NCLEX-PN Comprehensive Practice Exam
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A|
Instant Download Pdf
1. A practical nurse is caring for a client who has a respiratory rate of
8 breaths/min and is difficult to arouse. Which action should the
nurse take first?
a. Document the finding
b. Administer the prescribed oral medication
c. Assess the client's airway and breathing
d. Obtain the client's temperature
Answer: c. Assess the client's airway and breathing
Rationale: A markedly decreased respiratory rate with decreased level
of consciousness can indicate respiratory depression and threatens
airway and oxygenation. The nurse should immediately assess and
,support airway and breathing before completing routine assessments
or documentation.
2. A nurse is preparing to administer an oral medication. Which
action is most important for preventing medication errors?
a. Ask the client whether the medication looks familiar
b. Compare the medication label with the medication administration
record
c. Leave the medication at the bedside for the client
d. Ask another client to identify the medication
Answer: b. Compare the medication label with the medication
administration record
Rationale: Comparing the medication label with the medication
administration record is a fundamental medication-safety practice.
The nurse should verify the correct client, medication, dose, route, and
time according to facility policy and medication-administration
standards.
3. A client with heart failure reports increasing shortness of breath
and has bilateral crackles. Which position should the nurse use?
,a. Supine
b. Prone
c. High-Fowler's
d. Trendelenburg
Answer: c. High-Fowler's
Rationale: High-Fowler's positioning promotes lung expansion and
decreases the work of breathing. In a client with heart failure and
pulmonary congestion, upright positioning can also reduce venous
return to the heart and improve respiratory comfort.
4. A nurse is caring for a client with diabetes mellitus who is awake,
shaky, and diaphoretic. The blood glucose level is 54 mg/dL (3.0
mmol/L). What should the nurse do first?
a. Administer rapid-acting insulin
b. Give approximately 15 g of a fast-acting carbohydrate
c. Encourage the client to ambulate
d. Administer a high-protein meal immediately
Answer: b. Give approximately 15 g of a fast-acting carbohydrate
Rationale: The findings are consistent with hypoglycemia. An alert
client who can swallow should receive approximately 15 g of rapidly
, absorbed carbohydrate, followed by reassessment of blood glucose
according to the facility protocol. Insulin would worsen hypoglycemia.
5. Which finding should the nurse report immediately in a client
receiving a blood transfusion?
a. Mild thirst
b. Temperature increase with chills
c. Hunger
d. Heart rate of 76/min
Answer: b. Temperature increase with chills
Rationale: Fever and chills during a blood transfusion can indicate an
acute transfusion reaction. The nurse should stop the transfusion,
maintain intravenous access with appropriate fluid according to
policy, assess the client, and notify the appropriate healthcare
provider and blood bank.
6. A client is receiving oxygen through a nasal cannula at 2 L/min.
Which finding indicates that the therapy is having the desired
effect?
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A|
Instant Download Pdf
1. A practical nurse is caring for a client who has a respiratory rate of
8 breaths/min and is difficult to arouse. Which action should the
nurse take first?
a. Document the finding
b. Administer the prescribed oral medication
c. Assess the client's airway and breathing
d. Obtain the client's temperature
Answer: c. Assess the client's airway and breathing
Rationale: A markedly decreased respiratory rate with decreased level
of consciousness can indicate respiratory depression and threatens
airway and oxygenation. The nurse should immediately assess and
,support airway and breathing before completing routine assessments
or documentation.
2. A nurse is preparing to administer an oral medication. Which
action is most important for preventing medication errors?
a. Ask the client whether the medication looks familiar
b. Compare the medication label with the medication administration
record
c. Leave the medication at the bedside for the client
d. Ask another client to identify the medication
Answer: b. Compare the medication label with the medication
administration record
Rationale: Comparing the medication label with the medication
administration record is a fundamental medication-safety practice.
The nurse should verify the correct client, medication, dose, route, and
time according to facility policy and medication-administration
standards.
3. A client with heart failure reports increasing shortness of breath
and has bilateral crackles. Which position should the nurse use?
,a. Supine
b. Prone
c. High-Fowler's
d. Trendelenburg
Answer: c. High-Fowler's
Rationale: High-Fowler's positioning promotes lung expansion and
decreases the work of breathing. In a client with heart failure and
pulmonary congestion, upright positioning can also reduce venous
return to the heart and improve respiratory comfort.
4. A nurse is caring for a client with diabetes mellitus who is awake,
shaky, and diaphoretic. The blood glucose level is 54 mg/dL (3.0
mmol/L). What should the nurse do first?
a. Administer rapid-acting insulin
b. Give approximately 15 g of a fast-acting carbohydrate
c. Encourage the client to ambulate
d. Administer a high-protein meal immediately
Answer: b. Give approximately 15 g of a fast-acting carbohydrate
Rationale: The findings are consistent with hypoglycemia. An alert
client who can swallow should receive approximately 15 g of rapidly
, absorbed carbohydrate, followed by reassessment of blood glucose
according to the facility protocol. Insulin would worsen hypoglycemia.
5. Which finding should the nurse report immediately in a client
receiving a blood transfusion?
a. Mild thirst
b. Temperature increase with chills
c. Hunger
d. Heart rate of 76/min
Answer: b. Temperature increase with chills
Rationale: Fever and chills during a blood transfusion can indicate an
acute transfusion reaction. The nurse should stop the transfusion,
maintain intravenous access with appropriate fluid according to
policy, assess the client, and notify the appropriate healthcare
provider and blood bank.
6. A client is receiving oxygen through a nasal cannula at 2 L/min.
Which finding indicates that the therapy is having the desired
effect?
