NCLEX-RN REVIEW 2025–2026 | FULL QUESTION
BANK WITH ANSWERS & EXPLANATIONS
The nurse prepares to administer medication via IV push into an established IV line. Which
action does the nurse take?
A) Select the port farthest from the insertion site.
B) Ensure that the tubing above the injection port is patent.
C) Time the medication administration with a watch.
D) Explain the procedure to the client after completion.
B) Ensure that the tubing above the injection port is patent.
RATIONALE: Using a watch to time the administration ensures safe medication infusion.
Ideally, the watch should have a second hand or digital readout. Many medications that are
prescribed as IV push or bolus need to be given slowly over several minutes.
RATIONALE FOR INCORRECT ANSWERS:
A) Select the port farthest from the insertion site.
--The port selected should be the one closest to the IV insertion site for three reasons. Less
dilution of the medication will occur, the medication will move into the vascular system
more readily, and it is easier to assess if catheter placement is correct by blood return.
,B) Ensure that the tubing above the injection port is patent.
--Tubing above the port should be occluded by pinching the tubing gently, stopping the IV
solution flow while the medication is pushed.
D) Explain the procedure to the client after completion.
--Client teaching should be done prior to administration regarding purpose of the
medication and adverse effects to report.
The nurse is made aware of the following client situations.
The nurse should first assess the client who had
A) Glaucoma surgery and is reporting nausea and constipation
B) Right-sided thoracotomy and has 9/10 pain with inspiration and coughing
C) Laparoscopic cholecystectomy and is now reporting 6/10 right shoulder pain
D) Reduction of a dislocated shoulder and has numbness and tingling of the fingers
D) Reduction of a dislocated shoulder and has numbness and tingling of the fingers
,RATIONALE: Numbness and tingling are concerning for neurovascular impairment in a
client with a musculoskeletal trauma (e.g., dislocation, fracture). This client has a
circulation issue and should be assessed first. An urgent, focused neurovascular
assessment of the affected extremity should be performed.
RATIONALE FOR INCORRECT ANSWERS:
A) Glaucoma surgery and is reporting nausea and constipation Care for a client after ocular
surgery includes avoiding increases in intraocular pressure from straining, bearing down, or
heaving (e.g., during vomiting). The nurse should administer an antiemetic and assess this
client for presence of a postoperative paralytic ileus; however, this does not take priority
over neurovascular impairment.
B) Right-sided thoracotomy and has 9/10 pain with inspiration and coughing
Clients who undergo thoracotomy experience severe, pleuritic-type chest pain (i.e., sharp
pain that is worse with inspiration and coughing). The nurse should administer analgesics
and coach this client to splint the chest during coughing, but this does not take priority over
neurovascular impairment.
C) Laparoscopic cholecystectomy and is now reporting 6/10 right shoulder pain
During laparoscopic surgery, the abdomen is insufflated with carbon dioxide gas for better
visualization. The gas can sometimes be retained and irritate the phrenic nerve, which
causes referred pain to the shoulder. This client should be repositioned to the left side to
displace the gas pocket, but this does not take priority over neurovascular impairment.
, The nurse provides prenatal care at a busy obstetrics office. Which pregnant client should
the nurse prioritize to be seen first by the healthcare provider (HCP)?
A) A pregnant client who is 9 weeks' gestation who is experiencing fatigue, and reports
severe nausea and vomiting.
B) A pregnant client who is 14 weeks' gestation who reports urinary frequency and lower
pelvic pain.
C) A pregnant client who is 22 weeks' gestation who reports an increased fetal kick count.
D) A pregnant client who is 34 weeks' gestation who reports nausea and constant
epigastric pain.
D) A pregnant client who is 34 weeks' gestation who reports nausea and constant
epigastric pain.
RATIONALE: Severe epigastric pain is a symptom of preeclampsia, which can potentially
impact the safety of both the mother and the fetus; therefore, this nurse prioritizes this
client to be seen first by the HCP.
When prioritizing care the nurse should implement which action first?
A) Evaluate a.m. labs. on a client who is prescribed a potassium-sparing diuretic
B) Administer sliding scale insulin to a client with a blood glucose of 350 mmol/L
BANK WITH ANSWERS & EXPLANATIONS
The nurse prepares to administer medication via IV push into an established IV line. Which
action does the nurse take?
A) Select the port farthest from the insertion site.
B) Ensure that the tubing above the injection port is patent.
C) Time the medication administration with a watch.
D) Explain the procedure to the client after completion.
B) Ensure that the tubing above the injection port is patent.
RATIONALE: Using a watch to time the administration ensures safe medication infusion.
Ideally, the watch should have a second hand or digital readout. Many medications that are
prescribed as IV push or bolus need to be given slowly over several minutes.
RATIONALE FOR INCORRECT ANSWERS:
A) Select the port farthest from the insertion site.
--The port selected should be the one closest to the IV insertion site for three reasons. Less
dilution of the medication will occur, the medication will move into the vascular system
more readily, and it is easier to assess if catheter placement is correct by blood return.
,B) Ensure that the tubing above the injection port is patent.
--Tubing above the port should be occluded by pinching the tubing gently, stopping the IV
solution flow while the medication is pushed.
D) Explain the procedure to the client after completion.
--Client teaching should be done prior to administration regarding purpose of the
medication and adverse effects to report.
The nurse is made aware of the following client situations.
The nurse should first assess the client who had
A) Glaucoma surgery and is reporting nausea and constipation
B) Right-sided thoracotomy and has 9/10 pain with inspiration and coughing
C) Laparoscopic cholecystectomy and is now reporting 6/10 right shoulder pain
D) Reduction of a dislocated shoulder and has numbness and tingling of the fingers
D) Reduction of a dislocated shoulder and has numbness and tingling of the fingers
,RATIONALE: Numbness and tingling are concerning for neurovascular impairment in a
client with a musculoskeletal trauma (e.g., dislocation, fracture). This client has a
circulation issue and should be assessed first. An urgent, focused neurovascular
assessment of the affected extremity should be performed.
RATIONALE FOR INCORRECT ANSWERS:
A) Glaucoma surgery and is reporting nausea and constipation Care for a client after ocular
surgery includes avoiding increases in intraocular pressure from straining, bearing down, or
heaving (e.g., during vomiting). The nurse should administer an antiemetic and assess this
client for presence of a postoperative paralytic ileus; however, this does not take priority
over neurovascular impairment.
B) Right-sided thoracotomy and has 9/10 pain with inspiration and coughing
Clients who undergo thoracotomy experience severe, pleuritic-type chest pain (i.e., sharp
pain that is worse with inspiration and coughing). The nurse should administer analgesics
and coach this client to splint the chest during coughing, but this does not take priority over
neurovascular impairment.
C) Laparoscopic cholecystectomy and is now reporting 6/10 right shoulder pain
During laparoscopic surgery, the abdomen is insufflated with carbon dioxide gas for better
visualization. The gas can sometimes be retained and irritate the phrenic nerve, which
causes referred pain to the shoulder. This client should be repositioned to the left side to
displace the gas pocket, but this does not take priority over neurovascular impairment.
, The nurse provides prenatal care at a busy obstetrics office. Which pregnant client should
the nurse prioritize to be seen first by the healthcare provider (HCP)?
A) A pregnant client who is 9 weeks' gestation who is experiencing fatigue, and reports
severe nausea and vomiting.
B) A pregnant client who is 14 weeks' gestation who reports urinary frequency and lower
pelvic pain.
C) A pregnant client who is 22 weeks' gestation who reports an increased fetal kick count.
D) A pregnant client who is 34 weeks' gestation who reports nausea and constant
epigastric pain.
D) A pregnant client who is 34 weeks' gestation who reports nausea and constant
epigastric pain.
RATIONALE: Severe epigastric pain is a symptom of preeclampsia, which can potentially
impact the safety of both the mother and the fetus; therefore, this nurse prioritizes this
client to be seen first by the HCP.
When prioritizing care the nurse should implement which action first?
A) Evaluate a.m. labs. on a client who is prescribed a potassium-sparing diuretic
B) Administer sliding scale insulin to a client with a blood glucose of 350 mmol/L
