104 NCLEX-RN & NGN Practice
Questions with Detailed Rationales
EXAM
Questions 1-10: Medical-Surgical & Prioritization
Question 1
A nurse is caring for a client who is 2 hours post-operative after a
total hip arthroplasty. Which action should the nurse take first?
A. Administer prescribed opioid for pain.
B. Assess the client’s neurovascular status in the operative leg.
C. Encourage deep breathing and coughing.
D. Apply a cold pack to the incision site.
Correct Answer: B – Assess the client’s neurovascular status.
Rationale: After hip arthroplasty, the priority is to assess for signs
of compromised circulation or nerve damage (capillary refill,
pulses, sensation, movement). Pain management (A) and
respiratory exercises (C) are important but secondary to detecting
early complications like compartment syndrome or arterial
occlusion. Cold pack (D) is a comfort measure, not the first action.
Question 2
A nurse is preparing to administer insulin lispro (Humalog) to a
client with type 1 diabetes. Which actions are correct? (Select all
that apply.)
,A. Administer 15 minutes before a meal.
B. Shake the vial vigorously before drawing up.
C. Clear the tubing if using an insulin pump.
D. Inject into a site that will be exercised soon.
E. Rotate injection sites within one anatomical region.
Correct Answers: A, C, E
Rationale: Lispro is a rapid-acting insulin; it must be given within
15 minutes before a meal to match the rise in blood glucose (A).
When using an insulin pump, the tubing should be cleared of air
before connecting (C). Rotating injection sites within the same
anatomical region helps prevent lipodystrophy (E). Shaking the
vial (B) should be avoided; gently roll it to mix. Injecting into a site
that will be exercised soon (D) can cause erratic absorption and
hypoglycemia.
Question 3
The nurse in the intensive care unit is caring for a client in the
immediate postoperative period following abdominal surgery. The
nurse receives several prescriptions. Which prescription should the
nurse initiate first?
A. Morphine 4 mg IV push for pain.
B. Normal saline 2 L via rapid IV bolus.
C. Cefazolin 1 g IV every 8 hours.
D. Turn, cough, and deep breathe every 2 hours.
Correct Answer: B – Normal saline 2 L via rapid IV bolus.
,Rationale: In the immediate postoperative period after major
abdominal surgery, hypovolemia from fluid shifts is a common
concern. A rapid IV fluid bolus is a priority to maintain
hemodynamic stability and organ perfusion. Pain management,
antibiotics, and respiratory exercises are important but should
follow stabilization of fluid status.
Question 4
A housekeeping employee tells the nurse, “I have a headache.”
The employee asks for acetaminophen. How should the nurse
respond?
A. “I will give you a dose of acetaminophen.”
B. “You can take over-the-counter acetaminophen from the unit’s
supply.”
C. “I will call the employee health provider for you.”
D. “Wait until your break and go to the pharmacy.”
Correct Answer: C – “I will call the employee health provider
for you.”
Rationale: The nurse cannot dispense medications to employees;
medication administration is limited to clients under a provider’s
order. The proper action is to refer the employee to the employee
health provider or their own primary care provider.
, Question 5
A school nurse assesses an 8-year-old with a history of asthma.
The nurse notes mild wheezing and coughing. Which action
should the nurse perform first?
A. Administer the rescue inhaler.
B. Call the child’s parent.
C. Assess the client’s peak expiratory flow.
D. Send the child back to class.
Correct Answer: C – Assess the client’s peak expiratory flow.
Rationale: In a child with asthma who has mild symptoms,
assessment should come before intervention. Measuring peak
expiratory flow gives objective data about airway obstruction and
guides the decision to administer medication. This follows the
clinical judgment model of recognizing cues and analyzing them
before generating solutions.
Question 6
A client comes to the community mental health clinic seeking
treatment for severe anxiety associated with a job promotion that
requires a 30-minute commute via train. The nurse recognizes
that this client most likely suffers from which psychological
disorder?
A. Social anxiety disorder.
B. Agoraphobia.
Questions with Detailed Rationales
EXAM
Questions 1-10: Medical-Surgical & Prioritization
Question 1
A nurse is caring for a client who is 2 hours post-operative after a
total hip arthroplasty. Which action should the nurse take first?
A. Administer prescribed opioid for pain.
B. Assess the client’s neurovascular status in the operative leg.
C. Encourage deep breathing and coughing.
D. Apply a cold pack to the incision site.
Correct Answer: B – Assess the client’s neurovascular status.
Rationale: After hip arthroplasty, the priority is to assess for signs
of compromised circulation or nerve damage (capillary refill,
pulses, sensation, movement). Pain management (A) and
respiratory exercises (C) are important but secondary to detecting
early complications like compartment syndrome or arterial
occlusion. Cold pack (D) is a comfort measure, not the first action.
Question 2
A nurse is preparing to administer insulin lispro (Humalog) to a
client with type 1 diabetes. Which actions are correct? (Select all
that apply.)
,A. Administer 15 minutes before a meal.
B. Shake the vial vigorously before drawing up.
C. Clear the tubing if using an insulin pump.
D. Inject into a site that will be exercised soon.
E. Rotate injection sites within one anatomical region.
Correct Answers: A, C, E
Rationale: Lispro is a rapid-acting insulin; it must be given within
15 minutes before a meal to match the rise in blood glucose (A).
When using an insulin pump, the tubing should be cleared of air
before connecting (C). Rotating injection sites within the same
anatomical region helps prevent lipodystrophy (E). Shaking the
vial (B) should be avoided; gently roll it to mix. Injecting into a site
that will be exercised soon (D) can cause erratic absorption and
hypoglycemia.
Question 3
The nurse in the intensive care unit is caring for a client in the
immediate postoperative period following abdominal surgery. The
nurse receives several prescriptions. Which prescription should the
nurse initiate first?
A. Morphine 4 mg IV push for pain.
B. Normal saline 2 L via rapid IV bolus.
C. Cefazolin 1 g IV every 8 hours.
D. Turn, cough, and deep breathe every 2 hours.
Correct Answer: B – Normal saline 2 L via rapid IV bolus.
,Rationale: In the immediate postoperative period after major
abdominal surgery, hypovolemia from fluid shifts is a common
concern. A rapid IV fluid bolus is a priority to maintain
hemodynamic stability and organ perfusion. Pain management,
antibiotics, and respiratory exercises are important but should
follow stabilization of fluid status.
Question 4
A housekeeping employee tells the nurse, “I have a headache.”
The employee asks for acetaminophen. How should the nurse
respond?
A. “I will give you a dose of acetaminophen.”
B. “You can take over-the-counter acetaminophen from the unit’s
supply.”
C. “I will call the employee health provider for you.”
D. “Wait until your break and go to the pharmacy.”
Correct Answer: C – “I will call the employee health provider
for you.”
Rationale: The nurse cannot dispense medications to employees;
medication administration is limited to clients under a provider’s
order. The proper action is to refer the employee to the employee
health provider or their own primary care provider.
, Question 5
A school nurse assesses an 8-year-old with a history of asthma.
The nurse notes mild wheezing and coughing. Which action
should the nurse perform first?
A. Administer the rescue inhaler.
B. Call the child’s parent.
C. Assess the client’s peak expiratory flow.
D. Send the child back to class.
Correct Answer: C – Assess the client’s peak expiratory flow.
Rationale: In a child with asthma who has mild symptoms,
assessment should come before intervention. Measuring peak
expiratory flow gives objective data about airway obstruction and
guides the decision to administer medication. This follows the
clinical judgment model of recognizing cues and analyzing them
before generating solutions.
Question 6
A client comes to the community mental health clinic seeking
treatment for severe anxiety associated with a job promotion that
requires a 30-minute commute via train. The nurse recognizes
that this client most likely suffers from which psychological
disorder?
A. Social anxiety disorder.
B. Agoraphobia.
