NCLEX-RN Practice Examination
150 Questions with Detailed Rationales
SECTION 1: SAFE AND EFFECTIVE CARE ENVIRONMENT
(Questions 1-25)
1. The nurse is caring for a client who is scheduled for surgery. Which action
demonstrates the nurse's role as a client advocate?
A. Ensuring the client has signed the informed consent
B. Witnessing the client's signature on the consent form
C. Explaining the surgical procedure to the client
D. Answering the client's questions about the surgery
Answer: A
Rationale: The nurse's role as a client advocate includes ensuring that informed consent
has been obtained and that the client understands the procedure. The surgeon is
responsible for providing detailed explanations and obtaining consent. The nurse can
witness the signature but should not provide detailed surgical explanations .
2. A client is placed in seclusion after exhibiting violent behavior. The nurse
understands that seclusion:
A. Requires a written order within 1 hour of initiation
B. Can be initiated by the nurse without a provider order
C. Requires a written order within 4 hours of initiation
D. Can be maintained for up to 24 hours without reassessment
,Answer: A
Rationale: Seclusion or restraints require a written provider order within 1 hour of
initiation. The order must be time-limited and renewed. The client must be reassessed
frequently, and the least restrictive alternative should always be considered first .
3. A client falls while ambulating to the bathroom. What is the nurse's priority
action?
A. Document the incident in the client's medical record
B. Assess the client for injuries
C. Notify the healthcare provider
D. Complete an incident report
Answer: B
Rationale: The priority action is to assess the client for injuries. After ensuring the client's
safety, the nurse should notify the provider and document the incident. An incident report
should be completed according to facility policy .
4. The nurse is preparing to administer a blood transfusion. Which action is most
important prior to initiating the transfusion?
A. Obtain a signed consent form
B. Verify the client's identity using two identifiers
C. Check the client's vital signs
D. Administer premedication
Answer: B
Rationale: Verifying the client's identity using at least two identifiers (name, date of birth,
medical record number) is the most critical step to prevent transfusion errors. The blood
product must also be verified with another nurse. Vital signs are important but secondary
to correct identification .
,5. A client with a nasogastric tube attached to suction is at risk for which acid-base
imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: B
Rationale: Nasogastric suction removes gastric acid (HCl), leading to metabolic alkalosis.
The loss of hydrogen ions increases serum bicarbonate. Metabolic acidosis is associated
with diarrhea or renal failure. Respiratory imbalances are related to ventilation issues .
6. The nurse is caring for a client with a chest tube. Which finding indicates proper
functioning of the drainage system?
A. Continuous bubbling in the water seal chamber
B. Tidaling in the water seal chamber with respiration
C. No fluctuation in the water seal chamber
D. Continuous bubbling in the suction control chamber only
Answer: B
Rationale: Tidaling (fluctuation) in the water seal chamber with respiration indicates
proper chest tube function. Continuous bubbling in the water seal chamber indicates an
air leak. The suction control chamber should have continuous gentle bubbling .
7. A client with a tracheostomy has thick secretions. Which intervention should the
nurse implement first?
A. Increase tracheostomy tube size
B. Perform tracheostomy suctioning
C. Instill normal saline into the tracheostomy
D. Increase humidity and encourage coughing
, Answer: D
Rationale: The least invasive intervention should be attempted first. Increasing humidity
and encouraging the client to cough may help mobilize secretions without the need for
suctioning. Suctioning is performed when other methods fail .
8. The nurse is teaching a client about fall prevention at home. Which statement
indicates the need for further teaching?
A. "I will remove loose rugs from my home."
B. "I will use a night light in the hallway."
C. "I will wear non-skid slippers."
D. "I will place furniture in the center of the room for stability."
Answer: D
Rationale: Furniture should be placed against the walls to create clear pathways and
reduce fall risk. Removing loose rugs, using night lights, and wearing non-skid slippers are
all appropriate fall prevention strategies .
9. A client is receiving oxygen via nasal cannula at 2 L/min. The nurse notes the
client's respiratory rate has decreased to 8 breaths/min. What is the nurse's
priority action?
A. Decrease the oxygen flow rate
B. Assess the client's oxygen saturation
C. Encourage the client to take deep breaths
D. Notify the healthcare provider immediately
Answer: B
Rationale: The nurse should first assess the client's oxygen saturation to determine if the
decreased respiratory rate is causing hypoxia. The provider should be notified if the
saturation is low or if the client's condition is deteriorating .
150 Questions with Detailed Rationales
SECTION 1: SAFE AND EFFECTIVE CARE ENVIRONMENT
(Questions 1-25)
1. The nurse is caring for a client who is scheduled for surgery. Which action
demonstrates the nurse's role as a client advocate?
A. Ensuring the client has signed the informed consent
B. Witnessing the client's signature on the consent form
C. Explaining the surgical procedure to the client
D. Answering the client's questions about the surgery
Answer: A
Rationale: The nurse's role as a client advocate includes ensuring that informed consent
has been obtained and that the client understands the procedure. The surgeon is
responsible for providing detailed explanations and obtaining consent. The nurse can
witness the signature but should not provide detailed surgical explanations .
2. A client is placed in seclusion after exhibiting violent behavior. The nurse
understands that seclusion:
A. Requires a written order within 1 hour of initiation
B. Can be initiated by the nurse without a provider order
C. Requires a written order within 4 hours of initiation
D. Can be maintained for up to 24 hours without reassessment
,Answer: A
Rationale: Seclusion or restraints require a written provider order within 1 hour of
initiation. The order must be time-limited and renewed. The client must be reassessed
frequently, and the least restrictive alternative should always be considered first .
3. A client falls while ambulating to the bathroom. What is the nurse's priority
action?
A. Document the incident in the client's medical record
B. Assess the client for injuries
C. Notify the healthcare provider
D. Complete an incident report
Answer: B
Rationale: The priority action is to assess the client for injuries. After ensuring the client's
safety, the nurse should notify the provider and document the incident. An incident report
should be completed according to facility policy .
4. The nurse is preparing to administer a blood transfusion. Which action is most
important prior to initiating the transfusion?
A. Obtain a signed consent form
B. Verify the client's identity using two identifiers
C. Check the client's vital signs
D. Administer premedication
Answer: B
Rationale: Verifying the client's identity using at least two identifiers (name, date of birth,
medical record number) is the most critical step to prevent transfusion errors. The blood
product must also be verified with another nurse. Vital signs are important but secondary
to correct identification .
,5. A client with a nasogastric tube attached to suction is at risk for which acid-base
imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: B
Rationale: Nasogastric suction removes gastric acid (HCl), leading to metabolic alkalosis.
The loss of hydrogen ions increases serum bicarbonate. Metabolic acidosis is associated
with diarrhea or renal failure. Respiratory imbalances are related to ventilation issues .
6. The nurse is caring for a client with a chest tube. Which finding indicates proper
functioning of the drainage system?
A. Continuous bubbling in the water seal chamber
B. Tidaling in the water seal chamber with respiration
C. No fluctuation in the water seal chamber
D. Continuous bubbling in the suction control chamber only
Answer: B
Rationale: Tidaling (fluctuation) in the water seal chamber with respiration indicates
proper chest tube function. Continuous bubbling in the water seal chamber indicates an
air leak. The suction control chamber should have continuous gentle bubbling .
7. A client with a tracheostomy has thick secretions. Which intervention should the
nurse implement first?
A. Increase tracheostomy tube size
B. Perform tracheostomy suctioning
C. Instill normal saline into the tracheostomy
D. Increase humidity and encourage coughing
, Answer: D
Rationale: The least invasive intervention should be attempted first. Increasing humidity
and encouraging the client to cough may help mobilize secretions without the need for
suctioning. Suctioning is performed when other methods fail .
8. The nurse is teaching a client about fall prevention at home. Which statement
indicates the need for further teaching?
A. "I will remove loose rugs from my home."
B. "I will use a night light in the hallway."
C. "I will wear non-skid slippers."
D. "I will place furniture in the center of the room for stability."
Answer: D
Rationale: Furniture should be placed against the walls to create clear pathways and
reduce fall risk. Removing loose rugs, using night lights, and wearing non-skid slippers are
all appropriate fall prevention strategies .
9. A client is receiving oxygen via nasal cannula at 2 L/min. The nurse notes the
client's respiratory rate has decreased to 8 breaths/min. What is the nurse's
priority action?
A. Decrease the oxygen flow rate
B. Assess the client's oxygen saturation
C. Encourage the client to take deep breaths
D. Notify the healthcare provider immediately
Answer: B
Rationale: The nurse should first assess the client's oxygen saturation to determine if the
decreased respiratory rate is causing hypoxia. The provider should be notified if the
saturation is low or if the client's condition is deteriorating .
