NU180 | NU180 Nursing and Healthcare II | NCLEX
Style Exam 1 v3 Questions with Correct Answers
and Expert Explanation for Each Question
1. A nurse is caring for an older adult client who is at risk for pressure injuries. Which
intervention should the nurse prioritize in the plan of care?
A. Massage bony prominences daily.
B. Reposition the client every 2 hours.
C. Apply cornstarch to the skin folds.
D. Keep the head of the bed at 45 degrees.
Correct Answer: B
Expert Explanation: Repositioning the client at least every 2 hours relieves
pressure and prevents tissue ischemia. Massaging bony prominences is
contraindicated as it can cause deep tissue damage. Maintaining the head of the bed
below 30 degrees is preferred to reduce shearing forces.
2. A nurse is preparing to administer an intramuscular injection to an infant. Which
site is most appropriate for this client?
A. Deltoid
B. Vastus lateralis
C. Dorsogluteal
,D. Ventrogluteal
Correct Answer: B
Expert Explanation: The vastus lateralis is the preferred site for IM injections in
infants because it is the most developed muscle at birth. The deltoid is not
sufficiently developed in infants for medication volume. Using the dorsogluteal site
is avoided due to the proximity of the sciatic nerve.
3. A client is scheduled for a surgical procedure. Which action is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the surgery.
B. Ensuring the client understands the prognosis.
C. Providing alternative treatment options.
D. Witnessing the client’s signature on the consent form.
Correct Answer: D
Expert Explanation: The nurse’s legal role in informed consent is to witness the
client’s signature and ensure it is voluntary. The provider is responsible for
explaining the procedure, risks, benefits, and alternatives. If the nurse notices the
client does not understand, they must notify the provider to come back and clarify.
,4. Which clinical finding should the nurse report immediately for a client with a leg
cast?
A. Capillary refill of 2 seconds.
B. Warmth in the toes.
C. Paresthesia in the foot.
D. Mild swelling of the toes.
Correct Answer: C
Expert Explanation: Paresthesia, or numbness and tingling, can be an early sign of
compartment syndrome or nerve damage. Capillary refill of 2 seconds and warmth
are normal findings. While mild swelling can occur, paresthesia indicates a
neurovascular compromise that requires urgent assessment.
5. A nurse is teaching a client about using a cane. Which instruction should the nurse
include?
A. Keep the elbow straight when holding the cane.
B. Hold the cane on the weaker side.
C. Move the cane and the stronger leg together.
D. Hold the cane on the stronger side.
Correct Answer: D
, Expert Explanation: The cane should be held on the client’s unaffected or stronger
side to provide maximum support and balance. The cane and the weaker leg should
be moved forward simultaneously. The elbow should be slightly flexed at about 15
to 30 degrees to ensure proper ergonomics.
6. A client has a prescription for 0.9% sodium chloride 1000 mL to infuse over 8 hours.
The drop factor is 15 gtt/mL. What is the flow rate in gtt/min?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 125 gtt/min
Correct Answer: B
Expert Explanation: To calculate the rate: (Total volume in mL * drop factor) /
(time in minutes). So, (1000 * 15) / (8 * 60) equals , which is 31.25.
Rounded to the nearest whole number, the rate is 31 gtt/min.
7. A nurse is performing hand hygiene. Which action is correct when washing with
soap and water?
A. Keep hands higher than elbows.
B. Use hot water to kill bacteria.
Style Exam 1 v3 Questions with Correct Answers
and Expert Explanation for Each Question
1. A nurse is caring for an older adult client who is at risk for pressure injuries. Which
intervention should the nurse prioritize in the plan of care?
A. Massage bony prominences daily.
B. Reposition the client every 2 hours.
C. Apply cornstarch to the skin folds.
D. Keep the head of the bed at 45 degrees.
Correct Answer: B
Expert Explanation: Repositioning the client at least every 2 hours relieves
pressure and prevents tissue ischemia. Massaging bony prominences is
contraindicated as it can cause deep tissue damage. Maintaining the head of the bed
below 30 degrees is preferred to reduce shearing forces.
2. A nurse is preparing to administer an intramuscular injection to an infant. Which
site is most appropriate for this client?
A. Deltoid
B. Vastus lateralis
C. Dorsogluteal
,D. Ventrogluteal
Correct Answer: B
Expert Explanation: The vastus lateralis is the preferred site for IM injections in
infants because it is the most developed muscle at birth. The deltoid is not
sufficiently developed in infants for medication volume. Using the dorsogluteal site
is avoided due to the proximity of the sciatic nerve.
3. A client is scheduled for a surgical procedure. Which action is the nurse’s primary
responsibility regarding informed consent?
A. Explaining the risks and benefits of the surgery.
B. Ensuring the client understands the prognosis.
C. Providing alternative treatment options.
D. Witnessing the client’s signature on the consent form.
Correct Answer: D
Expert Explanation: The nurse’s legal role in informed consent is to witness the
client’s signature and ensure it is voluntary. The provider is responsible for
explaining the procedure, risks, benefits, and alternatives. If the nurse notices the
client does not understand, they must notify the provider to come back and clarify.
,4. Which clinical finding should the nurse report immediately for a client with a leg
cast?
A. Capillary refill of 2 seconds.
B. Warmth in the toes.
C. Paresthesia in the foot.
D. Mild swelling of the toes.
Correct Answer: C
Expert Explanation: Paresthesia, or numbness and tingling, can be an early sign of
compartment syndrome or nerve damage. Capillary refill of 2 seconds and warmth
are normal findings. While mild swelling can occur, paresthesia indicates a
neurovascular compromise that requires urgent assessment.
5. A nurse is teaching a client about using a cane. Which instruction should the nurse
include?
A. Keep the elbow straight when holding the cane.
B. Hold the cane on the weaker side.
C. Move the cane and the stronger leg together.
D. Hold the cane on the stronger side.
Correct Answer: D
, Expert Explanation: The cane should be held on the client’s unaffected or stronger
side to provide maximum support and balance. The cane and the weaker leg should
be moved forward simultaneously. The elbow should be slightly flexed at about 15
to 30 degrees to ensure proper ergonomics.
6. A client has a prescription for 0.9% sodium chloride 1000 mL to infuse over 8 hours.
The drop factor is 15 gtt/mL. What is the flow rate in gtt/min?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 125 gtt/min
Correct Answer: B
Expert Explanation: To calculate the rate: (Total volume in mL * drop factor) /
(time in minutes). So, (1000 * 15) / (8 * 60) equals , which is 31.25.
Rounded to the nearest whole number, the rate is 31 gtt/min.
7. A nurse is performing hand hygiene. Which action is correct when washing with
soap and water?
A. Keep hands higher than elbows.
B. Use hot water to kill bacteria.
