NCLEX Question Bank with Rationales
2025
A nurse is planning care for a patient with anorexia nervosa. Which goal is most appropriate for the
initial plan of care?
A) The patient will express satisfaction with body image within one week.
B) The patient will engage in social activities with peers during meal times.
C) The patient will independently plan and prepare all meals.
D) The patient will gain a specified amount of weight each week as agreed upon by the healthcare team.
ANS:
After a transfusion, the body reacts by destroying the transfused red blood cells. What is this reaction?
A) Rh negative
B) antihistamine
C) hemolytic
D) antibody ANS: C) Hemolytic
RATIONALE: A hemolytic reaction occurs when the body destroys transfused red blood cells.
The nurse prepares to perform the initial assessment on a school-age client. The client has an open
wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which precaution will the
nurse take?
A. Wear gloves only.
B. Wear gown and gloves.
C. Wear gown, gloves, and mask.
D. No precautions are necessary. ANS: B. Wear gown and gloves.
,RATIONALE: MRSA requires contact precautions. The nurse should wear clean, nonsterile gloves and
gown when entering the client?s room and when having any contact with the client or with surfaces that
the client touches.
The nurse has four phone messages. Which message does the nurse return first?
A) An older adult client undergoing bowel prep and reporting watery diarrhea.
B) A client with a newborn and experiencing breast engorgement.
C) A client who had a cataract extraction 3 days ago and reporting nausea.
D) A client diagnosed with a C6 spinal cord injury and reporting a headache. ANS: D) A client diagnosed
with a C6 spinal cord injury and reporting a headache.
RATIONALE:
A severe headache is indicative of autonomic dysreflexia in the client who has sustained a high-level
spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood pressure, and, if
untreated, can result in intracranial bleeding and death. This client is the most unstable and is
experiencing a potentially life-threatening issue that needs to be addressed immediately by the nurse.
The adult grandchild of a client diagnosed with Parkinson disease tells the nurse about proposed gift
ideas for the grandparent's birthday in 2 weeks. The grandchild asks the nurse which idea is best. Which
option is the best gift for the nurse to recommend?
A)Perfume and makeup.
B)Hearing aid with batteries.
C)Warming tray for food.
D)Quilt and soft pillow. ANS: C) Warming tray for food
RATIONALE: Warming trays can keep food hot, safe, and appealing during the slow eating process of the
client diagnosed with Parkinson disease. Eating is slow because of overall slowed body movement,
tremors, difficulty chewing and swallowing, fatigue, and need for rest periods. This choice directly
addresses a physiologic need.
,The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with asthma about
preventative care. Which statement by the parent indicates to the nurse that further teaching is
necessary?
A. "My child likes sleeping on the top bunk when visiting grandparents."
B. "My child sleeps on a zippered covered pillow and mattress."
C. "My child changes his clothes after playing outside."
D. "My child wears a mask while I vacuum the carpets." ANS: A."My child likes sleeping on the top bunk
when visiting grandparents."
RATIONALE:
Dust mites are a trigger for asthma. Fabric from bedding on the upper bunk can harbor dust mites. The
child is not to sleep or lie down on upholstered furniture. Use furniture that can be wiped with a damp
cloth such as wood, plastic, vinyl, or leather.
The home care nurse evaluates a client diagnosed with tuberculosis and receiving isoniazid, rifampin,
and pyrazinamide. Which client statement requires further assessment by the nurse?
A) "I have gained 5 pounds since I started taking the medication."
B) "I cover my nose and mouth when I cough or sneeze."
C) "I drink a glass of wine with dinner each night."
D) "I have stopped eating tuna salad sandwiches." ANS: C) "I drink a glass of wine with dinner each
night."
RATIONALE:
An adverse reaction of isoniazid is hepatitis. Instruct a client to avoid ingesting alcohol when taking the
medication.
RATIONALE FOR INCORRECT ANSWERS:
"I have gained 5 pounds since I started taking the medication."
, Weight loss is a symptom of TB. Gaining weight indicates the client is able to eat and is having minimal
GI upset due to the medications.
"I cover my nose and mouth when I cough or sneeze."
Covering the mouth and nose when coughing or sneezing is good hygiene and prevents the spread of
disease.
"I have stopped eating tuna salad sandwiches."
A client taking these medications should avoid tuna, aged cheese, red wine, and yeast extracts, as they
may cause the adverse effects of flushing, hypotension, palpitations, and diaphoresis.
The nurse in the emergency department assesses a client diagnosed with burns. Which observation
most concerns the nurse?
A) Redness and swelling with fluid-filled vesicles noted on right arm.
B) Charred, waxy, white appearance of skin on the left leg.
C) Reddened blotchy painful areas noted on the trunk.
D) Blistering and blanching of the skin noted on the back. ANS: B) Charred, waxy, white appearance of
skin on the left leg.
RATIONALE:
This describes a full-thickness burn. All the skin is destroyed and the muscle and bone may be involved.
The substance that remains is called eschar and is dry to the touch. Full-thickness burns do not heal
spontaneously and require grafting. All functions of the skin are lost.
RATIONALE FOR INCORRECT ANSWERS:
A) This describes a partial-thickness burn. Only part of the skin is damaged or destroyed. Large, thick-
walled blisters develop, and the underlying tissue is deep red and appears wet and shiny. The damaged
2025
A nurse is planning care for a patient with anorexia nervosa. Which goal is most appropriate for the
initial plan of care?
A) The patient will express satisfaction with body image within one week.
B) The patient will engage in social activities with peers during meal times.
C) The patient will independently plan and prepare all meals.
D) The patient will gain a specified amount of weight each week as agreed upon by the healthcare team.
ANS:
After a transfusion, the body reacts by destroying the transfused red blood cells. What is this reaction?
A) Rh negative
B) antihistamine
C) hemolytic
D) antibody ANS: C) Hemolytic
RATIONALE: A hemolytic reaction occurs when the body destroys transfused red blood cells.
The nurse prepares to perform the initial assessment on a school-age client. The client has an open
wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which precaution will the
nurse take?
A. Wear gloves only.
B. Wear gown and gloves.
C. Wear gown, gloves, and mask.
D. No precautions are necessary. ANS: B. Wear gown and gloves.
,RATIONALE: MRSA requires contact precautions. The nurse should wear clean, nonsterile gloves and
gown when entering the client?s room and when having any contact with the client or with surfaces that
the client touches.
The nurse has four phone messages. Which message does the nurse return first?
A) An older adult client undergoing bowel prep and reporting watery diarrhea.
B) A client with a newborn and experiencing breast engorgement.
C) A client who had a cataract extraction 3 days ago and reporting nausea.
D) A client diagnosed with a C6 spinal cord injury and reporting a headache. ANS: D) A client diagnosed
with a C6 spinal cord injury and reporting a headache.
RATIONALE:
A severe headache is indicative of autonomic dysreflexia in the client who has sustained a high-level
spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood pressure, and, if
untreated, can result in intracranial bleeding and death. This client is the most unstable and is
experiencing a potentially life-threatening issue that needs to be addressed immediately by the nurse.
The adult grandchild of a client diagnosed with Parkinson disease tells the nurse about proposed gift
ideas for the grandparent's birthday in 2 weeks. The grandchild asks the nurse which idea is best. Which
option is the best gift for the nurse to recommend?
A)Perfume and makeup.
B)Hearing aid with batteries.
C)Warming tray for food.
D)Quilt and soft pillow. ANS: C) Warming tray for food
RATIONALE: Warming trays can keep food hot, safe, and appealing during the slow eating process of the
client diagnosed with Parkinson disease. Eating is slow because of overall slowed body movement,
tremors, difficulty chewing and swallowing, fatigue, and need for rest periods. This choice directly
addresses a physiologic need.
,The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with asthma about
preventative care. Which statement by the parent indicates to the nurse that further teaching is
necessary?
A. "My child likes sleeping on the top bunk when visiting grandparents."
B. "My child sleeps on a zippered covered pillow and mattress."
C. "My child changes his clothes after playing outside."
D. "My child wears a mask while I vacuum the carpets." ANS: A."My child likes sleeping on the top bunk
when visiting grandparents."
RATIONALE:
Dust mites are a trigger for asthma. Fabric from bedding on the upper bunk can harbor dust mites. The
child is not to sleep or lie down on upholstered furniture. Use furniture that can be wiped with a damp
cloth such as wood, plastic, vinyl, or leather.
The home care nurse evaluates a client diagnosed with tuberculosis and receiving isoniazid, rifampin,
and pyrazinamide. Which client statement requires further assessment by the nurse?
A) "I have gained 5 pounds since I started taking the medication."
B) "I cover my nose and mouth when I cough or sneeze."
C) "I drink a glass of wine with dinner each night."
D) "I have stopped eating tuna salad sandwiches." ANS: C) "I drink a glass of wine with dinner each
night."
RATIONALE:
An adverse reaction of isoniazid is hepatitis. Instruct a client to avoid ingesting alcohol when taking the
medication.
RATIONALE FOR INCORRECT ANSWERS:
"I have gained 5 pounds since I started taking the medication."
, Weight loss is a symptom of TB. Gaining weight indicates the client is able to eat and is having minimal
GI upset due to the medications.
"I cover my nose and mouth when I cough or sneeze."
Covering the mouth and nose when coughing or sneezing is good hygiene and prevents the spread of
disease.
"I have stopped eating tuna salad sandwiches."
A client taking these medications should avoid tuna, aged cheese, red wine, and yeast extracts, as they
may cause the adverse effects of flushing, hypotension, palpitations, and diaphoresis.
The nurse in the emergency department assesses a client diagnosed with burns. Which observation
most concerns the nurse?
A) Redness and swelling with fluid-filled vesicles noted on right arm.
B) Charred, waxy, white appearance of skin on the left leg.
C) Reddened blotchy painful areas noted on the trunk.
D) Blistering and blanching of the skin noted on the back. ANS: B) Charred, waxy, white appearance of
skin on the left leg.
RATIONALE:
This describes a full-thickness burn. All the skin is destroyed and the muscle and bone may be involved.
The substance that remains is called eschar and is dry to the touch. Full-thickness burns do not heal
spontaneously and require grafting. All functions of the skin are lost.
RATIONALE FOR INCORRECT ANSWERS:
A) This describes a partial-thickness burn. Only part of the skin is damaged or destroyed. Large, thick-
walled blisters develop, and the underlying tissue is deep red and appears wet and shiny. The damaged
