NCLEX-RN comprehensive Exam With
Actual Questions & Verified
Answers,Plus Rationales/Expert
Verified For Guaranteed Pass
2025/2026 /Latest Update/Instant
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1. A nurse is caring for a client with heart failure who has dyspnea and edema. Which
intervention is the highest priority?
A. Administering diuretics as prescribed
B. Encouraging ambulation
C. Providing a low-sodium diet
D. Monitoring daily weight
A. Administering diuretics as prescribed
Rationale: Diuretics help reduce fluid overload, directly relieving symptoms like dyspnea
and edema. Immediate symptom relief takes priority over dietary measures or weight
monitoring.
2. A client with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which
action should the nurse take first?
A. Administer kayexalate
B. Prepare for dialysis
C. Place the client on a cardiac monitor
D. Restrict dietary potassium
C. Place the client on a cardiac monitor
Rationale: Hyperkalemia can cause life-threatening arrhythmias. Continuous cardiac
monitoring is essential before other interventions.
3. A nurse is teaching a client newly diagnosed with type 2 diabetes about self-
management. Which statement indicates understanding?
A. “I should check my blood sugar once a week.”
B. “I need to eat sweets whenever my blood sugar is high.”
, C. “I should take my medication even if I feel well.”
D. “Exercise is not necessary if I take medication.”
C. “I should take my medication even if I feel well.”
Rationale: Consistent medication adherence prevents complications, even if the client is
asymptomatic.
4. Which is the priority nursing action for a client with suspected sepsis?
A. Administer antibiotics immediately
B. Obtain a blood culture
C. Start IV fluids
D. Monitor vital signs
A. Administer antibiotics immediately
Rationale: Early antibiotic administration in sepsis is critical to reduce morbidity and
mortality. Blood cultures should be obtained before antibiotics if possible, but timely
treatment is priority.
5. A client receiving morphine reports respiratory rate of 8 breaths/min. What is the
nurse’s first action?
A. Administer naloxone
B. Stimulate the client to breathe
C. Call the physician
D. Document findings
B. Stimulate the client to breathe
Rationale: Immediate interventions for opioid-induced respiratory depression include
stimulating breathing and supporting ventilation. Naloxone may follow if needed.
6. A nurse is caring for a client with a chest tube. The drainage system is bubbling
continuously in the suction control chamber. What should the nurse do?
A. Clamp the chest tube
B. Increase suction
C. Continue to monitor
D. Notify the physician immediately
C. Continue to monitor
Rationale: Continuous bubbling in the suction control chamber is expected; intermittent
bubbling in the water seal chamber is what indicates a problem.
7. Which client statement indicates understanding of teaching about hypertension
management?
A. “I should take my medication only when I feel stressed.”
B. “I will limit my sodium intake and exercise regularly.”
, C. “I can stop my medication if my blood pressure improves.”
D. “I should only monitor my blood pressure at the clinic.”
B. “I will limit my sodium intake and exercise regularly.”
Rationale: Lifestyle modifications like reduced sodium intake and regular exercise help
manage hypertension effectively.
8. A client with COPD is experiencing shortness of breath and uses accessory muscles.
What is the priority nursing action?
A. Administer oxygen via nasal cannula
B. Encourage deep breathing and coughing
C. Assist the client to a high Fowler’s position
D. Increase fluid intake
C. Assist the client to a high Fowler’s position
Rationale: Positioning to high Fowler’s allows maximum lung expansion and eases
breathing; oxygen is secondary if hypoxemic.
9. A nurse is assessing a client 1 day post-op. The client has a temperature of 38.5°C,
tachycardia, and wound redness. What should the nurse do first?
A. Administer antibiotics
B. Obtain wound cultures
C. Notify the surgeon
D. Encourage oral fluids
B. Obtain wound cultures
Rationale: Identifying the causative organism before administering antibiotics ensures
appropriate treatment; monitoring for infection signs is critical.
10. Which action should a nurse take when preparing to administer an intramuscular
injection?
A. Aspirate before injecting
B. Massage the site immediately after injection
C. Use a 25-gauge needle for all clients
D. Inject into the subcutaneous tissue
A. Aspirate before injecting
Rationale: Aspirating ensures the needle is not in a blood vessel. Needle size depends on
medication and client size, and site selection is IM, not subcutaneous.
11. A nurse is teaching a client about warfarin therapy. Which statement indicates the
client understands the teaching?
A. “I should eat more green leafy vegetables.”
B. “I should take aspirin for headaches.”
Actual Questions & Verified
Answers,Plus Rationales/Expert
Verified For Guaranteed Pass
2025/2026 /Latest Update/Instant
Download Pdf
1. A nurse is caring for a client with heart failure who has dyspnea and edema. Which
intervention is the highest priority?
A. Administering diuretics as prescribed
B. Encouraging ambulation
C. Providing a low-sodium diet
D. Monitoring daily weight
A. Administering diuretics as prescribed
Rationale: Diuretics help reduce fluid overload, directly relieving symptoms like dyspnea
and edema. Immediate symptom relief takes priority over dietary measures or weight
monitoring.
2. A client with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which
action should the nurse take first?
A. Administer kayexalate
B. Prepare for dialysis
C. Place the client on a cardiac monitor
D. Restrict dietary potassium
C. Place the client on a cardiac monitor
Rationale: Hyperkalemia can cause life-threatening arrhythmias. Continuous cardiac
monitoring is essential before other interventions.
3. A nurse is teaching a client newly diagnosed with type 2 diabetes about self-
management. Which statement indicates understanding?
A. “I should check my blood sugar once a week.”
B. “I need to eat sweets whenever my blood sugar is high.”
, C. “I should take my medication even if I feel well.”
D. “Exercise is not necessary if I take medication.”
C. “I should take my medication even if I feel well.”
Rationale: Consistent medication adherence prevents complications, even if the client is
asymptomatic.
4. Which is the priority nursing action for a client with suspected sepsis?
A. Administer antibiotics immediately
B. Obtain a blood culture
C. Start IV fluids
D. Monitor vital signs
A. Administer antibiotics immediately
Rationale: Early antibiotic administration in sepsis is critical to reduce morbidity and
mortality. Blood cultures should be obtained before antibiotics if possible, but timely
treatment is priority.
5. A client receiving morphine reports respiratory rate of 8 breaths/min. What is the
nurse’s first action?
A. Administer naloxone
B. Stimulate the client to breathe
C. Call the physician
D. Document findings
B. Stimulate the client to breathe
Rationale: Immediate interventions for opioid-induced respiratory depression include
stimulating breathing and supporting ventilation. Naloxone may follow if needed.
6. A nurse is caring for a client with a chest tube. The drainage system is bubbling
continuously in the suction control chamber. What should the nurse do?
A. Clamp the chest tube
B. Increase suction
C. Continue to monitor
D. Notify the physician immediately
C. Continue to monitor
Rationale: Continuous bubbling in the suction control chamber is expected; intermittent
bubbling in the water seal chamber is what indicates a problem.
7. Which client statement indicates understanding of teaching about hypertension
management?
A. “I should take my medication only when I feel stressed.”
B. “I will limit my sodium intake and exercise regularly.”
, C. “I can stop my medication if my blood pressure improves.”
D. “I should only monitor my blood pressure at the clinic.”
B. “I will limit my sodium intake and exercise regularly.”
Rationale: Lifestyle modifications like reduced sodium intake and regular exercise help
manage hypertension effectively.
8. A client with COPD is experiencing shortness of breath and uses accessory muscles.
What is the priority nursing action?
A. Administer oxygen via nasal cannula
B. Encourage deep breathing and coughing
C. Assist the client to a high Fowler’s position
D. Increase fluid intake
C. Assist the client to a high Fowler’s position
Rationale: Positioning to high Fowler’s allows maximum lung expansion and eases
breathing; oxygen is secondary if hypoxemic.
9. A nurse is assessing a client 1 day post-op. The client has a temperature of 38.5°C,
tachycardia, and wound redness. What should the nurse do first?
A. Administer antibiotics
B. Obtain wound cultures
C. Notify the surgeon
D. Encourage oral fluids
B. Obtain wound cultures
Rationale: Identifying the causative organism before administering antibiotics ensures
appropriate treatment; monitoring for infection signs is critical.
10. Which action should a nurse take when preparing to administer an intramuscular
injection?
A. Aspirate before injecting
B. Massage the site immediately after injection
C. Use a 25-gauge needle for all clients
D. Inject into the subcutaneous tissue
A. Aspirate before injecting
Rationale: Aspirating ensures the needle is not in a blood vessel. Needle size depends on
medication and client size, and site selection is IM, not subcutaneous.
11. A nurse is teaching a client about warfarin therapy. Which statement indicates the
client understands the teaching?
A. “I should eat more green leafy vegetables.”
B. “I should take aspirin for headaches.”
