NCLEX-RN EXAM – QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS
| PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM UPDATE
• Core Domains
o Safe and Effective Care Environment
o Management of Care
o Safety and Infection Control
o Health Promotion and Maintenance
o Psychosocial Integrity
o Physiological Integrity
o Basic Care and Comfort
o Pharmacological and Parenteral Therapies
o Reduction of Risk Potential
o Physiological Adaptation
Introduction The purpose of this comprehensive assessment is to evaluate the clinical
judgment, critical thinking, and entry-level competencies required of candidates seeking
licensure as registered nurses. This exam evaluates essential knowledge across the lifespan,
focusing on safe, effective care delivery and client advocacy. Utilizing a structured multiple-
choice and scenario-based framework, the assessment mirrors the complexity of actual
clinical environments. Candidates must analyze client data, prioritize interventions, and
apply evidence-based practice to diverse healthcare scenarios. The emphasis remains firmly
on real-world application, ethical decision-making, regulatory compliance, and the reduction
of risk potential to ensure optimal patient outcomes across all healthcare delivery settings.*
SECTION ONE: QUESTIONS 1–100
Question 1
A client with a history of heart failure is admitted with dynamic changes in mental status,
generalized weakness, and deep tendon reflexes of 1+. The nurse notes flat T waves and
prominent U waves on the electrocardiogram. Which laboratory value should the nurse
review immediately?
A. Serum sodium 132 mEq/L B. Serum calcium 10.9 mg/dL C. Serum potassium 2.8 mEq/L D.
Serum magnesium 2.1 mEq/L
C. Serum potassium 2.8 mEq/L
, Explanation: The client's clinical presentation and electrocardiogram findings are classic
indicators of severe hypokalemia (normal range: 3.5 to 5.0 mEq/L). Prominent U waves,
flattened or inverted T waves, ST-segment depression, skeletal muscle weakness, and
decreased deep tendon reflexes are characteristic manifestations.
Question 2
The nurse is assigning care assignments for the upcoming shift. Which client is most
appropriate to assign to an experienced Licensed Practical Nurse (LPN)?
A. A client with a new diagnosis of Guillain-Barré syndrome who is experiencing ascending
paralysis. B. A client who underwent a total abdominal hysterectomy 48 hours ago and
requires a urinary catheter removal. C. A client admitted three hours ago with acute
pancreatitis who is requesting a change in pain medication. D. A client receiving a
continuous intravenous infusion of heparin for a newly diagnosed deep vein thrombosis.
B. A client who underwent a total abdominal hysterectomy 48 hours ago and requires a
urinary catheter removal.
Explanation: The LPN can care for stable clients with predictable outcomes. A client who
is 48 hours postoperative following a hysterectomy and requiring a standard procedural
intervention like catheter removal fits this scope. The other clients are unstable, require
complex assessments, or involve high-risk intravenous medications.
Question 3
A nurse in the emergency department is caring for an older adult client who was brought in
by a family member. The nurse notes multiple stage 2 pressure injuries on the client's
sacrum, poor skin turgor, and a strong odor of urine. The family member states, "I do the
best I can, but I am overwhelmed." Which action must the nurse take first?
A. Contact the hospital social worker to arrange for home health nursing resources. B.
Document the physical findings and report the suspected neglect to adult protective
services. C. Instruct the family member on the proper technique for frequent skin turning
and positioning. D. Request a prescription from the healthcare provider for an indwelling
urinary catheter.
B. Document the physical findings and report the suspected neglect to adult protective
services.
Explanation: The nurse has a legal and ethical obligation as a mandatory reporter to
report suspected vulnerable adult abuse or neglect to local protective services or regulatory
agencies. While the caregiver may be overwhelmed, the current clinical indicators suggest
neglect that requires official investigation.
Question 4
,A nurse is preparing to administer an intramuscular injection of iron dextran to a client.
Which technique should the nurse implement to ensure safe and proper administration?
A. Select a 25-gauge, 5/8-inch needle to prevent tissue irritation. B. Massage the injection
site firmly for 1 minute after withdrawing the needle. C. Displace the skin and subcutaneous
tissue laterally 1 to 1.5 inches before inserting the needle. D. Administer the injection into
the deltoid muscle for rapid systemic absorption.
C. Displace the skin and subcutaneous tissue laterally 1 to 1.5 inches before inserting the
needle.
Explanation: Iron dextran must be administered using the Z-track technique to prevent
the medication from leaking into subcutaneous tissues and causing severe staining or
irritation. Displacing the skin laterally before injection seals the medication within the
muscle track. Massaging the site is contraindicated.
Question 5
A client with a diagnosis of schizophrenia is admitted to the psychiatric unit. The client
stands in the middle of the dayroom, points to the corner, and says, "Look at those green
lizards climbing up the walls! They are going to bite me!" Which response by the nurse is
therapeutic?
A. There are no lizards on the wall, so you do not need to be afraid of them. B. I understand
that you see lizards, but I do not see any green lizards on the wall. C. Why do you think the
green lizards want to come over here and bite you? D. Let's go to your room and find some
insect spray to get rid of them quickly.
B. I understand that you see lizards, but I do not see any green lizards on the wall.
Explanation: This response validates the client's feelings and experience without
reinforcing the hallucination or arguing with the client. It presents reality calmly and directly
without making the client feel judged or dismissed.
Question 6
A nurse is caring for a client who is receiving a continuous intravenous infusion of oxytocin
for labor induction. The nurse notes that the fetal heart rate monitor shows late
decelerations. Which action should the nurse take first?
A. Increase the rate of the oxytocin infusion by 2 mU/min. B. Discontinue the continuous
intravenous oxytocin infusion. C. Administer oxygen via a simple face mask at 4 L/min. D.
Assist the client into a flat, supine positioning.
B. Discontinue the continuous intravenous oxytocin infusion.
, Explanation: Late decelerations indicate uteroplacental insufficiency and fetal distress.
The immediate priority action is to stop the oxytocin infusion to eliminate uterine
hyperstimulation and improve placental blood flow. Other interventions include turning the
client to the lateral position, increasing IV fluids, and giving oxygen.
Question 7
The nurse is reviewing laboratory results for a client who has been taking spironolactone for
the management of primary hypertension. Which laboratory finding requires immediate
intervention?
A. Serum sodium 136 mEq/L B. Serum potassium 5.6 mEq/L C. Serum creatinine 1.1 mg/dL
D. Fasting blood glucose 104 mg/dL
B. Serum potassium 5.6 mEq/L
Explanation: Spironolactone is a potassium-sparing diuretic. A serum potassium level of
5.6 mEq/L indicates hyperkalemia (normal range: 3.5 to 5.0 mEq/L), which carries a
significant risk of cardiac dysrhythmias and requires immediate medical management and
cessation of the drug.
Question 8
A nurse is providing discharge teaching to a client who has a new prescription for warfarin.
Which instruction should the nurse include in the teaching plan?
A. Increase your intake of green leafy vegetables to boost iron levels. B. Use a firm-bristled
toothbrush to maintain excellent oral hygiene. C. Take aspirin or ibuprofen if you experience
mild headaches or muscle aches. D. Report any unusual bruising, pink-tinged urine, or dark
tarry stools immediately.
D. Report any unusual bruising, pink-tinged urine, or dark tarry stools immediately.
Explanation: Warfarin is an anticoagulant that increases the risk of bleeding. Clients
must be taught to monitor for signs of hemorrhage, including ecchymosis, hematuria, and
melena. Intake of foods rich in vitamin K (like green leafy vegetables) must remain
consistent, and NSAIDs/aspirin should be avoided.
Question 9
A client who has a history of type 1 diabetes mellitus is brought to the emergency
department. The client is lethargic, has warm, flushed skin, and is exhibiting deep, rapid
respirations. The nurse notes a fruity odor on the client's breath. Which prescription should
the nurse anticipate executing first?
| PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM UPDATE
• Core Domains
o Safe and Effective Care Environment
o Management of Care
o Safety and Infection Control
o Health Promotion and Maintenance
o Psychosocial Integrity
o Physiological Integrity
o Basic Care and Comfort
o Pharmacological and Parenteral Therapies
o Reduction of Risk Potential
o Physiological Adaptation
Introduction The purpose of this comprehensive assessment is to evaluate the clinical
judgment, critical thinking, and entry-level competencies required of candidates seeking
licensure as registered nurses. This exam evaluates essential knowledge across the lifespan,
focusing on safe, effective care delivery and client advocacy. Utilizing a structured multiple-
choice and scenario-based framework, the assessment mirrors the complexity of actual
clinical environments. Candidates must analyze client data, prioritize interventions, and
apply evidence-based practice to diverse healthcare scenarios. The emphasis remains firmly
on real-world application, ethical decision-making, regulatory compliance, and the reduction
of risk potential to ensure optimal patient outcomes across all healthcare delivery settings.*
SECTION ONE: QUESTIONS 1–100
Question 1
A client with a history of heart failure is admitted with dynamic changes in mental status,
generalized weakness, and deep tendon reflexes of 1+. The nurse notes flat T waves and
prominent U waves on the electrocardiogram. Which laboratory value should the nurse
review immediately?
A. Serum sodium 132 mEq/L B. Serum calcium 10.9 mg/dL C. Serum potassium 2.8 mEq/L D.
Serum magnesium 2.1 mEq/L
C. Serum potassium 2.8 mEq/L
, Explanation: The client's clinical presentation and electrocardiogram findings are classic
indicators of severe hypokalemia (normal range: 3.5 to 5.0 mEq/L). Prominent U waves,
flattened or inverted T waves, ST-segment depression, skeletal muscle weakness, and
decreased deep tendon reflexes are characteristic manifestations.
Question 2
The nurse is assigning care assignments for the upcoming shift. Which client is most
appropriate to assign to an experienced Licensed Practical Nurse (LPN)?
A. A client with a new diagnosis of Guillain-Barré syndrome who is experiencing ascending
paralysis. B. A client who underwent a total abdominal hysterectomy 48 hours ago and
requires a urinary catheter removal. C. A client admitted three hours ago with acute
pancreatitis who is requesting a change in pain medication. D. A client receiving a
continuous intravenous infusion of heparin for a newly diagnosed deep vein thrombosis.
B. A client who underwent a total abdominal hysterectomy 48 hours ago and requires a
urinary catheter removal.
Explanation: The LPN can care for stable clients with predictable outcomes. A client who
is 48 hours postoperative following a hysterectomy and requiring a standard procedural
intervention like catheter removal fits this scope. The other clients are unstable, require
complex assessments, or involve high-risk intravenous medications.
Question 3
A nurse in the emergency department is caring for an older adult client who was brought in
by a family member. The nurse notes multiple stage 2 pressure injuries on the client's
sacrum, poor skin turgor, and a strong odor of urine. The family member states, "I do the
best I can, but I am overwhelmed." Which action must the nurse take first?
A. Contact the hospital social worker to arrange for home health nursing resources. B.
Document the physical findings and report the suspected neglect to adult protective
services. C. Instruct the family member on the proper technique for frequent skin turning
and positioning. D. Request a prescription from the healthcare provider for an indwelling
urinary catheter.
B. Document the physical findings and report the suspected neglect to adult protective
services.
Explanation: The nurse has a legal and ethical obligation as a mandatory reporter to
report suspected vulnerable adult abuse or neglect to local protective services or regulatory
agencies. While the caregiver may be overwhelmed, the current clinical indicators suggest
neglect that requires official investigation.
Question 4
,A nurse is preparing to administer an intramuscular injection of iron dextran to a client.
Which technique should the nurse implement to ensure safe and proper administration?
A. Select a 25-gauge, 5/8-inch needle to prevent tissue irritation. B. Massage the injection
site firmly for 1 minute after withdrawing the needle. C. Displace the skin and subcutaneous
tissue laterally 1 to 1.5 inches before inserting the needle. D. Administer the injection into
the deltoid muscle for rapid systemic absorption.
C. Displace the skin and subcutaneous tissue laterally 1 to 1.5 inches before inserting the
needle.
Explanation: Iron dextran must be administered using the Z-track technique to prevent
the medication from leaking into subcutaneous tissues and causing severe staining or
irritation. Displacing the skin laterally before injection seals the medication within the
muscle track. Massaging the site is contraindicated.
Question 5
A client with a diagnosis of schizophrenia is admitted to the psychiatric unit. The client
stands in the middle of the dayroom, points to the corner, and says, "Look at those green
lizards climbing up the walls! They are going to bite me!" Which response by the nurse is
therapeutic?
A. There are no lizards on the wall, so you do not need to be afraid of them. B. I understand
that you see lizards, but I do not see any green lizards on the wall. C. Why do you think the
green lizards want to come over here and bite you? D. Let's go to your room and find some
insect spray to get rid of them quickly.
B. I understand that you see lizards, but I do not see any green lizards on the wall.
Explanation: This response validates the client's feelings and experience without
reinforcing the hallucination or arguing with the client. It presents reality calmly and directly
without making the client feel judged or dismissed.
Question 6
A nurse is caring for a client who is receiving a continuous intravenous infusion of oxytocin
for labor induction. The nurse notes that the fetal heart rate monitor shows late
decelerations. Which action should the nurse take first?
A. Increase the rate of the oxytocin infusion by 2 mU/min. B. Discontinue the continuous
intravenous oxytocin infusion. C. Administer oxygen via a simple face mask at 4 L/min. D.
Assist the client into a flat, supine positioning.
B. Discontinue the continuous intravenous oxytocin infusion.
, Explanation: Late decelerations indicate uteroplacental insufficiency and fetal distress.
The immediate priority action is to stop the oxytocin infusion to eliminate uterine
hyperstimulation and improve placental blood flow. Other interventions include turning the
client to the lateral position, increasing IV fluids, and giving oxygen.
Question 7
The nurse is reviewing laboratory results for a client who has been taking spironolactone for
the management of primary hypertension. Which laboratory finding requires immediate
intervention?
A. Serum sodium 136 mEq/L B. Serum potassium 5.6 mEq/L C. Serum creatinine 1.1 mg/dL
D. Fasting blood glucose 104 mg/dL
B. Serum potassium 5.6 mEq/L
Explanation: Spironolactone is a potassium-sparing diuretic. A serum potassium level of
5.6 mEq/L indicates hyperkalemia (normal range: 3.5 to 5.0 mEq/L), which carries a
significant risk of cardiac dysrhythmias and requires immediate medical management and
cessation of the drug.
Question 8
A nurse is providing discharge teaching to a client who has a new prescription for warfarin.
Which instruction should the nurse include in the teaching plan?
A. Increase your intake of green leafy vegetables to boost iron levels. B. Use a firm-bristled
toothbrush to maintain excellent oral hygiene. C. Take aspirin or ibuprofen if you experience
mild headaches or muscle aches. D. Report any unusual bruising, pink-tinged urine, or dark
tarry stools immediately.
D. Report any unusual bruising, pink-tinged urine, or dark tarry stools immediately.
Explanation: Warfarin is an anticoagulant that increases the risk of bleeding. Clients
must be taught to monitor for signs of hemorrhage, including ecchymosis, hematuria, and
melena. Intake of foods rich in vitamin K (like green leafy vegetables) must remain
consistent, and NSAIDs/aspirin should be avoided.
Question 9
A client who has a history of type 1 diabetes mellitus is brought to the emergency
department. The client is lethargic, has warm, flushed skin, and is exhibiting deep, rapid
respirations. The nurse notes a fruity odor on the client's breath. Which prescription should
the nurse anticipate executing first?
