NCLEX-RN Practice Test Exam
1. A nurse is prioritizing care for four clients. Which client
should the nurse assess first?
A) A client with a new prescription for antihypertensives
B) A client with stable vital signs post-surgery
C) A client reporting chest pain rated 8/10
D) A client requesting pain medication for a headache
Correct Answer: C
Rationale: Chest pain rated 8/10 indicates a potential cardiac
emergency, requiring immediate assessment per American
Heart Association guidelines. The other clients have stable or
non-urgent needs that can wait until after the critical client is
assessed .
2. A client receives morphine 2 mg IV for pain. The nurse should
monitor for which adverse effect?
,A) Hypertension
B) Respiratory depression
C) Hyperglycemia
D) Tachycardia
Correct Answer: B
Rationale: Respiratory depression is a priority adverse effect of
morphine, per the Institute for Safe Medication Practices.
Opioids depress the central nervous system's respiratory drive,
and the nurse must monitor respiratory rate and depth closely .
3. A client with heart failure has a sudden increase in shortness
of breath. What should the nurse do first?
A) Administer a PRN diuretic
B) Assess oxygen saturation and respiratory status
C) Encourage fluid intake
D) Reposition the client to a supine position
Correct Answer: B
,Rationale: Assessing oxygen saturation and respiratory status is
the priority to address potential respiratory compromise, per
the American Heart Association. Assessment precedes
intervention in the nursing process .
4. A nurse is caring for a client post-operatively. Which finding
requires immediate intervention?
A) Temperature of 99.2°F
B) Oxygen saturation of 88%
C) Blood pressure of 120/80 mmHg
D) Heart rate of 72 bpm
Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxia,
requiring immediate action per the American Association of
Critical-Care Nurses. The other findings are within normal limits
or only mildly elevated .
5. A client is prescribed warfarin. The nurse should teach the
client to avoid which food?
, A) Apples
B) Leafy green vegetables
C) Carrots
D) Bananas
Correct Answer: B
Rationale: Leafy greens are high in vitamin K, which can reduce
warfarin's effectiveness, per the American Heart Association.
Clients on warfarin should maintain consistent vitamin K intake
rather than eliminating it entirely .
6. A nurse is preparing to insert a urinary catheter. What is the
first step?
A) Apply sterile gloves
B) Perform hand hygiene
C) Position the client
D) Open the catheter kit
1. A nurse is prioritizing care for four clients. Which client
should the nurse assess first?
A) A client with a new prescription for antihypertensives
B) A client with stable vital signs post-surgery
C) A client reporting chest pain rated 8/10
D) A client requesting pain medication for a headache
Correct Answer: C
Rationale: Chest pain rated 8/10 indicates a potential cardiac
emergency, requiring immediate assessment per American
Heart Association guidelines. The other clients have stable or
non-urgent needs that can wait until after the critical client is
assessed .
2. A client receives morphine 2 mg IV for pain. The nurse should
monitor for which adverse effect?
,A) Hypertension
B) Respiratory depression
C) Hyperglycemia
D) Tachycardia
Correct Answer: B
Rationale: Respiratory depression is a priority adverse effect of
morphine, per the Institute for Safe Medication Practices.
Opioids depress the central nervous system's respiratory drive,
and the nurse must monitor respiratory rate and depth closely .
3. A client with heart failure has a sudden increase in shortness
of breath. What should the nurse do first?
A) Administer a PRN diuretic
B) Assess oxygen saturation and respiratory status
C) Encourage fluid intake
D) Reposition the client to a supine position
Correct Answer: B
,Rationale: Assessing oxygen saturation and respiratory status is
the priority to address potential respiratory compromise, per
the American Heart Association. Assessment precedes
intervention in the nursing process .
4. A nurse is caring for a client post-operatively. Which finding
requires immediate intervention?
A) Temperature of 99.2°F
B) Oxygen saturation of 88%
C) Blood pressure of 120/80 mmHg
D) Heart rate of 72 bpm
Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxia,
requiring immediate action per the American Association of
Critical-Care Nurses. The other findings are within normal limits
or only mildly elevated .
5. A client is prescribed warfarin. The nurse should teach the
client to avoid which food?
, A) Apples
B) Leafy green vegetables
C) Carrots
D) Bananas
Correct Answer: B
Rationale: Leafy greens are high in vitamin K, which can reduce
warfarin's effectiveness, per the American Heart Association.
Clients on warfarin should maintain consistent vitamin K intake
rather than eliminating it entirely .
6. A nurse is preparing to insert a urinary catheter. What is the
first step?
A) Apply sterile gloves
B) Perform hand hygiene
C) Position the client
D) Open the catheter kit
