NCLEX PRACTICE QUESTIONS WITH CORRECT
ANSWERS
1. A nurse is assessing a client who is 1 day post-operative following abdominal
surgery. Which finding requires immediate intervention?
A. Heart rate of 98 bpm
B. Respiratory rate of 24 breaths/min
C. Temperature of 99.8°F (37.7°C)
D. Oxygen saturation of 89% on room air
Correct Answer: D
Rationale: An SpO2 of 89% indicates hypoxemia and is below the normal range
(95–100%). This could signal early hypoventilation, atelectasis, or pulmonary
embolism. The other findings are slightly elevated but not immediately life-
threatening in a post-op client.
---
2. A client with heart failure is prescribed furosemide (Lasix). Which laboratory
value should the nurse monitor most closely?
A. Sodium
B. Potassium
C. Calcium
D. Glucose
Correct Answer: B
,Rationale: Furosemide is a loop diuretic that causes potassium wasting.
Hypokalemia can lead to cardiac dysrhythmias. Sodium and calcium may be
affected but are not the priority; glucose may rise slightly but is not the most critical.
---
3. A nurse is providing discharge teaching to a client with a new prescription for
warfarin (Coumadin). Which statement by the client indicates a need for further
teaching?
A. "I will avoid eating large amounts of spinach and kale."
B. "I can take ibuprofen for my headaches."
C. "I will get my blood drawn regularly to check my INR."
D. "I should watch for bleeding gums or dark stools."
Correct Answer: B
Rationale: Ibuprofen (NSAID) increases bleeding risk when taken with warfarin.
Clients should use acetaminophen instead. Green leafy vegetables (vitamin K)
should be consistent but not avoided entirely. INR monitoring and bleeding signs are
correct statements.
---
4. A nurse is caring for a client with tuberculosis (TB). Which type of precautions
should be implemented?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions alone
, Correct Answer: C
Rationale: TB is transmitted via airborne droplet nuclei. Airborne precautions
require an N95 respirator and negative pressure room. Contact precautions are for
MRSA/VRE; droplet for influenza/meningitis.
---
5. A client reports chest pain unrelieved by rest. The nurse administers nitroglycerin
sublingually. After 5 minutes, the client says the pain is still an 8 out of 10. What
should the nurse do next?
A. Administer a second dose of nitroglycerin
B. Call the provider immediately
C. Apply oxygen at 2 L/min via nasal cannula
D. Obtain a stat electrocardiogram
Correct Answer: A
Rationale: Nitroglycerin can be given up to three doses 5 minutes apart. After the
first dose with no relief, the nurse should give a second dose. If no relief after three
doses, then notify provider and consider acute coronary syndrome.
---
6. A nurse is inserting an indwelling urinary catheter. Which technique is correct?
A. Insert the catheter until urine flows, then advance 1–2 inches
B. Use sterile gloves but clean technique for perineal care
C. Inflate the balloon before inserting the catheter
D. Use normal saline without preservatives to inflate the balloon
ANSWERS
1. A nurse is assessing a client who is 1 day post-operative following abdominal
surgery. Which finding requires immediate intervention?
A. Heart rate of 98 bpm
B. Respiratory rate of 24 breaths/min
C. Temperature of 99.8°F (37.7°C)
D. Oxygen saturation of 89% on room air
Correct Answer: D
Rationale: An SpO2 of 89% indicates hypoxemia and is below the normal range
(95–100%). This could signal early hypoventilation, atelectasis, or pulmonary
embolism. The other findings are slightly elevated but not immediately life-
threatening in a post-op client.
---
2. A client with heart failure is prescribed furosemide (Lasix). Which laboratory
value should the nurse monitor most closely?
A. Sodium
B. Potassium
C. Calcium
D. Glucose
Correct Answer: B
,Rationale: Furosemide is a loop diuretic that causes potassium wasting.
Hypokalemia can lead to cardiac dysrhythmias. Sodium and calcium may be
affected but are not the priority; glucose may rise slightly but is not the most critical.
---
3. A nurse is providing discharge teaching to a client with a new prescription for
warfarin (Coumadin). Which statement by the client indicates a need for further
teaching?
A. "I will avoid eating large amounts of spinach and kale."
B. "I can take ibuprofen for my headaches."
C. "I will get my blood drawn regularly to check my INR."
D. "I should watch for bleeding gums or dark stools."
Correct Answer: B
Rationale: Ibuprofen (NSAID) increases bleeding risk when taken with warfarin.
Clients should use acetaminophen instead. Green leafy vegetables (vitamin K)
should be consistent but not avoided entirely. INR monitoring and bleeding signs are
correct statements.
---
4. A nurse is caring for a client with tuberculosis (TB). Which type of precautions
should be implemented?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions alone
, Correct Answer: C
Rationale: TB is transmitted via airborne droplet nuclei. Airborne precautions
require an N95 respirator and negative pressure room. Contact precautions are for
MRSA/VRE; droplet for influenza/meningitis.
---
5. A client reports chest pain unrelieved by rest. The nurse administers nitroglycerin
sublingually. After 5 minutes, the client says the pain is still an 8 out of 10. What
should the nurse do next?
A. Administer a second dose of nitroglycerin
B. Call the provider immediately
C. Apply oxygen at 2 L/min via nasal cannula
D. Obtain a stat electrocardiogram
Correct Answer: A
Rationale: Nitroglycerin can be given up to three doses 5 minutes apart. After the
first dose with no relief, the nurse should give a second dose. If no relief after three
doses, then notify provider and consider acute coronary syndrome.
---
6. A nurse is inserting an indwelling urinary catheter. Which technique is correct?
A. Insert the catheter until urine flows, then advance 1–2 inches
B. Use sterile gloves but clean technique for perineal care
C. Inflate the balloon before inserting the catheter
D. Use normal saline without preservatives to inflate the balloon
