NCLEX-RN

Original fixed 85-question NCLEX-RN knowledge practice. Allow up to 5 hours including breaks. A basic calculator may be used for this paper practice. Read all selection and rounding directions. Later case updates are visible; learning points do not estimate CAT ability or predict passing. An RN is planning care with an experienced unlicensed assistive personnel (UAP) member on a rehabilitation unit. Facility policy permits UAP-assisted ambulation after the RN establishes the plan. Which assignment is appropriate?

• ☐ A. Assess whether a client with new dizziness can safely begin walking.
• ☐ B. Help a stable client walk the distance already prescribed in the care plan and report intolerance.
• ☐ C. Teach a client how to use a newly fitted walker for the first time.
• ☐ D. Decide whether a client's newly reported calf pain requires changing the mobility plan.

A hospitalized client develops new unexplained watery diarrhea after several days of antibiotics. Testing for Clostridioides difficile is pending. Which room and equipment plan should the RN implement now?

• ☐ A. A single room with a dedicated toilet and patient-care equipment under contact precautions.
• ☐ B. A negative-pressure room with airborne precautions and shared equipment after cleaning.
• ☐ C. A shared room with another client who has diarrhea from an established noninfectious cause.
• ☐ D. The current shared room with standard precautions until the laboratory identifies an organism.

The caregiver of a healthy 5-month-old says, "My baby has reflux and now rolls from back to stomach and stomach to back without help." Which teach-back statement shows understanding of safe sleep?

• ☐ A. "I will start each sleep on the stomach so reflux drains away."
• ☐ B. "I will raise one end of the mattress while continuing to place the baby on the back."
• ☐ C. "I will start every sleep on the back on a firm, flat surface; if the baby rolls independently, I can leave that position."
• ☐ D. "I will use a rolled blanket to hold the baby on the back after rolling begins."

During an inpatient suicide-risk assessment, a client says, "I am thinking about killing myself right now, and I have worked out how." What should the RN do first?

• ☐ A. Complete the remaining structured risk questions before arranging continuous observation.
• ☐ B. Arrange an urgent mental-health appointment and ask family to supervise until that visit.
• ☐ C. Obtain a commitment to seek staff help, then use the usual intermittent observation schedule.
• ☐ D. Keep the client under direct observation, secure dangerous objects, and obtain an urgent mental-health evaluation.

An immobile client has intact heels, frequent urinary leakage, and a recent decline in food intake. The client can make small position changes when prompted. Select exactly THREE measures that directly address these findings.

• ☐ A. Agree on an individualized repositioning schedule and document skin response.
• ☐ B. Massage persistently reddened areas before the next scheduled skin check.
• ☐ C. Use a barrier product and prompt gentle cleansing after leakage.
• ☐ D. Offer nutrition assessment and assistance with the client's preferred meals.
• ☐ E. Replace repositioning with a pressure-redistributing mattress alone.
• ☐ F. Keep the head of the bed elevated as high as possible throughout the day.

A UAP is assigned to measure intake and output for a stable rehabilitation client. Which instruction best establishes the RN's supervision of the assignment?

• ☐ A. "Record the volumes at the end of the shift; I will call you if I need anything sooner."
• ☐ B. "Use the collection method in the plan, report reduced output or a change in condition promptly, and tell me if you cannot complete it."
• ☐ C. "If the output falls, decide whether extra fluid will solve the problem and then notify me."
• ☐ D. "Compare today's totals with yesterday's and change the monitoring interval if needed."

A medication order reads "potassium chloride concentrate 20 mEq IV push now" for a client with low serum potassium. The vial label states that the concentrate must be diluted and administered by controlled IV infusion. Which response is appropriate?

• ☐ A. Dilute the dose in a small syringe and push it slowly through a running IV.
• ☐ B. Give half the ordered amount by IV push and request a repeat potassium level.
• ☐ C. Withhold administration and clarify an appropriate diluted infusion order with the prescriber and pharmacy.
• ☐ D. Use the existing infusion pump to deliver the undiluted concentrate more gradually.

At 09:20, a client develops sudden unilateral arm weakness and slurred speech. The RN stays with the client. The hospital stroke-response workflow states: activate the response immediately; while the team arrives obtain last-known-well time and bedside glucose; give those findings to the arriving team; then prepare transport for ordered brain imaging. Order the following action packets according to this workflow. Actions within a packet occur together. Order: , , ,

A client treated with insulin is difficult to arouse, cannot swallow safely, and has a bedside glucose of 38 mg/dL. The verified emergency order permits IV dextrose for severe hypoglycemia when IV access is patent. Which action should the RN take? The provided normal fasting-glucose reference for comparison is 70–99 mg/dL; the rescue decision follows the supplied symptom and treatment criteria.

• ☐ A. Protect the airway, activate urgent assistance, and administer the ordered IV rescue through the verified patent access.
• ☐ B. Place oral glucose gel in the client's mouth and reassess in 15 minutes.
• ☐ C. Wait for a laboratory glucose result before using the rescue order.
• ☐ D. Encourage the client to sit upright and drink juice with supervision.

A UAP helping a postoperative client reports that the client became short of breath during a previously tolerated walk. The client is now seated. What is the RN's best next action?

• ☐ A. Ask the UAP to repeat the walk more slowly to see whether the symptom persists.
• ☐ B. Change the assignment to bed bathing and review the report during rounds.
• ☐ C. Ask the UAP to obtain an oxygen saturation and independently decide whether the next walk is safe.
• ☐ D. Assess the client promptly and decide whether the activity plan and level of care need to change.

A client with suspected infectious pulmonary tuberculosis is admitted. Which placement and staff-protection arrangement addresses the main route of transmission?

• ☐ A. A private room with the door open and a surgical mask for staff during routine care.
• ☐ B. An airborne infection isolation room and appropriate fit-tested respiratory protection for staff.
• ☐ C. A contact-precaution room with dedicated equipment but no respirator requirement.
• ☐ D. A droplet-precaution room with staff masks only when within a short distance of the client.

A multidose vial assigned to several clients was taken into one client's treatment bay and placed beside used injection equipment. Which action should the RN take?

• ☐ A. Return the vial to the central preparation area after wiping its exterior.
• ☐ B. Use it for other clients if every entry is made with a new needle.
• ☐ C. Keep it for that one client only and follow policy for possible contamination; do not return it to shared use.
• ☐ D. Use it for other clients after replacing the needle and syringe and inspecting the solution.

Six weeks after giving birth, a client calls the clinic. Select every bracketed phrase that warrants urgent clinical evaluation. Only the bracketed phrases are eligible; record their IDs. [A: I am tired after being awake with the baby.] [B: I have a severe headache and my vision is blurry.] [C: I want help planning meals.] [D: My chest hurts and I am having trouble breathing.] [E: My incision discomfort has steadily improved.] [F: I am thinking about hurting myself.] Selected IDs:

An inpatient client is preparing a collaborative suicide safety plan with the RN. Which elements belong in the plan? Select all that apply.

• ☐ A. Personal warning signs that should prompt use of the plan.
• ☐ B. Use the completed safety plan as the assessment of any new suicidal thoughts.
• ☐ C. People and crisis services the client can contact for help.
• ☐ D. Specific steps to reduce access to dangerous items.
• ☐ E. Make urgent help contact depend on completing every coping exercise in the plan.
• ☐ F. Coping actions the client finds realistic and can try when distress begins.

A client has a prescribed fluid-monitoring plan. During one 4-hour period the client drinks 180 mL of tea and 120 mL of water, takes medication with 30 mL of water, and receives IV fluid at 50 mL/hour for all 4 hours. A frozen dessert is charted as 60 mL when melted; the client consumes the entire portion. What total intake should the RN record? Give a whole-number answer in mL. Response: mL

A client taking warfarin calls after starting a new prescription. The client reports black stools and new weakness; today's INR is 4.8 (laboratory normal INR reference 0.9–1.2 for a person not anticoagulated), above the clinic's prescribed target of 2.0–3.0. The standing order directs urgent assessment for suspected bleeding and holding the next dose pending prescriber review. Which response follows the order?

• ☐ A. Arrange urgent assessment, communicate the INR and new prescription, and withhold the next dose pending review.
• ☐ B. Recommend a vitamin-K-rich meal and keep the current dose until the next scheduled INR.
• ☐ C. Reduce the next dose by half and repeat the INR in one week.
• ☐ D. Explain that black stools are an expected anticoagulant effect if no external bleeding is visible.

Before hemodialysis, a client says, "The vibration in my fistula disappeared this morning." The RN cannot feel the usual thrill. What is the appropriate response?

• ☐ A. Record that the access is ready because there is no pain at the site.
• ☐ B. Notify the dialysis team promptly and have the access assessed before use.
• ☐ C. Apply a snug dressing and reassess the thrill after treatment.
• ☐ D. Use the access as planned unless the client also develops fever.

Case study 1 of 3, adult sepsis. A 54-year-old admitted with suspected pneumonia has a temperature of 39.2 degrees C, pulse 124/min, blood pressure 86/50 mm Hg, and new confusion. The urine collection shows 15 mL in the last hour. The client usually walks with a cane and was alert with a blood pressure of 122/76 mm Hg on admission. Which bracketed findings need prompt follow-up for this acute illness? Select all that apply; only the bracketed phrases are eligible. [A: temperature 39.2 degrees C] [B: pulse 124/min] [C: blood pressure 86/50 mm Hg] [D: usual cane use] [E: new confusion] [F: urine 15 mL in the last hour] Selected IDs:

Case study 1 of 3, adult sepsis. A 54-year-old admitted with suspected pneumonia has a temperature of 39.2 degrees C, pulse 124/min, blood pressure 86/50 mm Hg, and new confusion. The urine collection shows 15 mL in the last hour. The client usually walks with a cane and was alert with a blood pressure of 122/76 mm Hg on admission. The serum lactate is 3.6 mmol/L (laboratory reference 0.5–2.0 mmol/L). The team is evaluating possible sepsis. Classify each finding by its principal contribution to the assessment. Choose one column per row. P=possible impaired organ perfusion; I=infection context; B=unchanged background finding.

Case study 1 of 3, adult sepsis. A 54-year-old admitted with suspected pneumonia has a temperature of 39.2 degrees C, pulse 124/min, blood pressure 86/50 mm Hg, and new confusion. The urine collection shows 15 mL in the last hour. The client usually walks with a cane and was alert with a blood pressure of 122/76 mm Hg on admission. The lactate is 3.6 mmol/L (reference 0.5–2.0). Which problem has the highest priority?

• ☐ A. Fluid loss from fever that can be managed through the usual oral-intake plan.
• ☐ B. Pneumonia-related discomfort requiring analgesia before further perfusion assessment.
• ☐ C. Sepsis-associated perfusion deterioration requiring immediate team treatment.
• ☐ D. An isolated elevated lactate result requiring repeat testing before acting on the vital signs.

Case study 1 of 3, adult sepsis. A 54-year-old admitted with suspected pneumonia has a temperature of 39.2 degrees C, pulse 124/min, blood pressure 86/50 mm Hg, and new confusion. The urine collection shows 15 mL in the last hour. The client usually walks with a cane and was alert with a blood pressure of 122/76 mm Hg on admission. The prescriber has ordered blood cultures, repeat lactate, prompt IV antimicrobial treatment, and an initial crystalloid infusion with frequent perfusion reassessment. Select exactly THREE appropriate elements of the RN's immediate plan.

• ☐ A. Collect ordered cultures promptly when doing so will not substantially delay antimicrobial treatment.
• ☐ B. Wait for culture results to identify an organism before starting the antimicrobial.
• ☐ C. Administer the verified antimicrobial promptly and document when it starts.
• ☐ D. Track mentation, pressure, urine output, and response during the ordered fluid treatment.
• ☐ E. Judge the adequacy of the initial fluid response from lactate change rather than serial perfusion findings.
• ☐ F. Finish routine medication-list reconciliation before starting the verified emergency antimicrobial.

Case study 1 of 3, adult sepsis. A 54-year-old admitted with suspected pneumonia has a temperature of 39.2 degrees C, pulse 124/min, blood pressure 86/50 mm Hg, and new confusion. The urine collection shows 15 mL in the last hour. The client usually walks with a cane and was alert with a blood pressure of 122/76 mm Hg on admission. After the prescribed initial crystalloid, blood pressure is 78/44 mm Hg, confusion persists, and new crackles are heard. A repeat examination indicates that further fluid response must be reassessed. The emergency team is at the bedside and has a verified order for monitored norepinephrine support if hypotension persists. Choose the action and reason that best fit the current findings. Extra tokens are unused. Action: because Reason: . Action bank: A=Continue another fluid bolus without reassessment; B=Implement the verified hemodynamic-support order with the team and ongoing monitoring; C=Complete the antimicrobial infusion before calling attention to the falling pressure. Reason bank: D=Persistent hypotension and organ-perfusion changes require escalation after the initial treatment; E=Improved pressure and urine output show a sufficient initial response; F=New crackles alone prove that the client needs no further circulatory support.

Case study 1, later reassessment after ordered treatment. Select every supported statement in each row. Each ROW is a separate scoring group. A=improved perfusion is supported; B=an important perfusion concern remains; C=the underlying infection is proven resolved. The client remains under treatment for suspected infection.

An adult being treated for an asthma exacerbation was wheezing loudly on arrival. Thirty minutes later the wheeze is quieter, but the client can speak only one word at a time, appears exhausted, and has very poor air entry. Which interpretation should guide the RN's response?

• ☐ A. Less wheeze confirms that treatment is effective and permits routine observation.
• ☐ B. Reduced air movement with exhaustion indicates possible deterioration requiring urgent escalation.
• ☐ C. The breathing change is most consistent with anxiety because the noise is reduced.
• ☐ D. The client should practice slow breathing before the team reassesses treatment.

A home-care client nods through written instructions, then says, "I read slowly, and I understand health information best in Spanish." Which response best checks whether the client can use the plan?

• ☐ A. Provide appropriately translated plain-language instructions and qualified language assistance, then ask the client to explain the plan in their own words.
• ☐ B. Give the original English instructions to the client's visiting 12-year-old child and ask the child to check understanding later.
• ☐ C. Read the same English instructions more loudly and ask whether every point is clear.
• ☐ D. Ask the client to sign the instruction sheet after reading it privately.

In preoperative holding, a client who has signed the surgical consent says, "I thought this was a small procedure. I still do not understand what they will remove." What should the RN do?

• ☐ A. Explain the expected outcome in general terms and proceed because the form is signed.
• ☐ B. Ask the family to explain the procedure while transport waits outside.
• ☐ C. Have the client initial the existing form to confirm the earlier signature.
• ☐ D. Pause the preparation pathway and arrange for the responsible practitioner to answer the client's questions before proceeding.

An RN audits injection preparation. Which practices are unsafe? Select all that apply.

• ☐ A. Using a new sterile needle and syringe for each entry into a medication container.
• ☐ B. Changing the needle on a used syringe before using that syringe for another client.
• ☐ C. Preparing an injection on a clean surface away from used equipment.
• ☐ D. Using one single-dose vial for two clients because a fresh syringe is used for each.
• ☐ E. Using a syringe that has already connected to one client's IV tubing to enter a shared vial.
• ☐ F. Dedicating a multidose vial to one client when it enters that client's immediate treatment area.

The caregiver of a 20-month-old is concerned that the child is not gaining expected communication skills. There is no diagnosis yet. Which guidance should the RN provide about early intervention?

• ☐ A. A confirmed diagnosis is required before an early-intervention program can evaluate the child.
• ☐ B. Only a specialist can contact the program, so wait for the next specialist appointment.
• ☐ C. The caregiver can contact the local early-intervention program for evaluation without waiting for a diagnosis.
• ☐ D. Wait until school enrollment because the child is too young for developmental services.

A client says, "The voice says I should hurt the person in the next room." Which RN response is most appropriate?

• ☐ A. "I know you hear a voice, but I do not hear it. Tell me what it is saying and whether you feel you might act on it."
• ☐ B. "Try to distract yourself with the television; we can discuss the voice after group."
• ☐ C. "The person next door would never hurt you, so the voice has no reason to be there."
• ☐ D. "Ask the voice to explain its reasons before you decide what to do."

A caregiver asks how to explain a parent's death to a 6-year-old who repeatedly asks when the parent will wake up. Which guidance is most appropriate?

• ☐ A. Use "went to sleep" consistently so the child does not hear frightening words.
• ☐ B. Offer a simple truthful explanation that death means the body has stopped working and the parent will not return, and invite questions.
• ☐ C. Avoid further discussion until the child is old enough to understand death fully.
• ☐ D. Say the parent is away for a long trip, then explain death when the child stops asking.

A stroke-rehabilitation client has been eating the texture prescribed in the swallowing plan. During lunch the client develops coughing and a wet-sounding voice after several mouthfuls. The local plan directs the RN to stop oral intake and request reassessment for new swallowing concerns. What should the RN do?

• ☐ A. Offer water to clear the voice and continue the prescribed meal.
• ☐ B. Change the food to a thinner texture and observe the next few mouthfuls.
• ☐ C. Finish the meal slowly because the texture was previously approved.
• ☐ D. Stop the meal, assess the client, and obtain the directed swallowing reassessment.

The RN prepares a prescribed dose of insulin glargine for subcutaneous administration. Which checks and actions are appropriate? Select all that apply.

• ☐ A. Verify the exact insulin product and concentration against the prescription.
• ☐ B. Dilute the dose with saline when the required volume is small.
• ☐ C. Check the recent glucose findings and any hypoglycemia before administration.
• ☐ D. Administer it intravenously when a peripheral IV is already in place.
• ☐ E. Mix it in the same syringe with rapid-acting insulin to reduce injections.
• ☐ F. Use the specified subcutaneous route and follow the product's administration instructions.

A fresh urine specimen is ordered for culture from a client with an indwelling catheter. Which collection method should the RN use?

• ☐ A. Disinfect the sampling port and obtain fresh urine aseptically with the appropriate sterile device.
• ☐ B. Pour urine from the drainage bag into a sterile container.
• ☐ C. Disconnect the catheter from the tubing and catch urine as it flows.
• ☐ D. Remove the drainage-bag outlet cap and collect the specimen from the outlet.

A client with type 1 diabetes reports vomiting, intense thirst, and abdominal discomfort. The client is dehydrated and breathing deeply and rapidly. Bedside glucose is 420 mg/dL and ketones are detected. Choose ONE likely condition, TWO immediate nursing actions, and TWO monitoring priorities from their separate banks. Actions follow the supplied emergency pathway: activate urgent evaluation, maintain access for ordered tests and fluids, and do not independently select an insulin dose. The two entries within each side may be in either order. The provided normal fasting-glucose reference for comparison is 70–99 mg/dL; this symptomatic reading requires urgent evaluation rather than a screening diagnosis. Condition bank: A=isolated hypoglycemia; B=possible diabetic ketoacidosis; C=an uncomplicated gastrointestinal illness; D=isolated dehydration without a metabolic emergency. Action bank: E=activate urgent clinical evaluation; F=arrange outpatient review after attempting oral rehydration; G=maintain IV access for ordered tests and fluids; H=defer urgent notification until a repeat glucose is available; I=select and give an insulin dose before obtaining a prescription. Monitoring bank: J=serial glucose and ketone results; K=serial hemoglobin A1c during acute treatment; L=pressure, mentation and fluid balance; M=urine glucose alone without reassessing circulation; N=abdominal discomfort alone without repeat metabolic tests.

The RN is preparing a caregiver to help a client with limited mobility at home. The individualized plan includes skin checks, assisted position changes, and support for meals. Urinary leakage occurs between scheduled washes. A pressure-redistributing mattress has been arranged, and there is no clinical requirement for sustained head elevation. Which caregiver statements require correction? Select all that apply.

• ☐ A. "I will check the skin during care and ask for reassessment if redness persists."
• ☐ B. "The mattress helps, and I will still assist with the position changes in the plan."
• ☐ C. "I will massage a pressure area that stays red after pressure is relieved."
• ☐ D. "I will offer foods the client enjoys and report a continued decline in intake."
• ☐ E. "I will leave the bed head at 45 degrees overnight so care is easier in the morning."
• ☐ F. "I will clean the skin at the morning and evening washes and use absorbent pads between them."

An alert adult client tells the RN, "You may discuss my discharge plan with my sister, but not with my cousin." The cousin later asks for the medication list. What is the best response?

• ☐ A. Give the list because the cousin is helping the sister with transportation.
• ☐ B. Provide only the medication names, because doses are the private part.
• ☐ C. Explain that information cannot be shared without the client's permission and check whether the client wants to change the preference.
• ☐ D. Ask the sister to authorize release because the client named her as a support person.

During urinary-catheter rounds, the RN reviews the following practices. Classify each as P=preserves recommended catheter maintenance or C=requires correction. Choose one column per row.

After teaching a new home medication schedule, the RN wants to check understanding without making the client feel tested. Which request best uses teach-back?

• ☐ A. "Please show me how you will use this schedule tomorrow so I can check how clearly I explained it."
• ☐ B. "You understand when to take each dose, correct?"
• ☐ C. "Read every line aloud exactly as it is printed."
• ☐ D. "How many years have you managed medications on your own?"

Three months after a partner's death, a client says, "Some days I manage well, and other days I suddenly cry. I thought I should be over this by now." Which response is most appropriate?

• ☐ A. "Let us focus only on keeping your usual appointments; discussing the crying may intensify it."
• ☐ B. "Grief can vary from day to day. Tell me how you are managing daily life and what support would help."
• ☐ C. "The crying shows that more time alone is needed before you reconnect with support people."
• ☐ D. "Because you still have manageable days, we can assume the grief is not affecting your daily function."

A 32-year-old with a verified prescription for amoxicillin 500 mg by mouth is due for a dose. Allergy review is negative, renal function does not require dose adjustment, and the suspension is labeled 400 mg/5 mL. The oral syringe measures tenths of a mL. What volume should the RN give? Round once, at the end, to the nearest tenth of a mL. Response: mL

A postoperative client is alert, has no need for urine-output measurement, and can transfer with one-person assistance. The client asks to use the toilet but worries about falling. Which plan best supports comfort and safety?

• ☐ A. Insert a urinary catheter to avoid repeated assisted transfers.
• ☐ B. Ask the client to remain in bed and use an absorbent pad for all toileting.
• ☐ C. Encourage independent transfers so the client regains confidence quickly.
• ☐ D. Plan timely assisted toileting, keep the call device accessible, and use the assessed transfer assistance.

An adult has a verified order for ceftriaxone 1 g IV in a premixed 50 mL container over 30 minutes. Allergy and compatibility checks are complete; the line contains no incompatible calcium-containing infusion. What pump rate in mL/hour delivers this order? Give a whole-number answer. Response: mL/hour

An immobile client has an individualized pressure-prevention plan. For each new finding, choose R=requires focused reassessment or M=current plan may continue with scheduled monitoring. Judge the change from the stated baseline, rather than diagnosing from a single observation.

Case study 2 of 3, postpartum hemorrhage. Twenty minutes after a vaginal birth, a client has objectively measured cumulative blood loss of 380 mL with continued bleeding, a boggy uterus, pulse 118/min, and blood pressure 88/54 mm Hg. The client feels faint. Before birth, pulse was 82/min and pressure 118/72 mm Hg. Which findings support urgent recognition of postpartum hemorrhage? Select all that apply.

• ☐ A. Blood loss of 380 mL together with abnormal hemodynamic findings.
• ☐ B. A boggy uterus with ongoing bleeding.
• ☐ C. Faintness and the fall in blood pressure.
• ☐ D. The prebirth pulse of 82/min considered by itself.
• ☐ E. The fact that only 20 minutes have passed since birth as proof that treatment can wait.
• ☐ F. The pulse increase to 118/min.

Case study 2 of 3, postpartum hemorrhage. Twenty minutes after a vaginal birth, a client has objectively measured cumulative blood loss of 380 mL with continued bleeding, a boggy uterus, pulse 118/min, and blood pressure 88/54 mm Hg. The client feels faint. Before birth, pulse was 82/min and pressure 118/72 mm Hg. The placenta has been documented as complete. The team continues assessment for other causes. Classify each finding by what it principally supports: A=uterine atony; P=impaired perfusion; U=does not establish either by itself. Choose one column per row.

Case study 2 of 3, postpartum hemorrhage. Twenty minutes after a vaginal birth, a client has objectively measured cumulative blood loss of 380 mL with continued bleeding, a boggy uterus, pulse 118/min, and blood pressure 88/54 mm Hg. The client feels faint. Before birth, pulse was 82/min and pressure 118/72 mm Hg. The placenta is documented as complete, and no visible bleeding laceration has yet been identified. Complete the statement: The priority working concern is Blank 1, supported most directly by Blank 2. Each bank has unused choices. Blank 1: . Bank 1: A=suspected atony-related postpartum hemorrhage; B=normal early postpartum recovery; C=retained placenta established by the current record. Blank 2: . Bank 2: D=a boggy uterus with continued bleeding and hemodynamic change; E=the earlier normal pulse considered alone; F=the mere passage of 20 minutes.

Case study 2 of 3, postpartum hemorrhage. Twenty minutes after a vaginal birth, a client has objectively measured cumulative blood loss of 380 mL with continued bleeding, a boggy uterus, pulse 118/min, and blood pressure 88/54 mm Hg. The client feels faint. Before birth, pulse was 82/min and pressure 118/72 mm Hg. The unit hemorrhage protocol has been activated. Verified orders include an IV uterotonic and isotonic crystalloid, and the protocol calls for prompt uterine massage when atony is observed. Select exactly THREE appropriate care packets. Each packet may contain concurrent actions.

• ☐ A. Activate and coordinate the response team while continuing quantified blood-loss and perfusion checks.
• ☐ B. Begin the protocol-directed uterine massage for the observed poor tone.
• ☐ C. Delay treatment until cumulative loss reaches 500 mL, even if pressure continues to fall.
• ☐ D. Implement the verified uterotonic and fluid orders with monitoring.
• ☐ E. Stop measuring blood loss once the first treatment has begun.
• ☐ F. Stop uterine massage after the IV uterotonic begins, although the uterus remains boggy and bleeding continues.

Case study 2 of 3, postpartum hemorrhage. Twenty minutes after a vaginal birth, a client has objectively measured cumulative blood loss of 380 mL with continued bleeding, a boggy uterus, pulse 118/min, and blood pressure 88/54 mm Hg. The client feels faint. Before birth, pulse was 82/min and pressure 118/72 mm Hg. During the activated response, the uterus remains boggy and bleeding continues. IV treatment is underway. Which linked action and reason fit the protocol now? Not all tokens are used. Action: because Reason: . Action bank: A=Continue protocol-directed uterine massage while the team treats and reassesses; B=Stop massage when IV treatment starts without rechecking uterine tone; C=Use pulse alone to judge response without reassessing tone and bleeding. Reason bank: D=Persistent poor tone and bleeding support ongoing atony response; E=A firm uterus with stopped bleeding would show the poor-tone problem has resolved; F=Blood loss below 500 mL excludes hemorrhage despite abnormal vital signs.

Case study 2, reassessment after first-response care. Select every statement supported by each row. Each ROW is a separate scoring group. A=uterine tone or circulation has improved; B=important bleeding or perfusion concern remains; C=all hemorrhage care can stop.

A client with heart failure uses an individualized action plan: report a weight increase of more than 2 lb in 24 hours or new resting breathlessness to the clinical team the same day; severe difficulty breathing requires emergency help. Weight rises from 162 to 165 lb in 24 hours, and the client has new breathlessness while seated but can speak normally. Complete the statement: The change calls for Blank 1 because Blank 2. Choose the action and matching reason from their banks. Blank 1: . Bank 1: A=same-day clinical-team contact according to the plan; B=waiting for the next monthly visit; C=independently doubling the diuretic. Blank 2: . Bank 2: D=the weight increase and new resting symptom meet the supplied reporting criteria; E=normal speech proves that fluid status has not changed; F=only ankle swelling can trigger the action plan.

At discharge, the RN compares a verified home medication list with new orders. The prescriber has already explained that an intended dose change will be written into the updated plan. Classify each entry as C=clarify before final instructions or D=document the verified intended plan. Choose one column per row.

A urinary catheter was placed for a specific perioperative indication. On postoperative day 2, the indication has resolved, the client can use assisted toileting, and a verified order authorizes removal when the indication is no longer present. What should the RN do?

• ☐ A. Keep the catheter until discharge to avoid disrupting the earlier plan.
• ☐ B. Implement the removal order and arrange the appropriate toileting and follow-up plan.
• ☐ C. Keep the catheter because any surgery is an ongoing indication.
• ☐ D. Wait for symptoms of catheter infection before reconsidering removal.

A hospitalized client required a restraint during an episode of immediate unsafe behavior. The client is now calm, follows the agreed safety plan, and no longer meets the reason for restraint. The order has not yet expired. What should the RN do?

• ☐ A. Continue the restraint until the written order expires.
• ☐ B. Renew the order so the restraint is available if behavior changes later.
• ☐ C. Remove the restraint at the earliest safe opportunity, reassess, and document the change.
• ☐ D. Replace it with another restraint without assessing less restrictive options.

A client who had gestational diabetes says, "I feel well now, so I assume I do not need any further diabetes follow-up." Which reply is appropriate?

• ☐ A. "A history of gestational diabetes increases later type 2 diabetes risk; we should review the recommended follow-up screening plan."
• ☐ B. "Feeling well rules out diabetes after pregnancy."
• ☐ C. "Diabetes risk disappears once the pregnancy ends."
• ☐ D. "Screening matters only after thirst or frequent urination develops."

A client says, "My spiritual practice is important, but I do not want visitors from the community while I recover." Which response best respects the client's preference?

• ☐ A. Arrange a community visit because spiritual support is part of holistic care.
• ☐ B. Ask the family to decide which spiritual practices the client should receive.
• ☐ C. Omit all discussion of spiritual needs because the client declined visitors.
• ☐ D. Ask which private practices or support the client would like and honor the visitor preference.

A conscious client can swallow safely. For symptomatic glucose below 70 mg/dL, the verified plan calls for 15 g of rapid carbohydrate, a glucose recheck after 15 minutes, and another treatment if the repeat remains below 70. The client receives treatment for a glucose of 54 mg/dL. Fifteen minutes later the glucose is 62 mg/dL and symptoms persist. What should the RN do? The provided normal fasting-glucose reference for comparison is 70–99 mg/dL; the rescue decision follows the supplied symptom and treatment criteria.

• ☐ A. Stop treatment because the glucose has risen from its first value.
• ☐ B. Wait one hour before checking again to avoid treating the same episode twice.
• ☐ C. Repeat the prescribed rapid-carbohydrate treatment and reassess according to the plan.
• ☐ D. Give the next scheduled insulin dose before repeating any carbohydrate.

A bedbound client has repeated urine leakage, damp sacral skin, and limited ability to shift weight. There is no open wound. Complete the plan: use Blank 1 for the moisture exposure and Blank 2 for the pressure risk. Each bank has unused choices. Blank 1: . Bank 1: A=gentle cleansing and a suitable skin barrier after leakage; B=routine moisturizer after the scheduled bath as the moisture-protection treatment; C=absorbent-pad changes at planned turns, with skin cleansing reserved for the next bath. Blank 2: . Bank 2: D=an individualized repositioning and support-surface plan; E=use of the mattress to wait for the client to make spontaneous weight shifts; F=a standard turning timetable based on unit routine rather than the client's skin response.

An 18 kg child older than 3 months has a verified amoxicillin prescription for a mild ear infection: 25 mg/kg/day by mouth divided into two equal doses every 12 hours. Allergy review is negative and renal function is normal. Suspension is 400 mg/5 mL. What volume is one dose? Round once, at the end, to the nearest tenth of a mL. Response: mL per dose

After an ordered opioid dose, a postoperative client says the pain is better. Which bracketed findings require prompt reassessment for sedation or respiratory depression? Select all that apply; only the bracketed phrases are eligible. [A: Pain falls from 7/10 to 3/10.] [B: Respiratory rate falls from 16/min to 7/min.] [C: The client requests another blanket.] [D: The client cannot remain awake during conversation.] [E: The client repositions comfortably.] [F: Breaths are shallow and pauses occur.] Selected IDs:

An alert client receiving hemodialysis says, "I do not want today's treatment. I need to understand my options first." What is the RN's best response?

• ☐ A. Arrange a discussion of the client's concerns, options, and consequences with the care team while respecting the current refusal.
• ☐ B. Prepare the access because agreeing to previous sessions covers today's treatment.
• ☐ C. Ask family to consent for the client because missing treatment carries risk.
• ☐ D. Explain that the client can discuss alternatives only after completing the session.

A hospitalized client taking warfarin develops sudden weakness, black stools, and blood pressure 86/48 mm Hg. A standing pathway calls for urgent response to suspected bleeding with perfusion change. Which action takes priority?

• ☐ A. Obtain routine orthostatic measurements by helping the client stand before deciding whether to call the team.
• ☐ B. Hold the next warfarin dose and arrange review at the next scheduled anticoagulation appointment.
• ☐ C. Collect a stool specimen and wait for confirmation before initiating the urgent pathway.
• ☐ D. Activate urgent assessment, monitor perfusion, and communicate the anticoagulant exposure and current findings.

A client will begin home hemodialysis after discharge. The client is willing to learn but reports no available support partner, difficulty traveling to training, and uncertainty about the home setup. Which action best addresses these discharge barriers?

• ☐ A. Give the standard training dates and ask the client to call if attendance fails.
• ☐ B. Coordinate with the dialysis team and case-management or social-work staff to assess support, training access, and a feasible treatment plan.
• ☐ C. Tell the client that willingness to learn is sufficient to begin without further planning.
• ☐ D. Ask a neighbor to serve as the treatment partner without discussing requirements with the client.

An older inpatient becomes dizzy on standing after a medication change and needs help reaching the toilet. The RN is updating an individualized fall-prevention plan. Select exactly THREE appropriate interventions.

• ☐ A. Arrange toileting assistance matched to the current mobility assessment.
• ☐ B. Keep the call device within reach and explain when to ask for help.
• ☐ C. Carry forward the previous independent-transfer plan because the client is alert during the interview.
• ☐ D. Assess the new positional symptoms and communicate relevant medication or pressure findings.
• ☐ E. Use a bed-exit alarm as the main toileting intervention while the new symptoms are being assessed.
• ☐ F. Have the client test the usual walker on the trip to the toilet, then assess tolerance on return.

After reporting dizziness on standing, a client's transfer plan is revised to one-person assistance with the client's walking aid. Classify each proposed arrangement as P=matches the current plan or R=requires revision. Choose one column per row.

A postoperative adult who received an opioid is difficult to arouse, has slow shallow breathing at 6/min, and has a pulse. The verified rescue pathway calls for urgent help, airway and ventilation support, and an ordered opioid antagonist with repeated respiratory and sedation checks. Choose ONE likely problem, TWO immediate action packets, and TWO monitoring priorities for respiratory rescue and recurrent opioid effects. Side-pair order does not matter. Condition bank: A=suspected opioid-related respiratory depression; B=adequate analgesia without a safety problem; C=uncomplicated postoperative fatigue; D=isolated anxiety-related hyperventilation. Action bank: E=activate urgent help and support airway and ventilation; F=obtain a complete pain and function reassessment before activating respiratory help; G=hold further opioid and obtain a new rescue order before supporting ventilation; H=administer the ordered antagonist with the response team; I=increase supplemental oxygen and make the next scheduled sedation check the reassessment point. Monitoring bank: J=respiratory rate, depth and oxygenation; K=pain intensity and ability to reposition comfortably; L=blood pressure and pulse trend; M=alertness and recurrence of sedation; N=incision and drain-loss trend.

After hemodialysis, a client who was alert before treatment becomes dizzy when standing. Pressure is 86/50 mm Hg, down from 126/74. What should the RN do next?

• ☐ A. Help the client sit or lie safely, assess the symptoms and circulation, and notify the dialysis team according to the response plan.
• ☐ B. Repeat the standing pressure after another walk before deciding whether the decrease is clinically important.
• ☐ C. Compare the weight with the target and discharge if the fluid-removal goal has been reached.
• ☐ D. Provide discharge instructions and arrange reassessment at the next session if dizziness recurs.

A client receives hemodialysis for fluid overload. Which follow-up findings support improved fluid status rather than a treatment complication? Select all that apply.

• ☐ A. Less breathlessness with improved comfort while resting.
• ☐ B. Reduced edema compared with the pretreatment examination.
• ☐ C. New dizziness with pressure 82/46 mm Hg on sitting up.
• ☐ D. A weight change toward the prescribed target with stable circulation.
• ☐ E. New painful muscle cramps during the session.
• ☐ F. New faintness that prevents the client from sitting safely.

The RN receives four reports at shift change. Which client should be assessed first?

• ☐ A. A client with a painful swollen knee after a recent twist who can bear weight and has no sensory change.
• ☐ B. A client due for discharge who reports nausea after the first oral antibiotic dose and no rash or breathing change.
• ☐ C. A client who suddenly develops facial droop and cannot move one arm normally.
• ☐ D. A client with increased bilateral ankle edema over a week who speaks normally and denies resting breathlessness.

Case study 3 of 3, school-age asthma. A 9-year-old with asthma arrives after increasing breathlessness. The child speaks in short phrases, uses accessory muscles, and has reduced air entry with wheeze. Room-air oxygen saturation is 90 percent, pulse 126/min, and respiratory rate 34/min. The child is alert but tired. The caregiver reports usual activity without breathlessness yesterday. Select every bracketed finding that needs prompt severity assessment. Only bracketed phrases are eligible. [A: speaks in short phrases] [B: accessory-muscle use] [C: reduced air entry] [D: room-air saturation 90 percent] [E: usual activity yesterday] [F: alert but tired] Selected IDs:

Case study 3 of 3, school-age asthma. A 9-year-old with asthma arrives after increasing breathlessness. The child speaks in short phrases, uses accessory muscles, and has reduced air entry with wheeze. Room-air oxygen saturation is 90 percent, pulse 126/min, and respiratory rate 34/min. The child is alert but tired. The caregiver reports usual activity without breathlessness yesterday. During observation, compare the following changes with the initial assessment. Choose D=deterioration or I=improvement for each row.

Case study 3 of 3, school-age asthma. A 9-year-old with asthma arrives after increasing breathlessness. The child speaks in short phrases, uses accessory muscles, and has reduced air entry with wheeze. Room-air oxygen saturation is 90 percent, pulse 126/min, and respiratory rate 34/min. The child is alert but tired. The caregiver reports usual activity without breathlessness yesterday. After initial prescribed treatment, air entry becomes poorer and the child speaks only one word at a time. Which concern should the RN prioritize?

• ☐ A. Worsening acute asthma with risk of respiratory failure.
• ☐ B. Isolated anxiety because the child is in an unfamiliar setting.
• ☐ C. An uncomplicated bronchodilator effect that needs only routine reassurance.
• ☐ D. A resolved exacerbation because less wheeze is now heard.

Case study 3 of 3, school-age asthma. A 9-year-old with asthma arrives after increasing breathlessness. The child speaks in short phrases, uses accessory muscles, and has reduced air entry with wheeze. Room-air oxygen saturation is 90 percent, pulse 126/min, and respiratory rate 34/min. The child is alert but tired. The caregiver reports usual activity without breathlessness yesterday. Verified orders prescribe inhaled bronchodilator treatment, controlled oxygen with a specified target, and systemic corticosteroid treatment. The team is reassessing response. Classify each proposed nursing action as A=appropriate now or N=not supported by this plan. Choose one column per row.

Case study 3 of 3, school-age asthma. A 9-year-old with asthma arrives after increasing breathlessness. The child speaks in short phrases, uses accessory muscles, and has reduced air entry with wheeze. Room-air oxygen saturation is 90 percent, pulse 126/min, and respiratory rate 34/min. The child is alert but tired. The caregiver reports usual activity without breathlessness yesterday. Following the initial prescribed treatments, the child becomes drowsy, can speak only single words, and has very poor air entry. Which linked action and reason fit the change? Extra tokens remain unused. Action: because Reason: . Action bank: A=Recheck saturation before notifying the team about the new drowsiness; B=Obtain urgent emergency-team reassessment while maintaining ordered respiratory support; C=Interpret less wheeze as sufficient response and retain the earlier observation interval. Reason bank: D=Reduced wheeze proves that adequate airflow has returned; E=Drowsiness, limited speech and poor air entry indicate possible impending respiratory failure; F=The absence of louder wheeze establishes that the child has no severe airflow limitation.

Case study 3, reassessment after treatment. Select every statement supported by each row. Each ROW is a separate scoring group. A=respiratory improvement is supported; B=important airflow or oxygenation concern remains; C=current oxygenation is adequate on room air.

Which actions interrupt transmission between patient-care encounters? Select all that apply.

• ☐ A. Perform hand hygiene after removing gloves.
• ☐ B. Use the same gloves for the next client if no visible soil is present.
• ☐ C. Clean and disinfect reusable shared equipment before use with another client.
• ☐ D. Perform hand hygiene before the next clean patient-care task as indicated.
• ☐ E. Move a used blood-pressure cuff to the next client without cleaning because it touched intact skin.
• ☐ F. Treat glove use as a replacement for hand hygiene.

The unit medication-reconciliation workflow uses four dependent packets: verify the home list with the client and available records; compare it with current discharge orders; resolve unexplained differences with the responsible clinician; then give the client one verified updated plan. Order the packets for a discharge with an unexplained dose difference. Order: , , ,

A child is recovering from an asthma exacerbation. Which caregiver statement shows a need for further discharge teaching?

• ☐ A. "We will review the written action plan and how to get help if breathing worsens."
• ☐ B. "We will check that the prescribed controller is available and that the inhaler technique is correct."
• ☐ C. "We will attend the planned follow-up even if the child feels better."
• ☐ D. "Once the wheeze stops, we can rely only on the reliever and leave out the prescribed controller plan."

A client with suspected sepsis has received the initial prescribed fluid. Pressure remains low, urine output is falling, and new crackles appear. The care team is available for reassessment. Select exactly THREE nursing actions that support individualized hemodynamic management.

• ☐ A. Communicate the current pressure, urine, respiratory findings, and treatment response.
• ☐ B. Plan another same-volume bolus based on completion of the initial infusion.
• ☐ C. Assist with the team's ordered dynamic fluid-response assessment.
• ☐ D. Prepare and implement verified escalation orders with appropriate monitoring.
• ☐ E. Obtain the next ordered lactate result before relaying the falling urine output.
• ☐ F. Base the fluid-response report on pressure readings, leaving urine and mental-status trends for the routine shift summary.

An inpatient reports current suicidal thoughts with a plan. The RN is already present and can remain with the client. The unit pathway uses four packets: maintain direct observation and secure accessible dangerous items immediately; notify the urgent-response clinician while a colleague supports observation; obtain urgent safety evaluation; then document and communicate the agreed ongoing safety plan. Order these packets. No step permits leaving the client alone. Order: , , ,

A client taking warfarin is transferring to another unit. The client developed new black stools this morning, an urgent evaluation is pending, and the last dose time has been verified. Select exactly THREE details the receiving RN most needs for the current handoff.

• ☐ A. The new black stools and current circulation findings.
• ☐ B. The verified anticoagulant regimen and last dose time.
• ☐ C. The pending evaluation and any interim verified orders.
• ☐ D. The usual constipation-prevention advice from an earlier medication visit.
• ☐ E. The schedule of routine anticoagulation teaching sessions after discharge.
• ☐ F. The skin-care plan for an unchanged healed surgical site.

An RN receives a client who uses insulin glargine. Which information should be verified before the next prescribed dose? Select all that apply.

• ☐ A. The exact product, concentration, and prescribed route.
• ☐ B. The previous dose time and documented amount.
• ☐ C. Recent glucose values and any hypoglycemic episode.
• ☐ D. Use the total-unit dose on the transfer list to select whichever glargine concentration the ward stocks.
• ☐ E. A plan to mix glargine with another insulin to simplify administration.
• ☐ F. Whether the medication list and current orders agree.

A client becomes shaky and sweaty after insulin. Bedside glucose is 58 mg/dL. The client is alert and swallows safely. The verified plan specifies rapid oral carbohydrate for an alert client with glucose below 70, followed by a recheck in 15 minutes. Complete the statement: Begin Blank 1 and then Blank 2. The provided normal fasting-glucose reference for comparison is 70–99 mg/dL; the rescue decision follows the supplied symptom and treatment criteria. Blank 1: . Bank 1: A=the prescribed rapid oral carbohydrate treatment; B=the next scheduled insulin dose; C=a routine next-day laboratory review. Blank 2: . Bank 2: D=recheck glucose in 15 minutes and reassess symptoms; E=stop checking once the client starts eating; F=wait until the next meal to reassess.

A client receiving treatment for suspected sepsis was initially alert with improving pressure. During reassessment, pressure falls again and the client becomes confused. The team's plan calls for immediate notification of recurrent perfusion deterioration. Complete the statement: The RN should Blank 1 because Blank 2. Blank 1: . Bank 1: A=communicate the change promptly and implement verified escalation orders; B=wait for the next routine observation interval; C=use the earlier improving pressure as the current assessment. Blank 2: . Bank 2: D=the new pressure fall and confusion suggest renewed perfusion concern; E=the earlier pressure improvement establishes adequate current perfusion; F=new confusion favors an isolated cognitive change rather than renewed perfusion impairment.

A catheter audit finds that most unnecessary catheter-days occur after clients no longer need precise urine measurement and can use assisted toileting. Which improvement best targets the observed problem?

• ☐ A. Replace the collection bags more frequently for all catheterized clients.
• ☐ B. Introduce daily indication review with an authorized removal pathway and toileting support.
• ☐ C. Expand routine catheter-care teaching but leave review of continued indications to the discharge checklist.
• ☐ D. Introduce a urine-appearance checklist as the main daily criterion for deciding whether removal is due.

A client with heart failure has an individualized 1,500 mL daily fluid limit. The client has already taken 1,100 mL, including soup and medication water, and wants an evening snack. Which plan stays within the limit while respecting the stated preference?

• ☐ A. Add 450 mL of tea because only plain water counts as fluid.
• ☐ B. Add 500 mL of soup and omit it from the intake record.
• ☐ C. Choose 200 mL of tea and a frozen dessert charted as 150 mL when melted, recording both.
• ☐ D. Take 600 mL of fluid now and subtract it from tomorrow's allowance.