Mini Mock, Items 14 to 25: Next-Generation Formats, With Rationales

Format key. Trend, matrix, chart, bowtie, drop-down cloze, hot spot, fill-in-the-blank, select-all. Verify: How each of these formats is credited, including whether partial credit applies and how it is calculated, is published by NCSBN and changes. Confirm the current rules in the current candidate bulletin. Format anatomy → BOOK 01 · P60.

14. Trend. A client is being monitored after a fall with a head strike. Review the flow sheet.

Which conclusion does this trend most support?

1. Expected recovery, because each individual set of findings is acceptable on its own
2. Rising intracranial pressure
3. Hypovolemic shock from an unrecognized second injury
4. An adverse response to the pain medicine given at 0800

Item 14 — Answer: 2

• 2 is right. The widening pulse pressure, the falling heart rate, and the irregular respiratory pattern move together, and they arrive alongside a declining level of consciousness and a new pupil asymmetry.
• 1 is wrong. This is the trap the item is built on. Every column is individually unremarkable. Only the direction across the columns is abnormal.
• 3 is wrong. Hypovolemic shock produces a rising heart rate and a falling blood pressure. This is the opposite pattern in both.
• 4 is wrong. A drug effect would not produce a progressive pupil asymmetry with a widening pulse pressure.
• Trap 1. The rule: In a trend item, read across the row before you read down the column. The finding is the direction, not any single value.
• → BOOK 10 · P5

15. Matrix. A client with a history of heart failure is admitted with worsening symptoms. For each finding, indicate whether it is most consistent with left-sided failure or right-sided failure as presented in this client.

Item 15 — Answers: a Left, b Right, c Right, d Left, e Left, f Right, g Left

• a is Left. Fluid backing up behind the left ventricle lands in the pulmonary circulation.
• b is Right. Distended neck veins reflect systemic venous congestion behind the right side.
• c is Right. Dependent peripheral edema is systemic congestion, not pulmonary.
• d is Left. Orthopnea is pulmonary congestion that worsens when the client lies flat.
• e is Left. Frothy, blood-tinged sputum is fluid in the alveoli.
• f is Right. Weight gain occurs in both, and this is the trap. The abdominal fullness the stem attaches to it places this finding on the systemic side.
• g is Left. Exertional dyspnea with a dry night cough is pulmonary congestion at a milder stage.
• Trap 2. The rule: When a finding could belong to both columns, credit it where the stem's added detail places it. The extra clause in the row is not decoration.
• → BOOK 08 · P8

16. Chart. Review the client's record.

NURSES' NOTES · 0730. Client reports nausea this morning and says the room lights look to have yellow halos around them. Ate about a quarter of breakfast. VITAL SIGNS · 0730. Temperature 98.2 F. Heart rate 52, regular. Respirations 16. Blood pressure 118/70. LABORATORY · 0600. Serum potassium below the reference interval. Serum digoxin above the target the prescriber documented for this client. MAR · due 0800. Digoxin 0.25 mg by mouth daily. Potassium chloride 20 mEq by mouth daily. Furosemide 40 mg by mouth daily.

Which action should the nurse take at 0800?

1. Give the digoxin and the potassium chloride, and hold the furosemide
2. Hold the digoxin, give the potassium chloride as prescribed, and notify the prescriber of the heart rate, the laboratory results, and the client's symptoms before giving the furosemide
3. Give all three medicines as scheduled and recheck the heart rate in one hour
4. Hold all three medicines and recheck the laboratory work in the morning

Item 16 — Answer: 2

• 2 is right. The nausea, the visual halos, the low heart rate, and a level above the documented target form one picture, and the low potassium is what makes that picture worse. The digoxin is held, the replacement is given, and the prescriber decides about the diuretic.
• 1 is wrong. It gives the one drug the findings argue against.
• 3 is wrong. It gives everything and delays the notification by an hour, during which the client keeps absorbing the drug.
• 4 is wrong. Holding the potassium replacement removes the correction that would help, and waiting until morning is not a defensible interval for these findings.
• Trap 4. The rule: The deciding data on a chart item usually sits on the tab you have not opened yet. Two tabs, then commit.
• → BOOK 07 · P9

17. Bowtie. A client is two days after a hip replacement. The client suddenly reports sharp chest pain that worsens on inspiration and is visibly anxious. Heart rate 118. Respirations 30. Oxygen saturation 88 percent on room air. Lungs clear to auscultation bilaterally. No fever.

Select one condition, two immediate actions, and two parameters to monitor.

Conditions: pulmonary embolism · pneumonia · pulmonary edema · atelectasis · pneumothorax · panic response

Actions: apply supplemental oxygen and raise the head of the bed · notify the provider immediately and stay with the client · encourage hourly incentive spirometry · massage the affected calf to relieve discomfort · administer the prescribed as-needed antipyretic · ambulate the client to the hallway and back

Parameters: oxygen saturation and respiratory rate · heart rate and rhythm · bowel sounds · surgical drain output · deep tendon reflexes · capillary blood glucose

Item 17 — Condition: pulmonary embolism. Actions: apply oxygen and raise the head of the bed; notify the provider immediately and stay with the client. Parameters: oxygen saturation and respiratory rate; heart rate and rhythm.

• Pulmonary embolism is right. Sudden pleuritic pain with hypoxia, tachycardia, tachypnea, and clear lungs, in a post-operative orthopedic client, is the classic combination.
• Pneumonia is wrong. No fever and clear lungs, with an abrupt onset.
• Pulmonary edema is wrong. Clear lungs argue directly against it.
• Atelectasis is wrong. It develops gradually and would not produce this abrupt a picture.
• Pneumothorax is wrong. Breath sounds would be diminished or absent on one side.
• Panic response is wrong. The anxiety is real and it is the consequence of hypoxia, not the cause of it.
• Oxygen and positioning is right. It treats the hypoxia immediately and requires no order under most standing protocols.
• Notify and stay is right. This is one of the few situations where escalation is itself the timely intervention, because the definitive treatment is not a nursing action.
• Incentive spirometry is wrong. It is prevention, applied to the wrong moment.
• Massaging the calf is wrong. It is potentially harmful in a client with a suspected embolism.
• Antipyretic is wrong. There is no fever, and it treats nothing in this picture.
• Ambulating is wrong. It increases oxygen demand in a hypoxic client.
• Saturation and respiratory rate is right. These are the parameters that will move first with treatment.
• Heart rate and rhythm is right. The strain of the event shows here, and deterioration shows here early.
• Bowel sounds, drain output, reflexes, and glucose are wrong. None of them changes with this condition or with these actions.
• Trap 2. The rule: In a bowtie, the actions and parameters must follow from the condition you selected. An action that is good nursing but does not belong to your chosen condition earns nothing.
• → BOOK 09 · P11

18. Drop-down cloze. A client with diabetic ketoacidosis is receiving a continuous insulin infusion. The blood glucose has fallen to the value at which the unit protocol directs a change, and the anion gap has not yet closed. Complete the sentence.

The nurse should [1] because [2].

Choices for [1]: a. add dextrose to the intravenous fluid and continue the insulin infusion · b. stop the insulin infusion · c. increase the insulin infusion rate · d. hold the next potassium dose

Choices for [2]: a. the glucose has reached the protocol threshold for adding dextrose while the ketoacidosis is still resolving · b. the glucose is now normal, so insulin is no longer needed · c. the anion gap has widened · d. the potassium is above the target

Item 18 — Answers: [1] a, [2] a

• [1] a is right. Dextrose is added so the infusion can continue safely until the acidosis clears.
• [1] b is wrong. Stopping the insulin stops the process that is clearing the ketoacidosis, and the acidosis, not the glucose, is what is being treated.
• [1] c is wrong. Increasing the rate as glucose falls compounds the risk without addressing the acidosis any faster.
• [1] d is wrong. Insulin drives potassium into cells, so holding replacement at this point moves in the wrong direction.
• [2] a is right. It names both halves of the reasoning, the threshold and the unresolved acidosis.
• [2] b is wrong. It is the misconception the item exists to catch, and choosing it forces the wrong action in the first blank.
• [2] c is wrong. The stem states the gap has not yet closed, not that it has widened.
• [2] d is wrong. The stem says nothing about the potassium being high, and it would not justify adding dextrose.
• Trap 2. The rule: In a linked cloze, choose the rationale first and let it choose the action. An error in one blank forces an error in the other, so the blanks are worth one careful pass rather than two fast ones.
• → BOOK 06 · P8

19. Matrix. A client with severe neutropenia is admitted. For each action, indicate whether it is indicated or contraindicated for this client.

Item 19 — Answers: a Indicated, b Indicated, c Contraindicated, d Indicated, e Contraindicated, f Indicated, g Indicated

• a is Indicated. A private room reduces exposure from other clients and their visitors.
• b is Indicated. Hand hygiene is the single highest-value action on the list.
• c is Contraindicated. Standing water and plant material carry organisms this client cannot defend against. It is a kindness, and it is the trap.
• d is Indicated. Removing uncooked produce follows the protective diet protocol.
• e is Contraindicated. Rectal measurement risks mucosal injury and translocation of organisms in a neutropenic client.
• f is Indicated. Screening visitors closes the most common route in.
• g is Indicated. Oral care with a soft brush protects a mucosal barrier that is already vulnerable, and gentleness is what makes it safe.
• Trap 2. The rule: In an indicated-or-contraindicated matrix, run every option against the client's specific vulnerability, and be most suspicious of the ones that read as comfort.
• → BOOK 11 · P12

20. Hot spot. A nurse is locating the point of maximal impulse in an adult with no cardiac enlargement. Select the site where the nurse should place the stethoscope.

• A. Second intercostal space at the right sternal border
• B. Second intercostal space at the left sternal border
• C. Fourth intercostal space at the left sternal border
• D. Fifth intercostal space at the left midclavicular line
• E. Fifth intercostal space at the left anterior axillary line

Item 20 — Answer: D

• D is right. In an adult without enlargement, the apical impulse sits at the fifth intercostal space in the left midclavicular line.
• A is wrong. That is the aortic listening area.
• B is wrong. That is the pulmonic listening area.
• C is wrong. That is the tricuspid area, one interspace and one landmark off the target, which is what makes it the habitual wrong click.
• E is wrong. The impulse shifts laterally toward the axillary line when the heart is enlarged, and the stem specifically excludes that.
• Trap 2. The rule: On a hot spot, say the landmark out loud in full before you click, including the interspace and the vertical line, because the near-miss site is always adjacent.
• → BOOK 15 · P6

21. Fill-in-the-blank. A child weighs 66 pounds. The prescription reads 12 mg/kg by mouth for one dose. The pharmacy supplies an oral suspension labeled 250 mg per 5 mL. How many milliliters should the nurse administer for this dose? Record your answer using one decimal place.

Item 21 — Answer: 7.2 mL

• 7.2 is right. Convert the weight from pounds to kilograms first, multiply by the prescribed milligrams per kilogram to get the dose in milligrams, then divide by the concentration expressed as milligrams per milliliter.
• A larger answer of about 15.8 comes from skipping the conversion and treating 66 as kilograms. That is the trap the item is built on.
• An answer near 1.4 comes from dividing by the total 250 rather than by the concentration per milliliter.
• A whole-number answer means the value was rounded during the calculation rather than at the end.
• Trap 5. The rule: Read the unit before the digit. Convert first, calculate second, round once, and check that the volume you produced is a plausible thing to hand a child.
• → BOOK 06 · P5

22. Chart. Review the client's record.

NURSES' NOTES · 1400. Client is one day after a transurethral prostate resection with continuous bladder irrigation running. Reports lower abdominal fullness and bladder spasms. Irrigation outflow has slowed over the past hour and is dark red with small clots. Client also reports no bowel movement since admission. INTAKE AND OUTPUT · 0700 to 1400. Irrigation instilled 2400 mL. Total catheter drainage 2350 mL. Oral intake 480 mL.

Which finding should the nurse report to the prescriber first?

1. No bowel movement since admission
2. Oral intake lower than expected for the shift
3. Drainage volume less than the volume instilled, with slowed dark red outflow and reported bladder fullness
4. Reports of bladder spasms

Item 22 — Answer: 3

• 3 is right. Less coming out than went in, with slowing dark outflow and a client who feels full, is catheter obstruction from clot. That is time-critical, and it is the finding that ties three separate pieces of the chart together.
• 1 is wrong. It is abnormal, it needs addressing, and it is not urgent on this shift.
• 2 is wrong. Low oral intake is worth correcting and is not what the client is at risk from right now.
• 4 is wrong. Spasms are expected after this procedure. They are a symptom of the obstruction here, not the finding that carries the risk.
• Trap 1. The rule: When a chart offers two abnormal findings, ask which one has a clock attached. Report that one, and handle the other in the same shift.
• → BOOK 03 · P8

23. Select all that apply. A client on a medical unit is pacing in a shared room, speaking loudly, and clenching both fists. Which nursing actions are appropriate at this point? Select all that apply.

1. Move the other client out of the room and reduce noise and stimulation
2. Speak in a calm, low voice using short sentences
3. Stand at an angle, more than an arm's length away, with a clear path to the door for both of you
4. Ask the client what would help right now and offer two acceptable choices
5. Place a hand on the client's shoulder and tell the client to sit down
6. Tell the client that restraints will be used if the behavior continues
7. Ask several staff members to stand together in the doorway so the client sees the team

Item 23 — Answer: 1, 2, 3, 4

• 1 is right. Reducing stimulation and protecting the other client are both accomplished by the same move.
• 2 is right. Voice volume and sentence length are the two things a nurse controls that most reliably lower arousal.
• 3 is right. Angled stance, distance, and an exit for both parties are the standard safety positions.
• 4 is right. Offering limited real choices returns control to the client, which is the mechanism de-escalation actually runs on.
• 5 is wrong. Unexpected touch plus a command escalates arousal and removes control, and it puts the nurse inside striking distance. This is the option that sounds caring and is not.
• 6 is wrong. A threat is not an intervention, and naming restraint as a consequence is coercion rather than de-escalation.
• 7 is wrong. A visible group in the doorway reads as containment and reliably escalates. A show of support is staged out of sight until it is needed.
• Trap 7. The rule: In de-escalation items, keep every option that gives the client control and cut every option that takes it, however warm the wording is.
• → BOOK 14 · P9

24. A 15-month-old child is behind on immunizations and is brought to the clinic. The child has a clear runny nose and a temperature just above the child's usual reading, and is feeding and playing normally. The parent asks whether the shots should wait. Which response should the nurse make?

1. "We should wait until the runny nose has cleared completely before giving any vaccine."
2. "A mild illness like this is not a reason to postpone. We can give the doses that are due today."
3. "We can give one vaccine today and space the rest across monthly visits so the immune system is not overloaded."
4. "We will need the provider to clear the child in writing before any vaccine can be given today."

Item 24 — Answer: 2

• 2 is right. A mild illness without significant fever is not a reason to defer, and a child who is already behind loses protection with every deferred visit.
• 1 is wrong. Deferring for minor symptoms is the single most common cause of a catch-up schedule never catching up.
• 3 is wrong. Spreading doses across extra visits is based on a misconception and extends the period of vulnerability.
• 4 is wrong. It invents a barrier, and it converts a completed visit into a missed one.
• Trap 2. The rule: When a stem describes minor symptoms with normal feeding and activity, the question is testing whether you know a true contraindication from a convenient excuse.
• → BOOK 13 · P9

25. At the end of a shift, a nurse realizes that an assessment charted at 1600 was actually performed at 1500. A colleague offers to open the entry and change the time so the record reads consistently. What should the nurse do?

1. Accept the offer, because the change makes the record more accurate
2. Leave the entry as it is, because the difference is small
3. Make a late entry, dated and timed when it is written, stating the correct time of the assessment and the reason for the correction
4. Ask the charge nurse to delete the original entry so it can be re-entered correctly

Item 25 — Answer: 3

• 3 is right. A late entry corrects the record while preserving what was originally written and when, which is the whole point of an audit trail.
• 1 is wrong. It is kind, and it means someone else altering an entry under their own access. The record loses both accuracy about authorship and its trail.
• 2 is wrong. A known error left standing is a knowing inaccuracy, regardless of size.
• 4 is wrong. Deletion removes the history the record exists to preserve, and it is not how errors are corrected.
• Trap 4. The rule: Records are corrected by addition, never by replacement. If a proposed fix removes what was there before, it is not a correction.
• → BOOK 15 · P13

☐ 14 ☐ 15 ☐ 16 ☐ 17 ☐ 18 ☐ 19 ☐ 20 ☐ 21 ☐ 22 ☐ 23 ☐ 24 ☐ 25

Margin notethe format is new, the thinking isn't.

Watch outLinked drop-downs and matrix rows are where a single early error multiplies. Spend the extra fifteen seconds on the first blank and the first row.

TakeawayNext-generation formats change what you click, not what you decide.