100 NCLEX-Style Questions with Rationales with ans 2025
Encourage the patient to wash as much
Intervention for bathing assistance
as possible independently.
Assess the patient's level of conscious-
Important action for oral care
ness.
I will use a button hook to fasten my
Understanding adaptive equipment use
shirts.
Finding to report immediately Pulse oximetry 88% on room air.
Next action for elevated temperature Offer acetaminophen as prescribed.
Next assessment for irregular radial
Obtain an apical pulse for 1 full minute.
pulse
Drip rate calculation for Heparin IV 20 mL/hr.
Remaining mg after drawing from vial 250 mg.
Intradermal injection angle 15°.
Release skin immediately post-with-
Z-track IM injection technique
drawal.
Hold metoprolol if apical pulse is less
60 bpm.
than
Action if patient vomits after antibiotic Notify provider.
Correct site for SC insulin Abdomen.
Gait belt technique for left-sided weak-
Stand behind & to side of weak leg.
ness
Prevent foot drop in non-weight-bearing High-top tennis shoes.
Exercise to improve knee extension Quadriceps set.
Transfer bed to chair requirement Lock bed & wheelchair brakes.
Airborne isolation PPE Gown, gloves, N95
Break chain at transmission Hand hygiene between patients
C. difficile requires Soap & water handwashing on exit
Donning contact-plus PPE order Gown, mask/respirator, goggles, gloves
Biohazard bag disposal Saturated body fluids ’ biohazard
Malnutrition lab test
1/5
, 100 NCLEX-Style Questions with Rationales with ans 2025
Serum albumin reflects long-term nutri-
tion
Low-sodium diet choice Fresh fruit negligible sodium
Enteral feeding bloating Decrease rate reduces bloating
Clear-liquid diet includes Broth is clear liquid
Foley with no output 2 hrs: first Check tubing kinks
Urinary retention assessment Bladder ultrasound for residual
Diet to prevent constipation Fiber promotes bowel movements
Diarrhea avoid Carbonation increases gas/irritation
Earliest hypoxia symptom Tachycardia is early sign
COPD pursed-lip breathing to Prolong exhalation prevents collapse
ABG pH 7.28, PaCO 50, HCO 24 High CO & low pH ’ respiratory acidosis
Best position for oxygenation High-Fowler's maximizes lung expansion
2 L nasal cannula, dry nares Jelly soothes without blocking nares
Patient nods, doesn't speak Open-ended encourages sharing
Empathetic communication Acknowledging difficulty shows empathy
HIPAA in shift report Protect PHI in public
Prevent falls Non-skid reduces risk
Tight wrist restraint: first Check for neurovascular compromise
Extinguisher for electrical fires Class C for electrical
Home oxygen user avoid Synthetics generate static sparks
Water-based lotions Synthetics generate static sparks.
Guided imagery pain management Visualization of pleasant scenes.
Bolus before activity prevents break-
PCA patient pain 3/10 rest, 7/10 activity
through pain.
Pain in nonverbal patient FLACC assesses nonverbal pain.
Cultural beliefs prohibit transfusion Respect beliefs & explore options.
Culturally competent care Asking ensures individualized care.
2/5
Encourage the patient to wash as much
Intervention for bathing assistance
as possible independently.
Assess the patient's level of conscious-
Important action for oral care
ness.
I will use a button hook to fasten my
Understanding adaptive equipment use
shirts.
Finding to report immediately Pulse oximetry 88% on room air.
Next action for elevated temperature Offer acetaminophen as prescribed.
Next assessment for irregular radial
Obtain an apical pulse for 1 full minute.
pulse
Drip rate calculation for Heparin IV 20 mL/hr.
Remaining mg after drawing from vial 250 mg.
Intradermal injection angle 15°.
Release skin immediately post-with-
Z-track IM injection technique
drawal.
Hold metoprolol if apical pulse is less
60 bpm.
than
Action if patient vomits after antibiotic Notify provider.
Correct site for SC insulin Abdomen.
Gait belt technique for left-sided weak-
Stand behind & to side of weak leg.
ness
Prevent foot drop in non-weight-bearing High-top tennis shoes.
Exercise to improve knee extension Quadriceps set.
Transfer bed to chair requirement Lock bed & wheelchair brakes.
Airborne isolation PPE Gown, gloves, N95
Break chain at transmission Hand hygiene between patients
C. difficile requires Soap & water handwashing on exit
Donning contact-plus PPE order Gown, mask/respirator, goggles, gloves
Biohazard bag disposal Saturated body fluids ’ biohazard
Malnutrition lab test
1/5
, 100 NCLEX-Style Questions with Rationales with ans 2025
Serum albumin reflects long-term nutri-
tion
Low-sodium diet choice Fresh fruit negligible sodium
Enteral feeding bloating Decrease rate reduces bloating
Clear-liquid diet includes Broth is clear liquid
Foley with no output 2 hrs: first Check tubing kinks
Urinary retention assessment Bladder ultrasound for residual
Diet to prevent constipation Fiber promotes bowel movements
Diarrhea avoid Carbonation increases gas/irritation
Earliest hypoxia symptom Tachycardia is early sign
COPD pursed-lip breathing to Prolong exhalation prevents collapse
ABG pH 7.28, PaCO 50, HCO 24 High CO & low pH ’ respiratory acidosis
Best position for oxygenation High-Fowler's maximizes lung expansion
2 L nasal cannula, dry nares Jelly soothes without blocking nares
Patient nods, doesn't speak Open-ended encourages sharing
Empathetic communication Acknowledging difficulty shows empathy
HIPAA in shift report Protect PHI in public
Prevent falls Non-skid reduces risk
Tight wrist restraint: first Check for neurovascular compromise
Extinguisher for electrical fires Class C for electrical
Home oxygen user avoid Synthetics generate static sparks
Water-based lotions Synthetics generate static sparks.
Guided imagery pain management Visualization of pleasant scenes.
Bolus before activity prevents break-
PCA patient pain 3/10 rest, 7/10 activity
through pain.
Pain in nonverbal patient FLACC assesses nonverbal pain.
Cultural beliefs prohibit transfusion Respect beliefs & explore options.
Culturally competent care Asking ensures individualized care.
2/5
