to infants under 12 months of age due to the risk of
infant botulism. Honey can contain Clostridium botulinum spores, which can germinate in
an infant's immature digestive system and produce toxins that cause botulism. Soft cooked
vegetables (option a), mashed beans (option c), and small pieces of soft fruits (option d)
are all appropriate foods for a 9-month-old who has started solid foods and is developing
pincer grasp.
22. Correct Answer: c) Irregular menstrual cycles
Rationale: Irregular menstrual cycles are the most characteristic symptom of
perimenopause due to fluctuating hormone levels. During perimenopause, women
typically experience variations in cycle length, menstrual flow, and interval between
periods. Complete cessation of menstruation (option a) defines menopause, not
perimenopause. Increased menstrual regularity (option b) is not characteristic of
perimenopause. Decreased vaginal secretions (option d) are more commonly associated
with established menopause rather than perimenopause, although some vaginal changes
may begin during the perimenopausal transition.
23. Correct Answers: a, b, c
Rationale:
a) A history of previous falls is a strong predictor of future falls and indicates a need
for comprehensive assessment and intervention.
 b) Polypharmacy (use of four or more medications) increases fall risk due to potential
side effects and drug interactions that may affect balance and coordination.
c) Lower body weakness reduces stability and the ability to recover from loss of
balance, increasing fall risk.
d) Daily stretching exercises (incorrect) actually decrease fall risk by improving
flexibility and balance.
e) Well-lit living areas (incorrect) reduce fall risk by improving visibility of potential
hazards.
f) Normal blood pressure readings (incorrect) are generally protective; orthostatic
hypotension (a drop in blood pressure when changing positions) would increase fall
risk.
24. Correct Answer: a) Use 3-4 word sentences and be understood by strangers
Rationale: By age 3, children typically use 3-4 word sentences and their speech is
understandable to unfamiliar listeners about 75% of the time. While vocabulary and
pronunciation continue to develop, this represents typical language development for this
age. Naming all letters of the alphabet (option b) is generally a skill developed between
ages 4-5 years during the preschool period. Speaking without grammatical errors (option
c) is not expected at age 3; children continue to refine grammar well into early elementary
school. Following 5-step verbal commands (option d) exceeds typical receptive language
abilities for a 3-year-old, who can usually follow 2-3 step commands.
25. Correct Answer: b) Mediterranean diet
Rationale: The Mediterranean diet has the strongest evidence base for cardiovascular health
benefits, with multiple large studies demonstrating reduced risk of heart disease, stroke,
and cardiovascular mortality. This dietary pattern emphasizes fruits, vegetables, whole
grains, fish, olive oil, nuts, and limited red meat. Low-carbohydrate, high-protein diets
(option a) have mixed evidence regarding long-term cardiovascular effects and may
increase risk if they include high amounts of animal proteins and fats. While vegetarian
diets (option c) can be heart-healthy, a strict vegetarian diet is not necessarily superior to
the Mediterranean diet for cardiovascular outcomes and may require careful planning to
meet all nutritional needs. High-protein, low-fat diets (option d) have not been consistently
shown to improve cardiovascular outcomes more than the Mediterranean pattern.
26. Correct Priority Order: d, e, c, b, a
Rationale:
d) Select a broad-spectrum sunscreen with SPF 30 or higher - First choose an appropriate
product
e) Use approximately one ounce for full body coverage - Determine the correct amount
 c) Apply 15-30 minutes before sun exposure - Allow time for the sunscreen to bind to the
skin
b) Apply to all exposed skin areas including ears and neck - Ensure complete coverage
a) Reapply every two hours and after swimming or sweating - Maintain protection
throughout exposure
27. Correct Answer: The nurse should focus assessment on the shoulder blade area, waistline
symmetry, and alignment of the spine, looking for asymmetry when the patient bends
forward (Adam's forward bend test).
Rationale: Early signs of scoliosis include uneven shoulder heights, asymmetry of the
scapulae (shoulder blades), uneven waistline, and lateral curvature of the spine. The Adam's
forward bend test (having the patient bend forward at the waist with arms hanging freely)
helps visualize rotational deformities and rib humps, which are key indicators of scoliosis.
School screening programs typically assess these areas to identify adolescents who need
further evaluation.
28. Correct Answer: a) Taking 400 mcg of folic acid daily beginning at least one month before
conception
Rationale: The CDC and American College of Obstetricians and Gynecologists
recommend that all women of reproductive age consume 400 mcg of folic acid daily, ideally
beginning at least one month before conception and continuing through early pregnancy.
This recommendation aims to reduce the risk of neural tube defects, which develop in the
first 28 days after conception, often before a woman knows she is pregnant. Starting folic
acid only after pregnancy confirmation (option b) may be too late to prevent neural tube
defects. Taking 1000 mcg only during the first trimester (option c) exceeds the
recommended dose for women without specific risk factors and does not address the
critical pre-conception period. Using supplements only if dietary intake is inadequate
(option d) is problematic because many women do not get adequate folic acid through diet
alone, and assessment of dietary adequacy may be difficult.
29. Correct Answer: b) Children 6 months and older
Rationale: The CDC recommends annual influenza vaccination for everyone 6 months of
age and older, with rare exceptions. Children are highlighted as a priority group because
they are at higher risk for serious flu complications and can spread the virus in the
community. While healthy adults ages 25-40 (option a) should receive the vaccine, they are
not considered a higher priority group than children. Previous vaccination (option c) does
not eliminate the need for annual vaccination due to waning immunity and changing virus
strains. While individuals with egg allergies (option d) can receive influenza vaccines (with
certain precautions depending on severity of allergy), they are not specifically prioritized
over other groups.
30. Correct Answer: monthly
Rationale: The American Cancer Society and other health organizations recommend that
men perform testicular self-examination monthly to detect abnormal changes that could
indicate testicular cancer or other conditions. Monthly examination allows men to become
familiar with the normal feel of their testicles and more readily identify changes, while not
being so frequent as to discourage compliance. Testicular cancer is most common in men
between the ages of 15 and 35, making regular self-examination an important health
promotion activity for this age group.
31. Correct Answer: c) Look for signs of readiness such as staying dry for longer periods
Rationale: The most appropriate approach to toilet training is to look for signs of
developmental readiness, which typically include staying dry for longer periods (2 hours or
more), recognizing the sensation of needing to eliminate, showing interest in the toilet, and
having the physical ability to sit on and get off the toilet. Beginning training based solely
on walking ability (option a) ignores other important developmental factors. Punishment
techniques (option b) can create anxiety and resistance, potentially prolonging the process
and creating negative associations. Expecting simultaneous day and night dryness (option
d) is unrealistic; nighttime bladder control often develops months or even years after
daytime control due to physiological differences in sleep arousal and hormone production.
32. Correct Matching:
Iron → Legumes and red meat
Calcium → Leafy greens and dairy products
Omega-3 fatty acids → Fatty fish and flaxseeds
Vitamin C → Bell peppers and citrus fruits
Fiber → Whole grains and legumes
Rationale: Iron is found in high amounts in both animal sources (red meat, with heme iron
that is more easily absorbed) and plant sources (legumes, containing non-heme iron).
Calcium is abundant in dairy products and also found in significant amounts in leafy green
vegetables like kale and collard greens. Omega-3 fatty acids are primarily found in fatty fish
(such as salmon and mackerel) and certain plant sources like flaxseeds and walnuts. Vitamin
C is highest in fruits and vegetables, particularly bell peppers, citrus fruits, strawberries,
and broccoli. Fiber is most abundant in plant foods, especially whole grains, legumes, fruits,
and vegetables.
33. Correct Answer: c) Processed foods high in sodium
Rationale: The DASH (Dietary Approaches to Stop Hypertension) diet specifically
recommends limiting processed foods high in sodium, as reducing sodium intake is a key
component of this dietary pattern for blood pressure management. The DASH diet
encourages consumption of fresh fruits (option a), low-fat dairy products (option b), and
 whole grains (option d), all of which provide important nutrients like potassium, calcium,
magnesium, and fiber that help lower blood pressure. The DASH diet typically
recommends limiting sodium to 2,300 mg daily (with 1,500 mg for those who would
benefit from greater blood pressure reduction).
34. Correct Answer: b) Tobacco use
Rationale: Tobacco use is the most significant modifiable risk factor for multiple types of
cancer, including lung, head and neck, esophageal, pancreatic, bladder, and cervical cancers.
The World Health Organization estimates that tobacco use causes about 22% of cancer
deaths globally. Unlike family history (option a), age (option c), and gender (option d),
which are non-modifiable risk factors, tobacco use can be completely eliminated through
behavior change, making it the most impactful modifiable risk factor for cancer prevention.
35. Correct Answer: b) At least 60 minutes of active play daily
Rationale: Current physical activity guidelines for children ages 3-5 years recommend at
least 60 minutes of active play daily, which should include a mix of structured and
unstructured activities that develop a variety of motor skills. Structured sports training
(option a) is not developmentally appropriate as the primary form of physical activity for
5-year-olds, who benefit more from exploratory and varied movement experiences.
Limiting physical activity to prevent injuries (option c) is unnecessary and
counterproductive to developing motor skills and healthy habits. Focusing on specific
athletic skills (option d) is premature at this age; the emphasis should be on developing
fundamental movement skills through diverse activities.
36. Correct Answer: d) Yoga and weight-bearing exercises
Rationale: Weight-bearing exercises, including yoga poses that involve supporting body
weight, stimulate bone formation and help maintain or increase bone density. These
activities create mechanical stress on bones, which respond by becoming stronger.
Swimming (option a) and cycling (option b), while excellent cardiovascular exercises,
provide minimal bone-loading stimulus because they are non-weight-bearing activities
where body weight is supported by water or the bicycle. Walking on a treadmill (option c)
provides some weight-bearing benefit but typically creates less bone-loading stimulus than
activities involving resistance, impact, or varied directional forces like those found in yoga
and strength training.
37. Correct Answers: b, c, e
Rationale:
b) Regular physical activity helps control weight, improves insulin sensitivity, and reduces
diabetes risk.
c) Evidence from the Diabetes Prevention Program showed that losing 5-7% of body
weight significantly reduces diabetes risk in overweight individuals.
 e) Regular screening for prediabetes and diabetes is important for early detection and
intervention, especially for those with risk factors.
a) Eliminating all carbohydrates (incorrect) is not recommended; the focus should be
on choosing complex carbohydrates with fiber rather than refined carbohydrates.
d) Avoiding all sugar (incorrect) is overly restrictive; moderate consumption of sugar within
an overall healthy diet is acceptable for diabetes prevention.
f) Very low-calorie diets (incorrect) are not recommended for diabetes prevention;
moderate, sustainable calorie reduction with balanced nutrition is more effective.
38. Correct Answer: c) Changing cat litter
Rationale: Pregnant women should avoid changing cat litter due to the risk of
toxoplasmosis, a parasitic infection that can cross the placenta and cause serious
complications including miscarriage, stillbirth, or congenital defects. If changing cat litter
cannot be avoided, gloves should be worn and hands washed thoroughly afterward.
Microwave cooking (option a) does not pose a specific risk during pregnancy when used
properly. Cell phone use (option b) has not been proven to pose risks during pregnancy
based on current evidence. Using household cleaners with gloves (option d) is actually a
recommended precaution during pregnancy to minimize exposure to potentially harmful
chemicals.
39. Correct Answer: c) The child does not respond to their name
Rationale: By 12 months of age, infants should consistently respond to their name by
turning toward the speaker. Failure to respond to one's name by this age is a potential red
flag for developmental delay, particularly in the social-communication domain, and may
warrant further evaluation for autism spectrum disorder or hearing impairment. Not
walking independently (option a) is within normal limits at 12 months; many children begin
walking between 12-15 months. Not saying recognizable words (option b) is also within
normal range; while some 12-month-olds may have 1-3 words, others develop expressive
language slightly later. Not feeding with a spoon (option d) is developmentally appropriate;
self-feeding with utensils typically develops between 15-18 months.
40. Correct Answer: c) Begin with gentle walking and gradually increase activity
Rationale: After an uncomplicated vaginal delivery, it is generally recommended to begin
with gentle activities like walking and gradually increase exercise intensity as tolerated,
usually resuming pre-pregnancy exercise routines around 4-6 weeks postpartum with
healthcare provider approval. This gradual approach allows the body to heal while
preventing deconditioning. Avoiding all physical activity for six weeks (option a) is
unnecessarily restrictive and may lead to deconditioning and increased risk of
complications like thrombosis. Resuming pre-pregnancy exercise after the first week
(option b) is too soon for most women and may increase the risk of complications or
 injury. Focusing on abdominal strengthening exercises (option d) immediately postpartum
is not recommended; these should be introduced gradually and with proper technique to
avoid exacerbating diastasis recti.
41. Correct Answer: b) Using peer educators to discuss safe sexual practices
Rationale: Peer education is particularly effective for adolescents because they tend to be
more receptive to information from peers who they perceive as having similar experiences
and concerns. Peers can communicate in relatable language and address practical concerns
that adolescents might be hesitant to discuss with adults. Emphasizing abstinence only
(option a) has not been shown to be effective as a sole approach to STI prevention
education. While disease pathophysiology (option c) is important, technical information
alone without practical application is less effective for behavior change in adolescents.
Having parents present (option d) may inhibit open discussion about sensitive topics
related to sexual health.
42. Correct Answers: a, b, c, e
Rationale:
a) Annual mammogram for women age 55 is recommended by many organizations,
though some suggest biennial screening at this age.
b) Colorectal cancer screening is recommended starting at age 45-50 for average-risk
individuals.
c) PSA testing after discussing risks and benefits is an appropriate shared decision-
making approach for men in this age group.
d) Skin examination for suspicious lesions is appropriate as part of regular health
maintenance.
e) Annual chest X-ray (incorrect) is not recommended as a routine screening test due
to radiation exposure and lack of proven benefit.
f) Annual ECG (incorrect) is not recommended for asymptomatic individuals without
specific cardiovascular risk factors.
43. Correct Answer: c) Strength training of all major muscle groups at least twice weekly
Rationale: Current physical activity guidelines for adults recommend strength training that
involves all major muscle groups at least twice weekly, in addition to aerobic activity. This
comprehensive recommendation addresses both cardiovascular fitness and muscular
strength. Vigorous aerobic activity for 15 minutes daily (option a) falls short of
recommendations, which suggest at least 75 minutes of vigorous activity per week. Light
to moderate exercise for 20 minutes, three times weekly (option b) is insufficient to meet
current guidelines of 150 minutes of moderate-intensity activity per week. Daily high-
intensity interval training (option d) may be excessive and increase injury risk; rest and
recovery days are important components of exercise programs.
44. Correct Answer: a) During childhood and adolescence
Rationale: Peak bone mass is largely achieved by the end of adolescence, with
approximately 90% acquired by age 18 in girls and age 20 in boys. Therefore, optimizing
calcium intake during childhood and adolescence is critical for developing maximum bone
density, which helps reduce the risk of osteoporosis later in life. While calcium intake
remains important during pregnancy and lactation (option b), between ages 35-50 (option
c), and after menopause (option d), these periods occur after peak bone mass has largely
been established and thus have less impact on maximum attainable bone density.
45. Correct Answer: a) Development of breast buds
Rationale: According to Tanner stages of puberty, the earliest physical sign of puberty in
females is typically the development of breast buds (thelarche), which usually occurs
between ages 8-13. The growth of pubic hair (option b), while often an early sign, typically
begins after or simultaneously with breast development. Menstruation (option c) is a
relatively late event in pubertal development, usually occurring 2-3 years after the onset of
breast development. While an increase in height (option d) or growth spurt does occur
during puberty, it is not typically the earliest observable sign and often follows initial breast
development.
46. Correct Answer: b) "Even a modest weight loss of 5-10% can improve health outcomes."
Rationale: Evidence consistently shows that modest weight loss of 5-10% of initial body
weight can significantly improve various health parameters, including blood pressure,
cholesterol levels, and blood glucose control. This approach sets realistic, achievable goals
that are more likely to be maintained long-term. Suggesting a specific weight loss amount
(option a) without considering the individual's overall health context is inappropriate.
Recommending a very low-calorie diet (option c) for rapid weight loss is not sustainable
and may lead to nutritional deficiencies and weight cycling. Eliminating all carbohydrates
(option d) is an extreme approach not supported by evidence for long-term weight
management.
47. Correct Answer: c) Two doses of the recombinant zoster vaccine given 2-6 months apart
Rationale: Current CDC recommendations for the recombinant zoster vaccine (Shingrix)
include two doses given 2-6 months apart for adults aged 50 years and older, regardless of
whether they have had shingles before or previously received the older live zoster vaccine
(Zostavax). The vaccine remains beneficial after age 60 (option a is incorrect). A single
dose (option b) does not provide optimal protection; the two-dose series is recommended.
Unlike the influenza vaccine, annual vaccination (option d) is not recommended; the two-
dose series is expected to provide long-term protection.
48. Correct Answer: b) Roll from back to stomach and stomach to back
 Rationale: By 6 months of age, most infants can roll in both directions (from back to
stomach and stomach to back), which is an appropriate gross motor milestone for this age.
Pulling to a standing position using furniture (option a) typically develops around 9-10
months. Walking with one hand held (option c) usually emerges around 10-12 months.
Climbing stairs with alternating feet (option d) is a much later milestone, typically
developing around 3 years of age. Proper understanding of age-appropriate developmental
milestones helps nurses provide anticipatory guidance and identify potential developmental
delays.
49. Correct Answer: b) Evolution or change in the lesion over time
Rationale: In the ABCDE rule for skin cancer detection, "E" stands for Evolution or
change in the lesion over time. This includes changes in size, shape, color, elevation, or
symptoms such as itching or bleeding. The complete ABCDE rule includes: Asymmetry,
Border irregularity, Color variation, Diameter greater than 6mm, and Evolution. Elevation
(option a) is partially addressed under "D" for diameter, which includes assessment of
elevation. Eczema (option c) and excoriation (option d) are not part of the ABCDE criteria
for melanoma detection.
50. Correct Priority Order: c, e, b, a, d
Rationale:
c) Fertilization and implantation - Occurs within days after ovulation
e) Positive pregnancy test (urine hCG) - Detectable approximately 12-14 days after
fertilization
b) Fetal heartbeat detectable by Doppler - Typically around 8-10 weeks gestation
a) Quickening (maternal perception of fetal movement) - Usually felt between 16-22
weeks gestation
d) Fetal heartbeat detectable by fetoscope - Generally audible around 18-20 weeks
gestation
51. Correct Answer: a) No more than 1 drink per day and no more than 7 drinks per week
Rationale: Current guidelines from the U.S. Dietary Guidelines for Americans and other
health organizations recommend that women consume no more than 1 standard drink per
day and no more than 7 drinks per week to reduce health risks associated with alcohol
consumption. These gender-specific guidelines reflect differences in alcohol metabolism
and alcohol-related health risks between men and women. The recommendations of 2
drinks per day/10 per week (option b), 3 drinks per day/12 per week (option c), and 4
drinks on any occasion (option d) all exceed current guidelines for women and would
increase health risks including liver disease, certain cancers, and cardiovascular problems.
52. Correct Answer: The nurse should instruct women to begin breast self-examination in the
upper outer quadrant of the breast (typically indicated by an "X" in the upper outer portion
of the breast image).
Rationale: The examination should begin in the upper outer quadrant of the breast because
approximately 50% of breast cancers develop in this area, making it the most important
region to examine thoroughly. A systematic approach to breast self-examination improves
thoroughness and consistency. After examining the upper outer quadrant, the examination
should proceed in a pattern that ensures the entire breast tissue is examined, including the
tail of Spence extending toward the axilla.
53. Correct Answer: b) "Moderate weight loss can significantly reduce diabetes risk in
overweight individuals."
Rationale: Research, including the landmark Diabetes Prevention Program, has
demonstrated that moderate weight loss (5-7% of body weight) in overweight individuals
can reduce the risk of developing type 2 diabetes by approximately 58%. This evidence-
based statement reflects realistic, achievable goals for diabetes prevention. Complete
avoidance of all carbohydrates (option a) is neither necessary nor recommended for
diabetes prevention; focus should be on quality of carbohydrates rather than elimination.
Type 2 diabetes risk (option c) is influenced by both genetic and lifestyle factors, not solely
genetics. Daily blood glucose monitoring (option d) is not necessary for preventing
diabetes in non-diabetic individuals; screening at appropriate intervals based on risk factors
is the recommended approach.
54. Correct Answer: c) Leafy green vegetables
Rationale: Leafy green vegetables such as spinach, kale, and collard greens are among the
best natural sources of folate (naturally occurring form of folic acid). The term "folate"
derives from "foliage," reflecting its abundance in leafy plants. While citrus fruits (option
a) do contain some folate, they are not as rich a source as leafy greens. Dairy products
(option b) are not significant sources of folate. Lean meats (option d) contain minimal
folate; however, liver is an exception as it contains moderate amounts. Adequate folate
intake is particularly important before and during early pregnancy to reduce the risk of
neural tube defects.
55. Correct Matching:
Toddlers (1-3 years) → Safety measures and immunizations
School-age children (6-12 years) → Physical activity and health education
Adolescents (13-18 years) → Identity development and risk behavior prevention
Adults (30-50 years) → Chronic disease prevention and stress management
Older adults (65+ years) → Fall prevention and medication management
 Rationale: Each age group has specific health promotion priorities based on developmental
needs and common health risks. For toddlers, safety measures (preventing injuries) and
completing immunization series are primary concerns. School-age children benefit from
establishing physical activity habits and health education that builds foundational
knowledge. Adolescents face challenges related to identity formation and increased risk-
taking behaviors. Adults in middle age benefit from preventive strategies for chronic
diseases and stress management. Older adults have increasing risks related to falls and
medication interactions/adverse effects, making these key areas for health promotion
focus.
56. Correct Answer: b) Regular physical exercise
Rationale: Regular physical exercise has strong scientific evidence supporting its
effectiveness in reducing physiological stress responses, including lowering cortisol levels,
improving mood through endorphin release, and enhancing sleep quality. Exercise has
both immediate and long-term positive effects on stress reduction. Watching television
(option a) may provide temporary distraction but does not address underlying stress
physiology and may actually increase stress if used as avoidance behavior. Increased
caffeine consumption (option c) can elevate cortisol levels and exacerbate stress symptoms.
Working longer hours (option d) typically increases stress rather than reducing it,
contributing to burnout and chronic stress.
57. Correct Answer: b) Pap test every 3 years or HPV co-testing every 5 years
Rationale: For women aged 30-65 with normal prior screening results, current guidelines
from major organizations (including ACOG and USPSTF) recommend either a Pap test
every 3 years or HPV co-testing (Pap plus HPV test) every 5 years. Annual Pap tests
(option a) are no longer recommended for women with normal results due to the slow
progression of cervical changes and the potential harms of over-screening. HPV testing
alone every 10 years (option c) is not a current recommendation. Discontinuing screening
after three normal tests (option d) is not recommended; screening should continue until
age 65 for women with adequate prior screening and no history of significant cervical
abnormalities.
58. Correct Answer: a
Rationale:
a) Smallpox is the only disease on this list that has been officially declared eradicated
worldwide through vaccination efforts (certified by the World Health Organization
in 1980).
b) Polio (incorrect) has been eliminated in most countries but remains endemic in a
few regions, so it has not been globally eradicated.
 c) Measles (incorrect) continues to circulate globally with outbreaks occurring in
various regions despite vaccination efforts.
d) Diphtheria (incorrect) remains present worldwide, though incidence has
dramatically decreased through vaccination.
e) Rubella (incorrect) has been eliminated in some regions (including the Americas)
but not globally eradicated.
f) Tetanus (incorrect) cannot be eradicated through vaccination alone because the
causative organism (Clostridium tetani) exists in soil worldwide.
59. Correct Answer: c) Water-based exercise program
Rationale: For patients with osteoarthritis, especially older adults, water-based exercise
programs are often most appropriate because they provide resistance for strengthening
while reducing weight-bearing stress on affected joints. The buoyancy of water reduces
impact forces, decreases pain during movement, and allows for greater range of motion.
High-impact aerobics (option a) and long-distance running (option b) create excessive joint
stress and can exacerbate osteoarthritis symptoms. Competitive sports (option d) may
involve unpredictable movements, collisions, or falls that could increase injury risk in
patients with osteoarthritis, particularly older adults.
60. Correct Answer: c) Breastfeeding reduces the mother's risk of breast and ovarian cancer
Rationale: Research has consistently shown that breastfeeding is associated with reduced
maternal risk of breast and ovarian cancers, with longer duration of breastfeeding
providing greater protective effects. This is one of several evidence-based benefits of
breastfeeding for mothers. The statement that breastfeeding guarantees prevention of
allergies (option a) is incorrect; while breastfeeding may be associated with reduced risk of
some allergic conditions, it does not guarantee that allergies won't develop. Formula-fed
babies do not gain developmental milestones faster than breastfed babies (option b); in
fact, some research suggests slight developmental advantages for breastfed infants. The
claim that breastfed infants never experience digestive issues like colic (option d) is false;
breastfed infants can and do experience colic and other digestive symptoms.
61. Correct Answer: 600
Rationale: The recommended daily folic acid intake for pregnant women is 600 micrograms
(0.6 mg), which is higher than the 400 micrograms recommended for non-pregnant women
of childbearing age. This increased amount supports the rapid cell growth of the placenta
and fetus and helps prevent neural tube defects such as spina bifida and anencephaly. Many
prenatal vitamins contain the full recommended amount, but dietary sources of folate such
as leafy greens, beans, and fortified grains are also important components of a healthy
pregnancy diet.
62. Correct Answer: c) Supine position
 Rationale: According to the American Academy of Pediatrics, the safest sleep position for
infants is the supine position (lying completely on the back). This position has been shown
to significantly reduce the risk of Sudden Infant Death Syndrome (SIDS). The side-lying
position (option a) is not recommended as infants may roll onto their stomachs. The prone
position (option b) or stomach sleeping significantly increases SIDS risk and is not
recommended. Semi-Fowler's position (option d) with the head elevated is not
recommended for routine infant sleep and may create unsafe sleeping conditions.
63. Correct Answers: b, d, f
Rationale:
b) Varenicline (Chantix) is a prescription medication that works by blocking nicotine
receptors in the brain.
d) Bupropion (Zyban) is a prescription antidepressant also approved for smoking
cessation.
f) Nicotine nasal spray is a prescription nicotine replacement therapy.
a) Nicotine gum (incorrect) is available over-the-counter without a prescription.
b) Nicotine patches (incorrect) are available over-the-counter without a prescription.
e) Nicotine lozenges (incorrect) are available over-the-counter without a prescription.
64. Correct Answer: 9
Rationale: The mature pincer grasp, where the thumb and index finger are used to pick up
small objects with precision, typically develops around 9 months of age. This fine motor
milestone represents an important developmental advancement from the earlier palmar
grasp (using the whole hand) and crude pincer grasp (using the thumb and side of the index
finger). The mature pincer grasp enables infants to pick up small objects such as cereal
pieces and is a prerequisite for more advanced fine motor skills. Understanding normal
developmental milestones helps nurses identify potential delays that may require further
assessment.
65. Correct Answer: b) Acupressure
Rationale: Acupressure is a non-pharmacological pain management technique that involves
applying pressure to specific points along energy pathways or meridians in the body, based
on traditional Chinese medicine principles. Guided imagery (option a) involves using
mental visualization to promote relaxation and pain relief but does not involve energy
pathways. Progressive muscle relaxation (option c) involves tensing and relaxing muscle
groups sequentially to reduce tension and pain. Biofeedback (option d) uses electronic
monitoring of physiological processes to help patients gain conscious control over these
functions for pain management.
66. Correct Answer: 2300
 Rationale: The DASH (Dietary Approaches to Stop Hypertension) diet recommends
limiting sodium intake to 2300 milligrams per day for general hypertension management.
For individuals who would benefit from greater blood pressure reduction, a lower goal of
1500 mg/day is sometimes recommended. The 2300 mg recommendation represents a
significant reduction from the average American intake of approximately 3400 mg daily.
Sodium restriction works in conjunction with the DASH diet's emphasis on fruits,
vegetables, whole grains, lean proteins, and low-fat dairy to reduce blood pressure and
improve cardiovascular health.
67. Correct Priority Order: a, c, d, e, b
Rationale:
a) Apply a topical anesthetic to the injection sites - Should be done first, as these
medications need time (usually 30-60 minutes) to take effect
b) Explain the procedure using age-appropriate language - Preparation through
explanation helps reduce anxiety
c) Position the child securely on the parent's lap - Proper positioning provides comfort
and security
d) Administer the most painful vaccine last - This prevents increased anxiety for
subsequent injections
b) Distract the child during the injections - Distraction techniques are implemented during
the actual procedure
68. Correct Answer: a) 20/30
Rationale: For first-grade students (typically ages 6-7), visual acuity of 20/30 or worse is
considered a failed screening that requires referral to an eye care professional. This standard
reflects the visual demands of early elementary education, particularly learning to read. The
20/30 standard means the child needs to be at 20 feet to see what a person with normal
vision can see at 30 feet. The other options (20/40, 20/50, and 20/70) represent more
significant visual impairment that would also warrant referral but do not represent the
threshold for screening failure in this age group.
69. Correct Answer: c) Hypertension
Rationale: Hypertension is considered a major modifiable risk factor for cardiovascular
disease that can be controlled through lifestyle modifications and medication. Other major
modifiable risk factors include dyslipidemia, diabetes mellitus, smoking, physical inactivity,
and obesity. Age (option a), family history (option b), and gender (option d) are all non-
modifiable risk factors for cardiovascular disease. While these factors are important for risk
assessment, they cannot be changed through interventions, unlike hypertension which can
be managed effectively to reduce cardiovascular risk.
70. Correct Answer: 4
 Rationale: In an uncomplicated pregnancy, the standard prenatal visit schedule includes
visits every 4 weeks during the first and second trimesters (up to 28 weeks). After 28 weeks,
the frequency typically increases to every 2-3 weeks until 36 weeks, then weekly until
delivery. This schedule allows for appropriate monitoring of maternal and fetal well-being
while not being overly burdensome for women with uncomplicated pregnancies. The
schedule may be adjusted based on individual risk factors or complications that develop
during pregnancy.
71. Correct Answer: The nurse should direct parents to focus on the serving size, total sugars
(particularly added sugars), sodium content, and the ingredients list when reading food
labels.
Rationale: When addressing childhood obesity prevention, parents should be taught to
evaluate serving sizes to understand actual consumption amounts, limit added sugars which
contribute to excess calorie intake and weight gain, monitor sodium content which is often
high in processed foods, and review the ingredients list to identify unhealthy components
like trans fats or multiple forms of sugar. Teaching families to read and understand food
labels empowers them to make healthier food choices and compare similar products
effectively.
72. Correct Answer: c) 26 years
Rationale: According to current CDC recommendations, routine HPV vaccination is
recommended for all adolescents at age 11 or 12 years (can start at age 9) through age 26
for those not adequately vaccinated previously. While the FDA has approved the vaccine
for adults up to age 45, the CDC does not routinely recommend catch-up vaccination for
all adults ages 27-45; instead, this age group should make shared decisions with their
healthcare providers based on individual circumstances and risk factors. The options of 18
years (a) and 21 years (b) do not reflect current recommendations. Option d (45 years)
represents the maximum FDA-approved age, not the recommendation for routine
vaccination.
73. Correct Answer: c) A water-resistant sunscreen remains effective for up to 80 minutes
while swimming
Rationale: According to FDA regulations, "water-resistant" sunscreen maintains its stated
SPF level for 40 minutes of water exposure, while "very water-resistant" products maintain
protection for 80 minutes. The statement about SPF 30 blocking twice as many rays as
SPF 15 (option a) is incorrect; SPF 15 blocks about 93% of UVB rays, while SPF 30 blocks
about 97% (not double). Sunscreen should be applied 15-30 minutes before sun exposure
(option b), not immediately before. One application does not provide all-day protection
(option d); reapplication is recommended every 2 hours and after swimming or sweating.
74. Correct Matching:
 Rationale: Vitamin A is Vitamin A → Vision and immune function
Vitamin C → Collagen formation and iron absorption
Vitamin D → Bone health and calcium absorption
Vitamin E → Antioxidant protection of cells
Vitamin K → Blood clottingessential for vision (particularly night vision), cell growth,
and immune function. Vitamin C is necessary for collagen formation (important for
wound healing), antioxidant functions, and enhancing iron absorption from plant sources.
Vitamin D promotes calcium absorption in the gut and maintains bone health. Vitamin E
functions primarily as an antioxidant that protects cells from damage caused by free
radicals. Vitamin K is necessary for blood clotting and bone metabolism. Understanding
vitamin functions helps nurses provide accurate nutritional counseling.
75. Correct Answer: 7-9
Rationale: The National Sleep Foundation and American Academy of Sleep Medicine
recommend that adults (ages 18-64) should get 7-9 hours of sleep per night for optimal
health. This range provides adequate time for restorative processes to occur while
accounting for individual variation in sleep needs. Consistently sleeping less than 7 hours
is associated with adverse health outcomes including increased risk of obesity, diabetes,
hypertension, heart disease, stroke, and depression. Older adults (65+) may need slightly
less (7-8 hours), while younger populations typically require more sleep.
76. Correct Answer: b) CRAFFT
Rationale: The CRAFFT screening tool is specifically designed to identify substance abuse
disorders in adolescents and is recommended by the American Academy of Pediatrics for
substance use screening. The acronym CRAFFT stands for the key areas assessed: Car,
Relax, Alone, Forget, Friends, Trouble. The PHQ-9 (option a) is a depression screening
tool, not specific to substance abuse or adolescents. The CAGE questionnaire (option c)
is designed for adults to screen for alcohol use disorders and is not recommended for
adolescents. The AUDIT (option d) is an alcohol screening tool developed primarily for
adults, not specifically for adolescents.
77. Correct Answers: a, c, d, f
Rationale:
a) Using a booster seat in the car is appropriate; children should use a booster seat
until the vehicle seat belt fits properly (typically 4'9" tall, around ages 8-12).
b) Teaching the child how to swim is an important safety skill that reduces drowning
risk.
c) Storing cleaning products in a locked cabinet prevents accidental poisoning.
 f) Teaching street safety is appropriate for this age group with adult supervision.
b) Allowing bicycle riding without a helmet (incorrect) increases injury risk; helmets should
be worn at all times when cycling.
e) Allowing stove use with supervision (incorrect) is generally not age-appropriate for most
4-year-olds due to burn risks and limited coordination.
78. Correct Answer: 150
Rationale: According to the American College of Obstetricians and Gynecologists
(ACOG) and other health organizations, pregnant women with no contraindications
should engage in at least 150 minutes of moderate-intensity aerobic activity per week,
preferably spread throughout the week (e.g., 30 minutes, 5 days per week). This
recommendation is the same as for non-pregnant adults but with modifications for
comfort and safety as pregnancy progresses. Regular physical activity during pregnancy has
numerous benefits including reduced back pain, decreased gestational diabetes risk, and
improved psychological well-being.
79. Correct Answer: b) 3-4 months
Rationale: The American Dental Association recommends replacing toothbrushes every 3-
4 months, or sooner if the bristles become frayed or splayed. Regular replacement ensures
optimal cleaning effectiveness and reduces bacterial accumulation on worn bristles.
Replacing every 1-2 months (option a) is more frequent than generally necessary unless
bristles wear quickly. Waiting 6 months (option c) or 12 months (option d) is too long, as
brushes typically become ineffective and harbor more bacteria after 3-4 months of regular
use.
80. Correct Answer: b) "Have you noticed any changes in your urinary pattern?"
Rationale: Asking about changes in urinary patterns (such as frequency, urgency, hesitancy,
nocturia, or weak stream) is most appropriate for assessing prostate health, as these
symptoms commonly occur with benign prostatic hyperplasia or prostate cancer. While
family history of prostate cancer (option a) is an important risk factor to assess, it doesn't
directly evaluate current prostate health. Monthly testicular self-examinations (option c)
are relevant for testicular cancer detection but not prostate health. Rectal bleeding (option
d) is more commonly associated with colorectal issues rather than prostate problems,
though it could be relevant if considering a digital rectal exam or if there's prostate cancer
with local invasion.
81. Correct Answer: b) "Are you having thoughts of hurting yourself?"
Rationale: When a patient makes statements suggesting suicidal ideation, the nurse should
directly assess suicide risk by asking about thoughts of self-harm. This approach
acknowledges the patient's distress while obtaining crucial information for safety planning.
Saying "You have so much to live for" (option a) minimizes the patient's feelings and may
 make them feel misunderstood. Stating "Everyone feels down sometimes" (option c)
normalizes and diminishes the severity of the patient's depression. While informing the
doctor (option d) is important, it should follow assessment of immediate suicide risk.
82. Correct Answers: a, c, e
Rationale:
a) Deep breathing exercises help reduce anxiety by activating the parasympathetic
nervous system.
b) Guided imagery provides distraction and promotes relaxation through visualization
techniques.
e) Progressive muscle relaxation reduces physical tension associated with anxiety.
b) Providing detailed information about complications (incorrect) may increase anxiety in
an already anxious patient.
d) Limiting visitors (incorrect) may be appropriate in some cases but isn't universally
beneficial for pre-surgical anxiety.
f) Telling the patient not to worry (incorrect) dismisses their feelings and does not provide
constructive coping strategies.
83. Correct Answers: a, c, d, f
Rationale:
a) Decreased need for sleep is characteristic of mania, with patients often feeling
energized despite minimal sleep.
b) Rapid, pressured speech reflects the accelerated thinking and increased energy
associated with mania.
c) Flight of ideas (rapid shifting between unrelated topics) is common during manic
episodes.
f) Grandiose delusions (exaggerated beliefs about one's importance, power, or abilities)
frequently occur in mania.
b) Slowed psychomotor activity (incorrect) is associated with depression, not mania, which
features increased activity.
e) Flat affect (incorrect) is more characteristic of schizophrenia or depression rather than
mania, which typically presents with elevated or irritable mood.
84. Correct Answer: c) Administer benzodiazepines as prescribed
Rationale: The priority nursing intervention for alcohol withdrawal is administering
benzodiazepines as prescribed to prevent or treat serious complications such as seizures
and delirium tremens, which can be life-threatening. Benzodiazepines help manage
symptoms by acting on the same neurotransmitter system affected by alcohol. While
providing a quiet environment (option b) supports comfort, it doesn't address the
physiological aspects of withdrawal. Encouraging AA attendance (option a) is appropriate
 for recovery but not for acute withdrawal management. Restricting visitors (option d)
might be beneficial in some cases but is not the priority intervention for physiological
stabilization.
85. Correct Answer: d) "Are you currently having thoughts of harming yourself?"
Rationale: When a patient reports command hallucinations instructing self-harm, the most
important initial response is to assess immediate safety risk by determining if the patient
intends to act on these commands. This allows for appropriate safety interventions. While
acknowledging the frightening nature of hallucinations (option a) shows empathy, it
doesn't address immediate safety concerns. Asking for details about the voices (options b
and c) may be appropriate after assessing safety but should not be the initial response when
risk of self-harm is indicated.
86. Correct Answer: b) Teaching grounding techniques to use during flashbacks
Rationale: Grounding techniques (such as the 5-4-3-2-1 sensory awareness exercise) help
patients with PTSD reconnect with the present moment during flashbacks or dissociative
episodes, providing practical coping strategies. Encouraging avoidance of discussing the
trauma (option a) reinforces avoidance behavior, which perpetuates PTSD symptoms.
Suggesting exposure to similar traumatic content (option c) could trigger symptoms
without therapeutic context. Recommending the patient focus on forgetting (option d) is
unrealistic and dismisses the complexity of trauma processing.
87. Correct Answer: d) Spend time with the patient to explore reasons for not wanting to
attend
Rationale: Taking time to understand the patient's perspective demonstrates therapeutic
communication and patient-centered care. This approach may reveal underlying issues
such as anxiety, paranoia, or past negative group experiences that can be addressed
individually. Insisting on attendance (option a) or restricting privileges (option b) creates
an adversarial relationship and focuses on compliance rather than therapeutic outcomes.
Documenting non-compliance and waiting (option c) is passive and misses an opportunity
for therapeutic intervention.
88. Correct Answer: b) Bradycardia
Rationale: Bradycardia (heart rate <60 beats/minute) is a common physical finding in
patients with anorexia nervosa, resulting from the body's adaptation to conserve energy in
response to starvation. Other expected findings include hypotension (not hypertension as
in option a), hypothermia (not elevated temperature as in option c), and decreased bowel
sounds due to reduced gastrointestinal motility (not increased sounds as in option d). These
cardiovascular changes can lead to serious complications including arrhythmias and sudden
cardiac death.
89. Correct Answer: c) Offer to eat a small portion of the food to demonstrate it is safe
 Rationale: For a patient with paranoid delusions about poisoned food, having the nurse eat
some food first provides concrete evidence of safety that may help overcome the delusion
without directly challenging the patient's beliefs. This approach acknowledges the patient's
concern while modeling reality. Explaining the food isn't poisoned (option a) directly
contradicts the delusion and may increase the patient's paranoia. While family food (option
b) might be accepted, it doesn't address the underlying delusion. Simply documenting and
notifying (option d) fails to address the patient's nutritional needs.
90. Correct Matching:
"I didn't get the promotion because my boss hates me, not because of my performance."
→ Projection
"I'm not angry at my spouse; I'm just irritated with my coworker." → Displacement
"I know the diagnosis is serious, but everything will be fine." → Denial
"I forgot all about my appointment with the therapist." → Repression
"I'm not afraid of needles; they just make me feel uncomfortable." → Rationalization
Rationale: Projection involves attributing one's own unacceptable thoughts or feelings to
others (blaming the boss rather than accepting responsibility). Displacement transfers
emotions from their original source to a less threatening target (directing anger from
spouse to coworker). Denial involves refusing to accept reality despite evidence
(minimizing a serious diagnosis). Repression is the unconscious blocking of unacceptable
thoughts or feelings (forgetting the therapy appointment). Rationalization involves creating
acceptable explanations for unacceptable feelings or behaviors (reframing fear as mere
discomfort).
91. Correct Answer: c) Stay with the patient and maintain a calm, reassuring approach
Rationale: The priority intervention during a panic attack is to stay with the patient and
provide calm reassurance, which helps reduce the patient's fear and provides a stabilizing
presence during extreme anxiety. Panic attacks are temporary, and a supportive presence
helps patients cope as symptoms peak and subside. Antipsychotic medications (option a)
are not indicated for panic attacks and would be inappropriate. While a quiet environment
(option b) may help, maintaining presence is more important than location. Contacting
family members (option d) takes time and doesn't address the immediate need for support.
92. Correct Answer: d) Using open-ended questions
Rationale: Open-ended questions encourage patients to elaborate on topics because they
cannot be answered with a simple "yes" or "no" and invite patients to share their thoughts
and feelings more extensively. Reflecting (option a) involves paraphrasing or restating the
patient's message, which may clarify understanding but doesn't necessarily encourage
elaboration. "Why" questions (option b) often make patients feel defensive or imply
 judgment. Giving advice (option c) is directive rather than exploratory and may shut down
communication rather than encouraging it.
93. Correct Answer: b) Acknowledge the patient's anxiety and provide support during rituals
Rationale: Initially, acknowledging anxiety and providing support demonstrates
understanding of the distress driving OCD behaviors and builds therapeutic rapport, which
is essential for later therapeutic interventions. Preventing rituals abruptly (option a) can
dramatically increase anxiety and damage therapeutic alliance. Telling the patient their
behavior is irrational (option c) invalidates their experience and ignores that OCD patients
often recognize the irrationality but feel compelled by anxiety. Distraction (option d) may
be helpful in some cases but as an initial intervention may increase anxiety if implemented
before therapeutic relationship is established.
94. Correct Answer: c) "Do you feel safe in your current relationship?"
Rationale: This question is open-ended, non-judgmental, and focused on the patient's
perception of safety, making it the most appropriate screening question for domestic
violence. Asking directly about hitting (option a) may be too specific and confrontational
for initial screening. Asking why the patient stays (option b) implies judgment and places
blame on the victim. Asking about leaving (option d) assumes abuse has been disclosed
and may not be appropriate as an initial screening question.
95. Correct Answers: a, b, d, f
Rationale:
a) Declining academic performance often occurs due to changing priorities and
cognitive effects of substances.
b) Changes in peer group may reflect new associations with others who use substances.
c) Mood swings can result from intoxication, withdrawal, or the emotional impact of
substance use.
f) Secrecy about activities and whereabouts is common as adolescents try to hide substance
use.
c) Increased interest in family activities (incorrect) is unlikely; substance abuse typically
leads to decreased family engagement.
e) Improved personal hygiene (incorrect) is not characteristic; neglect of appearance and
hygiene is more common.
96. Correct Answer: b) Validating the emotional content without reinforcing the delusion
Rationale: This approach acknowledges the patient's emotional experience (e.g., fear,
suspicion) without validating the false belief, maintaining therapeutic rapport while
supporting reality orientation. Arguing with the patient (option a) may damage therapeutic
relationship and often strengthens delusional beliefs. Agreeing with the delusion (option
c) reinforces false beliefs and is counterproductive to treatment. Challenging the logic
 (option d) of delusions is generally ineffective as delusions are fixed beliefs resistant to
logical contradiction.
97. Correct Answer: a) The patient's current level of suicidal ideation and plan
Rationale: Assessing current suicidal ideation, plan, intent, and access to means is essential
for determining immediate safety needs and appropriate level of supervision for a patient
who has already attempted suicide. This information directly informs the suicide risk
assessment and safety planning. While family history (option b), religious beliefs (option
c), and insurance status (option d) may all be relevant to comprehensive care, they are
secondary to immediate safety assessment.
98. Correct Answer: c) "Schizophrenia has both genetic and environmental factors, but having
a relative with the disorder increases risk."
Rationale: This statement accurately reflects current understanding that schizophrenia has
multifactorial etiology with both genetic and environmental components. First-degree
relatives of people with schizophrenia have approximately 10% risk (compared to 1% in
general population), but genetics alone don't determine outcome. The statement that
schizophrenia is directly inherited (option a) oversimplifies the complex genetic
component. Claiming no genetic component (option b) contradicts established evidence.
Recommending genetic testing (option d) is inappropriate as specific predictive genetic
testing for schizophrenia is not currently available clinically.
99. Correct Answer: c) "I've kept everything exactly as it was when my spouse was alive.
Nothing can be moved."
Rationale: This statement suggests complicated grief, characterized by prolonged grief
reactions that interfere with normal functioning. The inability to move or change anything
after six months indicates difficulty accepting the reality of the loss and moving forward
with life. Thinking about the deceased daily (option a) and finding holidays difficult (option
d) are normal grief responses. Volunteering at the hospital (option b) represents
constructive channeling of grief and finding meaning, which is adaptive rather than
complicated grief.
100. Correct Answer: b) Anxiety related to threat to self-concept
Rationale: This nursing diagnosis most accurately reflects the core issue in generalized
anxiety disorder—persistent, excessive worry and anxiety related to perceived threats to
self-concept or well-being. While ineffective coping (option a) may be present, it doesn't
specify the primary problem of anxiety. Social isolation (option c) may be a consequence
of anxiety but is not the defining feature of generalized anxiety disorder. Disturbed sleep
(option d) represents a symptom rather than the primary problem for patients with
generalized anxiety disorder.
C. Psychosocial Integrity
1. Correct Answer: B. Complete a suicide risk assessment
Rationale: The client's statement suggests suicidal ideation, making suicide risk assessment
the highest priority nursing intervention to ensure client safety. This follows the nursing
process principle that safety concerns take precedence over other interventions. While the
other options may be appropriate, they should follow after ensuring the client's immediate
safety.
2. Correct Answer: B. "I understand you're hearing voices. I don't hear them, but I believe
that you do. Let's focus on keeping you safe."
Rationale: This response acknowledges the client's experience without reinforcing the
hallucination, establishes trust, and prioritizes safety. It demonstrates therapeutic
communication by validating the client's perception while maintaining reality. Options A
and C dismiss the client's experience, which could damage rapport, while option D does
not address the immediate safety concern.
3. Correct Answer: A, B, D
Rationale: Effective deep breathing techniques would result in decreased respiratory rate
and blood pressure as the parasympathetic nervous system is activated, promoting
relaxation. Improved concentration is also expected. Dilated pupils (C) would indicate
sympathetic nervous system activation (fight-or-flight response), and increased muscle
tension (E) would indicate stress, both contradicting the relaxation response.
4. Correct Answer: A. Acknowledge the client's feelings and encourage group discussion
Rationale: Acknowledging the client's feelings validates their experience, while encouraging
group discussion uses the therapeutic factor of universality, allowing other group members
to possibly relate and provide support. Changing the topic (B) invalidates the client's
feelings, option C removes the therapeutic opportunity from the group setting, and option
D does not therapeutically utilize the group process.
5. Correct Answer: C. Providing for physical and psychological safety
Rationale: Following a traumatic event like sexual assault, ensuring the client's physical and
psychological safety is the priority intervention according to Maslow's hierarchy of needs.
Safety must be established before addressing other psychological needs. Teaching coping
strategies (A) and talking about the experience (B) are important interventions but should
follow after safety is ensured. Medication (D) may be needed but is not the first-line
intervention.
6. Correct sequence: D, A, E, B, C
Rationale: In alcohol withdrawal with potential delirium tremens (indicated by vital sign
abnormalities, tremors, and hallucinations), monitoring vital signs (D) is the first priority
 to establish baseline and assess severity. Administering benzodiazepines (A) follows to
prevent worsening withdrawal symptoms and potential seizures. Assessing for seizure
activity (E) is next as seizures are a serious complication. Creating a safe environment (B)
follows, and reorientation (C) is important but less urgent than physiological stabilization.
7. Correct Answer: A. Precontemplation
Rationale: The client's statement indicates denial of a problem with cocaine use and lack
of recognition that change is needed, which defines the precontemplation stage in the
Transtheoretical Model of Change. Contemplation (B) would involve recognizing a
problem and considering change; preparation (C) would involve making plans to change;
and action (D) would involve actively modifying behavior.
8. Correct Answer: C. Restrict physical activity and monitor during and after meals
Rationale: For a client with anorexia nervosa with a significantly low BMI (16.2), restricting
physical activity to prevent further weight loss and monitoring during and after meals to
prevent purging behaviors are critical interventions. Allowing free choice of meals (A)
could enable restriction behaviors, a behavioral contract (B) is helpful but not the most
immediate intervention given the low BMI, and while body image education (D) is
important, medical stabilization takes precedence.
9. Correct Answer: A. Denial
Rationale: The client's statement indicates denial, the first stage of grief according to
Kübler-Ross's model, characterized by refusal to accept reality. The client is suggesting the
diagnosis must be a mistake rather than accepting it. Anger (B) would involve expressions
of frustration, bargaining (C) would involve attempts to negotiate or delay the outcome,
and depression (D) would involve sadness and withdrawal.
10. Correct Answer: C. Providing long-term counseling for those with persistent symptoms
Rationale: Tertiary prevention focuses on reducing long-term effects after an event has
occurred, which includes providing counseling for those with persistent psychological
symptoms following a disaster. Options A and B represent primary and secondary
prevention strategies that occur earlier in the crisis response timeline. Screening (D) is a
secondary prevention strategy.
11. Correct Answer: B. Providing a quiet environment with minimal stimulation
Rationale: For a client in the manic phase of bipolar disorder, reducing environmental
stimulation helps decrease hyperactivity and agitation. Additional stimulation (A and C)
would likely exacerbate symptoms, and allowing the client to lead activities (D) could
reinforce grandiose thinking and hyperactive behavior.
12. Correct Answer: [The correct area to click would be the amygdala]
Rationale: The amygdala is the brain structure most directly associated with the fear
response in PTSD. It is responsible for emotional processing, particularly fear conditioning
 and the fight-or-flight response. Research shows that the amygdala is hyperactive in
individuals with PTSD, contributing to the heightened fear response and hypervigilance
characteristic of the disorder.
13. Correct Answer: A. Development of insight
Rationale: The client's statement demonstrates developing insight, as they are beginning to
recognize that their thinking patterns (attributing all problems to themselves) may not be
accurate. This represents cognitive progress in therapy. The statement does not directly
relate to medication compliance (B), symptom management techniques (C), or social skills
training (D).
14. Correct Answer: B. Waves of sadness that come and go, with periods of positive memories
Rationale: Normal grief typically presents as waves of emotion that fluctuate over time,
with periods of sadness interspersed with positive memories of the deceased. Persistent
inability to accept the death after six months (A) suggests complicated grief. Preoccupation
with feelings of worthlessness (C) and suicidal ideation with a plan (D) are symptoms more
consistent with major depressive disorder rather than normal grief.
15. Correct Answer: A. Maintaining confidentiality
Rationale: Confidentiality is the most fundamental group norm to establish first, as it
creates psychological safety necessary for therapeutic disclosure. Without assurance of
confidentiality, group members may not engage authentically in the therapeutic process.
While the other options are important group norms, confidentiality forms the foundation
of trust required for effective group therapy.
16. Correct Answer: C. "Set clear, consistent consequences and follow through while
acknowledging positive behaviors."
Rationale: This approach aligns with evidence-based behavioral management strategies for
oppositional defiant disorder, combining appropriate limit-setting with positive
reinforcement. Option A is too punitive and may escalate defiant behavior, option B
minimizes the problem and provides no practical guidance, and option D could potentially
trigger power struggles that worsen oppositional behavior.
17. Correct Answer: B. Offer prepackaged food options and gradually build trust
Rationale: This approach respects the client's paranoid concerns while ensuring nutritional
needs are met and building a therapeutic alliance. Explaining safety guidelines (A) may not
address paranoid delusions, insisting the client eat (C) could increase paranoia and damage
trust, and recommending supplements (D) doesn't address the immediate need for
nutrition or the underlying paranoia.
18. Correct Answer: C. Mind reading
Rationale: Social anxiety disorder commonly involves the cognitive distortion of mind
reading, where individuals believe they know what others are thinking about them (typically
 assuming negative judgments). Catastrophizing (A) involves expecting the worst outcome,
all-or-nothing thinking (B) involves seeing situations in black and white terms, and
emotional reasoning (D) involves assuming feelings reflect reality.
19. Correct Answer: C. Respiratory rate of 8 breaths per minute
Rationale: A respiratory rate of 8 breaths per minute indicates respiratory depression,
which is a potentially life-threatening sign of opioid overdose requiring immediate medical
intervention. While the other options indicate concerns that should be addressed, they do
not represent the same level of immediate physiological danger.
20. Correct Answer: B. "I've been talking with a support group of other accident survivors."
Rationale: Seeking social support and discussing experiences with others who have had
similar experiences represents a positive, adaptive coping mechanism. Increasing alcohol
consumption (A) is maladaptive as it may lead to substance use disorder and doesn't
address the underlying trauma. Avoiding cars completely (C) represents avoidance
behavior that reinforces anxiety, and keeping excessively busy (D) is a form of avoidance
coping that may delay processing the trauma.
21. Correct Answer: B. "I understand you're upset about my absence. Let's discuss coping
strategies you can use during this time."
Rationale: This response acknowledges the client's feelings while maintaining appropriate
boundaries and focusing on developing healthy coping skills. It validates the client's
distress without reinforcing manipulative behavior. Option A invalidates the client's
feelings, option C crosses professional boundaries and reinforces dependency, and option
D minimizes the client's distress and could damage the therapeutic relationship.
22. Correct Answer: D. "I understand that feels real to you. How does having these thoughts
make you feel?"
Rationale: This response acknowledges the client's experience without reinforcing or
challenging the delusion directly. It shifts the focus to the emotional impact, which can
help build rapport and therapeutic alliance. Option A directly confronts the delusion,
which may increase defensiveness; option B partially confronts the delusion; and option C
dismisses the client's concerns, which may decrease trust.
23. Correct sequence: C, D, A, B, E
Rationale: When teaching progressive muscle relaxation, the nurse should first provide
instruction on proper breathing techniques (C) as the foundation for relaxation. Next,
asking clients to identify areas of tension (D) increases body awareness. Then, the process
begins with tensing muscles in the feet (A), followed by releasing that tension (B), and
finally moving progressively up the body (E) in a systematic manner.
24. Correct Answer: C. "Let's discuss the risks of that decision and explore alternatives for
celebrating without alcohol."
 Rationale: This response acknowledges the client's situation while encouraging exploration
of potential risks and alternatives. It promotes informed decision-making without being
judgmental. Option A minimizes the risk of relapse, option B is overly restrictive and may
not be realistic, and option D is judgmental and may damage rapport.
25. Correct Answer: C. Encourage the client to connect with their religious community for
support
Rationale: This intervention builds on the client's existing support system and spiritual
resources, which the client has identified as important. It respects the client's values while
promoting social connection during grief. Recommending medication (A) may be
premature without a full assessment of normal versus complicated grief. Suggesting
moving in with children (B) may foster dependency, and advising distraction through
hobbies (D) may discourage healthy grief processing.
26. Correct Answer: B. Approach calmly, assess safety, and engage the client in conversation
about their feelings
Rationale: This intervention prioritizes a therapeutic relationship while addressing safety
concerns. A calm approach helps de-escalate the situation and provides an opportunity to
understand the underlying emotional triggers for self-harm. Applying restraints (A) is
overly restrictive and should only be used as a last resort. Threatening restriction of
privileges (C) may increase distress, and calling for additional staff immediately (D) may
escalate the situation if not needed.
27. Correct Answer: C. Post-traumatic stress disorder
Rationale: The symptoms described (nightmares, flashbacks, avoidance behaviors)
occurring one month after a traumatic event are consistent with post-traumatic stress
disorder (PTSD). Acute stress disorder (D) has similar symptoms but is diagnosed only
within the first month following trauma. Adjustment disorder (A) typically involves less
severe symptoms without the characteristic re-experiencing phenomena. Major depressive
disorder (B) may co-occur but would not account for the flashbacks and specific trauma-
related avoidance.
28. Correct Answer: B. Guide the client through slow, deep breathing exercises
Rationale: During a panic attack, guiding the client through breathing exercises is the
appropriate first intervention as it helps reduce physiological arousal quickly without
requiring medication. Administering medication (A) may be appropriate but is not typically
the first intervention. Removing the client from stimulating environments (C) is helpful
but may not be immediately possible. Identifying triggers (D) is important for long-term
management but not during the acute episode.
29. Correct Answer: B. Set clear limits while remaining calm and non-confrontational
 Rationale: This approach maintains appropriate boundaries while avoiding power struggles
that could escalate the situation with a client with antisocial personality disorder. Remaining
calm prevents reinforcing manipulative behavior. Directly labeling behavior as
inappropriate (A) may provoke defensiveness. Allowing continued expression without
limits (C) may reinforce inappropriate behavior, and calling security (D) may escalate the
situation unnecessarily and damage the therapeutic relationship.
30. Correct Answer: C, D, E
Rationale: Questions about whether hallucinations command harm to self or others (C) are
critical for safety assessment. Understanding what makes hallucinations better or worse
(D) provides important information for intervention planning. Assessing the client's
insight into the hallucinations (E) helps determine their reality testing. Asking specifically
what voices they are hearing (A) may seem to validate the hallucinations, and asking if
hallucinations always occur with stress (B) makes an assumption about the pattern that
may not be accurate.
31. Correct Answer: B. Implement a structured routine with calming activities during peak
periods of sundowning
Rationale: This intervention addresses sundowning (increased confusion and agitation in
the evening) with non-pharmacological strategies that maintain dignity and reduce triggers
for agitation. Administering antipsychotics at first sign of agitation (A) does not address
underlying causes and these medications carry significant risks in dementia. Minimizing all
stimulation (C) may increase confusion and disorientation, and using restraints (D) can
increase agitation and is considered a last resort due to physical and psychological risks.
32. Correct Answer: B. Respect the client's silence while offering opportunities to contribute
Rationale: This approach respects the client's comfort level while leaving the door open
for participation when ready. Therapeutic groups recognize that clients benefit in different
ways, including through observation. Direct questioning (A) may increase anxiety and
discomfort. Suggesting individual therapy (C) may be premature and imply failure.
Requiring verbal participation (D) creates unnecessary pressure and may be
counterproductive.
33. Correct Answer: C. "I should avoid alcohol while taking this medication."
Rationale: Avoiding alcohol while taking selective serotonin reuptake inhibitors (SSRIs)
like sertraline is correct patient education due to potential interactions. The statement that
effects will be felt within 2-3 days (A) is incorrect, as SSRIs typically take 2-4 weeks for full
therapeutic effect. Stopping medication when feeling better (B) is incorrect and dangerous,
as this can lead to discontinuation syndrome and relapse. Taking double doses to make up
missed doses (D) is incorrect and potentially dangerous.
34. Correct Answer: C. Client will maintain adequate nutritional intake to support weight
restoration
Rationale: For a client with anorexia nervosa with a low BMI, nutritional rehabilitation and
weight restoration are the highest initial priorities to address medical stability. While body
image concerns (A), cognitive distortions (B), and coping mechanisms (D) are important
therapeutic goals, they would be addressed after medical stabilization has been achieved.
35. Correct Answer: A. The client has a history of previous suicide attempts
Rationale: Previous suicide attempts are one of the strongest predictors of future suicide
risk. While financial problems (B), living alone (C), and depression diagnosis (D) are all risk
factors, a history of previous attempts indicates the client has already acted on suicidal
thoughts in the past, making this the most significant risk factor among those listed.
36. Correct Answer: D. Tactfully redirect by acknowledging the client's input and inviting
others to share
Rationale: This approach manages the group dynamic while maintaining respect for all
members. It prevents one client from dominating while encouraging broader participation.
Asking the client to leave (A) is unnecessarily punitive and disruptive to the group. Ignoring
the behavior (B) fails to address the issue and may diminish the therapeutic value for other
group members. Addressing the behavior only privately (C) misses the opportunity to
model appropriate group interaction.
37. Correct Answer: B. Explore the client's concerns about medication and provide education
Rationale: This client-centered approach respects autonomy while attempting to
understand barriers to medication adherence. Education may address misconceptions and
reduce resistance. Requesting injectable medication (A) prematurely moves to more
restrictive interventions. Mentioning court-ordered medication (C) may damage trust and
increase paranoia. Involving family to convince the client (D) may undermine the
therapeutic relationship and the client's autonomy.
38. Correct Answer: C. Exploring issues related to control, self-esteem, and body image
Rationale: This intervention addresses the psychological factors underlying bulimia
nervosa, focusing on the core issues rather than just the symptoms. Monitoring for
electrolyte imbalances (A) and observing after meals (B) are important for physical safety
but don't address psychological causes. Maintaining a food diary (D) may be helpful for
monitoring but doesn't directly address underlying psychological issues.
39. Correct Answer: A. Encourage reminiscence and life review
Rationale: Life review and reminiscence therapy helps older adults integrate their life
experiences and find meaning, which can address feelings of uselessness and promote ego
integrity versus despair (Erikson's developmental stage). Suggesting new friendships (B)
may be helpful but doesn't address the core feeling of lost purpose. Reassuring that
 everyone feels this way (C) minimizes the client's unique experience. Recommending
increased family visits (D) may increase feelings of dependency rather than promoting the
client's sense of value.
40. Correct Answer: B. "I can see you're concerned about the medication. Can you tell me
more about your concerns?"
Rationale: This response acknowledges the client's feelings without reinforcing or
challenging the paranoid thought directly. It opens communication and may help identify
specific concerns that can be addressed. Option A is authoritative and may increase
paranoia, option C may seem threatening to a suspicious client, and option D avoids
addressing the underlying concern while potentially reinforcing medication avoidance.
41. Correct Answer: C. Implementing exposure and response prevention techniques
Rationale: Exposure and response prevention (ERP) is the evidence-based approach for
treating OCD. It involves gradually exposing the client to anxiety-provoking situations
(dirty hands) while preventing the compulsive response (washing). Preventing
handwashing completely (A) would likely increase anxiety to intolerable levels. Providing
gloves (B) accommodates the compulsion rather than treating it. Substituting another
activity (D) may simply transfer the compulsion rather than addressing the underlying
anxiety.
42. Correct Answer: B. "I'm concerned about what you're saying. Are you having thoughts of
harming yourself?"
Rationale: This response directly addresses potential suicidal ideation, which is suggested
by the client's statement. Assessing suicide risk is a priority when clients make statements
about being "better off without me." Option A dismisses the client's feelings, option C
provides reassurance without assessment, and option D minimizes the client's current
distress. All of these responses fail to address the potential safety concern.
43. Correct Answer: B. The client states the voices are telling them to harm staff
Rationale: Command hallucinations directing harm to self or others represent an
immediate safety risk requiring prompt intervention. The other hallucinations and
delusions (A, C, D), while concerning and requiring treatment, do not pose the same
immediate danger to the client or others.
44. Correct Answer: B. Processing the event with the client when calm
Rationale: After safety is established, processing the event with the client helps identify
triggers, explore alternative coping strategies, and restore therapeutic rapport. This
debriefing is crucial for both immediate and long-term behavioral management.
Documentation (A) is important but not the priority for therapeutic care. Increased
security (C) is reactive rather than therapeutic. Administering PRN medication (D)
addresses symptoms without addressing underlying issues.
45. Correct Answer: A. "That must be very distressing. Would you like to talk more about your
experience?"
Rationale: This response validates the client's experience and encourages exploration of
grief. Perceptual disturbances during grief (such as hearing the deceased) can be normal
and don't necessarily indicate hallucinations requiring psychiatric intervention. Option B
jumps to pharmacological intervention prematurely. Option C pathologizes a potentially
normal grief reaction. Option D dismisses the emotional experience through distraction.
46. Correct Answer: B. Universality
Rationale: Universality—the realization that others share similar experiences—is
particularly important in the early stages of group therapy for eating disorders, as it helps
reduce isolation and shame. Clients often believe their thoughts and experiences are
unique, and recognizing shared struggles can be therapeutic. Catharsis (A) typically occurs
after trust is established. Interpersonal learning (C) develops in later stages. While
installation of hope (D) is important, universality typically has a more immediate impact
on reducing isolation in eating disorder groups.
47. Correct Answer: C. "Using unprescribed benzodiazepines can be dangerous due to
potential interactions with other medications and risk of dependence."
Rationale: This statement accurately describes the risks of using unprescribed
benzodiazepines, including drug interactions, potential for dependency, and improper
dosing. Options A and B provide dangerous misinformation that could encourage unsafe
practices. Option D encourages continued misuse of medication.
48. Correct Answer: C. "It usually takes 2-4 weeks before you'll notice the full benefits of this
medication."
Rationale: Selective serotonin reuptake inhibitors (SSRIs) like sertraline typically take 2-4
weeks to reach full therapeutic effect. Setting appropriate expectations about medication
timeline is important for adherence. Suggesting a medication change (A) or dose increase
(B) after only one week is premature and potentially unsafe. Suggesting medication isn't
right (D) may discourage the client from continuing an appropriate treatment.
49. Correct Answer: B. Gradually introduce male staff members with the client's permission
Rationale: This intervention respects the client's trauma history while gradually working
toward comfort with male providers through a controlled, consent-based approach.
Assigning only female staff (A) accommodates avoidance, which may reinforce anxiety
long-term. Teaching that not all men are abusive (C) invalidates the client's anxiety and
trauma response. Using anxiolytic medication (D) treats symptoms without addressing the
underlying issue.
50. Correct Answer: C. Patient Health Questionnaire-9 (PHQ-9)
 Rationale: The PHQ-9 is a brief, validated screening tool widely used in primary care and
general settings for initial depression screening in adults. The Hamilton Rating Scale
(HAM-D) (A) is clinician-administered and more complex than needed for initial
screening. The Beck Depression Inventory (BDI) (B) is longer and often used for more
detailed assessment after initial screening. The Children's Depression Inventory (CDI) (D)
is designed specifically for children and adolescents, not adults.
51. Correct Answer: A. Stop the guided imagery immediately and implement grounding
techniques
Rationale: When a client with PTSD becomes agitated and hyperventilates during guided
imagery, the priority is to stop the triggering activity and help the client return to the
present moment through grounding techniques. Continuing with guided imagery (B) could
increase distress and potentially lead to retraumatization. Medication (C) may be
appropriate later but is not the first intervention. Encouraging detailed discussion of
trauma (D) during acute distress could worsen symptoms.
52. Correct Answer: A. "Thank you for the kind gesture, but I cannot accept expensive gifts
as it would be unethical."
Rationale: This response maintains professional boundaries while acknowledging the
client's feelings without rejection. It provides a clear explanation based on ethics rather
than personal preference. Option B may seem dismissive of the client's feelings. Option C
avoids addressing the boundary violation directly. Option D offers an interpretation that
may seem judgmental and could damage rapport.
53. Correct Answer: C. All-or-nothing thinking
Rationale: All-or-nothing (dichotomous) thinking is particularly characteristic of anorexia
nervosa, where clients often categorize foods as "good" or "bad" and body image as
"perfect" or "fat" with no middle ground. While personalization (A), catastrophizing (B),
and mind reading (D) may also occur in eating disorders, all-or-nothing thinking is most
central to the rigid cognitive patterns typically seen in anorexia nervosa.
54. Correct Answer: A. Risk for Injury related to altered sensory perception
Rationale: During alcohol detoxification, the client is at highest risk for complications
including seizures, delirium tremens, and accidents due to altered perception, making safety
the priority. While sleep disturbance (B), ineffective coping (C), and nutritional issues (D)
are important, they do not present the same immediate safety risk as potential injuries from
withdrawal symptoms.
55. Correct Answer: C. Serum lithium level
Rationale: Serum lithium levels must be monitored regularly because lithium has a narrow
therapeutic index, and levels that are too high can cause toxicity while levels that are too
low may not control symptoms. While complete blood count (A), liver function (B), and
 thyroid function (D) should be monitored periodically, serum lithium levels require the
most regular and careful monitoring.
56. Correct sequence: B, C, A, D, E
Rationale: The 4-7-8 breathing technique begins with exhaling completely through the
mouth (B) to empty the lungs. Then the client inhales quietly through the nose for 4 counts
(C), holds the breath for 7 counts (A), and exhales through the mouth for 8 counts (D).
The cycle repeats, beginning with closing the lips and inhaling through the nose (E).
57. Correct Answer: C. Ask another staff member to stay with the client while obtaining
assistance
Rationale: This response prioritizes both client safety and appropriate protocol. For a client
with recent suicide attempt, hiding objects raises immediate safety concerns. Having
another staff member remain ensures continuous observation while the nurse obtains
assistance. Confronting the client alone (A) may escalate the situation. Searching without
discussion (B) may damage rapport and trust. Leaving the room (D) could place the client
at risk if potentially dangerous items are present.
58. Correct Answer: C. Cognitive restructuring
Rationale: Cognitive restructuring helps clients identify and challenge negative automatic
thoughts, particularly helpful for social anxiety before situations like job interviews where
catastrophic thinking often occurs. Systematic desensitization (A) would be more
appropriate for longer-term treatment rather than preparation for an imminent event.
Thought stopping (B) may temporarily reduce anxiety but doesn't address underlying
cognitive patterns. Operant conditioning (D) focuses on behavior modification through
rewards/consequences rather than addressing thoughts.
59. Correct Answer: A. "My spouse kept giving me money even though they knew I would
spend it on drugs."
Rationale: This statement accurately describes enabling behavior, where someone
facilitates substance use by removing consequences or providing resources that support
addiction. Options B, C, and D all describe appropriate boundary-setting and supportive
behaviors rather than enabling.
60. Correct Answer: A. Fortune telling
Rationale: Fortune telling involves predicting negative outcomes without evidence, which
accurately describes the client's belief that something terrible will happen to their family.
Labeling (B) involves applying negative global descriptions to oneself or others.
Minimization (C) involves downplaying positive aspects or achievements. Emotional
reasoning (D) involves assuming feelings reflect reality (e.g., "I feel anxious, therefore there
must be danger").
61. Correct Answer: B. Delusion
 Rationale: The client's belief about a CIA microchip implanted in their tooth represents a
delusion, which is a fixed, false belief maintained despite evidence to the contrary. This
specific example is a delusion of persecution (belief that one is being harmed or targeted).
Hallucinations (A) involve sensory perceptions without external stimuli (hearing, seeing
things that aren't there). Illusions (C) are misinterpretations of actual stimuli. Loose
associations (D) refer to disorganized speech patterns where ideas shift between unrelated
topics.
62. Correct Answer: A. Delirium tremens
Rationale: Visual hallucinations (seeing insects—often referred to as "formication") are a
classic symptom of delirium tremens, a severe form of alcohol withdrawal that typically
occurs 48-72 hours after the last drink. Korsakoff's syndrome (B) is characterized by
confabulation and memory deficits but not typically hallucinations. Alcoholic hallucinosis
(C) primarily involves auditory rather than visual hallucinations. Wernicke's
encephalopathy (D) presents with the triad of confusion, ataxia, and ocular abnormalities
but not typically visual hallucinations.
63. Correct Answer: C. Establish a structured, low-stimulation routine
Rationale: For a client in a manic episode, reducing environmental stimulation and
providing structure helps prevent further escalation of symptoms and promotes safety.
During mania, clients are already experiencing excessive stimulation internally and are
easily distracted. Encouraging group activities (A) and providing stimulating environments
(B) would likely worsen manic symptoms. Allowing the client to direct their own care (D)
may be problematic due to poor judgment and impulsivity characteristic of mania.
64. Correct Answer: B. Assess for suicidal ideation, as increased energy may increase suicide
risk
Rationale: There is an important clinical phenomenon where severely depressed clients
may be at highest risk for suicide when their energy levels begin to improve but before
their mood fully elevates. This occurs because they now have the energy to act on
previously existing suicidal thoughts. The nurse should assess for this risk, particularly since
the client has only been on medication for three weeks. Options A, C, and D all miss this
important safety assessment.
65. Correct Answer: B. "Tell me more about what you're feeling right now."
Rationale: This response uses the therapeutic communication technique of exploration,
encouraging the spouse to express their feelings without judgment or premature advice. It
demonstrates presence and willingness to listen, which is crucial in grief support. Option
A minimizes feelings and places an unrealistic expectation on the spouse. Option C
dismisses the uniqueness of their grief experience. Option D jumps to a solution before
fully understanding the spouse's current emotional state.
66. Correct Answer: Bradycardia
Rationale: Bradycardia (heart rate below 60 beats per minute) is a common compensatory
mechanism in chronic malnutrition associated with anorexia nervosa. The body conserves
energy by slowing the heart rate. Other acceptable answers could include: hypothermia,
hypotension, lanugo (fine body hair), or amenorrhea, as these are also physiological
adaptations to starvation.
67. Correct Answer: C. "I notice my thoughts and feelings without judgment."
Rationale: This statement correctly describes the core principle of mindfulness meditation,
which involves present-moment awareness and non-judgmental observation of thoughts
and feelings. Option A incorrectly suggests thought suppression, which is contrary to
mindfulness principles. Option B describes cognitive restructuring, not mindfulness.
Option D describes guided imagery, which is a different relaxation technique.
68. Correct Answer: Clarification
Rationale: Clarification is the most appropriate therapeutic communication technique
when clients make vague statements. By asking the client to elaborate or explain what
"things aren't right" means specifically, the nurse can gather more concrete information
needed for assessment and intervention. Other acceptable answers might include:
exploration, focusing, or open-ended questioning, as these techniques also help elicit more
specific information.
69. Correct Answer: B. Cardiac arrhythmias
Rationale: Tricyclic antidepressants like clomipramine (Anafranil) can cause cardiac
conduction abnormalities and arrhythmias, which represent the most potentially serious
adverse effect. This is particularly concerning in clients with pre-existing cardiac
conditions. Tricyclics typically cause hypotension (not hypertension, A), increased appetite
(C) is a common but less serious side effect, and while photosensitivity (D) can occur, it's
not the most concerning side effect requiring monitoring.
70. Correct Answer: C. The caregiver reports significant weight loss and insomnia
Rationale: Significant weight loss and insomnia indicate physiological manifestations of
severe stress that suggest caregiver role strain has progressed to a level affecting physical
health. This requires immediate intervention. Occasional fatigue (A) is common and
expected. Hiring additional help (B) demonstrates positive coping and resource utilization.
Frustration with the healthcare system (D) may be a normal response but doesn't
necessarily indicate severe role strain.
71. Correct Answer: 1, 2, 4 (Head/face, Chest/heart, Extremities)
Rationale: During a panic attack, sympathetic nervous system activation ("fight or flight"
response) causes observable signs in multiple body areas: Head/face (1): dilated pupils,
sweating; Chest/heart (2): tachycardia, palpitations, rapid respiration; Extremities (4):
 trembling, tingling sensations, cold extremities due to peripheral vasoconstriction. The
abdominal area (3) may experience symptoms (e.g., nausea), but the most pronounced and
assessable signs of sympathetic activation are in the other areas.
72. Correct Answer: Grounding
Rationale: Grounding techniques are the most effective immediate intervention for
flashbacks in PTSD. These techniques help reconnect the person to the present moment
using sensory awareness (e.g., identifying five things they can see, four they can touch,
three they can hear, etc.). Other acceptable answers might include: sensory awareness,
reality orientation, or present-moment awareness techniques, as these have similar
functions in addressing flashbacks.
73. Correct Answer: C. Extrapyramidal side effects requiring intervention
Rationale: The symptoms described (muscle stiffness and akathisia—inability to remain
still, especially in the legs) are classic extrapyramidal side effects (EPS) of antipsychotic
medications like risperidone. These require intervention such as medication adjustment or
addition of an anticholinergic agent. These are not expected to diminish over time without
intervention (A). Neuroleptic malignant syndrome (B) includes severe rigidity but also
fever, altered consciousness, and autonomic instability. These symptoms are not consistent
with withdrawal (D) from the medication.
74. Correct Answer: C. "I've let my family down by not succeeding."
Rationale: The statement indicating that the client felt they "let family down by not
succeeding" in their suicide attempt suggests ongoing suicidal ideation and potential intent
to try again, representing the highest risk among the options. It implies the client regrets
the attempt's failure rather than the attempt itself. Options A and D suggest insight and
desire for treatment, which are positive signs. Option B directly states the client no longer
wants to die, indicating decreased risk.
75. Correct Answer: Consistent limit-setting
Rationale: Consistent limit-setting is crucial when working with families of clients with
eating disorders. This prevents reinforcing disordered behaviors while supporting recovery
through clear boundaries and expectations. Other acceptable answers might include:
avoiding power struggles, modeling healthy relationships with food, or separating the
illness from the person, as these are also important therapeutic principles in family-based
treatment for eating disorders.
76. Correct sequence: E, A, C, B, D
Rationale: The correct sequence for teaching progressive muscle relaxation begins with
deep breathing exercises (E) to initiate relaxation, followed by having the client identify
areas of tension (A) to increase body awareness. Next, the client is instructed to tense
specific muscle groups (C), then guided to completely relax those muscles (B). Finally, the
 client is taught to focus on the contrast between tension and relaxation (D) to enhance
awareness of the relaxed state.
77. Correct Answer: C. Offer to pause, explain each step, and obtain ongoing consent
Rationale: This trauma-informed approach respects the client's autonomy, provides
predictability, and helps the client maintain a sense of control during the examination,
which is particularly important for survivors of sexual abuse. Proceeding quickly (A) may
increase anxiety and potentially retraumatize the client. Asking another nurse (B) doesn't
address the underlying issue and may reinforce avoidance. Rescheduling (D) may be
necessary if the client requests it, but should not be the first intervention.
78. Correct Answer: Some degree of insight or doubt about the belief
Rationale: Unlike delusions, which are fixed false beliefs maintained with absolute
conviction despite contrary evidence, overvalued ideas are characterized by some degree
of insight or doubt about the belief. This partial insight makes overvalued ideas potentially
more responsive to cognitive interventions. Other acceptable answers might include: less
rigid conviction, susceptibility to questioning, or acknowledgment of possible alternatives,
as these all describe the relative flexibility compared to delusions.
79. Correct Answer: B. Deep exploration of personal issues and constructive feedback
between members
Rationale: The working stage of group therapy (also called the productive or mature stage)
is characterized by deeper exploration of personal issues, meaningful interpersonal
feedback, and constructive confrontation as trust has been established. Option A describes
the initial forming/storming stages, option C describes the early forming stage, and option
D describes the termination stage of group development.
80. Correct Answer: A. Bipolar I disorder
Rationale: The client's description indicates episodes of full mania (not sleeping for days,
excessive spending) alternating with major depressive episodes (barely able to get out of
bed), which is characteristic of Bipolar I disorder. Bipolar II disorder (B) involves
hypomania (less severe than full mania) and depression. Cyclothymic disorder (C) involves
numerous periods of hypomanic and depressive symptoms that are less severe than those
described. Rapid cycling (D) refers to the frequency of mood shifts (four or more episodes
per year) rather than the type of episodes experienced.
81. Correct Answer: A, B, C, E
Rationale: In adolescents, depression may be "masked" or present differently than in adults,
often manifesting as behaviors rather than expressed feelings of sadness. Declining
academic performance (A), increased risk-taking behaviors (B), somatic complaints
without medical cause (C), and social withdrawal from peers (E) are all common
manifestations of masked depression in adolescents. Expressed feelings of hopelessness
 (D) would be a more direct expression of depressive symptoms rather than a masked
presentation.
82. Correct Answer: B. Self-medication
Rationale: Self-medication refers to the use of substances (in this case, alcohol) to alleviate
specific symptoms (anxiety and sleep problems) without medical supervision. This pattern
is common in trauma survivors who haven't received appropriate treatment for their
symptoms. It's not a healthy coping mechanism (A) as it can lead to substance use disorder.
Substance-induced anxiety (C) refers to anxiety caused by substance use, not the reverse.
Dual diagnosis (D) refers to the co-occurrence of a substance use disorder and mental
health disorder, which may develop but isn't specifically indicated by the described
behavior.
83. Correct sequence: D, C, B, E, A
Rationale: When planning care for a client with acute schizophrenia, safety assessment (D)
is always the first priority. Establishing a therapeutic relationship (C) provides the
foundation for all other interventions. Using short, simple sentences (B) addresses the
immediate communication needs given the client's disorganized thinking. Administration
of prescribed medication (E) helps manage acute symptoms. Group therapy participation
(A) would be appropriate only after the client's acute symptoms are stabilized and they can
benefit from interpersonal interactions.
84. Correct Answer: A combination of cognitive-behavioral techniques, medication when
indicated, and acceptance of some degree of anxiety rather than trying to eliminate it
completely
Rationale: Effective anxiety management involves multiple approaches rather than simply
"controlling" worry. Cognitive-behavioral techniques help identify and modify anxiety-
provoking thoughts; medication may be indicated for symptom management; and learning
to accept some anxiety as a normal part of life (rather than struggling to eliminate it
completely) is a key component of modern anxiety treatment approaches like Acceptance
and Commitment Therapy.
85. Correct Answer: [Previous attempts]
Rationale: Previous suicide attempts are the single strongest predictor of future completed
suicide and should be documented as the most critical risk factor. While all the listed factors
(current plan/intent, access to means, recent losses, and support system) are important in
a comprehensive suicide risk assessment, research consistently shows that a history of
previous attempts is the strongest predictor of completed suicide.
86. Correct Answer: C. "If one identical twin has schizophrenia, the other has about a 50%
chance of developing it."
 Rationale: This statement accurately reflects the current understanding of the genetic
component of schizophrenia. Twin studies show concordance rates of approximately 50%
for identical twins, indicating both genetic and environmental factors play important roles.
Options A and D incorrectly state that schizophrenia is entirely genetically determined or
inevitable with family history, while option B incorrectly dismisses environmental factors,
which research shows are significant.
87. Correct Answer: A, C, E
Rationale: When a client with borderline personality disorder becomes angry about limits,
therapeutic responses acknowledge feelings without judgment (A), recognize that
discussion may be more productive later when emotions are less intense (C), and explain
that limits are universal rather than punitive (E). Options B and D are non-therapeutic as
they criticize the client's behavior and emotional response in ways likely to damage rapport
and escalate anger.
88. Correct Answer: B. Consider that depression may present differently in older adults
Rationale: Depression often presents atypically in older adults, with fewer reports of
sadness but more somatic complaints, anhedonia (loss of interest in previously enjoyed
activities), and sleep disturbances. Recognizing these age-specific presentations is crucial
for accurate assessment. Option A incorrectly assumes that sadness must be present for
depression diagnosis. Options C and D focus only on symptoms without addressing the
underlying condition.
89. Correct Answer: Acute Stress Disorder: Dissociative amnesia, Emotional numbing Post-
Traumatic Stress Disorder: Flashbacks, Avoidance of reminders, Hypervigilance,
Nightmares
Rationale: Both acute stress disorder (ASD) and post-traumatic stress disorder (PTSD)
share similar symptoms, but the key difference is timing—ASD occurs within the first
month after trauma, while PTSD is diagnosed when symptoms persist beyond one month.
While all symptoms can occur in both disorders, dissociative symptoms like dissociative
amnesia and emotional numbing are particularly characteristic of the acute response.
Flashbacks, avoidance behaviors, hypervigilance, and nightmares are core symptoms that,
when persistent beyond one month, are diagnostic of PTSD.
90. Correct Answer: D. Precontemplation
Rationale: The client's statement indicates they are in the precontemplation stage according
to the Transtheoretical Model of Change. This stage is characterized by minimization or
denial of the problem ("I'm cured now") and rationalization for continuing problematic
behaviors (believing controlled drinking is possible despite a history of alcohol use
disorder). Maintenance (A) would involve ongoing strategies to prevent relapse. Action (B)
 involves actively working on changing behavior. Contemplation (C) involves recognizing
a problem but not yet being ready to change.
91. Correct Answer: B. Major depression
Rationale: The described presentation—restricted affect, psychomotor retardation (slow
responses with long pauses), logical but slow thoughts, good grooming, and appropriate
eye contact—is consistent with major depression. Schizophrenia (A) typically presents with
more disorganized thinking and possibly poor self-care. Hypomania (C) would present
with elevated mood, increased rate of speech, and possibly pressured speech. Generalized
anxiety disorder (D) would likely present with more agitation, worry, and possibly poor
concentration rather than slowed responses.
92. Correct Answer: A, B, D
Rationale: Accurate pre-procedure teaching for electroconvulsive therapy (ECT) includes
informing the client they will be under general anesthesia (A), may experience temporary
memory impairment (B), and will receive a muscle relaxant to prevent injury from muscle
contractions (D). The client will not experience painful convulsions (C) due to the
anesthesia and muscle relaxant. Most psychiatric medications are not discontinued before
ECT (E); in fact, some may be continued as part of the treatment plan.
93. Correct Answer: Cognitive-behavioral therapy with gradual exposure therapy, possibly
combined with medication for symptom management
Rationale: The most effective evidence-based treatment for agoraphobia involves
cognitive-behavioral therapy (CBT) with gradual exposure therapy (systematic
desensitization), where the client progressively faces feared situations while using anxiety
management techniques. This may be combined with medication (typically SSRIs or
benzodiazepines) for symptom management, particularly in the early stages of treatment
or for severe cases.
94. Correct Answer: B. Auditory hallucination
Rationale: Hearing voices that aren't actually present is an auditory hallucination, which is
a false sensory perception without external stimuli. A delusion of grandeur (A) would
involve false beliefs about having special powers or importance. An idea of reference (C)
involves the false belief that neutral events or coincidences have special personal
significance. Thought insertion (D) is the delusion that thoughts are being placed in one's
mind by an external force.
95. Correct Answer: C. "I can't stop exercising because my thighs are huge even though I
weigh 85 pounds."
Rationale: This statement indicates the most severe body image distortion because it
demonstrates a complete disconnect between objective reality (significantly underweight at
85 pounds) and self-perception ("thighs are huge"). It also indicates compulsive exercise
 behavior despite dangerous weight, suggesting severe impairment in judgment related to
body image. Options A and D show some insight and less severe distortion, while option
B shows moderate distortion but doesn't indicate the extreme disconnect present in option
C.
96. Correct Answer: Assess vital signs, withhold the next lithium dose, contact the healthcare
provider, and obtain a STAT serum lithium level
Rationale: The symptoms described (nausea, vomiting, tremors) are potential signs of
lithium toxicity, which is a medical emergency requiring immediate intervention. The nurse
should assess vital signs to establish a baseline, withhold additional lithium to prevent
further elevation of levels, contact the provider for immediate orders, and obtain a STAT
serum lithium level to confirm toxicity and guide treatment.
97. Correct Answer: A, B, D, E
Rationale: Important education topics for families of clients with schizophrenia include
recognizing early warning signs of relapse (A), effective communication strategies (B), the
importance of medication adherence (D), and maintaining appropriate boundaries (E).
Option C is incorrect as family intervention cannot "cure" schizophrenia, though it can
improve outcomes and reduce relapse rates. Education should be realistic about the
chronic nature of the illness while emphasizing the significant improvements possible with
proper treatment.
98. Correct Answer: A, C, E
Rationale: Effective coping mechanisms for generalized anxiety disorder include regular
practice of relaxation techniques like progressive muscle relaxation (A), identifying and
challenging catastrophic thoughts using cognitive-behavioral techniques (C), and
scheduling worry time to contain anxious thoughts rather than allowing them to dominate
all waking hours (E). Avoidance of all anxiety-triggering situations (B) is a maladaptive
coping strategy that reinforces anxiety long-term. Using alcohol to manage anxiety (D) is
also maladaptive and potentially harmful.
99. Correct Answer: B. Lack of remorse for hurting others
Rationale: Lack of remorse or guilt after hurting others is a hallmark characteristic of
antisocial personality disorder, reflecting the impaired empathy and callousness that define
the disorder. Extreme fear of abandonment (A) is characteristic of borderline personality
disorder. Excessive attention to details (C) is associated with obsessive-compulsive
personality disorder. Unusual perceptual experiences (D) are more typical of schizotypal
personality disorder or psychotic disorders.
100. Correct Answer: C. "I can acknowledge my pain while still engaging in meaningful
activities."
 Rationale: This statement reflects the core principle of Acceptance and Commitment
Therapy (ACT)—accepting what cannot be changed (the presence of pain) while
committing to actions that align with personal values. Option A contradicts ACT principles
by suggesting elimination of negative thoughts, which ACT views as futile. Option B
represents hopelessness rather than acceptance. Option D misinterprets ACT as mere
distraction rather than meaningful engagement aligned with values.
101. Correct Answer: A. "You don't have to talk about it now, but I'm here when you're ready."
Rationale: This response demonstrates therapeutic communication by respecting the
client's boundaries while keeping the door open for future disclosure when trust is
established. This approach is particularly important with adolescents who may be reluctant
to discuss self-harm behaviors initially. Option B pressures the client inappropriately.
Option C makes assumptions and uses potentially triggering language. Option D is
judgmental and inaccurate—declining to discuss a topic is not non-compliance.
102. Correct sequence: D, A, B, E, C
Rationale: When working with a client experiencing paranoid delusions about food,
establishing rapport and a therapeutic relationship (D) is the essential first step to build
trust. Offering prepackaged food options (A) provides a practical immediate solution while
respecting the client's concerns. Explaining food safety protocols (B) addresses concerns
directly once some trust is established. Allowing family to bring food (E) provides another
acceptable option while maintaining nutritional intake. Requesting nutritional supplements
(C) would be a last resort if other interventions fail to maintain adequate nutrition.
103. Correct Answer: A, C, E
Rationale: Therapeutic group progress in substance use disorder treatment is demonstrated
by members challenging each other's rationalizations (A), offering constructive feedback
about recovery (C), and sharing personal experiences related to recovery challenges and
solutions (E). Monopolizing discussion (B) and promoting one's beliefs as superior (D) are
non-therapeutic behaviors that can hinder group progress by limiting equal participation
and creating division.
104. Correct Answer: Empowering parents/caregivers to take an active role in managing their
child's nutritional rehabilitation and recovery
Rationale: The primary goal of family-based treatment (FBT), also known as the Maudsley
approach, for adolescents with eating disorders is to empower parents/caregivers to take
charge of the recovery process, particularly nutritional rehabilitation. This approach views
parents as the best resource for their child's recovery rather than as contributing to the
problem. FBT positions parents as the experts on their child while providing them with
the skills and support needed to help their child overcome the eating disorder.
105. Correct Answer: C. Derealization
 Rationale: The experience described—flashbacks that feel completely real and involve re-
experiencing the traumatic event—is most accurately characterized as derealization, which
involves a sense that one's surroundings are unreal or distorted. Dissociative amnesia (A)
involves gaps in memory. Depersonalization (B) involves feeling detached from oneself or
one's body. Emotional flooding (D) refers to overwhelming emotions but doesn't capture
the perceptual disturbance described.
106. Correct Answer: A. Difficulty making everyday decisions without excessive advice from
others
Rationale: Difficulty making everyday decisions without excessive reassurance or advice is
a core characteristic of dependent personality disorder that significantly impacts
functioning and should be addressed in the plan of care. The other options describe
features of different personality disorders: disregard for norms and others' rights (B) is
characteristic of antisocial personality disorder, extreme perfectionism (C) relates to
obsessive-compulsive personality disorder, and grandiosity (D) is associated with
narcissistic personality disorder.
107. Correct Answer: [Zone 3: Sitting at eye level across from client]
Rationale: When communicating with a client experiencing hallucinations, sitting at eye
level across from the client (Zone 3) represents the most therapeutic positioning. This
approach is non-threatening, establishes eye contact, communicates equality in the
relationship, and allows the nurse to maintain a safe but engaging distance. Standing over
the client (Zone 1) can appear threatening. Standing at the doorway (Zone 2) may suggest
fear or disengagement. Standing behind the client (Zone 4) could increase paranoia and
prevent observation of facial expressions.
108. Correct Answer: A, C, D
Rationale: Complicated grief differs from normal grief primarily in its persistence and
intensity. Characteristics include intense yearning for the deceased that hasn't diminished
over time (A), inability to accept the reality of the loss (C), and preoccupation with thoughts
of the deceased that interferes with daily functioning (D). Occasional sadness when
reminded of the deceased (B) and finding comfort in memories (E) are features of normal
grief that typically don't indicate complication.
109. Correct Answer: C. Metabolic syndrome
Rationale: Metabolic syndrome (including weight gain, dyslipidemia, insulin resistance, and
hypertension) is a significant side effect of olanzapine that requires careful monitoring and
intervention due to its long-term health implications, including increased risk of
cardiovascular disease and diabetes. While photosensitivity (A), dry mouth (B), and
sedation (D) are potential side effects, they generally have less serious long-term health
consequences compared to metabolic syndrome.
110. Correct Answer: Generalized anxiety disorder (GAD)
Rationale: The constellation of symptoms described—persistent worry about multiple
circumstances, muscle tension, fatigue, irritability, and sleep disturbance lasting more than
six months with significant functional impairment—meets the diagnostic criteria for
generalized anxiety disorder (GAD). The key features are the pervasive nature of the worry,
its persistence over time, physical symptoms of anxiety, and functional impairment.
111. Correct Matches:
Mindfulness: C. Being aware of and present in the current moment
Distress tolerance: A. Surviving crisis situations without making things worse
Emotion regulation: D. Changing or managing intense emotions
Interpersonal effectiveness: B. Balancing wants and needs in relationships
Rationale: These matches correctly align each DBT skill module with its primary
therapeutic focus. Mindfulness teaches awareness of the present moment without
judgment. Distress tolerance focuses on managing crisis situations without engaging in
harmful behaviors. Emotion regulation involves identifying, experiencing, and influencing
emotions effectively. Interpersonal effectiveness teaches skills for maintaining
relationships while achieving objectives and maintaining self-respect.
112. Correct Answer: B. Simultaneous symptoms of mania and depression
Rationale: A mixed episode in bipolar disorder is characterized by the simultaneous
presence of manic and depressive symptoms, such as agitation and racing thoughts
alongside depressed mood and suicidal ideation. This differs from rapid cycling (C), which
involves distinct episodes changing relatively quickly but not simultaneously present.
Option A describes a purely manic episode, while option D describes hypomania, not a
mixed state.
113. Correct Answer: A. Having the client touch increasingly "contaminated" objects while
preventing hand washing
Rationale: This correctly describes exposure and response prevention (ERP) for OCD,
where the client is gradually exposed to anxiety-provoking stimuli (touching
"contaminated" objects) while preventing the compulsive response (hand washing).
Redirecting to another activity (B) doesn't address the underlying anxiety. Providing
antibacterial gel (C) is a replacement compulsion, not ERP. Limiting and gradually reducing
(D) still allows the compulsion rather than preventing the response part of ERP.
114. Correct Answer: Depersonalization
Rationale: The symptom described—feeling like one is outside one's body, observing
oneself—is depersonalization, a dissociative symptom characterized by feeling detached
from one's mental processes or body. This is a common trauma-related symptom that can
occur in post-traumatic stress disorder and other trauma-related conditions.
 Depersonalization typically involves a disruption in self-awareness and can be frightening
for individuals experiencing it.
115. Correct Answer: C. Cardiac dysrhythmias
Rationale: For a client with severe anorexia nervosa (BMI 15.8), cardiac dysrhythmias
represent the most immediate life-threatening complication requiring assessment and
intervention. Severe malnutrition and electrolyte imbalances can lead to QT prolongation,
bradycardia, and other potentially fatal heart rhythm abnormalities. While amenorrhea (A),
osteopenia (B), and lanugo (D) are complications of anorexia nervosa, they don't present
the same immediate risk to life as cardiac complications.
116. Correct Answer: C. Remove environmental stimuli and speak in a calm, clear manner
Rationale: When a client is experiencing acute psychosis with agitation, the first
intervention should focus on de-escalation techniques, including removing environmental
stimuli and using calm, clear communication. This non-restrictive approach promotes
safety while maintaining the client's dignity. Medication (A), seclusion (B), and restraints
(D) represent more restrictive interventions that should only be implemented if less
restrictive measures have failed, following the principle of using the least restrictive
intervention first.
117. Correct Answer: B. Explain that therapeutic effects typically take 2-6 weeks while
side effects may appear earlier
Rationale: This response provides accurate education about SSRIs—therapeutic effects
typically require 2-6 weeks to develop, while side effects often appear earlier in treatment.
This timing discrepancy is important information for clients to prevent discontinuation
due to perceived ineffectiveness. Recommending a medication change (A) is premature
after only two weeks. Suggesting discontinuation (C) is inappropriate as side effects are
often temporary. Doubling the dose (D) could increase side effects and is not evidence-
based practice.
118. Correct Answer: A, B, D
Rationale: Evidence-based parenting strategies for ADHD include establishing consistent
routines and clear expectations (A), providing frequent and immediate positive
reinforcement (B), and using developmentally appropriate time-out procedures (D).
Removing structure (C) would likely increase ADHD symptoms, as children with ADHD
typically benefit from structure and predictability. Punishing more severely (E) is
counterproductive and potentially harmful, as positive reinforcement is generally more
effective than punishment for children with ADHD.
119. Correct Answer: C. Psychotic symptoms present for substantial periods when mood
symptoms are not active
 Rationale: The defining characteristic of schizoaffective disorder is the presence of
psychotic symptoms (hallucinations or delusions) for substantial periods in the absence of
prominent mood symptoms. This distinguishes it from mood disorders with psychotic
features, where psychotic symptoms occur only during mood episodes (option B). Options
A, B, and D do not accurately describe the diagnostic criteria for schizoaffective disorder.
120. Correct Answer: C. Specific plan with access to lethal means
Rationale: Having a specific suicide plan with access to lethal means represents the most
significant acute risk factor for suicide completion among the options listed. This indicates
both intent and capability, which dramatically increases imminent risk. While history of
childhood trauma (A), recent diagnosis of chronic illness (B), and family history of suicide
(D) are all important risk factors to consider in a comprehensive assessment, they generally
represent more chronic or background risk rather than acute risk.
D. Physiological Integrity
1. Correct Answer: b) Respiratory rate
Rationale: Opioids like morphine can cause respiratory depression, which is the most
concerning side effect. Monitoring respiratory rate is crucial.
2. Correct Answer: d) Hematocrit
Rationale: Hematocrit helps to assess the severity of dehydration as it reflects the
proportion of red blood cells to plasma, which increases when a patient is dehydrated.
3. Correct Answer: a) Administer a nonsteroidal anti-inflammatory drug (NSAID)
Rationale: NSAIDs are commonly used for managing acute pain, especially if the pain is
related to inflammation.
4. Correct Answer: b) Hyperkalemia
Rationale: Chronic kidney disease can result in the buildup of potassium in the blood due
to impaired renal excretion.
5. Correct Answer: b) Stop the transfusion and notify the healthcare provider
Rationale: The patient is showing signs of a blood transfusion reaction. The transfusion
must be stopped immediately.
6. Correct Answer: a) Administer a probiotic as prescribed
Rationale: Antibiotics can disrupt the gut microbiome, and probiotics help restore
normal flora, reducing the risk of Clostridium difficile infection.
7. Correct Answer: c) Obtain blood cultures
Rationale: Fever and swelling at the insertion site of a central venous catheter (CVC)
suggest infection, and blood cultures are necessary to identify the causative organism.
8. Correct Answer: b) Tachycardia
Rationale: Bronchodilators often cause tachycardia as a side effect because they stimulate
beta-2 receptors, which can increase heart rate.
9. Correct Answer: b) Blood glucose levels
Rationale: TPN solutions contain glucose, which can cause hyperglycemia. Monitoring
blood glucose is essential to prevent complications.
10. Correct Answer: b) Apply compression stockings as prescribed
Rationale: Compression stockings help prevent DVT by promoting venous return and
reducing stasis of blood in the lower extremities.
11. Correct Answer: b) Potassium
Rationale: Diuretics, especially loop diuretics, can lead to potassium loss, so monitoring
potassium levels is critical.
12. Correct Answer: b) Change positions slowly to avoid dizziness
Rationale: Antihypertensive medications can cause orthostatic hypotension, so patients
should be instructed to change positions slowly to avoid dizziness.
13. Correct Answer: a) Verify the patient’s identity using two identifiers
Rationale: Verifying the patient’s identity with two identifiers is crucial to ensure patient
safety during blood transfusion.
14. Correct Answer: a) Encourage coughing and deep breathing exercises
Rationale: Coughing and deep breathing exercises help to prevent atelectasis by
promoting lung expansion and clearing secretions.
15. Correct Answer: b) Bleeding
Rationale: Heparin is an anticoagulant, and the primary complication is bleeding.
Monitoring for signs of bleeding is essential.
16. Correct Answer: a) Heart rate
Rationale: Beta-blockers reduce heart rate, so monitoring heart rate is essential to ensure
it does not drop too low.
17. Correct Answer: a) Discontinue the IV and notify the healthcare provider
Rationale: Redness, swelling, and warmth at the IV site indicate infiltration or phlebitis,
and the IV should be stopped immediately to prevent further complications.
18. Correct Answer: b) Place the patient in a prone position
Rationale: Prone positioning helps improve oxygenation in ARDS by promoting better
lung expansion and improving ventilation.
19. Correct Answer: a) Administer an antiemetic as prescribed
Rationale: Nausea and vomiting are common side effects of chemotherapy.
Administering antiemetics helps to prevent further discomfort and complications.
20. Correct Answer: a) Encourage early ambulation
Rationale: Early ambulation is the best intervention for ileus as it promotes peristalsis and
helps restore normal bowel function.
21. Correct Answer: d) Stop the transfusion immediately and notify the healthcare provider
Rationale: The patient is likely experiencing a transfusion reaction, and the transfusion
should be stopped immediately to prevent further complications.
22. Correct Answer: a) "Rinse your mouth after each use to prevent fungal infections."
Rationale: Corticosteroids can cause fungal infections in the mouth, so it is important for
patients to rinse their mouth after each use.
23. Correct Answer: a) Administer an antipyretic medication
Rationale: The patient’s fever is likely due to a postoperative infection, and administering
an antipyretic can help reduce the fever while further investigations are conducted.
24. Correct Answer: b) Take the prescribed bowel prep medication the night before the
procedure
Rationale: The patient should take bowel prep medication as directed to ensure the colon
is thoroughly cleaned before the procedure.
25. Correct Answer: b) Stop the infusion immediately and assess for infiltration
Rationale: Infiltration at the IV site indicates a complication, and the infusion should be
stopped immediately to assess the situation.
26. Correct Answer: b) Obtain an ECG
Rationale: An ECG is essential in diagnosing a myocardial infarction (MI) to assess the
heart's electrical activity.
27. Correct Answer: a) Encourage the patient to drink more fluids
Rationale: Dry mucous membranes are a side effect of corticosteroid inhalers, and
increasing fluid intake can help alleviate the dryness.
28. Correct Answer: b) Hyponatremia
Rationale: Burns, especially large ones, can lead to fluid shifts and cause hyponatremia
due to dilutional effects.
29. Correct Answer: d) Stop the transfusion immediately and notify the healthcare provider
Rationale: This is a serious allergic reaction, and immediate cessation of the transfusion is
necessary to prevent harm.
30. Correct Answer: c) Bruising or petechiae
Rationale: Thrombocytopenia caused by chemotherapy can result in easy bruising or
small red or purple spots under the skin.
31. Correct Answer: b) Need for antibiotic therapy
Rationale: An elevated WBC count indicates infection, and the patient may require
antibiotic therapy to treat the infection.
32. Correct Answer: b) Blood pressure
Rationale: Blood pressure must be monitored during a blood transfusion to assess for
transfusion-related complications like anaphylaxis or hypotension.
33. Correct Answer: d) Tremors
Rationale: Hyperthyroidism often causes tremors due to excess thyroid hormone
stimulating the nervous system.
34. Correct Answer: b) Serum potassium levels
Rationale: Patients with renal failure are at risk for electrolyte imbalances, especially
hyperkalemia, and potassium levels should be closely monitored.
35. Correct Answer: b) Encourage deep breathing exercises
Rationale: Restlessness and rapid breathing are signs of hypoxia, and deep breathing
exercises can help alleviate these symptoms.
36. Correct Answer: a) Severe, sudden upper abdominal pain
Rationale: Acute pancreatitis is characterized by severe, sudden upper abdominal pain
often radiating to the back.
37. Correct Answer: b) Potassium
Rationale: Diuretics can lead to hypokalemia, so monitoring potassium levels is important
to prevent complications.
38. Correct Answer: b) Increased urine output
Rationale: A positive response to IV fluids in dehydration would be an increase in urine
output, indicating improved hydration status.
39. Correct Answer: c) Obtain a consent form
Rationale: It is essential to ensure the patient has signed a consent form before
undergoing the thoracentesis procedure.
40. Correct Answer: b) Administer fluids to maintain blood pressure
Rationale: Sepsis causes fluid shifts, and aggressive fluid resuscitation is crucial to
maintain adequate blood pressure and perfusion.
41. Correct Answer: a) Stop the infusion and notify the healthcare provider
Rationale: Peaked T waves on the ECG indicate hyperkalemia, which can be caused by
the potassium infusion. The infusion must be stopped immediately to prevent further
complications.
42. Correct Answer: d) Both b and c
Rationale: NSAIDs and cranberry juice can interact with warfarin and increase the risk of
bleeding. Patients on warfarin should avoid these substances.
43. Correct Answer: c) Stop the transfusion immediately and keep the IV line open with
saline
Rationale: This is an allergic reaction to the blood transfusion. The first action is to stop
the transfusion and keep the IV line open with saline while notifying the healthcare
provider.
44. Correct Answer: a) Nausea, vomiting, and visual disturbances
Rationale: These are common signs of digoxin toxicity, which can occur when the drug
level exceeds therapeutic limits.
45. Correct Answer: d) All of the above
Rationale: Monitoring oxygen saturation, pain management, and early ambulation are all
essential in the postoperative period.
46. Correct Answer: c) Serum sodium
Rationale: Sodium levels are crucial in the assessment of dehydration, as dehydration can
cause both hypernatremia or hyponatremia.
47. Correct Answer: c) Stop the PCA pump and assess the patient’s respiratory status
Rationale: The patient is experiencing respiratory depression, which can be a side effect
of PCA. The first priority is to stop the pump and assess the respiratory status.
48. Correct Answer: d) High serum creatinine levels
Rationale: High serum creatinine levels are a sign of kidney dysfunction and are
important to monitor in patients with chronic kidney disease.
49. Correct Answer: c) Rinse your mouth with water after using the inhaler to prevent a
fungal infection
Rationale: Corticosteroid inhalers can cause fungal infections in the mouth, so rinsing the
mouth is important to prevent this side effect.
50. Correct Answer: c) Decreased blood pressure and increased heart rate
Rationale: Sepsis can cause cardiovascular instability, and these changes in vital signs
require immediate attention.
51. Correct Answer: c) Assess for signs of shock and notify the healthcare provider
Rationale: The patient’s agitation and dropping blood pressure may indicate shock. The
nurse should assess the patient for other signs of shock and notify the healthcare
provider.
52. Correct Answer: d) Hyponatremia
Rationale: Dehydration and diuretics can lead to low sodium levels, which are a common
concern in patients with liver disease.
53. Correct Answer: c) Acute hemolytic reaction
Rationale: The patient’s symptoms indicate an acute hemolytic reaction, which occurs
when the body attacks the transfused blood cells.
54. Correct Answer: a) Administer an opioid antagonist, such as naloxone
Rationale: Respiratory depression from morphine requires the immediate administration
of naloxone to reverse the effect.
55. Correct Answer: b) A piece of candy or glucose tablets
Rationale: Glucose tablets or candy are fast-acting sources of glucose for hypoglycemia.
56. Correct Answer: b) Administer anticoagulant medication as prescribed
Rationale: Anticoagulants help prevent further clotting in patients with DVT, reducing
the risk of complications.
57. Correct Answer: c) If you notice any increased swelling or redness at the incision site,
contact your healthcare provider
Rationale: Increased swelling or redness could be a sign of infection or other
complications, and the patient should contact their healthcare provider if this occurs.
58. Correct Answer: b) Stop the antibiotic and notify the healthcare provider
Rationale: A new-onset rash is a sign of an allergic reaction. The antibiotic should be
stopped, and the healthcare provider should be notified for alternative treatments.
59. Correct Answer: b) Turn the patient to their side to prevent aspiration
Rationale: Turning the patient to their side during a seizure is the best intervention to
prevent aspiration and ensure airway protection.
60. Correct Answer: c) Sit upright and lean forward on a table
Rationale: During a thoracentesis, the patient should be positioned upright with their
arms on a table to expand the chest and facilitate the procedure.
61. Correct Answer: b) Stop the transfusion immediately and administer normal saline
Rationale: The symptoms indicate an acute transfusion reaction, and the nurse must stop
the transfusion immediately and administer saline to prevent further reaction.
62. Correct Answer: a) Administer insulin as usual and monitor blood glucose levels
Rationale: For patients with diabetes undergoing surgery, it is essential to monitor blood
glucose levels closely and adjust insulin as necessary to prevent hyperglycemia or
hypoglycemia.
63. Correct Answer: a) Check the patient's blood type and crossmatch with the donor blood
Rationale: Before administering blood, confirming compatibility through blood typing
and crossmatching is vital to prevent transfusion reactions.
64. Correct Answer: b) Hold your breath for at least 10 seconds after inhaling
Rationale: This allows the medication to settle into the lungs for maximum effectiveness.
It's essential for the patient to hold their breath after inhaling a dry powder inhaler.
65. Correct Answer: a) Measure the patient’s heart rate and blood pressure
Rationale: Beta-blockers lower the heart rate and blood pressure, so it's important to
monitor these vital signs before administration.
66. Correct Answer: b) Increased white blood cell count and productive cough
Rationale: Pneumonia commonly presents with an elevated white blood cell count and a
productive cough as the body attempts to fight off the infection.
67. Correct Answer: a) Stop the IV infusion and remove the IV catheter
Rationale: Pain, redness, and swelling at the IV site indicate possible phlebitis or
infiltration, and the nurse should stop the infusion and remove the catheter immediately.
68. Correct Answer: b) Rinse the mouth thoroughly after using the inhaler to prevent oral
thrush
Rationale: Corticosteroid inhalers can cause oral thrush, so rinsing the mouth is essential
to prevent fungal infections.
69. Correct Answer: a) Insert a Foley catheter to relieve the urinary retention
Rationale: The patient is experiencing acute urinary retention, which can be relieved by
inserting a catheter.
70. Correct Answer: a) Clear liquid diet for the first 24 hours
Rationale: After a colonoscopy, patients are typically started on a clear liquid diet and
gradually advanced based on their tolerance.
71. Correct Answer: b) Assess the patient's electrolytes, especially sodium levels
Rationale: The patient’s confusion and seizures could indicate electrolyte imbalances,
particularly hyponatremia, and must be addressed promptly.
72. Correct Answer: b) Decreased respiratory rate and drowsiness
Rationale: Opioid medications, such as morphine, can cause sedation and respiratory
depression, which requires immediate intervention.
73. Correct Answer: c) I will skip meals occasionally to reduce my insulin needs
Rationale: Skipping meals can cause hypoglycemia, which is dangerous for patients on
insulin therapy. It is essential to eat regular meals.
74. Correct Answer: b) Platelet count and activated partial thromboplastin time (aPTT)
Rationale: Heparin therapy requires monitoring of platelet counts to assess for
thrombocytopenia and aPTT to monitor the anticoagulant effect.
75. Correct Answer: d) Avoid visitors who may have a cold or infection
Rationale: Patients receiving chemotherapy have compromised immune systems, making
them more susceptible to infections. Limiting exposure to sick individuals is essential.
76. Correct Answer: a) Administer a rapid-acting carbohydrate such as orange juice
Rationale: A rapid-acting carbohydrate like orange juice can quickly raise blood glucose
levels in patients experiencing hypoglycemia.
77. Correct Answer: a) Decrease salt intake and increase potassium-rich foods
Rationale: Reducing salt intake helps control hypertension, and increasing potassium
intake can help balance electrolytes, especially in patients on antihypertensive
medications.
78. Correct Answer: b) Have the patient perform pursed-lip breathing
Rationale: Pursed-lip breathing helps increase oxygenation and decrease the work of
breathing in patients with COPD.
79. Correct Answer: c) Monitoring blood glucose levels regularly
Rationale: Patients receiving TPN are at risk for hyperglycemia, and regular monitoring
of blood glucose is essential to prevent complications.
80. Correct Answer: b) Notify the healthcare provider for possible wound infection
Rationale: Greenish drainage suggests the presence of infection, and the healthcare
provider should be notified for possible intervention and further management.
81. Correct Answer: b) The patient is experiencing frequent episodes of hypoglycemia during
the night
Rationale: Frequent hypoglycemia episodes at night indicate that the insulin regimen may
need to be adjusted.
82. Correct Answer: a) Notify the healthcare provider and continue to monitor the patient
Rationale: A GCS score of 10 indicates moderate impairment and requires monitoring
and reporting to the healthcare provider.
83. Correct Answer: b) Hold the heparin and notify the healthcare provider immediately
Rationale: The aPTT value of 100 seconds is elevated and may indicate a risk for
bleeding, requiring immediate intervention.
84. Correct Answer: b) Hemoglobin and hematocrit
Rationale: Erythropoietin is used to stimulate red blood cell production, and hemoglobin
and hematocrit are monitored to assess its effectiveness.
85. Correct Answer: a) Stop the transfusion immediately and maintain an intravenous line
with normal saline
Rationale: The first priority is to stop the transfusion and maintain IV access for further
interventions.
86. Correct Answers: a) Decreased respiratory rate, c)** Nausea and vomiting, d)**
Constipation
Rationale: Opioids can cause respiratory depression, nausea, vomiting, and constipation
as common side effects.
87. Correct Answer: d) Rotate injection sites to prevent tissue damage
Rationale: Rotating injection sites helps prevent tissue damage and ensures proper
medication absorption.
88. Correct Answers: 4, 1, 3, 2
Rationale: The correct order for managing fluid overload includes assessing urine output,
elevating the legs, monitoring respiratory distress, and administering diuretics as
prescribed.
89. Correct Answer: c) Blood glucose levels
Rationale: Continuous enteral feeding can affect blood glucose levels, requiring
monitoring to prevent hyperglycemia.
90. Correct Answer: b) A baseline pain rating
Rationale: Before administering pain medication, it is essential to assess the patient’s
current pain level for a baseline comparison.
91. Correct Answer: a) Use aseptic technique during catheter insertion and maintenance
Rationale: Aseptic technique helps prevent catheter-associated urinary tract infections.
 92. Correct Answer: a) Muscle pain and weakness
Rationale: Atorvastatin can cause muscle pain and weakness, which can lead to
myopathy.
93. Correct Answer: c) Signs of hemolytic reaction
Rationale: The first 15 minutes after initiating a transfusion are critical to monitor for
signs of a hemolytic reaction.
94. Correct Answer: a) "Rinse your mouth with water after using the inhaler to prevent oral
thrush."
Rationale: Rinsing the mouth prevents fungal infections like oral thrush after using
inhaled corticosteroids.
95. Correct Answer: b) Heart rate and blood pressure
Rationale: Beta-blockers affect heart rate and blood pressure, requiring assessment before
administration.
96. Correct Answer: b) "You should not cross your legs when sitting or standing."
Rationale: After hip replacement surgery, avoiding leg crossing prevents dislocation of
the hip joint.
97. Correct Answer: b) Slow the infusion rate and notify the healthcare provider
Rationale: Shortness of breath and crackles indicate fluid overload, requiring a reduction
in IV rate and further medical evaluation.
98. Correct Answer: b) Monitor vital signs, especially respiratory status, and elevate the
patient’s legs to reduce fluid retention.
Rationale: Fluid overload requires prompt action to assess respiratory status and manage
swelling.
99. Correct Answer: a) Leafy green vegetables
Rationale: Leafy green vegetables are rich in vitamin K, which affects warfarin’s
anticoagulant action.
100.Correct Answer: c) Signs of hemolytic reaction
Rationale: The first 15 minutes after initiating a transfusion are critical to monitor for
signs of a hemolytic reaction.
 Appendices
NCLEX Tips
 NEVER ask "why?" or say "do not worry"
 NEVER leave the patient alone
 ALWAYS choose the safest answer possible
 DO NOT read into the question
 DO NOT "do nothing" or "continue to document" unless everything is normal or
expected
 NEVER persuade the patient
 ELIMINATE answers with absolute words: "ALWAYS, NEVER, ONLY"
 DO NOT delegate what you can EAT (Evaluation, Assessment, Teaching)
 ELIMINATE answers with YES/NO questions
 COMA, COMA, AND RULE: All parts of the answer must be correct!
 Pay attention to words such as "PRIORITY, FIRST, BEST, INITIAL," etc.
 Assume you ALWAYS have an order
 READ the question and the answer you choose before clicking NEXT
 DO NOT be too quick to answer familiar questions. ALWAYS carefully read and
understand questions before answering
 Try getting clues from the answers and begin to eliminate choices that are: not safe, not a
priority, etc., if you don't know the topic/question

Strategies to Use for the NCLEX

Strategy Explanation

Expected vs. Unexpected Prioritize the expected conditions or outcomes;

unexpected scenarios may indicate complications.

Chronic vs. Acute Chronic conditions are stable; acute conditions often
require immediate intervention.
 Stable vs. Unstable Stable patients require less immediate attention than
unstable patients who may deteriorate rapidly.

Potential vs. Actual Problem Actual problems need to be addressed first, but
potential issues should be monitored.

Safe vs. Unsafe Eliminate unsafe interventions and prioritize actions

that maintain patient safety.

Fast vs. Slow Prioritize urgent issues that require immediate action,
rather than those that can be handled later.

Physical vs. Psychosocial Physical issues take precedence when life-threatening.

Psychosocial issues, while important, often follow.

A, B, C's Focus on Airway, Breathing, and Circulation first—

these are life-threatening issues.

Getting clues from the answers Eliminate answers that seem irrelevant, and use the
other answers as clues to the correct one.

If you can do one thing for your patient Think about the most critical action that will affect
and go home, what should it be? patient survival or well-being.

Substance Use and Withdrawal:

Barbiturates, Alcoholism, Opioids/Narcotics:

Withdrawal vs Intoxication Minor Withdrawal vs Major Withdrawal

Talkative Slurred Speech

Slurred Speech Hallucinations/Delirium

Hallucinations/Delirium Euphoric feeling

Euphoric feeling Fever

Decrease respiration Seizures

Seizures Insomnia

Insomnia Tremors

Tremors Anxiety/Tachycardia

Anxiety/Tachycardia Dilated eyes

Dilated eyes Diaphoresis

Diaphoresis Abdominal cramps

Abdominal cramps Eyes watering

Eyes watering Yawning

Yawning Fever

Can be life-threatening Hypertension

Hypertension Seizures

Seizures Tremors

Tremors Tachycardia
 Agitation Anxiety

Anxiety Irritability

Irritability Nausea/Vomiting

Nausea/Vomiting "Hangover"

Pinpoint pupils Slurred speech

Slurred speech Respiratory depression

Respiratory depression Unconsciousness/death

Medical Procedures and Pre/Post Care Instructions

Cerebral Angiography:

Before (Steps Nurse Should Perform) After (Steps Nurse Should Perform)

1. Informed consent 1. Neurological assessment every 15-30 mins

until vitals stable

2. Explain the procedure 2. Keep flat in bed 12 to 14 hours

3. Lie the patient flat 3. Check puncture site every hour

4. Dye injected into femoral artery 4. Immobilize puncture site for 6 to 8 hours
(Fluoroscopy & radiologic films taken after
injection)

5. Prepare sedation 5. Assess distal pulses, color, & temperature

6. Shave skin & prepare the skin 6. Observe symptoms of complications
(allergic response to dye, puncture site,
hematoma)

7. Mark peripheral pulses 7. Force fluids

8. Explain to the patient that they may 8. Accurate I&O

experience warmth and metallic taste when dye
injected

Cardiac Catheterization:
Before (Steps Nurse Should Perform) After (Steps Nurse Should Perform)

1. Informed consent 1. Monitor vitals every 15 min for 2

hours; then every 30 min for 1 hour

2. Explain the procedure 2. Check pulses, sensations, and bleeding

at the insertion site

3. NPO 8-12 hours 3. Bed rest 6-8 hours with insertion site
extremity straight

4. Have patient empty bladder

5. Check pulse

6. Explain the patient may experience heart

palpitations and a desire to cough when dye injected
Lumbar Puncture:
Before (Steps Nurse Should Perform) After (Steps Nurse Should
Perform)

1. Informed consent 1. Neuro checks every 15-30

minutes

2. Explain the procedure 2. Position flat for several hours

3. Position patient in lateral recumbent/fetal position at the 3. Encourage PO fluids to 3,000

edge of the bed mL

Drainage Types:
Type Description

Sanguineous Bright red - indicates active bleeding

Serous Watery or clear - usually normal

Serosanguineous Pink tinged - indicative of some bleeding

Purulent Yellow/green - Infection

Normal Postpartum Vitals:

Vital Normal Range

Temperature Could increase to 100.4°F (Any higher elevation may indicate infection and
must be reported)
Pulse May decrease to 50 bpm (Pulse >100 bpm could indicate excessive blood loss
or infection)

Respirations Should be within normal limits (If RR increases significantly, suspect

pulmonary embolism, uterine atony or hemorrhage)

Blood Should be within normal limits (If significant decrease, suspect hypovolemia)
Pressure

Normal Pediatric Vitals:

Age Group RR HR BP

Newborn 30-60 breaths/min 120-160 bpm 65/40 mm Hg

1-4 years 20-40 breaths/min 80-140 bpm 90-99/60-65 mm Hg

5-12 years 15-25 breaths/min 70-115 bpm 100-110/56-60 mm Hg

Adult 12-20 breaths/min 60-100 bpm <120/80 mm Hg

Urinary Frequency Teaching:

Teaching Points

1. Empty the bladder frequently (every 2 hours)

2. Drink at least 2000 mL of fluid per day

3. Limit fluid intake before bedtime (NOT avoiding fluid intake)

4. Perform Kegel exercises to strengthen the perineal muscles

 5. Wear a perineal pad

Food and Diets:

Potassium Rich Foods:

Kiwi, Oranges, Dried Fruit, Bananas, Cantaloupe, Avocados, Broccoli, Dried Beans/Peas, Lima
Beans, Mushrooms, Potatoes, Seaweed, Soybeans, Spinach

Iron-rich foods:

Red meat, Kidney & Lima beans, Egg yolk, Chickpeas, Cooked Swiss chard, Liver, Molasses,
Lentils, Carrots, Raisins, Apricots, Kale, Spinach, Organ Meats, Clams

Magnesium (1.5-2.5)

Below 1.5 = Hypomagnesemia Above 2.5 = Hypermagnesemia

Arrhythmias, Seizures, Tetany Arrhythmias, Muscle weakness & fatigue,

Nausea/Vomiting

Muscle weakness, Irritability Flushing & Sweating, Loss of deep tendon reflexes,
Respiratory depression

Lethargy, Dizziness, Confusion Hypotension, Loss of consciousness

  Post-op 12 hours
Organs to Prioritize:
Normal Chemistry Values:
 Brain
Lab Test Normal Range
 Lungs
Glucose 70-110 mg/dL  Heart
 Liver
BUN 7-22 mg/dL  Kidney
 Pancreas
Creatinine 0.5-1.2 mg/dL
Single Unstable Clients:
CPK 21-232 mcg/L
 Hypoglycemia (<70 mg/dl): Brain will
Urine Specific Gravity 1.010-1.030 die
 Creatine >1.3: Bad kidney
Bilirubin <1.0 mg/dL  WOF (Watch Out for) Infection:
 Patients with chemo, immunosuppressed,
Total Cholesterol 130-200 mg/dL neutropenic precautions
 Toxic Lab Levels:
 DIGOXIN: >2mg/dl
Words to Remember for Laws  Lithium: >1.5mg/dl
and Prioritization  Phenytoin: >20mg/dl
 Pain:
Unstable Conditions:
 Unstable patient with chest pain =
 Sudden Myocardial Infarction
 New  Patient on a cast with unrelieved pain
 Rapid despite meds = Compartment Syndrome
 Worsening
ABC Prioritization Keywords
 Acute
Airway:
 Returning from surgery
 Post-op 2-4 hours Throat swelling
 Stable Conditions: Noisy, squeaky breathing (Stridor)
 Chronic
Breathing:
 For discharge
Increased PaCO2 (>45 mmHg) Grand Mal: Jerking movements & eventual
loss of consciousness; post-ictal confusion,
Sudden altered mental status, confusion,
incontinence
irritability = Hypoxia
Myoclonic: Awake with short periods of
Circulation:
LOC
No pulse, unpalpable pulse, diminished pulse
Disseminated Intravascular Coagulation (DIC)
(pedal pulse only confirmed with Doppler)
Symptoms:
BP:
Echymosis
Severely low BP (Systolic BP <90mmHg)
Hematomas
HTN Crisis (Systolic BP >180 mmHg) – risk
for aneurysm, MODS, stroke Hemoptysis
Bleeding: Melena
Hard, rigid, board-like abdomen due to Pallor
trauma or surgery
Hematuria
Ruptured appendix = sudden relief of pain
WOF (Watch Out For):
Labs for bleeding:
Lungs: Pulmonary Embolism (PE) – chest
PLT <150k (Thrombocytopenia) pain, dyspnea, SOB
PTT and INR too high Legs: Deep Vein Thrombosis (DVT) – pain,
redness, warmth, swelling
Hirschsprung Disease (Aganglionic)
Symptoms: Brain: Stroke – headache, speech changes,
paralysis, dizziness
No meconium within 1st 24 hours
Management: Anticoagulants
Abdominal distention
Post-Thyroidectomy
WOF: Necrotic enterocolitis
Signs of Hypocalcemia: Muscle twitching &
Seizures spasms
Petit Mal (Absence seizure): Blank stare and DOC (Drug of Choice): IV calcium
impaired LOC; occurs in ages 3-15 gluconate
Simple (Jacksonian): Awake, but exhibit WOF: Stridor, difficulty swallowing
abnormal motor or autonomic behaviors (laryngeal edema)
Frequent swallowing (bleeding)
Hypocalcemia symptoms: Chvostek's sign,
Donning and Doffing Personal
Trousseau's sign, muscle cramps, paresthesia,
peri-oral numbness, tetany, seizures, cardiac
Protective Equipment (PPE)
arrhythmias Donning Doffing
Bedside Equipment: Airway equipment &
calcium gluconate 1. Gown 1. Gloves

Post-Cardiac Catheterization 2. Mask 2. Face shield/goggles

Assessment:
3. Goggles 3. Gown
Check pulses of the extremity distal to the
puncture site; neurological vascular status
4. Gloves 4. Mask/respirator
(NVS)
Monitor for hematoma formation at the
puncture site
Asthma Exacerbation
Position supine with head of bed slightly Symptoms:
elevated (no more than 30 degrees) for 4-6
hours Tachypnea

Phenylketonuria (PKU) Dyspnea

Genetic disorder causing CNS damage from Persistent cough

toxic levels of phenylalanine (protein) Use of accessory muscles
Symptoms: Musty odor urine, Tachycardia
hypopigmentation of hair, skin, and irises
Wheezing
Diagnosis: Guthrie test (heel blood test)
WOF: Absence of wheezing (may indicate
Dietary Management: Low-phenylalanine impending respiratory failure)
formula, Lofenalac milk
DOC (Drug of Choice): Oxygen & Albuterol
Avoid: Beta-adrenergic blockers (cause
bronchoconstriction)
Pregnancy-Induced Hypertension (PIH)
Symptoms:
Increased BP Hemodilution (low sodium, elevated urine
specific gravity)
Oliguria
Oliguria
Cerebral/visual changes
Treatment:
Pulmonary edema
Fluid restriction
Cyanosis
Tolvaptan (Vasopressin antagonist)
Epigastric pain/RUQ pain
WOF: Hepatotoxicity, Hypernatremia
Increased liver enzymes
Domestic Violence
Thrombocytopenia
Signs:
Renal insufficiency
Bruises and broken bones
WOF: HELLP Syndrome (Hemolysis,
Elevated Liver Enzymes, Low Platelets) Unintended pregnancies, miscarriages,
abortions, low birth weight
DOC: Magnesium sulfate (MgSO4)
Alcoholism
Normal Hours of Sleep by Age
Depression
Age Group Normal Sleep Hours
Management:
Newborn 16-18 hours/day Safety first; provide hotlines
Neutropenia
Infant 14-15 hours/day
Teaching Points:
Toddler 12-14 hours/day Brush teeth twice daily with a soft toothbrush

Preschool 12-14 hours/day Wear mask, gown, or gloves when in contact

with low neutrophil count
Avoid cleaning pets
Syndrome of Inappropriate Antidiuretic Hormone Handwashing before touching any patient
(SIADH) belongings
Symptoms: Clean patient’s room once daily
Polydipsia (excessive thirst) Inspect skin and mucous membranes for
fissures and abscesses
CANE Usage (Cane opposite the affected leg) Tachycardia
Elbow angle: 15-30 degrees Tachypnea
Cane advance: 6-10 inches, along with the Cushing’s Triad (Increase in ICP):
affected leg
Hypertension
Rubber tip: Must always be applied
Bradycardia
Tetralogy of Fallot (TOF)
Bradypnea
Symptoms:
Charcot's Triad (Multiple Sclerosis):
Pulmonary stenosis
Scanning speech (Long pauses in every
Right ventricular hypertrophy syllable)
Overriding aorta Intentional tremor
Ventricular septal defect Nystagmus
Cyanosis and hypoxemia (Tet spells) Beck's Triad (Cardiac Tamponade):
Clubbing fingers Big jugular vein distention
Polycythemia (increased clot risk) Extreme hypotension
Management: Muffled heart sounds
Position: Knee to chest (for infants) or Virchow’s Triad (Deep Vein Thrombosis – DVT):
squatting (older children)
Homan's sign: Calf pain during flexion
Oxygen: 100%
Hypercoagulability
Morphine sulfate
Damage to the endothelial wall
IV fluids
Triad of Pre-Eclampsia:
Small and frequent feedings
Proteinuria
Document absence of cyanosis when
Raising blood pressure
feeding, pink lips when crying, RR at 32 bpm
Edema
Triad Symptoms of Diseases
Triad of Leptospirosis:
Shock Triad:
Jaundice
Hypotension
Renal impairment
Hemorrhage Triad of Meniere’s Disease:
Triad of Nephrotic Syndrome: Sensorineural hearing loss
Edema Tinnitus
Proteinuria Vertigo
Hypoalbuminemia Appendicitis:
Triad of Impairment in Autism: Vomiting
Social communication Increased WBC
Social interaction Hyperpyrexia (fever)
Social imagination Pheochromocytoma:
Note: Individuals with autism may have difficulty in
Hyperglycemia
all of these areas.
Headache
Beck’s Cognitive Triad of Depression:
Hypertension
Negative views about the future: (e.g., “I’ll
never be good at anything”) Triad of Niacin Deficiency:
Negative views about the world: (e.g., Dermatitis
“Everyone is against me because I’m Diarrhea
worthless”)
Dementia
Negative views about oneself: (e.g., “I’m
worthless and inadequate”) Triad of ALS (Lou Gehrig’s Disease):

Whipple’s Triad of Hypoglycemia (H2G): Tongue atrophy

Hypoglycemic symptoms Fasciculation (muscle twitching)

Serum glucose <50 mg/dl Quadriplegia

Glucose injection gives symptomatic relief Classic Triad of Diabetes Mellitus (3 P’s):

Classic Triad of Diabetic Ketoacidosis (DKA): Polydipsia (Excessive thirst)

Ketosis Polyphagia (Excessive hunger)

Acidosis Polyuria (Frequent urination)

Hyperglycemia Key Symptoms and Management for Various

Conditions
Diabetes Insipidus: Increased TCVP and neck vein distention
Symptoms: Seizures
Dry mouth Management:
Weight loss Fluid management:
Increased pulse, flat neck veins Hypertonic fluids
Polyuria Monitor serum sodium levels
Elevated sodium levels Medications:
Decreased urine specific gravity Corticosteroids
Management: Chemotherapy
Fluid management: Diuretics
Isotonic fluids first, followed by hypotonic Demeclocycline (induces diuresis)
fluids
Diabetic Ketoacidosis (DKA):
Medications:
Symptoms:
Corticosteroids
High blood glucose
Vasopressin
Polydipsia, polyuria, polyphagia
Monitoring:
Kussmaul’s breathing
Monitor weight and I&O
Acetone breath
Regular serum sodium checks
Electrolyte imbalances (e.g., low potassium)
Watch for:
Diabetic retinopathy
Circulatory overload
Diabetic neuropathy
Syndrome of Inappropriate Antidiuretic Hormone
Management:
(SIADH):
Fluid management:
Symptoms:
Isotonic fluids initially, followed by
Weight gain
hypotonic fluids
Decreased urine output (oliguria)
Insulin therapy for glucose regulation
Dilutional hyponatremia
Electrolyte management: Potassium and Monitor for weight gain and electrolyte
sodium levels must be monitored imbalances
Monitor: CBG levels and urine output Avoid: High-impact activities
Addison’s Disease (Adrenal Insufficiency): Diet: Control glucose and sodium intake
Symptoms: Pheochromocytoma:
Fatigue, weight loss, darkened skin Symptoms:
(bronzing)
Severe hypertension
Low blood pressure, electrolyte imbalances
Tachycardia, headache, sweating
Hyponatremia, hyperkalemia, hypoglycemia
Chest pain, nausea, vomiting
Management:
Management:
Medications:
Emergency: Anti-hypertensive medications
Hydrocortisone or prednisone (e.g., sodium nitroprusside)
Fluids and isotonic solutions Surgical: Adrenalectomy (removal of the
adrenal glands)
Diet: Increase salt intake
Monitor: BP closely
Monitor: Electrolytes, weight, and blood
pressure Avoid triggers: Emotional stress, cold
temperature
Risk: Risk for infection, trauma, and shock
Multiple Myeloma:
Cushing’s Disease:
Symptoms:
Symptoms:
Severe bone pain, fractures
Hyperglycemia, moon face, truncal obesity
Elevated calcium, kidney damage
Hyperkalemia, hypertension, muscle
weakness Bence-Jones protein in urine
Poor wound healing, osteoporosis Osteoporosis and osteomalacia
Increased risk for infections and bleeding Management:
Management: Pain management: Opioids and other
analgesics
Medications:
Chemotherapy for cancer control
Corticosteroids (e.g., prednisone)
Fluids to manage calcium levels and kidney Myasthenia Gravis:
function
Symptoms:
Monitoring: Regular kidney function tests
Drooping eyelids (ptosis)
and pain management
Muscle weakness (including respiratory
Sickle Cell Anemia:
muscles)
Symptoms:
Difficulty swallowing (dysphagia)
Pain crises, typically in chest, abdomen, and
Management:
joints
Medications: Cholinesterase inhibitors (e.g.,
Fever, fatigue, anemia
neostigmine)
Risk of stroke and organ damage
Monitor: Respiratory status and swallowing
Management:
Antidote for overdose: Atropine sulfate
Hydration: IV fluids (isotonic)
Schizophrenia:
Oxygenation: Oxygen therapy as needed
Symptoms:
Pain management: Morphine (avoid demerol)
Positive symptoms: Hallucinations,
Monitor: Risk for infection, especially in the delusions, disorganized speech
spleen (spleen sequestration)
Negative symptoms: Apathy, lack of
Polycythemia Vera: motivation, social withdrawal
Symptoms: Management:
Ruddy complexion Medications: Antipsychotics (e.g., clozapine,
olanzapine)
Hypertension, increased RBC count
Therapy: Focus on reality-based interactions
Risk of clot formation, pruritus (itching)
Support: Family education and verbalization
Elevated platelets, basophils
of feelings
Management:
Systemic Lupus Erythematosus (SLE):
Hydration and Elevate legs to reduce swelling
Symptoms:
Medications: Antihypertensive drugs (e.g.,
Butterfly rash (malar rash)
hydralazine), sodium nitroprusside
Fatigue, photosensitivity
Avoid iron supplements and spicy foods
Joint pain, kidney issues (lupus nephritis) Olive-shaped mass on palpation
Management: Projectile vomiting
Medications: Corticosteroids, Metabolic alkalosis
fluoroquinolones, methotrexate
Dehydration and hypokalemia
Monitor: Kidney function, and
Sunken fontanels, eyeballs, and thirst
photosensitivity
Weight loss and U-wave on ECG
Protect: Use sunscreen for photosensitivity
Management:
Surgical intervention: Fredt or Ramstedt
Basilar Skull Fracture:
procedure to repair pyloric stenosis
Symptoms:
Monitor input & output, small frequent
Battle’s sign (bruising behind the ears) feedings
Racoon eyes (bruising around the eyes) Hirschsprung Disease:
Clear fluid leaking from the nose or ears (CSF Cause: Abnormality in the large intestine’s
leak) anatomical structure due to absence of
ganglion cells.
Management:
Symptoms:
Report immediately and provide supportive
care Severe constipation
Monitor: For signs of brain injury or Green fecaloid vomiting
meningitis
Ribbon-like stools
Treatment: Mannitol to decrease intracranial
Severe abdominal distention
pressure
Management:
Pyloric Stenosis:
Colon resection (endorectal pull-through)
Cause: Autoimmune
Watch for severe abdominal pain and fever,
Pathophysiology: Narrowing of the pyloric
indicating infection
sphincter prevents backflow.
Phenylketonuria (PKU):
Symptoms:
Cause: Deficiency of the enzyme
Distended abdomen
phenylalanine hydroxylase leading to toxic
Severe abdominal distention buildup.
Symptoms: Polycythemia is expected, monitor RBC
count
Musty odor to urine
Cystic Fibrosis:
Mental retardation
Cause: Autosomal recessive disorder
Albinism
Pathophysiology: Overproduction of thick
Developmental delay
mucus affecting multiple organs (pancreas,
Brain damage if untreated lungs, intestines, liver)
Management: Symptoms:
Avoid foods high in phenylalanine (e.g., red Malnutrition and delayed growth
meat, beans, dairy)
Pneumonia
Special formula (Lofenalac)
Malabsorption
Diagnosis via Guthrie test (heel prick)
Infertility
Congenital Heart Defects:
Bleeding tendencies
Cause: Blood flow rerouting due to shunts
Management:
(holes) in the heart.
Use of flutter mucus devices, chest
Types:
physiotherapy
Left-to-Right Shunting (Acyanotic):
Nutritional support (high-fat, high-protein
Examples: PDA, COA, VSD, ASD diet, pancrelipase)
Symptoms: FVE (fluid volume excess) Oxygen therapy if necessary
Murmur (e.g., loud machinery in PDA) Gastric Ulcer:
Right-to-Left Shunting (Cyanotic): Cause: Stress, H. pylori infection, certain
Example: Tetralogy of Fallot (TOF) medications

Symptoms: Cyanosis during feeding and Symptoms:

crying (Tet spells) Severe gastric pain (30-60 mins after meals)
Management: Nausea and vomiting
For cyanotic defects: Positioning the baby in Hematemesis (vomiting blood)
knee-to-chest position
Management:
Antibiotics for H. pylori infection Hepatic encephalopathy (confusion)
Avoid spicy foods, high-fat foods, caffeine, Management:
and gastric irritants
Rest and a healthy diet
Monitor for complications such as shock and
Medications: Interferon for chronic hepatitis
perforation
Liver biopsy to assess damage
Gastrectomy (Surgical Removal of Stomach):
Ascites management: Paracentesis
Types:
Use of diuretics for fluid buildup
Total gastrectomy: Entire stomach removed
Hepatic Encephalopathy:
Partial gastrectomy: Part of the stomach
removed Cause: Liver failure, cirrhosis
Billroth I: Gastro-duodenostomy Symptoms:
Billroth II: Gastro-jejunostomy Confusion and changes in mental status
Management of Complications: Asterixis (flapping tremors)
Dumping syndrome (rapid evacuation of Jaundice
food) Management:
Pernicious anemia due to vitamin B12 Osmotic laxatives (e.g., lactulose)
deficiency
Neomycin to reduce ammonia production
Weight management and frequent small
meals Consider dialysis in severe cases

Avoid carbohydrates and water immediately Esophageal Varices:

after meals Cause: Portal hypertension from liver
Liver Disease (Hepatitis): cirrhosis

Symptoms: Symptoms:

Jaundice (yellowing of the skin and eyes) Vomiting blood (hematemesis)

Clay-colored stool Black, tarry stools (melena)

Dark urine Risk for aspiration

Ascites (fluid in abdomen) Management:

Pruritus (itching)
Sengstaken-Blakemore tube for controlling Band ligation or sclerotherapy
bleeding