NCLEX RN Nursing Q&A | Questions And Answers | 2026
Update | 100% Correct.
1. A nurse is assessing a client with left-sided heart failure. Which finding is most
indicative of this condition?
A. Peripheral edema
B. Jugular vein distention
C. Crackles in the lungs
D. Hepatomegaly
Correct Answer: C
Rationale: Left-sided heart failure causes pulmonary congestion leading to crackles.
Peripheral edema, JVD, and hepatomegaly are more associated with right-sided
heart failure.
2. A nurse is caring for a postoperative client. Which intervention should be prioritized
to prevent deep vein thrombosis (DVT)?
A. Encourage fluid restriction
B. Maintain bed rest
C. Encourage early ambulation
D. Apply cold compresses
Correct Answer: C
Rationale: Early ambulation promotes circulation and prevents clot formation. Bed
rest increases DVT risk, and cold compresses do not prevent thrombosis.
3. A client with diabetes mellitus has a blood glucose level of 55 mg/dL. What is the
nurse’s first action?
A. Administer insulin
B. Provide 15 g of fast-acting carbohydrates
C. Start IV fluids
D. Notify the provider
Correct Answer: B
Rationale: Hypoglycemia is treated immediately with fast-acting carbohydrates.
Insulin would worsen the condition, and notifying the provider is secondary after
stabilization.
4. A nurse is teaching a client about infection prevention. Which statement indicates
understanding?
A. “I will take antibiotics whenever I feel sick.”
B. “I will wash my hands regularly.”
, C. “I don’t need vaccines if I feel healthy.”
D. “I should avoid all public places.”
Correct Answer: B
Rationale: Hand hygiene is the most effective infection prevention method. Misuse of
antibiotics and avoiding vaccines are incorrect practices.
5. A nurse is caring for a client with hyperkalemia. Which ECG change is expected?
A. Flattened T waves
B. U waves
C. Peaked T waves
D. Prolonged QT interval
Correct Answer: C
Rationale: Hyperkalemia causes tall, peaked T waves. Flattened T waves and U
waves are seen in hypokalemia.
6. A nurse is assessing a client with increased intracranial pressure (ICP). Which finding
requires immediate intervention?
A. Headache
B. Vomiting
C. Unequal pupils
D. Restlessness
Correct Answer: C
Rationale: Unequal pupils indicate possible brain herniation, a medical emergency.
Other symptoms are concerning but less immediately critical.
7. A nurse is administering a blood transfusion. Which action is most important?
A. Use a 20-gauge IV catheter
B. Verify blood with another nurse
C. Warm the blood before infusion
D. Infuse rapidly
Correct Answer: B
Rationale: Verification prevents transfusion reactions. Using appropriate IV size is
important but secondary to correct identification.
8. A nurse is caring for a client with COPD. Which oxygen delivery method is most
appropriate?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 1–2 L/min
C. Simple mask at 10 L/min
D. Venturi mask at 100%
Correct Answer: B
, Rationale: COPD clients require low-flow oxygen to prevent suppression of
respiratory drive.
9. A nurse is teaching about a low-sodium diet. Which food should the client avoid?
A. Fresh fruits
B. Baked chicken
C. Canned soup
D. Steamed vegetables
Correct Answer: C
Rationale: Canned soups are high in sodium. Fresh and unprocessed foods are
preferred.
10. A nurse is assessing a newborn. Which finding requires immediate attention?
A. Heart rate of 130 bpm
B. Respiratory rate of 50/min
C. Cyanosis of hands and feet
D. Central cyanosis
Correct Answer: D
Rationale: Central cyanosis indicates inadequate oxygenation. Peripheral cyanosis is
normal in newborns.
11. A nurse is caring for a client with hypocalcemia. Which symptom is expected?
A. Muscle weakness
B. Tetany
C. Bradycardia
D. Hyporeflexia
Correct Answer: B
Rationale: Hypocalcemia causes neuromuscular excitability leading to tetany.
12. A nurse is caring for a client with a nasogastric tube. What is the best method to
verify placement?
A. Auscultation of air
B. X-ray confirmation
C. Checking pH
D. Observing drainage
Correct Answer: B
Rationale: X-ray is the most reliable method to confirm NG tube placement.
13. A nurse is assessing pain. Which scale is best for a 3-year-old child?
A. Numeric scale
, B. Visual analog scale
C. FLACC scale
D. Glasgow scale
Correct Answer: C
Rationale: FLACC is appropriate for young children who cannot verbalize pain
effectively.
14. A nurse is caring for a client with sepsis. Which intervention is priority?
A. Administer antibiotics
B. Monitor intake
C. Provide nutrition
D. Encourage rest
Correct Answer: A
Rationale: Early antibiotic administration is critical in sepsis management.
15. A nurse is evaluating a client with dehydration. Which lab value is expected?
A. Low hematocrit
B. High sodium
C. Low potassium
D. Low BUN
Correct Answer: B
Rationale: Dehydration leads to hypernatremia due to fluid loss.
16. A nurse is caring for a client receiving heparin. Which lab value should be monitored?
A. INR
B. PT
C. aPTT
D. Platelet count
Correct Answer: C
Rationale: aPTT is used to monitor heparin therapy effectiveness.
17. A nurse is caring for a client with a pressure ulcer. Which intervention promotes
healing?
A. Keep wound dry
B. Increase protein intake
C. Limit repositioning
D. Apply heat
Correct Answer: B
Rationale: Protein supports tissue repair and healing.
Update | 100% Correct.
1. A nurse is assessing a client with left-sided heart failure. Which finding is most
indicative of this condition?
A. Peripheral edema
B. Jugular vein distention
C. Crackles in the lungs
D. Hepatomegaly
Correct Answer: C
Rationale: Left-sided heart failure causes pulmonary congestion leading to crackles.
Peripheral edema, JVD, and hepatomegaly are more associated with right-sided
heart failure.
2. A nurse is caring for a postoperative client. Which intervention should be prioritized
to prevent deep vein thrombosis (DVT)?
A. Encourage fluid restriction
B. Maintain bed rest
C. Encourage early ambulation
D. Apply cold compresses
Correct Answer: C
Rationale: Early ambulation promotes circulation and prevents clot formation. Bed
rest increases DVT risk, and cold compresses do not prevent thrombosis.
3. A client with diabetes mellitus has a blood glucose level of 55 mg/dL. What is the
nurse’s first action?
A. Administer insulin
B. Provide 15 g of fast-acting carbohydrates
C. Start IV fluids
D. Notify the provider
Correct Answer: B
Rationale: Hypoglycemia is treated immediately with fast-acting carbohydrates.
Insulin would worsen the condition, and notifying the provider is secondary after
stabilization.
4. A nurse is teaching a client about infection prevention. Which statement indicates
understanding?
A. “I will take antibiotics whenever I feel sick.”
B. “I will wash my hands regularly.”
, C. “I don’t need vaccines if I feel healthy.”
D. “I should avoid all public places.”
Correct Answer: B
Rationale: Hand hygiene is the most effective infection prevention method. Misuse of
antibiotics and avoiding vaccines are incorrect practices.
5. A nurse is caring for a client with hyperkalemia. Which ECG change is expected?
A. Flattened T waves
B. U waves
C. Peaked T waves
D. Prolonged QT interval
Correct Answer: C
Rationale: Hyperkalemia causes tall, peaked T waves. Flattened T waves and U
waves are seen in hypokalemia.
6. A nurse is assessing a client with increased intracranial pressure (ICP). Which finding
requires immediate intervention?
A. Headache
B. Vomiting
C. Unequal pupils
D. Restlessness
Correct Answer: C
Rationale: Unequal pupils indicate possible brain herniation, a medical emergency.
Other symptoms are concerning but less immediately critical.
7. A nurse is administering a blood transfusion. Which action is most important?
A. Use a 20-gauge IV catheter
B. Verify blood with another nurse
C. Warm the blood before infusion
D. Infuse rapidly
Correct Answer: B
Rationale: Verification prevents transfusion reactions. Using appropriate IV size is
important but secondary to correct identification.
8. A nurse is caring for a client with COPD. Which oxygen delivery method is most
appropriate?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 1–2 L/min
C. Simple mask at 10 L/min
D. Venturi mask at 100%
Correct Answer: B
, Rationale: COPD clients require low-flow oxygen to prevent suppression of
respiratory drive.
9. A nurse is teaching about a low-sodium diet. Which food should the client avoid?
A. Fresh fruits
B. Baked chicken
C. Canned soup
D. Steamed vegetables
Correct Answer: C
Rationale: Canned soups are high in sodium. Fresh and unprocessed foods are
preferred.
10. A nurse is assessing a newborn. Which finding requires immediate attention?
A. Heart rate of 130 bpm
B. Respiratory rate of 50/min
C. Cyanosis of hands and feet
D. Central cyanosis
Correct Answer: D
Rationale: Central cyanosis indicates inadequate oxygenation. Peripheral cyanosis is
normal in newborns.
11. A nurse is caring for a client with hypocalcemia. Which symptom is expected?
A. Muscle weakness
B. Tetany
C. Bradycardia
D. Hyporeflexia
Correct Answer: B
Rationale: Hypocalcemia causes neuromuscular excitability leading to tetany.
12. A nurse is caring for a client with a nasogastric tube. What is the best method to
verify placement?
A. Auscultation of air
B. X-ray confirmation
C. Checking pH
D. Observing drainage
Correct Answer: B
Rationale: X-ray is the most reliable method to confirm NG tube placement.
13. A nurse is assessing pain. Which scale is best for a 3-year-old child?
A. Numeric scale
, B. Visual analog scale
C. FLACC scale
D. Glasgow scale
Correct Answer: C
Rationale: FLACC is appropriate for young children who cannot verbalize pain
effectively.
14. A nurse is caring for a client with sepsis. Which intervention is priority?
A. Administer antibiotics
B. Monitor intake
C. Provide nutrition
D. Encourage rest
Correct Answer: A
Rationale: Early antibiotic administration is critical in sepsis management.
15. A nurse is evaluating a client with dehydration. Which lab value is expected?
A. Low hematocrit
B. High sodium
C. Low potassium
D. Low BUN
Correct Answer: B
Rationale: Dehydration leads to hypernatremia due to fluid loss.
16. A nurse is caring for a client receiving heparin. Which lab value should be monitored?
A. INR
B. PT
C. aPTT
D. Platelet count
Correct Answer: C
Rationale: aPTT is used to monitor heparin therapy effectiveness.
17. A nurse is caring for a client with a pressure ulcer. Which intervention promotes
healing?
A. Keep wound dry
B. Increase protein intake
C. Limit repositioning
D. Apply heat
Correct Answer: B
Rationale: Protein supports tissue repair and healing.
