Question

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Answer 1

Correct Answers:

Instruct the client to look up and down without moving his head.

Rationale :

🔷 Cranial nerve III is the oculomotor nerve, which controls most extraocular eye movements.

🔷 It is responsible for moving the eye upward, downward, and medially, making this assessment appropriate.

🔷 Cranial nerve III also controls pupil constriction and elevation of the upper eyelid.

🔷 In a client with head trauma, abnormal cranial nerve III findings may indicate increased intracranial pressure or nerve compression.

🔷 The nurse should observe for unequal pupils, ptosis, impaired eye movement, diplopia, and decreased level of consciousness.

Have the client stand with eyes closed and touch his nose.

🔷This evaluates coordination and cerebellar function.

🔷It does not specifically test cranial nerve III.

Observe the client's ability to smile and frown.

🔷Smiling and frowning assess cranial nerve VII, the facial nerve.

🔷This does not evaluate oculomotor eye movement.

Ask the client to shrug his shoulders against passive resistance.

🔷Shoulder shrug assesses cranial nerve XI, the spinal accessory nerve.

🔷It does not provide information about eye movement or pupil response.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Inserting a nasogastric tube for a client

Rationale :

💎 Inserting a nasogastric tube is an appropriate task for an LPN when allowed by facility policy and state practice regulations.

💎 This task requires licensed nursing skill, knowledge of anatomy, and the ability to recognize complications.

💎 LPNs can perform certain technical procedures for stable clients under the supervision of an RN.

💎 The RN remains responsible for overall assessment, care planning, evaluation, and verifying placement according to policy.

💎 This task should not be assigned to assistive personnel because it requires clinical judgment and technical competence.

Providing postmortem care for a client

💎Postmortem care is usually a routine task that can be assigned to assistive personnel after the RN completes required assessments.

💎It does not require the technical nursing skill expected of the LPN in this assignment question.

Measuring a client's I&O

💎Measuring intake and output is appropriate for assistive personnel.

💎The nurse is responsible for interpreting abnormal trends and reporting concerns.

Obtaining a client's weight

💎Obtaining a client’s weight is a routine, noninvasive task.

💎It is appropriate for assistive personnel, while the nurse evaluates significant changes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Temporary urinary retention

Rationale :

🔶 Temporary urinary retention can occur after removal of an indwelling urinary catheter, especially in an older adult client.

🔶 While the catheter was in place, the bladder drained continuously and did not need to contract normally.

🔶 After removal, bladder tone may be reduced temporarily, making it difficult for the client to void.

🔶 The nurse should monitor the time of first void, amount voided, bladder distention, and suprapubic discomfort.

🔶 If the client cannot void within the expected timeframe, the nurse should perform a bladder scan or notify the provider according to facility policy.

Urinary frequency for several days

🔶Urinary frequency for several days is not the expected outcome after catheter removal.

🔶Persistent frequency may indicate irritation, infection, or incomplete bladder emptying.

Highly concentrated urine

🔶Highly concentrated urine is more commonly associated with dehydration.

🔶It is not an expected outcome specifically caused by catheter removal.

Blood-tinged urine

🔶Blood-tinged urine may indicate urethral trauma or irritation.

🔶It is not the expected finding after catheter removal and should be monitored if present.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Administer an antiemetic.

Rationale :

🟢 Morphine commonly causes nausea and vomiting by stimulating the chemoreceptor trigger zone in the brain.

🟢 A client using a PCA pump after total hip arthroplasty should receive prescribed antiemetic therapy when nausea occurs.

🟢 Controlling nausea improves comfort and helps the client participate in deep breathing, turning, coughing, and early mobility.

🟢 Vomiting can increase pain, increase aspiration risk, and interfere with postoperative recovery.

🟢 The nurse should also continue assessing respiratory rate, sedation level, bowel function, pain relief, and PCA effectiveness.

Encourage use of the incentive spirometer.

🟢Incentive spirometry is important for preventing postoperative atelectasis.

🟢It does not directly relieve morphine-induced nausea and vomiting.

Insert a nasogastric tube.

🟢A nasogastric tube is not the first intervention for opioid-related nausea.

🟢It may be considered only for persistent vomiting, obstruction, or severe gastric distention.

Auscultate bowel sounds.

🟢Auscultating bowel sounds may help evaluate opioid-related decreased bowel motility.

🟢However, the priority action for active nausea and vomiting is administering an antiemetic.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Chocolate

Rationale :

🔵 Chocolate should be avoided by clients with GERD because it can relax the lower esophageal sphincter.

🔵 When the lower esophageal sphincter relaxes, stomach acid can reflux into the esophagus.

🔵 This reflux causes symptoms such as heartburn, regurgitation, chest discomfort, cough, and sour taste.

🔵 Common GERD triggers include chocolate, peppermint, caffeine, alcohol, fatty foods, spicy foods, and acidic foods.

🔵 The client should also avoid lying down after meals, large meals, and eating close to bedtime.

Apples

🔵Apples are not a common GERD trigger for most clients.

🔵Individual tolerance varies, but apples are not the priority food to avoid.

Nonfat milk

🔵Nonfat milk is lower in fat and is less likely to worsen GERD than high-fat dairy products.

🔵Whole milk or high-fat dairy may aggravate reflux more than nonfat milk.

Oatmeal

🔵Oatmeal is usually tolerated well by clients with GERD because it is low in fat and high in fiber.

🔵It does not commonly relax the lower esophageal sphincter.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Increased heart rate

Rationale :

🟣 Increased heart rate after thoracentesis can indicate a serious complication such as pneumothorax or bleeding.

🟣 Thoracentesis involves removing fluid or air from the pleural space, and lung tissue can be accidentally punctured.

🟣 If pneumothorax occurs, the client may develop tachycardia, dyspnea, chest pain, decreased breath sounds, and oxygen desaturation.

🟣 Tachycardia may be an early sign that the client is compensating for respiratory compromise or blood loss.

🟣 The nurse should immediately assess respiratory status, oxygen saturation, lung sounds, and notify the provider.

Decreased temperature

🟣A decreased temperature is not a typical immediate complication after thoracentesis.

🟣Fever later may suggest infection, but decreased temperature is not the priority concern.

Discomfort at the puncture site

🟣Mild puncture-site discomfort can be expected after thoracentesis.

🟣It should be monitored, but it is not as urgent as signs of cardiopulmonary compromise.

Serosanguineous drainage from the puncture site

🟣A small amount of serosanguineous drainage can occur after thoracentesis.

🟣Excessive bleeding, respiratory distress, or unstable vital signs would be more concerning.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Cigarette smoking

Rationale :

⭐ Cigarette smoking is a modifiable risk factor for cardiovascular disease because the client can stop or reduce tobacco use.

⭐ Smoking damages blood vessel lining, promotes atherosclerosis, increases clot formation, and causes vasoconstriction.

⭐ It also reduces oxygen delivery by increasing carbon monoxide levels in the blood.

⭐ Smoking increases the risk of myocardial infarction, stroke, peripheral arterial disease, hypertension, and coronary artery disease.

⭐ The nurse should include smoking cessation counseling, nicotine replacement options, support groups, and relapse-prevention strategies.

Increasing age

⭐Increasing age is a nonmodifiable cardiovascular risk factor.

⭐The client cannot change age, but can reduce overall risk through healthy behaviors.

Diagnosis of diabetes mellitus

⭐Diabetes mellitus increases cardiovascular risk, but having the diagnosis itself is not fully modifiable.

⭐Glucose control is modifiable, but the condition is not the best answer.

Family history of cardiac disease

⭐Family history is a nonmodifiable risk factor because genetic risk cannot be changed.

⭐Clients with family history should focus on controlling modifiable risks.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

35 mg/dL

Rationale :

🔴 Dehydration commonly causes an elevated blood urea nitrogen, or BUN, level.

🔴 When fluid volume is low, renal blood flow decreases and urea becomes more concentrated in the bloodstream.

🔴 A BUN of 35 mg/dL is elevated and strongly supports dehydration.

🔴 Additional dehydration findings may include dry mucous membranes, poor skin turgor, tachycardia, hypotension, decreased urine output, and dark urine.

🔴 The nurse should anticipate interventions to restore fluid volume and monitor renal function, electrolytes, and intake and output.

10 mg/dL

🔴A BUN of 10 mg/dL is generally within the expected adult range.

🔴It does not suggest dehydration.

16.5 mg/dL

🔴A BUN of 16.5 mg/dL is also within the expected adult range.

🔴It is not the best finding for a dehydrated client.

3.1 mg/dL

🔴A BUN of 3.1 mg/dL is low rather than high.

🔴Low BUN may occur with liver disease, malnutrition, or overhydration.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Distended bladder
Tenderness over the symphysis pubis
Voiding 30 mL frequently
Report of feeling pressure

Rationale :

Distended bladder

🟡 A distended bladder is a major sign of urinary retention.

🟡 In prostatic hypertrophy, the enlarged prostate compresses the urethra and blocks normal urine flow.

🟡 Urine remains trapped in the bladder, causing bladder enlargement.

🟡 The nurse may palpate or percuss bladder fullness in the suprapubic area.

🟡 This finding requires monitoring because prolonged retention can cause infection, bladder damage, and kidney complications.

Tenderness over the symphysis pubis

🟡 Tenderness over the symphysis pubis occurs because the bladder lies behind this area.

🟡 When the bladder becomes overdistended, pressure and discomfort develop in the lower abdomen.

🟡 This finding supports urinary retention in a client with prostatic hypertrophy.

🟡 The client may also describe pelvic pressure, urgency, or incomplete emptying.

🟡 The nurse should assess urine output, bladder distention, and postvoid residual as indicated.

Voiding 30 mL frequently

🟡 Voiding small amounts frequently can indicate overflow urinary retention.

🟡 The bladder remains full, but only small amounts leak or pass around the obstruction.

🟡 This pattern may be mistaken for urinary frequency, but it actually suggests poor bladder emptying.

🟡 Prostatic hypertrophy commonly causes weak stream, hesitancy, dribbling, nocturia, and incomplete emptying.

🟡 The nurse should monitor postvoid residual and report significant retention.

Report of feeling pressure

🟡 A feeling of pressure is expected when the bladder is overfilled with retained urine.

🟡 Pressure may be felt in the suprapubic or lower abdominal area.

🟡 This occurs because urine continues to collect behind the obstruction.

🟡 Persistent urinary retention can lead to urinary tract infection, hydronephrosis, and renal impairment.

🟡 The nurse should assess bladder status and urinary output promptly.

Dysuria

🟡Dysuria means painful or burning urination and is more commonly associated with urinary tract infection.

🟡It is not the best manifestation of urinary retention caused by prostatic hypertrophy.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Serosanguineous drainage at this time is a manifestation of possible dehiscence.

Rationale :

🟠 Serosanguineous drainage 1 week after abdominal surgery can indicate possible wound dehiscence.

🟠 Dehiscence is the partial or complete separation of the surgical wound edges.

🟠 A sudden appearance or increase in pink, watery, blood-tinged drainage may occur before the incision opens.

🟠 Abdominal wounds are especially vulnerable because coughing, vomiting, obesity, infection, malnutrition, and increased abdominal pressure place tension on the incision.

🟠 The nurse should assess the wound, reduce strain on the incision, place the client in a low-Fowler’s position, cover an open wound with sterile saline-moistened gauze, and notify the provider.

Serosanguineous drainage at this time is expected after abdominal surgery.

🟠A small amount of serosanguineous drainage may be expected early after surgery.

🟠At 1 week postoperative, new or increased drainage is more concerning for impaired wound healing.

Serosanguineous drainage at this time is a manifestation of infection.

🟠Infection is usually associated with purulent drainage, redness, warmth, swelling, fever, odor, and increased pain.

🟠Serosanguineous drainage alone at this stage is more concerning for possible wound separation.

Serosanguineous drainage at this time is a manifestation of hemorrhage.

🟠Hemorrhage is usually associated with bright red bleeding, rapid drainage, hypotension, tachycardia, and signs of shock.

🟠Serosanguineous drainage is blood-tinged fluid and is more consistent with possible dehiscence in this scenario.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Custom N150 Final Assessment Spring 2026

No.

1 :
A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

2 :
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

3 :
A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

4 :
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

5 :
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid

6 :
A nurse is monitoring a client following a thoracentesis .The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

7 :
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?

8 :
A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission?

9 :
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

10 :
A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?

Connect With Us

Custom N150 Final Assessment Spring 2026

No.

1 : A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

2 : At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

3 : A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

4 : A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

5 : A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid

6 : A nurse is monitoring a client following a thoracentesis .The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

7 : A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?

8 : A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission?

9 : A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

10 : A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?

1 :
A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

2 :
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

3 :
A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

4 :
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

5 :
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid

6 :
A nurse is monitoring a client following a thoracentesis .The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

7 :
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?

8 :
A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission?

9 :
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

10 :
A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?