NCLEX-RN – QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS | PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM UPDATE
Core Domains
Management of Care
Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Basic Care and Comfort
Pharmacological and Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation
Introduction
The purpose of this comprehensive examination is to evaluate the foundational knowledge,
clinical judgment, and safe practice capabilities of candidates entering professional nursing
practice. This assessment rigorously measures essential skills and core competencies
across diverse healthcare settings, ensuring that graduates possess the clinical acumen
required to provide safe, effective patient care. Utilizing a robust combination of direct
multiple-choice inquiries and complex scenario-based clinical items, the assessment
,challenges candidates to analyze patient data, prioritize interventions, and navigate ethical
dilemmas. There is a strong, continuous emphasis on real-world clinical application,
evidence-based decision-making, and proactive risk mitigation to safeguard patient
outcomes across the lifespan.
Section One: Questions 1–100
Question 1
A nurse is caring for a client admitted with acute exacerbation of chronic obstructive
pulmonary disease (COPD). The client is receiving oxygen via nasal cannula at 2 L/min.
Arterial blood gas (ABG) results indicate pH 7.31, PaCO2 58 mm Hg, HCO3 28 mEq/L,
and PaO2 62 mm Hg. Which interpretation of these laboratory values is correct?
A. Uncompensated metabolic acidosis
B. Fully compensated respiratory alkalosis
C. Partially compensated respiratory acidosis
D. Partially compensated metabolic alkalosis
🟢 C. Partially compensated respiratory acidosis
🔴 Explanation: The pH is below normal (7.31), indicating acidemia. The PaCO2 is
elevated (58 mm Hg), which is the primary respiratory cause of the acidosis. The HCO3 is
also elevated (28 mEq/L), indicating that the kidneys have begun attempting to
compensate by retaining bicarbonate. Because the pH has not yet returned to the normal
range, the imbalance is partially compensated.
Question 2
,An emergency department nurse receives a client who sustained severe electrical burns
from a high-voltage power line. Which action is the immediate priority for this client?
A. Administering prescribed intravenous opioid analgesics
B. Securing the airway and evaluating for cervical spine injury
C. Assessing total body surface area using the rule of nines
D. Initiating large-bore intravenous fluid resuscitation
🟢 B. Securing the airway and evaluating for cervical spine injury
🔴 Explanation: According to standard trauma and emergency nursing priorities
(ABCDEs), airway management and cervical spine stabilization take absolute precedence
over pain management, fluid resuscitation, and wound assessment to prevent immediate
mortality from airway obstruction or neurological injury.
Question 3
A newly admitted client diagnosed with major depressive disorder states to the nurse, "I
am a complete failure and everyone would be better off if I were dead." What is the most
appropriate initial nursing response?
A. "Why do you feel that you are a failure?"
B. "Are you having thoughts of suicide or ending your life?"
C. "You have so much to live for; let's focus on positive things."
D. "I need to notify your primary healthcare provider immediately."
🟢 B. "Are you having thoughts of suicide or ending your life?"
, 🔴 Explanation: When a client expresses statements suggestive of self-harm or
hopelessness, the nurse must directly and clearly assess for suicidal ideation. Asking
directly about suicide does not plant the idea; rather, it provides a safe opportunity for the
client to express feelings and allows the nurse to implement appropriate safety measures.
Question 4
A client is prescribed digoxin 0.25 mg orally daily for heart failure. Prior to administering the
medication, which assessment finding requires the nurse to withhold the dose and notify
the primary healthcare provider?
A. Blood pressure of 128/82 mm Hg
B. Serum potassium level of 4.2 mEq/L
C. Apical pulse rate of 52 beats per minute
D. Respiratory rate of 16 breaths per minute
🟢 C. Apical pulse rate of 52 beats per minute
🔴 Explanation: Digoxin has a negative chronotropic effect and can cause severe
bradycardia and toxicity. The nurse must withhold the medication and notify the provider if
the adult client's apical pulse is less than 60 beats per minute. A potassium level of 4.2
mEq/L is within normal limits, and blood pressure and respiratory rate are not direct
contraindications for digoxin administration.
Question 5
A nurse is providing discharge instructions to a client who has received a prescription for
warfarin. Which dietary instruction should the nurse emphasize?
ANSWERS | PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM UPDATE
Core Domains
Management of Care
Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Basic Care and Comfort
Pharmacological and Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation
Introduction
The purpose of this comprehensive examination is to evaluate the foundational knowledge,
clinical judgment, and safe practice capabilities of candidates entering professional nursing
practice. This assessment rigorously measures essential skills and core competencies
across diverse healthcare settings, ensuring that graduates possess the clinical acumen
required to provide safe, effective patient care. Utilizing a robust combination of direct
multiple-choice inquiries and complex scenario-based clinical items, the assessment
,challenges candidates to analyze patient data, prioritize interventions, and navigate ethical
dilemmas. There is a strong, continuous emphasis on real-world clinical application,
evidence-based decision-making, and proactive risk mitigation to safeguard patient
outcomes across the lifespan.
Section One: Questions 1–100
Question 1
A nurse is caring for a client admitted with acute exacerbation of chronic obstructive
pulmonary disease (COPD). The client is receiving oxygen via nasal cannula at 2 L/min.
Arterial blood gas (ABG) results indicate pH 7.31, PaCO2 58 mm Hg, HCO3 28 mEq/L,
and PaO2 62 mm Hg. Which interpretation of these laboratory values is correct?
A. Uncompensated metabolic acidosis
B. Fully compensated respiratory alkalosis
C. Partially compensated respiratory acidosis
D. Partially compensated metabolic alkalosis
🟢 C. Partially compensated respiratory acidosis
🔴 Explanation: The pH is below normal (7.31), indicating acidemia. The PaCO2 is
elevated (58 mm Hg), which is the primary respiratory cause of the acidosis. The HCO3 is
also elevated (28 mEq/L), indicating that the kidneys have begun attempting to
compensate by retaining bicarbonate. Because the pH has not yet returned to the normal
range, the imbalance is partially compensated.
Question 2
,An emergency department nurse receives a client who sustained severe electrical burns
from a high-voltage power line. Which action is the immediate priority for this client?
A. Administering prescribed intravenous opioid analgesics
B. Securing the airway and evaluating for cervical spine injury
C. Assessing total body surface area using the rule of nines
D. Initiating large-bore intravenous fluid resuscitation
🟢 B. Securing the airway and evaluating for cervical spine injury
🔴 Explanation: According to standard trauma and emergency nursing priorities
(ABCDEs), airway management and cervical spine stabilization take absolute precedence
over pain management, fluid resuscitation, and wound assessment to prevent immediate
mortality from airway obstruction or neurological injury.
Question 3
A newly admitted client diagnosed with major depressive disorder states to the nurse, "I
am a complete failure and everyone would be better off if I were dead." What is the most
appropriate initial nursing response?
A. "Why do you feel that you are a failure?"
B. "Are you having thoughts of suicide or ending your life?"
C. "You have so much to live for; let's focus on positive things."
D. "I need to notify your primary healthcare provider immediately."
🟢 B. "Are you having thoughts of suicide or ending your life?"
, 🔴 Explanation: When a client expresses statements suggestive of self-harm or
hopelessness, the nurse must directly and clearly assess for suicidal ideation. Asking
directly about suicide does not plant the idea; rather, it provides a safe opportunity for the
client to express feelings and allows the nurse to implement appropriate safety measures.
Question 4
A client is prescribed digoxin 0.25 mg orally daily for heart failure. Prior to administering the
medication, which assessment finding requires the nurse to withhold the dose and notify
the primary healthcare provider?
A. Blood pressure of 128/82 mm Hg
B. Serum potassium level of 4.2 mEq/L
C. Apical pulse rate of 52 beats per minute
D. Respiratory rate of 16 breaths per minute
🟢 C. Apical pulse rate of 52 beats per minute
🔴 Explanation: Digoxin has a negative chronotropic effect and can cause severe
bradycardia and toxicity. The nurse must withhold the medication and notify the provider if
the adult client's apical pulse is less than 60 beats per minute. A potassium level of 4.2
mEq/L is within normal limits, and blood pressure and respiratory rate are not direct
contraindications for digoxin administration.
Question 5
A nurse is providing discharge instructions to a client who has received a prescription for
warfarin. Which dietary instruction should the nurse emphasize?
