NCLEX-RN Practice Examination
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
1. A client is admitted with suspected bacterial meningitis. Which precaution
should the nurse implement first?
A. Airborne precautions
B. Contact precautions
C. Droplet precautions
D. Standard precautions only
Answer: C
Rationale: Bacterial meningitis is transmitted via large respiratory droplets;
therefore, droplet precautions (private room, surgical mask for staff within 3
feet) are initiated immediately. Airborne precautions are needed for pathogens
such as tuberculosis. Contact precautions would be added if there is drainage or
diarrhea, but droplet is the primary initial action.
2. The nurse is supervising a newly licensed registered nurse (RN) who is
inserting a nasogastric tube. Which action by the new RN requires
immediate intervention?
A. Measures the tube from the tip of the nose to the earlobe to the xiphoid
process
B. Lubricates the first 3 inches of the tube with water-soluble lubricant
C. Instructs the client to flex the chin to the chest during insertion
D. Advances the tube while the client swallows sips of water
Answer: C
Rationale: During NG tube insertion, the client should tilt the head forward (chin
to chest) to close the glottis and facilitate passage into the esophagus.
,Instructing the client to flex the chin toward the chest is correct and does not
require intervention. Measuring NEX, lubricating, and advancing while
swallowing are all appropriate. The question asks which action requires
intervention; the correct action does not need intervention. (Review: The
incorrect action would be extending the neck, which opens the airway. Thus, if
the new RN instructed chin flexed, that’s proper, so no intervention. The prompt
is tricky; the answer is the one that is correct, so intervention is not needed?
Wait, the question: “requires immediate intervention” meaning the action is
wrong. So I need to pick the wrong action. Re-reading: They ask which action by
the new RN requires immediate intervention. That means the new RN is doing
something incorrect. So the correct answer is the action that is incorrect, and we
should intervene. So I need to identify an error. Let’s examine: A. Measuring
from nose to earlobe to xiphoid — correct. B. Lubricating first 3 inches — correct.
C. Instructs chin to chest — correct, actually recommended. D. Advances while
swallowing — correct. That would mean none require intervention. That’s not
good. So I’ll change the scenario: The nurse is supervising a newly licensed RN
inserting an NG tube. Which action by the new RN would require immediate
intervention? Choose the incorrect action. I’ll make C “Instructs the client to
hyperextend the neck” which is wrong. So I’ll adjust: I’ll write item with an
incorrect action that needs intervention. Let’s reconstruct: “The nurse is
supervising a newly licensed RN inserting a nasogastric tube. Which action by
the new RN requires immediate intervention? A. Measures the tube from the tip
of the nose to the earlobe to the xiphoid process. B. Lubricates the first 3 inches
of the tube with water-soluble lubricant. C. Instructs the client to hyperextend
the neck during insertion. D. Advances the tube while the client swallows water.”
Now C is wrong, so answer C. I’ll go with that. I'll rewrite item 2.
So revised:
2. The nurse is supervising a newly licensed registered nurse inserting a
nasogastric tube. Which action by the new RN requires immediate
intervention?
A. Measures the tube from the tip of the nose to the earlobe to the xiphoid
process
, B. Lubricates the first 3 inches of the tube with water-soluble lubricant
C. Instructs the client to hyperextend the neck during insertion
D. Advances the tube while the client swallows sips of water
Answer: C
Rationale: Hyperextending the neck during insertion opens the trachea and
increases the risk of the tube entering the airway. The client should be
positioned with the chin tucked to the chest to close the glottis. The other
actions—measuring NEX, lubricating the tip, and advancing while swallowing—
are correct and facilitate safe passage.
I'll proceed with that. All good.
3. A client receiving total parenteral nutrition (TPN) through a central line
develops sudden onset of chest pain, dyspnea, and hypotension. What
should the nurse do first?
A. Notify the health care provider
B. Obtain an electrocardiogram (ECG)
C. Clamp the catheter and place the client in left lateral Trendelenburg
position
D. Administer oxygen at 10 L/min via nonrebreather mask
Answer: C
Rationale: The manifestations suggest an air embolism, a life-threatening
complication of central venous catheters. Immediate actions are to clamp the
catheter to prevent more air entry and position the client on the left side with
the head down (Trendelenburg) to trap air in the right atrium. Oxygen and
notification follow after the initial emergent positioning.
4. The nurse is caring for a client with major depressive disorder who states, “I
don’t want to live anymore.” What is the priority nursing intervention?
A. Encourage the client to attend group therapy
B. Inquire if the client has a specific suicide plan
C. Distract the client with a pleasant activity
D. Document the statement and continue monitoring
, Answer: B
Rationale: A statement of suicidal ideation demands immediate assessment of
lethality. Asking about a specific plan, means, and timeline determines the level
of risk and guides safety measures such as one-to-one observation or removal of
harmful objects. Encouraging activities or documenting alone does not address
immediate safety.
5. A client with chronic atrial fibrillation is prescribed warfarin. The
international normalized ratio (INR) is 1.8. What action should the nurse
take first?
A. Administer vitamin K as ordered
B. Hold the next dose and repeat INR in 6 hours
C. Contact the health care provider for a dose adjustment
D. Administer the ordered dose and document the result
Answer: C
Rationale: A therapeutic INR for atrial fibrillation is typically 2.0–3.0. An INR of
1.8 is subtherapeutic, increasing stroke risk. The nurse should notify the
provider, who may increase the dose. Holding the dose would further lower the
INR, and vitamin K is an antidote for elevated INR, not low. Administering the
same dose without communication may leave the client unprotected.
6. A postpartum client who delivered vaginally 8 hours ago reports perineal
pain. The nurse observes a 4-cm bluish, tender mass at the vaginal introitus.
What complication should the nurse suspect?
A. Rectocele
B. Bartholin cyst
C. Hematoma
D. Vaginal hematoma (the correct answer is C, but I need to label option
letters. I'll put C. Vaginal hematoma as correct. Wait "C. Hematoma"
already, so C. Hematoma is correct. I'll make D something else. So revise:
A. Rectocele
B. Bartholin cyst
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
1. A client is admitted with suspected bacterial meningitis. Which precaution
should the nurse implement first?
A. Airborne precautions
B. Contact precautions
C. Droplet precautions
D. Standard precautions only
Answer: C
Rationale: Bacterial meningitis is transmitted via large respiratory droplets;
therefore, droplet precautions (private room, surgical mask for staff within 3
feet) are initiated immediately. Airborne precautions are needed for pathogens
such as tuberculosis. Contact precautions would be added if there is drainage or
diarrhea, but droplet is the primary initial action.
2. The nurse is supervising a newly licensed registered nurse (RN) who is
inserting a nasogastric tube. Which action by the new RN requires
immediate intervention?
A. Measures the tube from the tip of the nose to the earlobe to the xiphoid
process
B. Lubricates the first 3 inches of the tube with water-soluble lubricant
C. Instructs the client to flex the chin to the chest during insertion
D. Advances the tube while the client swallows sips of water
Answer: C
Rationale: During NG tube insertion, the client should tilt the head forward (chin
to chest) to close the glottis and facilitate passage into the esophagus.
,Instructing the client to flex the chin toward the chest is correct and does not
require intervention. Measuring NEX, lubricating, and advancing while
swallowing are all appropriate. The question asks which action requires
intervention; the correct action does not need intervention. (Review: The
incorrect action would be extending the neck, which opens the airway. Thus, if
the new RN instructed chin flexed, that’s proper, so no intervention. The prompt
is tricky; the answer is the one that is correct, so intervention is not needed?
Wait, the question: “requires immediate intervention” meaning the action is
wrong. So I need to pick the wrong action. Re-reading: They ask which action by
the new RN requires immediate intervention. That means the new RN is doing
something incorrect. So the correct answer is the action that is incorrect, and we
should intervene. So I need to identify an error. Let’s examine: A. Measuring
from nose to earlobe to xiphoid — correct. B. Lubricating first 3 inches — correct.
C. Instructs chin to chest — correct, actually recommended. D. Advances while
swallowing — correct. That would mean none require intervention. That’s not
good. So I’ll change the scenario: The nurse is supervising a newly licensed RN
inserting an NG tube. Which action by the new RN would require immediate
intervention? Choose the incorrect action. I’ll make C “Instructs the client to
hyperextend the neck” which is wrong. So I’ll adjust: I’ll write item with an
incorrect action that needs intervention. Let’s reconstruct: “The nurse is
supervising a newly licensed RN inserting a nasogastric tube. Which action by
the new RN requires immediate intervention? A. Measures the tube from the tip
of the nose to the earlobe to the xiphoid process. B. Lubricates the first 3 inches
of the tube with water-soluble lubricant. C. Instructs the client to hyperextend
the neck during insertion. D. Advances the tube while the client swallows water.”
Now C is wrong, so answer C. I’ll go with that. I'll rewrite item 2.
So revised:
2. The nurse is supervising a newly licensed registered nurse inserting a
nasogastric tube. Which action by the new RN requires immediate
intervention?
A. Measures the tube from the tip of the nose to the earlobe to the xiphoid
process
, B. Lubricates the first 3 inches of the tube with water-soluble lubricant
C. Instructs the client to hyperextend the neck during insertion
D. Advances the tube while the client swallows sips of water
Answer: C
Rationale: Hyperextending the neck during insertion opens the trachea and
increases the risk of the tube entering the airway. The client should be
positioned with the chin tucked to the chest to close the glottis. The other
actions—measuring NEX, lubricating the tip, and advancing while swallowing—
are correct and facilitate safe passage.
I'll proceed with that. All good.
3. A client receiving total parenteral nutrition (TPN) through a central line
develops sudden onset of chest pain, dyspnea, and hypotension. What
should the nurse do first?
A. Notify the health care provider
B. Obtain an electrocardiogram (ECG)
C. Clamp the catheter and place the client in left lateral Trendelenburg
position
D. Administer oxygen at 10 L/min via nonrebreather mask
Answer: C
Rationale: The manifestations suggest an air embolism, a life-threatening
complication of central venous catheters. Immediate actions are to clamp the
catheter to prevent more air entry and position the client on the left side with
the head down (Trendelenburg) to trap air in the right atrium. Oxygen and
notification follow after the initial emergent positioning.
4. The nurse is caring for a client with major depressive disorder who states, “I
don’t want to live anymore.” What is the priority nursing intervention?
A. Encourage the client to attend group therapy
B. Inquire if the client has a specific suicide plan
C. Distract the client with a pleasant activity
D. Document the statement and continue monitoring
, Answer: B
Rationale: A statement of suicidal ideation demands immediate assessment of
lethality. Asking about a specific plan, means, and timeline determines the level
of risk and guides safety measures such as one-to-one observation or removal of
harmful objects. Encouraging activities or documenting alone does not address
immediate safety.
5. A client with chronic atrial fibrillation is prescribed warfarin. The
international normalized ratio (INR) is 1.8. What action should the nurse
take first?
A. Administer vitamin K as ordered
B. Hold the next dose and repeat INR in 6 hours
C. Contact the health care provider for a dose adjustment
D. Administer the ordered dose and document the result
Answer: C
Rationale: A therapeutic INR for atrial fibrillation is typically 2.0–3.0. An INR of
1.8 is subtherapeutic, increasing stroke risk. The nurse should notify the
provider, who may increase the dose. Holding the dose would further lower the
INR, and vitamin K is an antidote for elevated INR, not low. Administering the
same dose without communication may leave the client unprotected.
6. A postpartum client who delivered vaginally 8 hours ago reports perineal
pain. The nurse observes a 4-cm bluish, tender mass at the vaginal introitus.
What complication should the nurse suspect?
A. Rectocele
B. Bartholin cyst
C. Hematoma
D. Vaginal hematoma (the correct answer is C, but I need to label option
letters. I'll put C. Vaginal hematoma as correct. Wait "C. Hematoma"
already, so C. Hematoma is correct. I'll make D something else. So revise:
A. Rectocele
B. Bartholin cyst
