NCLEX-RN // EXAM REVIEW
Questions and answers // Test Bank
A patient with heart failure asks why daily weight monitoring is important, what is the best
explanation
✔️✔️ Daily weight helps detect fluid retention early, which can indicate worsening heart failure
before symptoms become severe
A nurse is caring for a patient with a urinary catheter, what is the priority action to prevent
infection
✔️✔️ Maintain a closed drainage system and ensure proper perineal hygiene to reduce risk of
urinary tract infection
A patient reports chest pain radiating to the left arm, what is the nurse’s immediate priority
✔️✔️ Assess vital signs and initiate emergency protocols as this may indicate a myocardial
infarction
A postoperative patient has shallow breathing, what is the most appropriate nursing intervention
✔️✔️ Encourage deep breathing and use of an incentive spirometer to prevent atelectasis
A diabetic patient asks why foot care is essential, what should the nurse explain
✔️✔️ Proper foot care prevents infections and complications due to decreased sensation and poor
circulation
A patient with hypertension asks about lifestyle changes, what is the best advice
✔️✔️ Reducing salt intake, exercising regularly, and managing stress can help control blood
pressure
A nurse observes a patient becoming confused suddenly, what should be the first action
✔️✔️ Assess oxygenation and blood glucose levels to identify possible causes of acute confusion
A patient is on anticoagulant therapy, what teaching is most important
✔️✔️ Report any signs of bleeding such as bruising, blood in urine, or black stools immediately
A patient recovering from surgery complains of pain, what is the nurse’s priority
✔️✔️ Assess pain level and administer prescribed analgesics promptly to promote comfort and
healing
A patient with asthma experiences wheezing, what is the nurse’s immediate intervention
✔️✔️ Administer prescribed bronchodilator to relieve airway constriction
A patient asks why turning frequently in bed is important, what is the correct response
✔️✔️ Frequent repositioning prevents pressure ulcers and improves circulation
1
,A nurse notes decreased urine output in a patient, what should be done first
✔️✔️ Assess fluid intake and check for signs of dehydration or kidney impairment
A patient is receiving IV fluids, what complication should the nurse monitor for
✔️✔️ Watch for signs of fluid overload such as edema and difficulty breathing
A patient with anemia feels fatigued, what should the nurse explain
✔️✔️ Fatigue occurs due to reduced oxygen-carrying capacity of the blood
A patient with pneumonia has thick secretions, what nursing action is best
✔️✔️ Encourage increased fluid intake to help thin secretions
A nurse is educating a patient about infection prevention, what is key advice
✔️✔️ Regular handwashing is the most effective way to prevent infections
A patient experiences dizziness upon standing, what is the likely cause
✔️✔️ Orthostatic hypotension due to sudden drop in blood pressure
A patient is on bed rest, what complication is most concerning
✔️✔️ Risk of deep vein thrombosis due to immobility
A nurse is caring for a patient with fever, what is the priority intervention
✔️✔️ Monitor temperature and provide antipyretics as prescribed
A patient with kidney disease asks about diet, what should the nurse include
✔️✔️ Limit sodium, potassium, and protein intake as advised
A patient reports severe abdominal pain, what is the first nursing action
✔️✔️ Assess pain characteristics and notify the healthcare provider
A patient with COPD asks why smoking cessation is important
✔️✔️ Smoking worsens lung damage and decreases oxygen exchange
A nurse is administering medication, what is the most important step
✔️✔️ Verify the five rights of medication administration
A patient feels anxious before surgery, what should the nurse do
✔️✔️ Provide reassurance and explain the procedure clearly
A patient with diarrhea is at risk for what complication
✔️✔️ Dehydration and electrolyte imbalance
A nurse notices swelling in a patient’s legs, what could this indicate
✔️✔️ Possible fluid retention or heart failure
2
, A patient with a wound asks how to promote healing
✔️✔️ Keep the wound clean and maintain proper nutrition
A patient is on oxygen therapy, what safety measure is essential
✔️✔️ Avoid open flames and ensure proper oxygen equipment use
A nurse observes a rash after medication administration, what is the priority
✔️✔️ Stop the medication and assess for allergic reaction
A patient with stroke has difficulty swallowing, what intervention is needed
✔️✔️ Perform a swallowing assessment to prevent aspiration
A patient asks about signs of infection, what should the nurse say
✔️✔️ Redness, swelling, warmth, and fever are common signs
A nurse is caring for a patient with hypoglycemia, what is the immediate action
✔️✔️ Administer glucose or sugary drink if patient is conscious
A patient is dehydrated, what symptom is expected
✔️✔️ Dry mouth and decreased urine output
A patient with burns needs what priority care
✔️✔️ Fluid resuscitation to prevent shock
A nurse notices confusion in an elderly patient, what should be assessed
✔️✔️ Check for infection or medication side effects
A patient with high potassium levels is at risk for what
✔️✔️ Cardiac arrhythmias
A patient asks why exercise is important, what is the best answer
✔️✔️ Exercise improves cardiovascular health and overall wellbeing
A nurse is caring for a patient with nausea, what is appropriate
✔️✔️ Provide small frequent meals and antiemetics
A patient with low oxygen saturation requires what
✔️✔️ Supplemental oxygen therapy
A nurse notes redness over a bony area, what is the priority
✔️✔️ Relieve pressure immediately
A patient asks about fluid intake importance, what should be explained
✔️✔️ Adequate fluids support body functions and prevent dehydration
3
Questions and answers // Test Bank
A patient with heart failure asks why daily weight monitoring is important, what is the best
explanation
✔️✔️ Daily weight helps detect fluid retention early, which can indicate worsening heart failure
before symptoms become severe
A nurse is caring for a patient with a urinary catheter, what is the priority action to prevent
infection
✔️✔️ Maintain a closed drainage system and ensure proper perineal hygiene to reduce risk of
urinary tract infection
A patient reports chest pain radiating to the left arm, what is the nurse’s immediate priority
✔️✔️ Assess vital signs and initiate emergency protocols as this may indicate a myocardial
infarction
A postoperative patient has shallow breathing, what is the most appropriate nursing intervention
✔️✔️ Encourage deep breathing and use of an incentive spirometer to prevent atelectasis
A diabetic patient asks why foot care is essential, what should the nurse explain
✔️✔️ Proper foot care prevents infections and complications due to decreased sensation and poor
circulation
A patient with hypertension asks about lifestyle changes, what is the best advice
✔️✔️ Reducing salt intake, exercising regularly, and managing stress can help control blood
pressure
A nurse observes a patient becoming confused suddenly, what should be the first action
✔️✔️ Assess oxygenation and blood glucose levels to identify possible causes of acute confusion
A patient is on anticoagulant therapy, what teaching is most important
✔️✔️ Report any signs of bleeding such as bruising, blood in urine, or black stools immediately
A patient recovering from surgery complains of pain, what is the nurse’s priority
✔️✔️ Assess pain level and administer prescribed analgesics promptly to promote comfort and
healing
A patient with asthma experiences wheezing, what is the nurse’s immediate intervention
✔️✔️ Administer prescribed bronchodilator to relieve airway constriction
A patient asks why turning frequently in bed is important, what is the correct response
✔️✔️ Frequent repositioning prevents pressure ulcers and improves circulation
1
,A nurse notes decreased urine output in a patient, what should be done first
✔️✔️ Assess fluid intake and check for signs of dehydration or kidney impairment
A patient is receiving IV fluids, what complication should the nurse monitor for
✔️✔️ Watch for signs of fluid overload such as edema and difficulty breathing
A patient with anemia feels fatigued, what should the nurse explain
✔️✔️ Fatigue occurs due to reduced oxygen-carrying capacity of the blood
A patient with pneumonia has thick secretions, what nursing action is best
✔️✔️ Encourage increased fluid intake to help thin secretions
A nurse is educating a patient about infection prevention, what is key advice
✔️✔️ Regular handwashing is the most effective way to prevent infections
A patient experiences dizziness upon standing, what is the likely cause
✔️✔️ Orthostatic hypotension due to sudden drop in blood pressure
A patient is on bed rest, what complication is most concerning
✔️✔️ Risk of deep vein thrombosis due to immobility
A nurse is caring for a patient with fever, what is the priority intervention
✔️✔️ Monitor temperature and provide antipyretics as prescribed
A patient with kidney disease asks about diet, what should the nurse include
✔️✔️ Limit sodium, potassium, and protein intake as advised
A patient reports severe abdominal pain, what is the first nursing action
✔️✔️ Assess pain characteristics and notify the healthcare provider
A patient with COPD asks why smoking cessation is important
✔️✔️ Smoking worsens lung damage and decreases oxygen exchange
A nurse is administering medication, what is the most important step
✔️✔️ Verify the five rights of medication administration
A patient feels anxious before surgery, what should the nurse do
✔️✔️ Provide reassurance and explain the procedure clearly
A patient with diarrhea is at risk for what complication
✔️✔️ Dehydration and electrolyte imbalance
A nurse notices swelling in a patient’s legs, what could this indicate
✔️✔️ Possible fluid retention or heart failure
2
, A patient with a wound asks how to promote healing
✔️✔️ Keep the wound clean and maintain proper nutrition
A patient is on oxygen therapy, what safety measure is essential
✔️✔️ Avoid open flames and ensure proper oxygen equipment use
A nurse observes a rash after medication administration, what is the priority
✔️✔️ Stop the medication and assess for allergic reaction
A patient with stroke has difficulty swallowing, what intervention is needed
✔️✔️ Perform a swallowing assessment to prevent aspiration
A patient asks about signs of infection, what should the nurse say
✔️✔️ Redness, swelling, warmth, and fever are common signs
A nurse is caring for a patient with hypoglycemia, what is the immediate action
✔️✔️ Administer glucose or sugary drink if patient is conscious
A patient is dehydrated, what symptom is expected
✔️✔️ Dry mouth and decreased urine output
A patient with burns needs what priority care
✔️✔️ Fluid resuscitation to prevent shock
A nurse notices confusion in an elderly patient, what should be assessed
✔️✔️ Check for infection or medication side effects
A patient with high potassium levels is at risk for what
✔️✔️ Cardiac arrhythmias
A patient asks why exercise is important, what is the best answer
✔️✔️ Exercise improves cardiovascular health and overall wellbeing
A nurse is caring for a patient with nausea, what is appropriate
✔️✔️ Provide small frequent meals and antiemetics
A patient with low oxygen saturation requires what
✔️✔️ Supplemental oxygen therapy
A nurse notes redness over a bony area, what is the priority
✔️✔️ Relieve pressure immediately
A patient asks about fluid intake importance, what should be explained
✔️✔️ Adequate fluids support body functions and prevent dehydration
3
