NCLEX-style · 58 questions · Test 2

NCLEX Practice Test 2

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 2 — 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: Albuterol-ipratropium nebulizer q20 min × 3; reassess
Order: Methylprednisolone 125 mg IV once
Order: Oxygen to maintain SpO₂ 92–95%
Order: Peak flow after treatments; notify if < 50% personal best

Question 1 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Marcus Webb, 24-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings indicate a severe asthma exacerbation?

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

A. Peak flow 43% of personal bestB. Inability to speak in full sentencesC. Temperature 37.2 °C without purulent sputumD. Rising PaCO₂ with respiratory acidosisE. SpO₂ 98% on room air without distress

Question 2 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Marcus Webb, 24-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which problem best explains the ABG findings?

A. Metabolic alkalosis from vomitingB. Respiratory acidosis from air trapping and fatigueC. Normal compensatory pattern requiring no actionD. Primary respiratory alkalosis only

Question 3 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Marcus Webb, 24-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which problem is the greatest immediate threat?

A. Mild seasonal allergy symptoms onlyB. Stable chronic asthma without acute changeC. Isolated low-grade fever without respiratory distressD. Severe asthma with risk of respiratory failure

Question 4 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Marcus Webb, 24-year-old man 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
Document peak flow before and after treatments
Withhold all bronchodilators because of tachycardia
Administer IV corticosteroid per order
Encourage large oral fluid bolus before breathing assessment

Question 5 of 58 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Marcus Webb, 24-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which action should the nurse take first?

A. Administer ordered nebulized bronchodilator and oxygen; prepare for repeat assessmentB. Complete discharge teaching on pollen avoidanceC. Obtain peak flow only after all treatments are finished in 4 hoursD. Place client supine flat to improve diaphragm excursion

Question 6 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Marcus Webb, 24-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Two hours later: speaks in full sentences, peak flow 320 L/min, RR 20/min, SpO₂ 94% on 2 L/min, wheeze at bases only. Which indicate improvement?

Trend snapshot
Peak flow 180→320 L/min; RR 32→20; speaks phrases only→full sentences; wheeze diffuse→bases only.

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

A. Peak flow increased toward personal bestB. Respiratory rate decreasedC. Persistent inability to speakD. Wheeze limited to basesE. New somnolence with rising PaCO₂

Question 7 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Jordan Ellis, 28-year-old woman, 2 hours post vaginal delivery in the Labor and delivery recovery. Review the case exhibit tabs, then answer the following. Which findings suggest postpartum hemorrhage?

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

A. Heart rate 124/min with BP 92/58 mmHgB. Boggy fundus above the umbilicusC. Pad saturated in 15 minutesD. SpO₂ 96% without distressE. Declining hemoglobin from admission

Question 8 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

A. Primary postpartum infection without bleedingB. Expected lochia rubra requiring no actionC. Uterine atony with possible bladder distention contributingD. Amniotic fluid embolism as first explanation

Question 9 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

A. Expected lochia rubra without hemodynamic changeB. Postpartum hemorrhage from uterine atonyC. Routine postpartum fatigue onlyD. Unrelated urinary tract infection without bleeding

Question 10 of 58 — Generate solutions

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

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

Action

Problem

Action

Monitor

Question 11 of 58 — Take action

Extended Multiple Response — Select all that applyTake action

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

A. Activate emergency help and notify the providerB. Perform fundal massage and assess or empty the bladderC. Administer ordered uterotonic and IV fluidsD. Delay interventions until hemoglobin results returnE. Ambulate to the bathroom alone to encourage voiding

Question 12 of 58 — Evaluate outcomes

Multiple Choice — Select the best answerEvaluate outcomes

A. Failed response; no further assessments neededB. Ready for immediate discharge without hemoglobin recheckC. Effective response; continue monitoring vitals, fundus, and lochia per protocolD. Stop all uterine assessments because bleeding slowed

Question 13 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Dorothy Kane, 71-year-old woman in the Stroke unit, within 3 hours of symptom onset. Review the case exhibit tabs, then answer the following. Which findings are consistent with acute stroke?

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

A. Sudden unilateral facial droopB. Left arm drift on examC. Slurred speechD. Gradual symptom progression over 2 weeksE. Failed swallow screen with cough

Question 14 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Dorothy Kane, 71-year-old woman in the Stroke unit, within 3 hours of symptom onset. Review the case exhibit tabs, then answer the following. Which factor most increases risk of cardioembolic stroke in this client?

A. Age alone without other historyB. Glucose 142 mg/dL onlyC. Room-air SpO₂ 96%D. Atrial fibrillation with recent anticoagulant interruption

Question 15 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Dorothy Kane, 71-year-old woman in the Stroke unit, within 3 hours of symptom onset. Review the case exhibit tabs, then answer the following. Which problem is the highest priority in the first hours of care?

A. Acute ischemic stroke within thrombolytic windowB. Dehydration from missed oral fluids onlyC. Chronic atrial fibrillation without acute symptomsD. Routine anxiety about hospitalization

Question 16 of 58 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

The nurse is caring for Dorothy Kane, 71-year-old woman in the Stroke unit, within 3 hours of symptom onset. Review the case exhibit tabs, then answer the following. Which interventions are appropriate now?

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

A. Strict NPO with swallow precautionsB. Frequent neuro assessments per stroke scaleC. Place meal tray at bedside for encouragementD. Log exact last-known-well timeE. Notify stroke team of BP 188/102 for protocol-based management if thrombolysis is considered

Question 17 of 58 — Take action

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

The nurse is caring for Dorothy Kane, 71-year-old woman in the Stroke unit, within 3 hours of symptom onset. Review the case exhibit tabs, then answer the following. Complete the nursing note:

Client remains NPO. Swallow screen failed with cough. Family educated that .

Question 18 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Dorothy Kane, 71-year-old woman in the Stroke unit, within 3 hours of symptom onset. Review the case exhibit tabs, then answer the following. After tPA and 24 h: NIHSS improved from 12 to 6, no hemorrhage on repeat CT, BP 148/86. Which indicate positive response?

Trend snapshot
NIHSS 12→6; BP 188/102→148/86; no hemorrhage on repeat imaging; remains NPO pending SLP.

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

A. Decreased NIHSS scoreB. No hemorrhagic conversion on CTC. New severe headache with vomitingD. Stable blood pressure within ordered parametersE. Worsening arm weakness after tPA

Question 19 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Robert Finley, 52-year-old man in the Medical-surgical unit, hospital day 2. Review the case exhibit tabs, then answer the following. Which findings suggest moderate to severe alcohol withdrawal?

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 Robert Finley, 52-year-old man in the Medical-surgical unit, hospital day 2. Review the case exhibit tabs, then answer the following. Which complication is the nurse most concerned about next?

A. Primary hypothyroid crisisB. Seizure or delirium tremens if withdrawal progresses untreatedC. Stable self-limited tremor requiring no monitoringD. Opioid overdose

Question 21 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Robert Finley, 52-year-old man in the Medical-surgical unit, hospital day 2. Review the case exhibit tabs, then answer the following. Which problem is the highest priority as CIWA rises to 24 with increasing agitation?

A. Resolved pancreatitis pain onlyB. Routine sleep hygiene without withdrawal symptomsC. Stable chronic hypertension without autonomic changesD. Escalating alcohol withdrawal with seizure and delirium risk

Question 22 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Robert Finley, 52-year-old man in the Medical-surgical unit, hospital day 2. 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
Administer thiamine before or with dextrose-containing fluids
Leave client unattended in bathroom with CIWA > 15
Use CIWA scores to guide benzodiazepine dosing
Promise unlimited beer at home to reduce agitation

Question 23 of 58 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Robert Finley, 52-year-old man in the Medical-surgical unit, hospital day 2. Review the case exhibit tabs, then answer the following. Client reports seeing "bugs on the wall" and pulls at IV. Best response?

A. Stay with client, provide reassurance in calm low voice, medicate per CIWA, notify providerB. "Those bugs are not real—stop complaining."C. Turn off lights and leave room to promote restD. Remove monitoring to reduce stimulation

Question 24 of 58 — Evaluate outcomes

Multiple Choice — Select the best answerEvaluate outcomes

The nurse is caring for Robert Finley, 52-year-old man in the Medical-surgical unit, hospital day 2. Review the case exhibit tabs, then answer the following. After 24 h protocol: CIWA 8, slept 4 h, no seizures, oriented ×3. Appropriate evaluation?

A. Withdrawal resolved permanently; stop all assessmentsB. Improving; continue CIWA monitoring on tapering schedule and maintain fall precautionsC. Failed treatment; discharge immediatelyD. Resume alcohol to prevent recurrence

Question 25 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Henry Okafor, 64-year-old man in the Outpatient dialysis unit. Review the case exhibit tabs, then answer the following. Which findings indicate dangerous hyperkalemia?

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 Henry Okafor, 64-year-old man in the Outpatient dialysis unit. Review the case exhibit tabs, then answer the following. Which factor most contributed to this potassium level?

A. Primary hypokalemia from diureticsB. Acute respiratory alkalosisC. Iron deficiency anemiaD. Missed dialysis with potassium-rich intake and potassium-sparing drugs

Question 27 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Henry Okafor, 64-year-old man in the Outpatient dialysis unit. Review the case exhibit tabs, then answer the following. Which problem is the greatest immediate threat to this client?

A. Life-threatening cardiac dysrhythmia from severe hyperkalemia with ECG changesB. Chronic anemia onlyC. Mild hypertension without ECG changesD. Routine fistula maintenance visit

Question 28 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Henry Okafor, 64-year-old man in the Outpatient dialysis 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
Administer insulin with dextrose per protocol; monitor glucose
Use fistula for dialysis access with aseptic technique
Give oral potassium supplement
Repeat 12-lead ECG after calcium and temporizing therapy

Question 29 of 58 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Henry Okafor, 64-year-old man in the Outpatient dialysis unit. Review the case exhibit tabs, then answer the following. Sequence emergent hyperkalemia stabilization (1 = first). Temporizing therapy and dialysis preparation overlap per protocol.

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

Continuous cardiac monitoring and emergency notification
IV calcium for ECG changes per order
Insulin with dextrose and/or other temporizing therapy per order; monitor glucose and potassium
Initiate emergent dialysis when access is ready

Question 30 of 58 — Evaluate outcomes

Multiple Choice — Select the best answerEvaluate outcomes

The nurse is caring for Henry Okafor, 64-year-old man in the Outpatient dialysis unit. Review the case exhibit tabs, then answer the following. Post-dialysis: K⁺ 4.9 mEq/L, QRS normalized, HR 78 regular. Best evaluation?

A. Treatment failed; no further labs neededB. Resume spironolactone immediately without provider orderC. Effective treatment; continue monitoring, reconcile meds, plan adherence follow-upD. Client may skip next session if feeling well

Question 31 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Sofia Mendez, 34-year-old woman in the Burn unit, within 6 h of injury. Review the case exhibit tabs, then answer the following. Which findings suggest inadequate fluid resuscitation in this burn client?

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

A. Urine output 18 mL/hB. HR 118/min with BP 98/62 mmHgC. Pain 8/10 onlyD. 28% TBSA partial-thickness burnE. SpO₂ 94% on 2 L/min without airway injury

Question 32 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Sofia Mendez, 34-year-old woman in the Burn unit, within 6 h of injury. Review the case exhibit tabs, then answer the following. Using Parkland (4 mL × kg × %TBSA), what is the estimated 24-hour fluid volume?

A. 680 mL totalB. 7,616 mL LR in first 24 h (half in first 8 h)C. 2,800 mL only in final 16 hD. No fluids needed for partial-thickness burns

Question 33 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Sofia Mendez, 34-year-old woman in the Burn unit, within 6 h of injury. Review the case exhibit tabs, then answer the following. Which problem should be addressed first during resuscitation?

A. Resolved pain after analgesia onlyB. Routine post-burn itching without hemodynamic changeC. Inadequate perfusion from burn shock during fluid resuscitationD. Stable outpatient wound care need

Question 34 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Sofia Mendez, 34-year-old woman in the Burn unit, within 6 h of injury. 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
Elevate burned arms to reduce edema
Pop blisters at bedside for drainage
Monitor hourly urine output and vital signs
Document infusion rate and wound appearance

Question 35 of 58 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Sofia Mendez, 34-year-old woman in the Burn unit, within 6 h of injury. Review the case exhibit tabs, then answer the following. Urine output remains 20 mL/h despite increasing LR. First action?

A. Restrict fluids to prevent pulmonary edema in all burnsB. Discharge if pain controlledC. Apply ice directly to open blistersD. Notify burn provider; increase fluids per protocol; reassess perfusion

Question 36 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Sofia Mendez, 34-year-old woman in the Burn unit, within 6 h of injury. Review the case exhibit tabs, then answer the following. After fluid adjustment: urine 55 mL/h × 3 h, HR 92, BP 112/70, pain 4/10. Positive outcomes?

Trend snapshot
Urine 18→55 mL/h; HR 118→92; BP 98/62→112/70; pain 8→4/10.

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

A. Urine output within goal rangeB. Improved hemodynamic stabilityC. Persistent oliguria < 0.5 mL/kg/hD. Reduced pain with analgesiaE. New circumferential eschar with absent pulses

Question 37 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Carla Nguyen, 45-year-old woman in the Oncology unit. Review the case exhibit tabs, then answer the following. Which findings define neutropenic fever requiring urgent action?

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

Question 38 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Carla Nguyen, 45-year-old woman in the Oncology unit. Review the case exhibit tabs, then answer the following. Why is empiric broad-spectrum antibiotic therapy indicated?

A. Neutropenic clients can deteriorate rapidly from occult infectionB. Fever always represents viral illness onlyC. ANC 320 is normal after chemoD. Oral mucositis eliminates need for cultures

Question 39 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Carla Nguyen, 45-year-old woman in the Oncology unit. Review the case exhibit tabs, then answer the following. Which problem requires the most urgent treatment?

A. Chronic cancer-related fatigue without feverB. Stable outpatient oral mucositis onlyC. Neutropenic fever with risk of sepsisD. Resolved prior infection without new fever

Question 40 of 58 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

The nurse is caring for Carla Nguyen, 45-year-old woman in the Oncology unit. Review the case exhibit tabs, then answer the following. Which interventions are appropriate?

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

A. Strict hand hygiene and safe food handling per facility neutropenia policy (avoid raw/home-prepared high-risk foods)B. Daily oral care with soft brush for mucositisC. Allow raw vegetable salad from homeD. Monitor for new focal symptoms and hypotensionE. Place in semi-private room with roommate who has influenza

Question 41 of 58 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Carla Nguyen, 45-year-old woman in the Oncology unit. Review the case exhibit tabs, then answer the following. Sequence neutropenic fever care (1 = first).

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

Draw blood cultures from separate sites
Administer IV antibiotic as ordered
Monitor vitals and reassess for sepsis

Question 42 of 58 — Evaluate outcomes

Multiple Choice — Select the best answerEvaluate outcomes

The nurse is caring for Carla Nguyen, 45-year-old woman in the Oncology unit. Review the case exhibit tabs, then answer the following. 48 h later: afebrile × 24 h, cultures pending no growth, ANC rising to 890. Best evaluation?

A. Stop all antibiotics without provider inputB. Positive early response; continue antibiotics per oncologist and monitor countsC. Discharge with no follow-upD. Resume chemotherapy immediately without clearance

Question 43 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Amira Hassan, 4-year-old girl in the Pediatric intensive care unit. Review the case exhibit tabs, then answer the following. Which findings support bacterial meningitis?

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

A. CSF neutrophilic pleocytosis with low glucoseB. Neck stiffness and photophobiaC. Non-blanching petechial rashD. Temperature 39.4 °C with tachycardiaE. Normal CSF with high protein only

Question 44 of 58 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Amira Hassan, 4-year-old girl in the Pediatric intensive care unit. Review the case exhibit tabs, then answer the following. Petechiae with meningeal signs most urgently suggests:

A. Benign viral exanthem onlyB. Allergic reaction to ceftriaxone before first doseC. Iron deficiencyD. Possible meningococcemia requiring immediate isolation and antibiotic therapy

Question 45 of 58 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Amira Hassan, 4-year-old girl in the Pediatric intensive care unit. Review the case exhibit tabs, then answer the following. Which problem is the highest priority?

A. Bacterial meningitis with risk of sepsis and increased ICPB. Viral upper respiratory infection onlyC. Routine childhood fever without meningeal signsD. Unrelated otitis media without systemic illness

Question 46 of 58 — Generate solutions

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

The nurse is caring for Amira Hassan, 4-year-old girl in the Pediatric intensive care unit. Review the case exhibit tabs, then answer the following. Complete the bow-tie for suspected meningococcal meningitis.

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 Amira Hassan, 4-year-old girl in the Pediatric intensive care unit. Review the case exhibit tabs, then answer the following. The preschooler becomes irritable with a high-pitched cry, increasing vomiting, and declining interaction. Best action?

A. Feed child orally to sootheB. Notify provider immediately; assess for increased ICP; maintain head midline; prepare for possible imagingC. Dim lights and skip neuro checks to restD. Discharge if temperature drops once

Question 48 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Amira Hassan, 4-year-old girl in the Pediatric intensive care unit. Review the case exhibit tabs, then answer the following. Day 3: afebrile 24 h, alert, cultures growing Neisseria meningitidis, no new petechiae. Positive indicators?

Trend snapshot
Temp 39.4→37.2 °C; lethargic→alert; petechiae stable→no new lesions.

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

A. Sustained defervescenceB. Improved level of consciousnessC. No new purpuric lesionsD. New seizures and declining GCSE. Persistent fever with hypotension

Question 49 of 58 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Tyler Brooks, 29-year-old man in the Medical unit, postoperative day 1. Review the case exhibit tabs, then answer the following. Review the trend data. Which interpretations are correct?

Trend snapshot
Trend — RR 16→8/min; SpO₂ 97→89%; sedation increasing; pain score falling despite respiratory depression.

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

A. Declining RR with falling SpO₂ suggests opioid-induced respiratory depressionB. Low pain score alone proves safe opioid useC. Trend analysis is more useful than an isolated RR readingD. Hold PCA and notify provider; prepare to support airway and give naloxone if orderedE. Administer another PCA bolus because pain was 6 earlier

Question 50 of 58 — Generate solutions

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

The nurse is caring for Baby girl Kim, 36 hours old in the Mother-baby unit. Review the case exhibit tabs, then answer the following. Complete the bow-tie for this 38-week term newborn whose confirmed TSB is above the hour-specific phototherapy threshold on the nomogram (exclusive breastfeeding, 7% weight loss, inadequate stools).

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

Action

Problem

Action

Monitor

Question 51 of 58 — Recognize cues

Multiple Choice — Select the best answerRecognize cues

The nurse is caring for Baby Liam, 5-week-old male infant in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which finding is most consistent with pyloric stenosis in this infant?

A. Bilious vomiting with double-bubble on X-rayB. Currant-jelly stool with abdominal rigidityC. High-pitched cry with hyperactive bowel sounds onlyD. Projectile nonbilious vomiting with hypochloremic metabolic alkalosis

Question 52 of 58 — Take action

Extended Multiple Response — Select all that applyTake action

The nurse is caring for Tanya Brooks, 28-year-old woman in labor in the Labor and delivery unit. Review the case exhibit tabs, then answer the following. Which actions should the nurse take for this client after epidural placement?

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

A. Position client to alleviate hypotension and improve placental perfusionB. Notify provider of late decelerations and hypotensionC. Insert urinary catheter if unable to void and bladder distendedD. Discontinue fetal monitoring because pain is controlledE. Ambulate client alone to the bathroom without assistance

Question 53 of 58 — Take action

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

The nurse is caring for Marcus Lee, 58-year-old man on peritoneal dialysis in the Home health visit. Review the case exhibit tabs, then answer the following. Complete the priority nursing action.

For suspected peritoneal dialysis-associated peritonitis, the nurse should first .

Question 54 of 58 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Jamie Ellis, 34-year-old adult in the Inpatient psychiatric unit. Review the case exhibit tabs, then answer the following. Classify each intervention for acute agitation on the psychiatric unit.

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
Move to quieter area with decreased stimuli
Use calm voice and set clear limits
Restrain without provider order for convenience
Maintain 1:1 observation per order

Question 55 of 58 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Aisha Patel, 22-year-old woman in the Neurology unit. Review the case exhibit tabs, then answer the following. Place seizure precaution actions in priority order (1 = first) after a witnessed tonic-clonic seizure.

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

Ensure airway patency and recovery position
Note time and characteristics of the seizure
Apply oxygen if SpO₂ drops below ordered threshold
Document seizure duration and postictal neurological status

Question 56 of 58 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Diego Ramos, 42-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Which precaution is required for this client?

A. Contact precautions only with gown and glovesB. Droplet precautions with surgical mask at doorway onlyC. Airborne isolation with N95 respirator for staff entering roomD. Standard precautions without isolation

Question 57 of 58 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Rachel Kim, 38-year-old woman in the Critical care unit. Review the case exhibit tabs, then answer the following. Which findings are consistent with thyroid storm?

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

A. Temperature 39.8 °C with tachycardia 148/minB. Agitation, tremor, and GI symptomsC. Bradycardia and hypothermiaD. Suppressed TSH with elevated free T4E. Stable vital signs without hypermetabolic signs

Question 58 of 58 — Take action

Bow-Tie — Select actions and monitoring for the central problemTake action

The nurse is caring for Emma Torres, 4-year-old girl in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Complete the bow-tie for pediatric sepsis with signs of shock.

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

Action

Problem

Action

Monitor

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