VERIFIED QUESTIONS, ACCURATE ANSWERS & DETAILED
RATIONALES, FULL-LENGTH PRACTICE TESTS, NCLEX
READINESS & PASS-FOCUSED REVIEW
Question 1:
A nurse is caring for a client with heart failure. Which of the following assessments would
indicate a worsening condition?
A) Weight loss of 2 lbs
B) Increased shortness of breath with exertion
C) Decreased blood pressure
D) Improved peripheral edema
Correct Option: B) Increased shortness of breath with exertion
Rationale: Increased shortness of breath with exertion indicates worsening heart failure, as it
reflects poor cardiac output and fluid congestion.
Question 2:
A nurse teaches a client with diabetes about foot care. Which statement by the client indicates a
need for further teaching?
A) "I should inspect my feet daily for any injuries."
B) "I can wear the same pair of shoes every day."
C) "I need to keep my feet clean and dry."
D) "I should report any sores to my healthcare provider immediately."
Correct Option: B) "I can wear the same pair of shoes every day."
Rationale: It is important for individuals with diabetes to rotate their shoes to prevent pressure
sores and improve foot health. Wearing the same shoes daily can cause issues.
Question 3:
Which assessment finding is a priority for the nurse to report for a patient receiving heparin
therapy?
A) Mild bruising
B) Platelet count of 150,000/mm³
C) APTT of 80 seconds
D) Blood glucose level of 120 mg/dL
Correct Option: C) APTT of 80 seconds
, Rationale: An APTT of 80 seconds indicates that the patient is at an increased risk for bleeding
due to over anticoagulation and should be reported immediately.
Question 4:
A nurse is assessing a newborn. Which of the following findings requires immediate
intervention?
A) Weight of 3,200 grams
B) Jaundice noted on the third day of life
C) Heart rate of 160 beats per minute
D) Respiratory rate of 80 breaths per minute
Correct Option: D) Respiratory rate of 80 breaths per minute
Rationale: A respiratory rate of 80 breaths per minute in a newborn is significantly elevated and
could indicate respiratory distress, warranting immediate intervention.
Question 5:
A nurse is caring for a client diagnosed with pneumonia. What is the most important nursing
intervention?
A) Administer oxygen as prescribed
B) Encourage fluids
C) Provide education on smoking cessation
D) Monitor temperature
Correct Option: A) Administer oxygen as prescribed
Rationale: Administering oxygen is a priority intervention for a client with pneumonia to ensure
adequate oxygenation and prevent hypoxia.
Question 6:
A nurse is preparing to administer a medication via nasogastric tube. Which of the following
actions is most appropriate?
A) Crush all tablets before administration
B) Mix the medication with fruit juice
C) Use a large syringe for instillation
D) Confirm tube placement before administering the medication
Correct Option: D) Confirm tube placement before administering the medication