NCLEX RN PRACTICE Exam– Questions And Answers | Verified
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1. A nurse is assessing a client admitted with heart failure who reports increasing shortness
of breath and dependent edema. Which assessment finding requires immediate
intervention?
A. Trace pedal edema in the lower extremities bilaterally
B. An oral temperature of 98.8°F (37.1°C)
C. Crackles audible in the lower lung fields bilaterally
D. A sudden weight gain of 2.2 kg (4.8 lbs) over the past 24 hours
Answer: D. A sudden weight gain of 2.2 kg (4.8 lbs) over the past 24 hours
Rationale: A rapid weight gain of over two kilograms in a single day is the most sensitive and
immediate indicator of acute fluid retention and worsening heart failure. Crackles and pedal
edema are expected chronic or progressive findings, whereas rapid weight gain signifies acute
decompensation requiring prompt medical management.
2. A nurse prepares to administer a scheduled dose of digoxin to a client with atrial
fibrillation. Which pre-administration assessment is most critical?
A. Assessing peripheral capillary refill time
B. Auscultating the apical pulse for one full minute
C. Checking the client's most recent serum sodium level
D. Measuring the client's abdominal girth
Answer: B. Auscultating the apical pulse for one full minute
Rationale: Digoxin has a negative chronotropic effect and can induce severe bradycardia or
toxicity. The nurse must assess the apical heart rate for a full minute prior to administration and
withhold the medication if the rate falls below the established clinical parameter, typically 60
beats per minute.
3. A client diagnosed with type 1 diabetes mellitus is found unconscious, cool, and clammy.
Which initial action should the nurse take?
A. Administer regular insulin subcutaneously as prescribed
,B. Check the client's blood pressure using a manual cuff
C. Administer 50% dextrose intravenous push per protocol
D. Obtain a comprehensive metabolic panel immediately
Answer: C. Administer 50% dextrose intravenous push per protocol
Rationale: The clinical presentation of altered consciousness, diaphoresis, and cool skin strongly
indicates acute hypoglycemia. Immediate intravenous administration of concentrated glucose is
life-saving, whereas insulin would worsen the condition.
4. A nurse cares for a client who is 4 hours postoperative following a thyroidectomy. Which
finding demands immediate notification of the healthcare provider?
A. Mild soreness at the surgical incision site during swallowing
B. The client speaking in a hoarse, strained whisper
C. A blood pressure reading of 128/82 mmHg
D. Drowsiness immediately following general anesthesia emergence
Answer: B. The client speaking in a hoarse, strained whisper
Rationale: Hoarseness and a strained voice following a thyroidectomy indicate laryngeal nerve
damage or acute laryngeal edema, which can rapidly progress to complete airway obstruction.
This is a surgical emergency.
5. A client with chronic kidney disease has a serum potassium level of 6.2 mEq/L. Which
electrocardiogram (ECG) change is most characteristic of this electrolyte imbalance?
A. Flattened T waves and prominent U waves
B. Prolonged PR intervals and ST-segment depression
C. Tall, peaked T waves and widened QRS complexes
D. Shortened QT intervals and normal ST segments
Answer: C. Tall, peaked T waves and widened QRS complexes
Rationale: Severe hyperkalemia significantly alters myocardial repolarization and
depolarization, classically presenting on the ECG with tall, peaked T waves, prolonged PR
intervals, widened QRS complexes, and potentially ventricular fibrillation.
, 6. A nurse is teaching a client newly diagnosed with hypertension about lifestyle
modifications. Which statement by the client indicates an understanding of the dietary
changes required?
A. "I will increase my daily intake of processed canned foods for convenience."
B. "I should incorporate foods rich in potassium, such as bananas and leafy greens."
C. "I can continue to use table salt freely as long as I avoid fatty red meats."
D. "I need to eliminate all dairy products from my daily diet completely."
Answer: B. "I should incorporate foods rich in potassium, such as bananas and leafy
greens."
Rationale: Potassium helps blunt the hypertensive effects of sodium and supports vascular
health. Processed foods and table salt are high in sodium and should be restricted, while dairy
products are not strictly contraindicated.
7. A client with a nasogastric tube connected to low intermittent suction reports nausea and
upper abdominal fullness. What is the nurse's first action?
A. Irrigate the nasogastric tube with sterile normal saline
B. Check the patency and placement of the nasogastric tube
C. Administer the prescribed antiemetic medication intravenously
D. Disconnect the suction and clamp the tube for two hours
Answer: B. Check the patency and placement of the nasogastric tube
Rationale: Nausea and fullness in a client with a nasogastric tube typically indicate tube
blockage or displacement, preventing gastric decompression. The nurse must first verify patency
before attempting irrigation or administering medications.
8. A nurse assesses a client receiving a transfusion of packed red blood cells who begins to
develop lower back pain, chills, and dark urine after 15 minutes. What is the priority
nursing action?
A. Slow the transfusion rate and administer an antihistamine
B. Stop the transfusion immediately and infuse normal saline through new tubing
C. Document the findings and notify the blood bank after the infusion completes
D. Apply a warm blanket and reassess vital signs in 15 minutes
And Well Detailed Answers Plus Rationales | Guaranteed Pass |
Latest Exam Update | Exam Prep | Study Guide | Practice Test|
Download Instant Pdf
1. A nurse is assessing a client admitted with heart failure who reports increasing shortness
of breath and dependent edema. Which assessment finding requires immediate
intervention?
A. Trace pedal edema in the lower extremities bilaterally
B. An oral temperature of 98.8°F (37.1°C)
C. Crackles audible in the lower lung fields bilaterally
D. A sudden weight gain of 2.2 kg (4.8 lbs) over the past 24 hours
Answer: D. A sudden weight gain of 2.2 kg (4.8 lbs) over the past 24 hours
Rationale: A rapid weight gain of over two kilograms in a single day is the most sensitive and
immediate indicator of acute fluid retention and worsening heart failure. Crackles and pedal
edema are expected chronic or progressive findings, whereas rapid weight gain signifies acute
decompensation requiring prompt medical management.
2. A nurse prepares to administer a scheduled dose of digoxin to a client with atrial
fibrillation. Which pre-administration assessment is most critical?
A. Assessing peripheral capillary refill time
B. Auscultating the apical pulse for one full minute
C. Checking the client's most recent serum sodium level
D. Measuring the client's abdominal girth
Answer: B. Auscultating the apical pulse for one full minute
Rationale: Digoxin has a negative chronotropic effect and can induce severe bradycardia or
toxicity. The nurse must assess the apical heart rate for a full minute prior to administration and
withhold the medication if the rate falls below the established clinical parameter, typically 60
beats per minute.
3. A client diagnosed with type 1 diabetes mellitus is found unconscious, cool, and clammy.
Which initial action should the nurse take?
A. Administer regular insulin subcutaneously as prescribed
,B. Check the client's blood pressure using a manual cuff
C. Administer 50% dextrose intravenous push per protocol
D. Obtain a comprehensive metabolic panel immediately
Answer: C. Administer 50% dextrose intravenous push per protocol
Rationale: The clinical presentation of altered consciousness, diaphoresis, and cool skin strongly
indicates acute hypoglycemia. Immediate intravenous administration of concentrated glucose is
life-saving, whereas insulin would worsen the condition.
4. A nurse cares for a client who is 4 hours postoperative following a thyroidectomy. Which
finding demands immediate notification of the healthcare provider?
A. Mild soreness at the surgical incision site during swallowing
B. The client speaking in a hoarse, strained whisper
C. A blood pressure reading of 128/82 mmHg
D. Drowsiness immediately following general anesthesia emergence
Answer: B. The client speaking in a hoarse, strained whisper
Rationale: Hoarseness and a strained voice following a thyroidectomy indicate laryngeal nerve
damage or acute laryngeal edema, which can rapidly progress to complete airway obstruction.
This is a surgical emergency.
5. A client with chronic kidney disease has a serum potassium level of 6.2 mEq/L. Which
electrocardiogram (ECG) change is most characteristic of this electrolyte imbalance?
A. Flattened T waves and prominent U waves
B. Prolonged PR intervals and ST-segment depression
C. Tall, peaked T waves and widened QRS complexes
D. Shortened QT intervals and normal ST segments
Answer: C. Tall, peaked T waves and widened QRS complexes
Rationale: Severe hyperkalemia significantly alters myocardial repolarization and
depolarization, classically presenting on the ECG with tall, peaked T waves, prolonged PR
intervals, widened QRS complexes, and potentially ventricular fibrillation.
, 6. A nurse is teaching a client newly diagnosed with hypertension about lifestyle
modifications. Which statement by the client indicates an understanding of the dietary
changes required?
A. "I will increase my daily intake of processed canned foods for convenience."
B. "I should incorporate foods rich in potassium, such as bananas and leafy greens."
C. "I can continue to use table salt freely as long as I avoid fatty red meats."
D. "I need to eliminate all dairy products from my daily diet completely."
Answer: B. "I should incorporate foods rich in potassium, such as bananas and leafy
greens."
Rationale: Potassium helps blunt the hypertensive effects of sodium and supports vascular
health. Processed foods and table salt are high in sodium and should be restricted, while dairy
products are not strictly contraindicated.
7. A client with a nasogastric tube connected to low intermittent suction reports nausea and
upper abdominal fullness. What is the nurse's first action?
A. Irrigate the nasogastric tube with sterile normal saline
B. Check the patency and placement of the nasogastric tube
C. Administer the prescribed antiemetic medication intravenously
D. Disconnect the suction and clamp the tube for two hours
Answer: B. Check the patency and placement of the nasogastric tube
Rationale: Nausea and fullness in a client with a nasogastric tube typically indicate tube
blockage or displacement, preventing gastric decompression. The nurse must first verify patency
before attempting irrigation or administering medications.
8. A nurse assesses a client receiving a transfusion of packed red blood cells who begins to
develop lower back pain, chills, and dark urine after 15 minutes. What is the priority
nursing action?
A. Slow the transfusion rate and administer an antihistamine
B. Stop the transfusion immediately and infuse normal saline through new tubing
C. Document the findings and notify the blood bank after the infusion completes
D. Apply a warm blanket and reassess vital signs in 15 minutes
