NCLEX-style · 58 questions · Test 1

NCLEX Practice Test 1

NCLEX-style clinical judgment practice — one item at a time with tabbed case exhibits, check-answer feedback, and item rationales with option-level feedback.

This is a fixed 58-item NCLEX-style / NGN-style formative practice set — not a computerized adaptive NCLEX simulation. Scores are for learning only and do not predict NCLEX success.

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Test 1 — eight unfolding NCLEX-style cases with tabbed exhibits and staged chart updates on later items. Tap Check answer, then Next. Timer pauses only after a complete answer is checked.

Case chartsTabbed exhibits with staged updates

CJMM stepsRecognize through evaluate

Formative scoringComponent-level credit

SummaryCJMM & Client Needs review

Choose a mode

Study mode — immediate rationale and option feedback after each Check answer.Exam mode — responses are saved without correctness, score, or rationale until you finish each unfolding case (or each standalone item). Full teaching review unlocks then.

Progress saves automatically on this device. You can leave and resume later.

Question 1 of 58Total time: 0:00

Case exhibitQuestion

Recognize cues

☰ Review chart tabs before answering. Later items in each case may add timestamped updates.

Order: Furosemide 40 mg IV push now, then 20 mg IV q12h
Order: Oxygen per protocol; maintain SpO₂ ≥ 92%
Order: Strict I&O; fluid restriction 1,500 mL/24 h
Hold: Home digoxin until potassium rechecked

Question 1 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is reviewing the chart for Elena Rios, who was admitted 18 hours ago with worsening dyspnea. Which findings are most consistent with acute pulmonary edema?

Select all that apply. You may choose more than one option.

A. SpO₂ 88% on room air with tachypneaB. Pink frothy sputumC. Temperature 37.1 °C without chillsD. Bilateral crackles to mid-lung fieldsE. Hypertension as the only abnormal finding

Question 2 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

Using the case data for Elena Rios, the nurse analyzes findings to determine the primary problem. Which problem best explains this presentation?

A. Hospital-acquired pneumonia without overloadB. Acute decompensated heart failure with pulmonary congestionC. Primary hypernatremiaD. Opioid-induced respiratory depression

Question 3 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse must prioritize interventions for Elena Rios. Which finding should the nurse address first?

A. Potassium 3.2 mEq/LB. Client reports bland-tasting foodC. Creatinine 1.4 mg/dLD. SpO₂ 88% with RR 28/min and accessory muscle use

Question 4 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is planning care and must classify interventions for Elena Rios. Classify each nursing action.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Apply oxygen and elevate HOB
Give home digoxin without potassium review
Give IV furosemide per order with strict I&O
Encourage 2 L oral fluid intake

Question 5 of 58 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Elena Rios, 72-year-old woman in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which action should the nurse take first?

A. Apply oxygen per protocol and elevate the head of the bedB. Complete low-sodium diet teaching firstC. Obtain repeat BNP before furosemideD. Place client in Trendelenburg position

Question 6 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

Two hours after IV furosemide and low-flow oxygen, the nurse evaluates outcomes for Elena Rios. Two hours after furosemide and 2 L/min O₂: urine +350 mL, RR 22, SpO₂ 94% on 2 L/min, crackles at bases only. Which indicate improvement?

Trend snapshot
RR 28→22; SpO₂ 88% RA→94% on 2 L/min; crackles mid-lung→bases; urine output increased.

Select all that apply. You may choose more than one option.

Question 7 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for James Okonkwo, 68-year-old man in the Orthopedic unit, postoperative day 2. Review the case exhibit tabs, then answer the following. Which assessment findings suggest an existing deep vein thrombosis in the operative leg?

Select all that apply. You may choose more than one option.

A. Unilateral calf tenderness and warmthB. Left calf 2 cm larger than rightC. Clean dry hip incision without calf symptomsD. Reluctance to ambulate after surgery (risk factor, not diagnostic of DVT)E. Equal calves without pain or swelling

Question 8 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for James Okonkwo, 68-year-old man in the Orthopedic unit, postoperative day 2. Review the case exhibit tabs, then answer the following. Most likely hypothesis for unilateral calf findings on postoperative day 2?

A. Chronic bilateral venous insufficiency onlyB. Expected symmetric postoperative findingC. Deep vein thrombosis in the operative legD. Upper extremity compartment syndrome

Question 9 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for James Okonkwo, 68-year-old man in the Orthopedic unit, postoperative day 2. Review the case exhibit tabs, then answer the following. Which problem should the nurse prioritize in this situation?

A. Expected postoperative incision healing onlyB. Suspected deep vein thrombosis with risk of pulmonary embolismC. Routine fever without leg findingsD. Chronic bilateral edema unrelated to surgery

Question 10 of 58 — Generate solutions

Bow-Tie — Select actions and monitoring for the central problemGenerate solutions

The nurse is caring for James Okonkwo, 68-year-old man in the Orthopedic unit, postoperative day 2. Review the case exhibit tabs, then answer the following. Complete the bow-tie for suspected DVT.

Actions take place on the left and right; monitoring parameters below.

Action

Problem

Action

Monitor

Question 11 of 58 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for James Okonkwo, 68-year-old man in the Orthopedic unit, postoperative day 2. Review the case exhibit tabs, then answer the following. Place actions in priority order (1=first).

Assign rank 1 to the first action (one rank per row).

Assess respiratory status and SpO₂
Notify provider of calf findings
Elevate leg; avoid massage or vigorous movement

Question 12 of 58 — Evaluate outcomes

Multiple Choice — Select the best answerEvaluate outcomes

The nurse is caring for James Okonkwo, 68-year-old man in the Orthopedic unit, postoperative day 2. Review the case exhibit tabs, then answer the following. After confirmed DVT and therapeutic anticoagulation, which outcome shows appropriate care?

A. Increased calf pain after family-taught massageB. Long-distance ambulation despite acute swellingC. No new dyspnea; stable pain; anticoagulation on scheduleD. SCDs applied directly over tender calf

Question 13 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Liam Chen, 3-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which findings indicate moderate dehydration?

Select all that apply. You may choose more than one option.

Question 14 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Liam Chen, 3-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which problem best explains the labs?

A. Primary hyperkalemiaB. Diabetic ketoacidosisC. SIADHD. Isotonic dehydration from gastroenteritis with mild hemoconcentration (elevated BUN, rising hematocrit)

Question 15 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Liam Chen, 3-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which problem is the highest priority for this child?

A. Moderate dehydration from ongoing GI lossesB. Primary hyperkalemiaC. Stable well-child visitD. Unrelated febrile illness without dehydration cues

Question 16 of 58 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

The nurse is caring for Liam Chen, 3-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Appropriate interventions now?

Select all that apply. You may choose more than one option.

A. Weigh on same scaleB. Offer 5–10 mL ORS every 5–10 min if toleratedC. Restrict all fluidsD. Monitor cap refill and mental statusE. Sports drinks only

Question 17 of 58 — Take action

Cloze (Drop-Down) — Complete the clinical statementTake action

The nurse is caring for Liam Chen, 3-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Complete the nursing note:

ORS tolerated 40 mL in first hour. Cap refill 2 s. Parent verbalized understanding of .

Question 18 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Liam Chen, 3-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. After 4 h ORS: wet diaper, HR 118, playful, weight 12.3 kg. Positive outcomes?

Trend snapshot
HR 148→118; weight 12.0→12.3 kg; urine output resumed; irritable→playful.

Select all that apply. You may choose more than one option.

Question 19 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Alex Rivera, 19-year-old nonbinary student in the Inpatient psychiatric unit. Review the case exhibit tabs, then answer the following. Which cues increase suicide risk?

Select all that apply. You may choose more than one option.

Question 20 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Alex Rivera, 19-year-old nonbinary student in the Inpatient psychiatric unit. Review the case exhibit tabs, then answer the following. Most accurate interpretation?

A. Denying a plan eliminates riskB. Giving possessions may signal preparation; risk remains highC. No-harm contract replaces observationD. Flat affect means malingering

Question 21 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Alex Rivera, 19-year-old nonbinary student in the Inpatient psychiatric unit. Review the case exhibit tabs, then answer the following. Highest priority?

A. Discharge diet teachingB. Unsupervised night walksC. Hold sertraline due to past nauseaD. Maintain continuous safety monitoring per protocol

Question 22 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Alex Rivera, 19-year-old nonbinary student in the Inpatient psychiatric unit. Review the case exhibit tabs, then answer the following. Classify each approach.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Ask directly about suicidal thoughts privately
Allow belt and glass mirror in room
Document mood and statements each shift
Promise total confidentiality if client shares a plan

Question 23 of 58 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Alex Rivera, 19-year-old nonbinary student in the Inpatient psychiatric unit. Review the case exhibit tabs, then answer the following. Client says, "I don't want to talk about it." Best response?

A. "I hear this is hard. I'm here to keep you safe. Are you having thoughts of hurting yourself today?"B. "You'll lose privileges if you won't talk."C. "Everyone feels sad sometimes."D. "Let's talk about music instead."

Question 24 of 58 — Evaluate outcomes

Multiple Choice — Select the best answerEvaluate outcomes

The nurse is caring for Alex Rivera, 19-year-old nonbinary student in the Inpatient psychiatric unit. Review the case exhibit tabs, then answer the following. After 48 h: engages in group, denies current intent, sleeps 5 h, no new giving-away gestures. Appropriate evaluation?

A. Risk eliminated; stop all checksB. Some improvement; continue safety protocol and reassess each shiftC. Ready for unsupervised leave todayD. PHQ-9 tracking unnecessary

Question 25 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Priya Sharma, 34-year-old, G2P1 at 38 weeks in the Antepartum unit. Review the case exhibit tabs, then answer the following. Findings consistent with hypoglycemia in pregnancy?

Select all that apply. You may choose more than one option.

Question 26 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Priya Sharma, 34-year-old, G2P1 at 38 weeks in the Antepartum unit. Review the case exhibit tabs, then answer the following. Most likely cause of glucose 62 mg/dL?

A. DKAB. PreeclampsiaC. HHSD. Skipped bedtime snack with NPH on board

Question 27 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Priya Sharma, 34-year-old, G2P1 at 38 weeks in the Antepartum unit. Review the case exhibit tabs, then answer the following. Which problem is the highest priority right now?

A. Symptomatic hypoglycemia on insulin therapyB. Routine prenatal discomfortC. Stable chronic hypertension without symptomsD. Expected third-trimester fatigue only

Question 28 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Priya Sharma, 34-year-old, G2P1 at 38 weeks in the Antepartum unit. Review the case exhibit tabs, then answer the following. Classify each action.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Perform NST as ordered
Hold scheduled insulin, give 15 g fast-acting carbohydrate, and recheck glucose in 15 minutes per protocol
Skip all meals before induction
Notify provider of recurrent fasting lows

Question 29 of 58 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Priya Sharma, 34-year-old, G2P1 at 38 weeks in the Antepartum unit. Review the case exhibit tabs, then answer the following. Hypoglycemia treatment steps in order (1=first).

Assign rank 1 to the first action (one rank per row).

Confirm glucose and symptoms
Give 15 g fast-acting carbohydrate
Recheck glucose in 15 minutes and notify provider if still low

Question 30 of 58 — Evaluate outcomes

Multiple Choice — Select the best answerEvaluate outcomes

The nurse is caring for Priya Sharma, 34-year-old, G2P1 at 38 weeks in the Antepartum unit. Review the case exhibit tabs, then answer the following. 30 min later: glucose 98 mg/dL, symptoms resolved, NST reactive. Correct evaluation?

A. Failed NST; stat cesareanB. Stop all glucose checks until laborC. Resolved; document response, reinforce bedtime snack, continue surveillanceD. Double NPH dose

Question 31 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Marie Foster, 81-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings suggest sepsis in this client?

Select all that apply. You may choose more than one option.

A. Lactate 3.8 mmol/L with rising trendB. Hypotension BP 92/54 mmHg after fluidC. Temperature 38.9 °C with tachycardiaD. SpO₂ 94% on 2 L/min only without other signsE. Acute change in mental status

Question 32 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Marie Foster, 81-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which problem is the most likely source of infection?

A. Primary hypothyroid crisisB. Urinary tract infection progressing to urosepsisC. Stable chronic dementia without acute changeD. Hyperglycemic hyperosmolar state only

Question 33 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Marie Foster, 81-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which problem requires the most urgent intervention?

A. Resolved mild dehydration without infection cuesB. Chronic dementia at baseline without acute changeC. Urosepsis with persistent hypotension after fluidsD. Stable urinary retention without systemic signs

Question 34 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Marie Foster, 81-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Classify each nursing action.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Apply oxygen to maintain SpO₂ ≥ 94%
Delay antibiotics until culture results return in 48 h
Measure urine output; notify if < 0.5 mL/kg/h
Discharge home with oral cranberry supplement only

Question 35 of 58 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Marie Foster, 81-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Place time-critical sepsis actions in priority order (1 = first). Cultures, fluids, and antibiotics may overlap per sepsis bundle.

Assign rank 1 to the first action (one rank per row).

Activate sepsis response and obtain blood cultures if ordered
Begin IV fluid resuscitation and reassess perfusion
Administer IV antibiotic within 1 hour of recognition when ordered

Question 36 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Marie Foster, 81-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Four hours later: BP 108/62 mmHg, lactate 2.1 mmol/L, urine 45 mL/h, alert to person. Which findings show improvement?

Trend snapshot
Trend — 4 h: BP 92/54 → 108/62; lactate 3.8 → 2.1 mmol/L; urine 15 mL/h → 45 mL/h; mental status confused → oriented to person.

Select all that apply. You may choose more than one option.

A. Lactate decreasing toward normalB. Improved blood pressure after fluidsC. Adequate urine outputD. Persistent lactate above 4 mmol/LE. New onset hypotension 80/40 mmHg

Question 37 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Marcus Lee, 22-year-old man in the Medical ICU step-down. Review the case exhibit tabs, then answer the following. Which findings are consistent with diabetic ketoacidosis?

Select all that apply. You may choose more than one option.

A. Glucose 486 mg/dL with anion gap 28B. pH 7.18 with bicarbonate 8 mEq/LC. Kussmaul respirationsD. Blood pressure 120/80 mmHg with bradycardiaE. History of insulin omission during illness

Question 38 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Marcus Lee, 22-year-old man in the Medical ICU step-down. Review the case exhibit tabs, then answer the following. Which complication is the nurse at highest risk to miss during insulin infusion?

A. Immediate hyperkalemia requiring kayexalate before any insulinB. Respiratory alkalosis from overcorrectionC. Hypoglycemia in the first 30 minutes at glucose 486 mg/dLD. Hypokalemia as insulin drives potassium intracellularly

Question 39 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Marcus Lee, 22-year-old man in the Medical ICU step-down. Review the case exhibit tabs, then answer the following. Which problem is the highest priority on admission?

A. Diabetic ketoacidosis with severe metabolic acidosis and dehydrationB. Routine hyperglycemia without acid-base disturbanceC. Isolated nausea without metabolic derangementD. Stable chronic diabetes without acute change

Question 40 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Marcus Lee, 22-year-old man in the Medical ICU step-down. Review the case exhibit tabs, then answer the following. Classify each intervention during DKA treatment.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Monitor potassium and add replacement per order when safe
Stop insulin infusion when glucose reaches 250 mg/dL without reducing rate per protocol
Document hourly glucose and neurological status
Encourage client to omit all fluids to lower glucose faster

Question 41 of 58 — Take action

Cloze (Drop-Down) — Complete the clinical statementTake action

The nurse is caring for Marcus Lee, 22-year-old man in the Medical ICU step-down. Review the case exhibit tabs, then answer the following. Complete the nursing note:

Insulin infusion running at protocol rate. Glucose down from 486 to 310 mg/dL in 2 h. Potassium now 3.8 mEq/L with adequate urine output. Nurse notified provider and .

Question 42 of 58 — Evaluate outcomes

Multiple Choice — Select the best answerEvaluate outcomes

The nurse is caring for Marcus Lee, 22-year-old man in the Medical ICU step-down. Review the case exhibit tabs, then answer the following. Twelve hours later: glucose 198 mg/dL, pH 7.32, bicarbonate 18, anion gap 12, client alert. Which evaluation is correct?

A. Treatment failed; stop insulin immediatelyB. Resolving DKA; continue protocol with dextrose-containing fluids and adjusted insulin; monitor gapC. Client ready for discharge without endocrinology follow-upD. No further electrolyte monitoring needed during active insulin infusion

Question 43 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Sofia Alvarez, 8-year-old girl in the School nurse office / EMS en route. Review the case exhibit tabs, then answer the following. Which findings indicate anaphylaxis requiring emergency treatment?

Select all that apply. You may choose more than one option.

A. Signs of poor perfusion (weak pulses, delayed cap refill) with BP 88/50 mmHg after allergen exposureB. Wheeze with respiratory distress and SpO₂ 91%C. Generalized urticaria with angioedemaD. Isolated itchy eyes without other symptomsE. Vomiting after known allergen exposure

Question 44 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Sofia Alvarez, 8-year-old girl in the School nurse office / EMS en route. Review the case exhibit tabs, then answer the following. Which problem best explains the rapid deterioration?

A. Simple food intolerance without immune responseB. Asthma exacerbation only without allergic componentC. Hyperventilation from anxiety aloneD. IgE-mediated anaphylaxis from peanut exposure

Question 45 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Sofia Alvarez, 8-year-old girl in the School nurse office / EMS en route. Review the case exhibit tabs, then answer the following. Which problem is the highest priority?

A. Anaphylaxis with airway compromise and poor perfusionB. Mild seasonal allergy without systemic signsC. Panic attack without urticaria or wheezeD. Food intolerance with isolated stomach ache only

Question 46 of 58 — Generate solutions

Bow-Tie — Select actions and monitoring for the central problemGenerate solutions

The nurse is caring for Sofia Alvarez, 8-year-old girl in the School nurse office / EMS en route. Review the case exhibit tabs, then answer the following. Complete the bow-tie for anaphylaxis management.

Actions take place on the left and right; monitoring parameters below.

Action

Problem

Action

Monitor

Question 47 of 58 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Sofia Alvarez, 8-year-old girl in the School nurse office / EMS en route. Review the case exhibit tabs, then answer the following. After first weight-based epinephrine dose (0.3 mg IM), wheezing persists and perfusion remains poor at 10 minutes. What should the nurse do?

A. Discharge because one dose was givenB. Administer second IM epinephrine per protocol and continue monitoringC. Switch to oral prednisone onlyD. Place in Trendelenburg with head down only

Question 48 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Sofia Alvarez, 8-year-old girl in the School nurse office / EMS en route. Review the case exhibit tabs, then answer the following. After second epinephrine and EMS care: wheeze cleared, SpO₂ 98%, BP 102/64, rash fading. Which outcomes indicate stabilization?

Trend snapshot
Trend — post-treatment: SpO₂ 91% → 98%; BP 88/50 → 102/64; wheeze present → cleared; urticaria spreading → fading.

Select all that apply. You may choose more than one option.

A. Improved oxygen saturationB. Normalized blood pressure for ageC. Resolution of wheezeD. Persistent angioedema with wheeze and SpO₂ 91%E. New hypotension 70/40 mmHg

Question 49 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for David Nguyen, 55-year-old man in the Cardiac observation unit. Review the case exhibit tabs, then answer the following. Review the troponin trend. Which interpretations are correct?

Trend snapshot
Trend — troponin: 0.04 ng/mL (0 h) → 0.18 ng/mL (3 h) → 0.52 ng/mL (6 h), with ongoing chest pressure.

Select all that apply. You may choose more than one option.

A. Rising troponin suggests myocardial injuryB. A single normal troponin at arrival rules out acute coronary syndromeC. Serial trends are more diagnostic than one isolated valueD. Declining symptoms after nitroglycerin eliminate need for monitoringE. The pattern warrants continued cardiac monitoring and cardiology involvement

Question 50 of 58 — Generate solutions

Bow-Tie — Select actions and monitoring for the central problemGenerate solutions

The nurse is caring for Helen Walsh, 78-year-old woman in the Skilled nursing facility. Review the case exhibit tabs, then answer the following. Complete the bow-tie for pressure injury prevention.

Actions take place on the left and right; monitoring parameters below.

Action

Problem

Action

Monitor

Question 51 of 58 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Robert Kane, 68-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Which action should the nurse take first?

A. Administer the scheduled warfarin dose on timeB. Recheck INR in one week and continue warfarinC. Encourage high-fiber diet only without notifying the providerD. Hold warfarin and notify the provider immediately

Question 52 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Margaret Cole, 82-year-old woman in the Acute care unit. Review the case exhibit tabs, then answer the following. Which findings support acute delirium related to infection in this client?

Select all that apply. You may choose more than one option.

A. Acute change in mental status from baselineB. Urinalysis with nitrites and pyuriaC. Temperature 38.4 °C with tachycardiaD. Chronic osteoarthritis knee pain aloneE. Unsteady gait with fall risk

Question 53 of 58 — Take action

Cloze (Drop-Down) — Complete the clinical statementTake action

The nurse is caring for James Ortiz, 54-year-old man with type 2 diabetes in the Outpatient diabetes clinic. Review the case exhibit tabs, then answer the following. Complete the priority nursing action.

For symptomatic hypoglycemia with glucose 58 mg/dL, the nurse should first .

Question 54 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Linda Park, 45-year-old woman in the Preoperative unit. Review the case exhibit tabs, then answer the following. Classify each preoperative action for this client.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Verify surgical consent and site marking
Allow a full breakfast before transport
Administer ordered preoperative antibiotic
Remove dentures and confirm NPO status

Question 55 of 58 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Carlos Mendez, 60-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Place initial chest pain actions in priority order (1 = first).

Assign rank 1 to the first action (one rank per row).

Obtain 12-lead ECG within 10 minutes
Establish IV access and attach cardiac monitor
Administer aspirin 325 mg chewed if not contraindicated and ordered
Obtain serial troponin per ACS protocol while continuing cardiac monitoring

Question 56 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Gloria Stein, 72-year-old woman in the Radiology holding area. Review the case exhibit tabs, then answer the following. Which problem is the highest priority before contrast administration?

A. Mild hypertension without symptomsB. Routine pre-procedure anxiety onlyC. Acute kidney injury risk with dehydration and reduced eGFRD. Chronic arthritis pain unrelated to renal function

Question 57 of 58 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

The nurse is caring for Henry Wu, 70-year-old man in the Progressive care unit. Review the case exhibit tabs, then answer the following. Which interventions are appropriate for this client with a new tracheostomy?

Select all that apply. You may choose more than one option.

A. Use sterile technique when performing tracheostomy careB. Maintain humidification and monitor SpO₂C. Deflate the cuff completely without provider orderD. Suction only when clinically indicated, limiting passesE. Place client supine flat without head support during meals

Question 58 of 58 — Generate solutions

Bow-Tie — Select actions and monitoring for the central problemGenerate solutions

The nurse is caring for Evelyn Ross, 76-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Complete the bow-tie for acute decompensated heart failure with pulmonary congestion.

Actions take place on the left and right; monitoring parameters below.

Action

Problem

Action

Monitor

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