Comprehensive NCLEX-RN Practice
Exam: 120 Questions with Detailed
Rationales
Questions 1–10: Emergency & Priority Assessment
1. A nurse enters a client's room and finds the client unresponsive and not
breathing. What is the nurse's FIRST action?
A. Call the provider
B. Activate the emergency response system
C. Begin CPR
D. Check the client's pulse
✅ Answer: B
Rationale: The nurse must first activate the emergency response system to obtain help
and equipment before initiating CPR. In a hospital setting, this means calling a code or
rapid response team.
2. Which client should the nurse assess FIRST?
A. Client with pain rated 7/10
B. Client with new onset confusion
C. Client requesting discharge instructions
D. Client with blood glucose 210 mg/dL
✅ Answer: B
Rationale: Acute mental status changes may indicate hypoxia, stroke, infection, or other
,life-threatening conditions and require immediate assessment. Stable pain and blood
glucose can be addressed after the priority client is evaluated.
3. A client suddenly reports chest pain and shortness of breath. What is the nurse's
FIRST action?
A. Obtain an ECG
B. Administer oxygen
C. Assess airway and breathing
D. Notify the provider
✅ Answer: C
Rationale: The ABCs (Airway, Breathing, Circulation) always come first. The nurse must
assess airway and breathing before initiating other interventions such as oxygen
administration or ECG.
4. Which assessment finding requires immediate intervention?
A. Pain 5/10
B. Blood pressure 88/52 mmHg
C. Glucose 170 mg/dL
D. Nausea
✅ Answer: B
Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which may signal
shock or hypovolemia and requires immediate intervention. The other findings are
abnormal but not immediately life-threatening.
5. A nurse notes a respiratory rate of 32/min and use of accessory muscles. What is
the nurse's FIRST action?
A. Notify the provider
B. Administer oxygen
C. Assess airway patency
D. Obtain ABGs
,✅ Answer: C
Rationale: Always assess airway and breathing before initiating interventions.
Tachypnea with accessory muscle use indicates respiratory distress, but airway patency
must be confirmed first.
6. A client with pneumonia suddenly becomes confused and restless. What should
the nurse do FIRST?
A. Notify the provider
B. Reassess temperature
C. Assess oxygen saturation
D. Administer antipyretics
✅ Answer: C
Rationale: Sudden confusion and restlessness in a client with pneumonia may indicate
hypoxia. Oxygenation must be assessed immediately before other interventions.
7. A ventilator alarm suddenly stops sounding while in use. What is the nurse's
FIRST action?
A. Restart the ventilator immediately
B. Notify the maintenance department
C. Turn off the ventilator
D. Check the client's respiratory status and airway
✅ Answer: D
Rationale: Always assess the patient FIRST. Equipment issues are secondary to airway
and breathing. The nurse must ensure the client is safe and breathing adequately before
troubleshooting the ventilator.
8. Which client is at greatest risk for aspiration?
A. Client with GERD
B. Client with a feeding tube and decreased LOC
C. Client with nausea
D. Client with abdominal pain
, ✅ Answer: B
Rationale: Decreased level of consciousness (LOC) impairs the gag reflex and airway
protection, placing the client at highest risk for aspiration, especially with a feeding tube
in place.
9. Which client should the nurse see FIRST?
A. Post-op client requesting pain medication
B. Client with oxygen saturation of 86%
C. Client awaiting discharge
D. Client with nausea
✅ Answer: B
Rationale: An oxygen saturation of 86% indicates significant hypoxemia and respiratory
compromise, which takes priority over pain, nausea, or discharge needs.
10. A client receiving opioids is difficult to arouse. What is the nurse's priority?
A. Notify the provider
B. Administer naloxone
C. Assess respiratory rate and oxygenation
D. Document findings
✅ Answer: C
Rationale: Opioid-induced sedation can lead to respiratory depression. The priority is to
assess respiratory rate and oxygenation to determine if naloxone administration is
needed.
Questions 11–20: Infection Control & Safety
11. Which action best prevents infection?
A. Wearing gloves
Exam: 120 Questions with Detailed
Rationales
Questions 1–10: Emergency & Priority Assessment
1. A nurse enters a client's room and finds the client unresponsive and not
breathing. What is the nurse's FIRST action?
A. Call the provider
B. Activate the emergency response system
C. Begin CPR
D. Check the client's pulse
✅ Answer: B
Rationale: The nurse must first activate the emergency response system to obtain help
and equipment before initiating CPR. In a hospital setting, this means calling a code or
rapid response team.
2. Which client should the nurse assess FIRST?
A. Client with pain rated 7/10
B. Client with new onset confusion
C. Client requesting discharge instructions
D. Client with blood glucose 210 mg/dL
✅ Answer: B
Rationale: Acute mental status changes may indicate hypoxia, stroke, infection, or other
,life-threatening conditions and require immediate assessment. Stable pain and blood
glucose can be addressed after the priority client is evaluated.
3. A client suddenly reports chest pain and shortness of breath. What is the nurse's
FIRST action?
A. Obtain an ECG
B. Administer oxygen
C. Assess airway and breathing
D. Notify the provider
✅ Answer: C
Rationale: The ABCs (Airway, Breathing, Circulation) always come first. The nurse must
assess airway and breathing before initiating other interventions such as oxygen
administration or ECG.
4. Which assessment finding requires immediate intervention?
A. Pain 5/10
B. Blood pressure 88/52 mmHg
C. Glucose 170 mg/dL
D. Nausea
✅ Answer: B
Rationale: A blood pressure of 88/52 mmHg indicates hypotension, which may signal
shock or hypovolemia and requires immediate intervention. The other findings are
abnormal but not immediately life-threatening.
5. A nurse notes a respiratory rate of 32/min and use of accessory muscles. What is
the nurse's FIRST action?
A. Notify the provider
B. Administer oxygen
C. Assess airway patency
D. Obtain ABGs
,✅ Answer: C
Rationale: Always assess airway and breathing before initiating interventions.
Tachypnea with accessory muscle use indicates respiratory distress, but airway patency
must be confirmed first.
6. A client with pneumonia suddenly becomes confused and restless. What should
the nurse do FIRST?
A. Notify the provider
B. Reassess temperature
C. Assess oxygen saturation
D. Administer antipyretics
✅ Answer: C
Rationale: Sudden confusion and restlessness in a client with pneumonia may indicate
hypoxia. Oxygenation must be assessed immediately before other interventions.
7. A ventilator alarm suddenly stops sounding while in use. What is the nurse's
FIRST action?
A. Restart the ventilator immediately
B. Notify the maintenance department
C. Turn off the ventilator
D. Check the client's respiratory status and airway
✅ Answer: D
Rationale: Always assess the patient FIRST. Equipment issues are secondary to airway
and breathing. The nurse must ensure the client is safe and breathing adequately before
troubleshooting the ventilator.
8. Which client is at greatest risk for aspiration?
A. Client with GERD
B. Client with a feeding tube and decreased LOC
C. Client with nausea
D. Client with abdominal pain
, ✅ Answer: B
Rationale: Decreased level of consciousness (LOC) impairs the gag reflex and airway
protection, placing the client at highest risk for aspiration, especially with a feeding tube
in place.
9. Which client should the nurse see FIRST?
A. Post-op client requesting pain medication
B. Client with oxygen saturation of 86%
C. Client awaiting discharge
D. Client with nausea
✅ Answer: B
Rationale: An oxygen saturation of 86% indicates significant hypoxemia and respiratory
compromise, which takes priority over pain, nausea, or discharge needs.
10. A client receiving opioids is difficult to arouse. What is the nurse's priority?
A. Notify the provider
B. Administer naloxone
C. Assess respiratory rate and oxygenation
D. Document findings
✅ Answer: C
Rationale: Opioid-induced sedation can lead to respiratory depression. The priority is to
assess respiratory rate and oxygenation to determine if naloxone administration is
needed.
Questions 11–20: Infection Control & Safety
11. Which action best prevents infection?
A. Wearing gloves
