NCLEX RN PRACTICE
-
QUESTIONS | EXAM READY -
NCLEX QUESTIONS FOR RN
EXAM PREP & NURSING
STUDENTS
• Sepsis recognition
A 68-year-old male admitted with pneumonia has T
39.4°C (103°F), HR 122/min, RR 28/min, BP 88/52 mm
Hg, SpO₂ 90% on 2 L NC, and new confusion.
Which action should the nurse take first?
A. Administer acetaminophen
B. Increase oxygen to 4 L/min via nasal cannula
C. Notify the provider of the fever
D. Prepare to obtain a sputum culture
Correct: B
Rationale: This client shows signs of shock and
hypoxemia. Improving oxygenation is an immediate
priority while the nurse also activates rapid sepsis
, management. Fever control and cultures are important,
but airway/breathing comes first.
• Postoperative hemorrhage
A 42-year-old female is 1 hour post-thyroidectomy. She
reports tightness in the neck, has a rapidly enlarging
neck swelling, HR 118/min, and BP 94/60 mm Hg.
Which finding requires immediate intervention?
A. Mild sore throat
B. Neck swelling with tightness
C. Pain rated 5/10
D. Hoarseness that improves with rest
Correct: B
Rationale: Neck swelling after thyroidectomy can
indicate hematoma and airway compromise. This is an
emergency. The other findings may occur
postoperatively but are less urgent.
• C. difficile precautions (SATA)
A 77-year-old male has watery diarrhea 8 times in 12
hours and a stool test positive for C. difficile.
Which actions should the nurse take? Select all that
apply.
A. Place the client in contact precautions
B. Use soap and water for hand hygiene
C. Clean surfaces with bleach-based disinfectant
D. Use an alcohol-based hand rub after leaving the
room
E. Dedicate equipment to the client when possible
, Correct: A, B, C, E
Rationale: Contact precautions, soap-and-water hand
hygiene, sporicidal cleaning, and dedicated equipment
reduce transmission. Alcohol hand rub is less effective
against C. difficile spores.
• Health promotion: vaccine teaching
A 29-year-old pregnant client at 28 weeks asks which
vaccine is recommended during this pregnancy.
Which response should the nurse give?
A. “MMR is recommended now.”
B. “The live varicella vaccine is recommended now.”
C. “Tdap is recommended during this pregnancy.”
D. “No vaccines are recommended during pregnancy.”
Correct: C
Rationale: Tdap is recommended during each
pregnancy to protect the newborn from pertussis. Live
vaccines such as MMR and varicella are not given during
pregnancy.
• Psychosocial integrity: panic attack
A 24-year-old female in the emergency department
says, “I feel like I cannot breathe and I am going to die.”
She is pacing, hyperventilating, and has a normal SpO₂
of 99%.
Which action should the nurse take first?
A. Teach relaxation breathing in detail
B. Stay with the client and speak in a calm voice
C. Give the client written information about anxiety
, D. Ask the client to describe recent stressors
Correct: B
Rationale: The nurse’s presence and calm
communication reduce panic and promote safety.
Teaching and assessment can follow once the client is
calmer.
• Digoxin toxicity
A 71-year-old male with heart failure takes digoxin and
furosemide. He reports nausea, blurred yellow vision,
and a pulse of 52/min. Potassium is 3.1 mEq/L.
Which action should the nurse take first?
A. Give the scheduled digoxin dose
B. Hold the digoxin and notify the provider
C. Encourage the client to increase fluid intake
D. Administer the furosemide early
Correct: B
Rationale: Signs of digoxin toxicity are present, and
hypokalemia increases the risk. Holding the medication
and notifying the provider is appropriate. Giving digoxin
could worsen toxicity.
• DKA priority
A 19-year-old male with type 1 diabetes has blood
glucose 548 mg/dL, pH 7.18, ketones in urine, RR
32/min, and dry mucous membranes.
Which order should the nurse implement first?
A. Start IV isotonic fluids
B. Give subcutaneous rapid-acting insulin
, C. Administer sodium bicarbonate
D. Begin a carbohydrate-controlled meal
Correct: A
Rationale: Fluid volume deficit is the immediate
problem in DKA. IV fluids come before insulin because
circulation and perfusion must be supported first.
• Preeclampsia severe features
A 32-year-old pregnant client at 35 weeks has BP
168/112 mm Hg, headache, blurry vision, and right
upper quadrant pain.
Which action should the nurse take first?
A. Place the client in a dark room
B. Prepare to administer magnesium sulfate
C. Encourage oral fluids
D. Recheck blood pressure in 30 minutes
Correct: B
Rationale: Severe preeclampsia increases the risk of
seizure. Magnesium sulfate is the priority medication to
prevent eclampsia. Delaying treatment is unsafe.
• Isolation precautions (SATA)
A 56-year-old female has suspected measles and is
coughing with fever, coryza, and conjunctivitis.
Which actions should the nurse take? Select all that
apply.
A. Place the client in airborne precautions
B. Use a fit-tested N95 respirator
C. Keep the room door closed
, D. Place the client in a shared room with another febrile
client
E. Limit transport outside the room
Correct: A, B, C, E
Rationale: Measles requires airborne isolation, a
respirator, a closed door, and limited transport.
Cohorting in a shared room is inappropriate.
• Delegation
A medical-surgical unit is short-staffed.
Which task is appropriate for the RN to delegate to
unlicensed assistive personnel (UAP)?
A. Teach incentive spirometer use to a postoperative
client
B. Assess pain after IV morphine
C. Obtain routine vital signs on a stable client
D. Evaluate a new chest tube drainage system
Correct: C
Rationale: Routine vital signs on a stable client are
within UAP scope. Teaching, assessment, and evaluation
require nursing judgment and cannot be delegated.
• Opioid safety
A 60-year-old male receiving IV morphine for acute
pancreatitis becomes difficult to arouse. RR is 6/min and
SpO₂ is 84%.
Which action should the nurse take first?
A. Administer naloxone
B. Place the client flat in bed
, C. Document the findings and recheck in 15 minutes
D. Encourage the client to cough and deep breathe
Correct: A
Rationale: Severe respiratory depression is present.
Naloxone reverses opioid effects and is the priority. The
other actions do not address the immediate threat.
• Airway emergency: cloze-style
A 6-year-old child with suspected epiglottitis is drooling,
leaning forward, and has stridor.
The nurse should first _____.
A. inspect the throat with a tongue depressor
B. keep the child calm and prepare for airway support
C. obtain a throat culture
D. offer sips of water
Correct: B
Rationale: This is an airway emergency. Agitating the
child or manipulating the airway can precipitate
complete obstruction. The nurse should minimize
distress and prepare for airway management.
• Stroke response
A 74-year-old female suddenly develops right-sided
weakness and slurred speech 45 minutes ago. BP is
176/98 mm Hg, glucose is 104 mg/dL, and CT has not yet
been completed.
Which action should the nurse expect next?
A. Administer aspirin immediately
B. Prepare for non-contrast CT of the head
, C. Give oral fluids to prevent dehydration
D. Lower the blood pressure to normal range with IV
antihypertensives
Correct: B
Rationale: Imaging must rule out hemorrhage before
thrombolytic decisions. Aspirin and aggressive BP
lowering may be inappropriate until stroke type is
known.
• Hypoglycemia
A 46-year-old female with diabetes is sweaty, shaky,
and confused. Blood glucose is 48 mg/dL, and she is
awake but cannot safely swallow.
Which action should the nurse take first?
A. Give 15 g oral glucose gel
B. Administer IV dextrose
C. Encourage her to eat a sandwich
D. Recheck the glucose in 30 minutes
Correct: B
Rationale: The client cannot safely swallow, so oral
treatment is unsafe. IV dextrose is the best immediate
treatment. Waiting risks neuroglycopenia.
• Priority triage
The nurse in the emergency department receives four
clients.
Which client should be assessed first?
A. A 19-year-old with an ankle sprain and pain rated
8/10
, B. A 67-year-old with COPD and new confusion, RR
30/min, SpO₂ 86%
C. A 34-year-old with a migraine and photophobia
D. A 45-year-old with a minor laceration needing
sutures
Correct: B
Rationale: New confusion with hypoxemia in a COPD
client suggests respiratory failure. Airway and
oxygenation take priority over pain or minor injuries.
• Pediatric safety
A 3-year-old child has fever, drooling, muffled voice,
and is sitting upright in the “tripod” position.
Which action should the nurse take?
A. Obtain a throat swab
B. Place the child supine for assessment
C. Notify the provider and prepare for airway
management
D. Encourage the child to drink cold water
Correct: C
Rationale: These are classic signs of epiglottitis and
potential airway obstruction. The airway must be
protected; throat swabs can worsen obstruction.
• Suicidal ideation
A 28-year-old male says, “I have a plan to kill myself
tonight.”
Which action should the nurse take first?
A. Ask the client to sign a no-suicide contract
, B. Leave the client alone while charting
C. Remove potential hazards and stay with the client
D. Refer the client to a support group
Correct: C
Rationale: Immediate safety is the priority. A no-suicide
contract is not a substitute for observation, and the
client should not be left alone.
• Magnesium sulfate toxicity
A pregnant client receiving magnesium sulfate for
preeclampsia has RR 10/min, absent deep tendon
reflexes, and urine output 20 mL/hr.
Which action should the nurse take first?
A. Increase the magnesium infusion rate
B. Stop the infusion and prepare calcium gluconate
C. Place the client in the Trendelenburg position
D. Encourage ambulation
Correct: B
Rationale: These are signs of magnesium toxicity.
Stopping the infusion and preparing the antidote are
priorities. Increasing the infusion would be dangerous.
• Electrolyte imbalance
A 63-year-old male taking hydrochlorothiazide reports
muscle weakness and palpitations. Labs: K 2.9 mEq/L.
Which provider order should the nurse question?
A. Potassium chloride replacement
B. Repeat serum potassium level
C. Administer additional hydrochlorothiazide
-
QUESTIONS | EXAM READY -
NCLEX QUESTIONS FOR RN
EXAM PREP & NURSING
STUDENTS
• Sepsis recognition
A 68-year-old male admitted with pneumonia has T
39.4°C (103°F), HR 122/min, RR 28/min, BP 88/52 mm
Hg, SpO₂ 90% on 2 L NC, and new confusion.
Which action should the nurse take first?
A. Administer acetaminophen
B. Increase oxygen to 4 L/min via nasal cannula
C. Notify the provider of the fever
D. Prepare to obtain a sputum culture
Correct: B
Rationale: This client shows signs of shock and
hypoxemia. Improving oxygenation is an immediate
priority while the nurse also activates rapid sepsis
, management. Fever control and cultures are important,
but airway/breathing comes first.
• Postoperative hemorrhage
A 42-year-old female is 1 hour post-thyroidectomy. She
reports tightness in the neck, has a rapidly enlarging
neck swelling, HR 118/min, and BP 94/60 mm Hg.
Which finding requires immediate intervention?
A. Mild sore throat
B. Neck swelling with tightness
C. Pain rated 5/10
D. Hoarseness that improves with rest
Correct: B
Rationale: Neck swelling after thyroidectomy can
indicate hematoma and airway compromise. This is an
emergency. The other findings may occur
postoperatively but are less urgent.
• C. difficile precautions (SATA)
A 77-year-old male has watery diarrhea 8 times in 12
hours and a stool test positive for C. difficile.
Which actions should the nurse take? Select all that
apply.
A. Place the client in contact precautions
B. Use soap and water for hand hygiene
C. Clean surfaces with bleach-based disinfectant
D. Use an alcohol-based hand rub after leaving the
room
E. Dedicate equipment to the client when possible
, Correct: A, B, C, E
Rationale: Contact precautions, soap-and-water hand
hygiene, sporicidal cleaning, and dedicated equipment
reduce transmission. Alcohol hand rub is less effective
against C. difficile spores.
• Health promotion: vaccine teaching
A 29-year-old pregnant client at 28 weeks asks which
vaccine is recommended during this pregnancy.
Which response should the nurse give?
A. “MMR is recommended now.”
B. “The live varicella vaccine is recommended now.”
C. “Tdap is recommended during this pregnancy.”
D. “No vaccines are recommended during pregnancy.”
Correct: C
Rationale: Tdap is recommended during each
pregnancy to protect the newborn from pertussis. Live
vaccines such as MMR and varicella are not given during
pregnancy.
• Psychosocial integrity: panic attack
A 24-year-old female in the emergency department
says, “I feel like I cannot breathe and I am going to die.”
She is pacing, hyperventilating, and has a normal SpO₂
of 99%.
Which action should the nurse take first?
A. Teach relaxation breathing in detail
B. Stay with the client and speak in a calm voice
C. Give the client written information about anxiety
, D. Ask the client to describe recent stressors
Correct: B
Rationale: The nurse’s presence and calm
communication reduce panic and promote safety.
Teaching and assessment can follow once the client is
calmer.
• Digoxin toxicity
A 71-year-old male with heart failure takes digoxin and
furosemide. He reports nausea, blurred yellow vision,
and a pulse of 52/min. Potassium is 3.1 mEq/L.
Which action should the nurse take first?
A. Give the scheduled digoxin dose
B. Hold the digoxin and notify the provider
C. Encourage the client to increase fluid intake
D. Administer the furosemide early
Correct: B
Rationale: Signs of digoxin toxicity are present, and
hypokalemia increases the risk. Holding the medication
and notifying the provider is appropriate. Giving digoxin
could worsen toxicity.
• DKA priority
A 19-year-old male with type 1 diabetes has blood
glucose 548 mg/dL, pH 7.18, ketones in urine, RR
32/min, and dry mucous membranes.
Which order should the nurse implement first?
A. Start IV isotonic fluids
B. Give subcutaneous rapid-acting insulin
, C. Administer sodium bicarbonate
D. Begin a carbohydrate-controlled meal
Correct: A
Rationale: Fluid volume deficit is the immediate
problem in DKA. IV fluids come before insulin because
circulation and perfusion must be supported first.
• Preeclampsia severe features
A 32-year-old pregnant client at 35 weeks has BP
168/112 mm Hg, headache, blurry vision, and right
upper quadrant pain.
Which action should the nurse take first?
A. Place the client in a dark room
B. Prepare to administer magnesium sulfate
C. Encourage oral fluids
D. Recheck blood pressure in 30 minutes
Correct: B
Rationale: Severe preeclampsia increases the risk of
seizure. Magnesium sulfate is the priority medication to
prevent eclampsia. Delaying treatment is unsafe.
• Isolation precautions (SATA)
A 56-year-old female has suspected measles and is
coughing with fever, coryza, and conjunctivitis.
Which actions should the nurse take? Select all that
apply.
A. Place the client in airborne precautions
B. Use a fit-tested N95 respirator
C. Keep the room door closed
, D. Place the client in a shared room with another febrile
client
E. Limit transport outside the room
Correct: A, B, C, E
Rationale: Measles requires airborne isolation, a
respirator, a closed door, and limited transport.
Cohorting in a shared room is inappropriate.
• Delegation
A medical-surgical unit is short-staffed.
Which task is appropriate for the RN to delegate to
unlicensed assistive personnel (UAP)?
A. Teach incentive spirometer use to a postoperative
client
B. Assess pain after IV morphine
C. Obtain routine vital signs on a stable client
D. Evaluate a new chest tube drainage system
Correct: C
Rationale: Routine vital signs on a stable client are
within UAP scope. Teaching, assessment, and evaluation
require nursing judgment and cannot be delegated.
• Opioid safety
A 60-year-old male receiving IV morphine for acute
pancreatitis becomes difficult to arouse. RR is 6/min and
SpO₂ is 84%.
Which action should the nurse take first?
A. Administer naloxone
B. Place the client flat in bed
, C. Document the findings and recheck in 15 minutes
D. Encourage the client to cough and deep breathe
Correct: A
Rationale: Severe respiratory depression is present.
Naloxone reverses opioid effects and is the priority. The
other actions do not address the immediate threat.
• Airway emergency: cloze-style
A 6-year-old child with suspected epiglottitis is drooling,
leaning forward, and has stridor.
The nurse should first _____.
A. inspect the throat with a tongue depressor
B. keep the child calm and prepare for airway support
C. obtain a throat culture
D. offer sips of water
Correct: B
Rationale: This is an airway emergency. Agitating the
child or manipulating the airway can precipitate
complete obstruction. The nurse should minimize
distress and prepare for airway management.
• Stroke response
A 74-year-old female suddenly develops right-sided
weakness and slurred speech 45 minutes ago. BP is
176/98 mm Hg, glucose is 104 mg/dL, and CT has not yet
been completed.
Which action should the nurse expect next?
A. Administer aspirin immediately
B. Prepare for non-contrast CT of the head
, C. Give oral fluids to prevent dehydration
D. Lower the blood pressure to normal range with IV
antihypertensives
Correct: B
Rationale: Imaging must rule out hemorrhage before
thrombolytic decisions. Aspirin and aggressive BP
lowering may be inappropriate until stroke type is
known.
• Hypoglycemia
A 46-year-old female with diabetes is sweaty, shaky,
and confused. Blood glucose is 48 mg/dL, and she is
awake but cannot safely swallow.
Which action should the nurse take first?
A. Give 15 g oral glucose gel
B. Administer IV dextrose
C. Encourage her to eat a sandwich
D. Recheck the glucose in 30 minutes
Correct: B
Rationale: The client cannot safely swallow, so oral
treatment is unsafe. IV dextrose is the best immediate
treatment. Waiting risks neuroglycopenia.
• Priority triage
The nurse in the emergency department receives four
clients.
Which client should be assessed first?
A. A 19-year-old with an ankle sprain and pain rated
8/10
, B. A 67-year-old with COPD and new confusion, RR
30/min, SpO₂ 86%
C. A 34-year-old with a migraine and photophobia
D. A 45-year-old with a minor laceration needing
sutures
Correct: B
Rationale: New confusion with hypoxemia in a COPD
client suggests respiratory failure. Airway and
oxygenation take priority over pain or minor injuries.
• Pediatric safety
A 3-year-old child has fever, drooling, muffled voice,
and is sitting upright in the “tripod” position.
Which action should the nurse take?
A. Obtain a throat swab
B. Place the child supine for assessment
C. Notify the provider and prepare for airway
management
D. Encourage the child to drink cold water
Correct: C
Rationale: These are classic signs of epiglottitis and
potential airway obstruction. The airway must be
protected; throat swabs can worsen obstruction.
• Suicidal ideation
A 28-year-old male says, “I have a plan to kill myself
tonight.”
Which action should the nurse take first?
A. Ask the client to sign a no-suicide contract
, B. Leave the client alone while charting
C. Remove potential hazards and stay with the client
D. Refer the client to a support group
Correct: C
Rationale: Immediate safety is the priority. A no-suicide
contract is not a substitute for observation, and the
client should not be left alone.
• Magnesium sulfate toxicity
A pregnant client receiving magnesium sulfate for
preeclampsia has RR 10/min, absent deep tendon
reflexes, and urine output 20 mL/hr.
Which action should the nurse take first?
A. Increase the magnesium infusion rate
B. Stop the infusion and prepare calcium gluconate
C. Place the client in the Trendelenburg position
D. Encourage ambulation
Correct: B
Rationale: These are signs of magnesium toxicity.
Stopping the infusion and preparing the antidote are
priorities. Increasing the infusion would be dangerous.
• Electrolyte imbalance
A 63-year-old male taking hydrochlorothiazide reports
muscle weakness and palpitations. Labs: K 2.9 mEq/L.
Which provider order should the nurse question?
A. Potassium chloride replacement
B. Repeat serum potassium level
C. Administer additional hydrochlorothiazide
