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NCLEX- CRIS-TEST 2025| BRAND NEW ACTUAL EXAM
WITH 100% VERIFIED QUESTIONS AND CORRECT
SOLUTIONS| GUARANTEED VALUE PACK| ACE YOUR
GRADES.
The nurse cares for a client with a cuffed tracheostomy tube. Before performing
oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of
the following is the MOST appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. -
(answers)1) CORRECT - Implementation: outcome desired; cuff inflation decreases
the risk of aspiration; cuff position and pressure should be assessed frequently;
swallowing and breathing will cause tracheostomy tube movement
2) Implementation: outcome not desired; accumulated oral secretions above the
cuff will drain into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff pressure should be less than 20
mm Hg (25 cm H2O); risk of trauma to trachea with higher pressures
4) Implementation: outcome not desired; increases the risk of trauma to lower
airways
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A young adult brings a friend to the emergency department and states that the
friend has been using heroin. Which action by the nurse is the MOST appropriate?
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date. - (answers)1) Assessment: outcome not
priority but may be appropriate; pinpoint pupils are a sign of heroin overdose
2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired
alveolar gas exchange and possible respiratory arrest
3) Assessment: outcome not priority; most important to assess airway and
breathing
4) Assessment: outcome not priority but may be appropriate; drowsiness and
euphoria may be seen; not priority
The client tells the clinic nurse that the client is thinking about using nicotine
polacrilex (Nicorette). Which question is MOST important for the nurse to ask?
1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
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3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?" - (answers)1) Assessment: outcome not
priority but may be appropriate; can be asked as part of assessment
2) Assessment: outcome not priority but may be appropriate; should be assessed
for further teaching
3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction;
increases heart rate and myocardial oxygen consumption; increased risk of angina
and myocardial infarction
4) Assessment: outcome may be appropriate but not priority; gum is place
between cheek and gums; may stain dental work
The nurse cares for the client with a client controlled analgesia (PCA) pump. The
nurse determines that the client has pressed the button 11 times and received 6
doses of morphine during the last hour. Which is the MOST appropriate action for
the nurse to take?
1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain. - (answers)1) Assessment: outcome not
priority but may be appropriate; if tubing is obstructed, alarm is activated
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2) Assessment: outcome may be appropriate but not priority; more important to
determine pain level, description of the pain, region and radiation of the pain, and
relieving factors
3) Implementation: outcome not desired; more important to assess severity of
pain and pain relief first
4) CORRECT - Assessment: outcome priority; must validate that client is in pain
before implementation
A pregnant woman receives an epidural anesthetic. After administration of the
epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50.
Which action by the nurse is MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed elevated. - (answers)1)
Implementation: outcome not desired; no increase in venous return
2) Implementation: outcome not desired; will decrease venous return
3) CORRECT - Implementation: outcome desired; will increase venous return and
cardiac output; fetal pressure on inferior vena cava reduced
NCLEX- CRIS-TEST 2025| BRAND NEW ACTUAL EXAM
WITH 100% VERIFIED QUESTIONS AND CORRECT
SOLUTIONS| GUARANTEED VALUE PACK| ACE YOUR
GRADES.
The nurse cares for a client with a cuffed tracheostomy tube. Before performing
oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of
the following is the MOST appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. -
(answers)1) CORRECT - Implementation: outcome desired; cuff inflation decreases
the risk of aspiration; cuff position and pressure should be assessed frequently;
swallowing and breathing will cause tracheostomy tube movement
2) Implementation: outcome not desired; accumulated oral secretions above the
cuff will drain into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff pressure should be less than 20
mm Hg (25 cm H2O); risk of trauma to trachea with higher pressures
4) Implementation: outcome not desired; increases the risk of trauma to lower
airways
,2|Page
A young adult brings a friend to the emergency department and states that the
friend has been using heroin. Which action by the nurse is the MOST appropriate?
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date. - (answers)1) Assessment: outcome not
priority but may be appropriate; pinpoint pupils are a sign of heroin overdose
2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired
alveolar gas exchange and possible respiratory arrest
3) Assessment: outcome not priority; most important to assess airway and
breathing
4) Assessment: outcome not priority but may be appropriate; drowsiness and
euphoria may be seen; not priority
The client tells the clinic nurse that the client is thinking about using nicotine
polacrilex (Nicorette). Which question is MOST important for the nurse to ask?
1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
,3|Page
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?" - (answers)1) Assessment: outcome not
priority but may be appropriate; can be asked as part of assessment
2) Assessment: outcome not priority but may be appropriate; should be assessed
for further teaching
3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction;
increases heart rate and myocardial oxygen consumption; increased risk of angina
and myocardial infarction
4) Assessment: outcome may be appropriate but not priority; gum is place
between cheek and gums; may stain dental work
The nurse cares for the client with a client controlled analgesia (PCA) pump. The
nurse determines that the client has pressed the button 11 times and received 6
doses of morphine during the last hour. Which is the MOST appropriate action for
the nurse to take?
1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain. - (answers)1) Assessment: outcome not
priority but may be appropriate; if tubing is obstructed, alarm is activated
, 4|Page
2) Assessment: outcome may be appropriate but not priority; more important to
determine pain level, description of the pain, region and radiation of the pain, and
relieving factors
3) Implementation: outcome not desired; more important to assess severity of
pain and pain relief first
4) CORRECT - Assessment: outcome priority; must validate that client is in pain
before implementation
A pregnant woman receives an epidural anesthetic. After administration of the
epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50.
Which action by the nurse is MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
4. Place the client supine with the foot of the bed elevated. - (answers)1)
Implementation: outcome not desired; no increase in venous return
2) Implementation: outcome not desired; will decrease venous return
3) CORRECT - Implementation: outcome desired; will increase venous return and
cardiac output; fetal pressure on inferior vena cava reduced
