NCLEX-RN Exam Prep Bundle | 100 NGN-
Style Practice Questions, Detailed Rationales,
Nursing Prioritization & Clinical Judgment
Review
1. A nurse is caring for a client who is experiencing hypoglycemia. Which
assessment finding should the nurse expect?
A. Bradycardia
B. Cool, clammy skin
C. Decreased hunger
D. Deep, slow respirations
Correct Answer: B. Cool, clammy skin
Rationale: Hypoglycemia activates the sympathetic nervous system, causing diaphoresis,
cool clammy skin, tachycardia, tremors, and anxiety. Bradycardia is not expected. Hunger
typically increases rather than decreases. Deep respirations are more commonly associated
with diabetic ketoacidosis.
2. A nurse is assessing a client who may have increased intracranial
pressure (ICP). Which finding requires immediate intervention?
A. Headache rated 4/10
B. Restlessness and confusion
C. Pupils equal and reactive
D. Blood pressure 118/76 mm Hg
Correct Answer: B. Restlessness and confusion
Rationale: Restlessness and confusion are often early signs of increased ICP and
decreased cerebral perfusion. Early recognition is critical because neurological
deterioration can progress rapidly.
3. A nurse is preparing to administer a blood transfusion. Which action
should the nurse take first?
,A. Start the transfusion at the prescribed rate
B. Verify the client's identity with another licensed nurse
C. Obtain post-transfusion vital signs
D. Administer acetaminophen
Correct Answer: B. Verify the client's identity with another licensed nurse
Rationale: Client identification and verification of the blood product with another licensed
nurse are critical safety steps before initiating a transfusion. Incorrect identification can
result in life-threatening transfusion reactions.
4. A nurse is caring for four clients. Which client should the nurse assess
first?
A. A client with chronic heart failure reporting fatigue
B. A client one day postoperative reporting incisional pain of 5/10
C. A client with asthma who has wheezing and increasing shortness of breath
D. A client awaiting discharge instructions
Correct Answer: C. A client with asthma who has wheezing and increasing
shortness of breath
Rationale: Using the ABC framework (Airway, Breathing, Circulation), breathing
difficulties take priority. Increasing shortness of breath and wheezing may indicate
worsening respiratory compromise requiring immediate intervention.
5. A nurse is teaching a client about warfarin therapy. Which statement by
the client indicates understanding of the teaching?
A. "I should increase my intake of leafy green vegetables."
B. "I will take aspirin daily unless instructed otherwise."
C. "I will notify my provider if I notice unusual bleeding."
D. "I do not need regular laboratory monitoring."
Correct Answer: C. "I will notify my provider if I notice unusual
bleeding."
Rationale: Warfarin increases bleeding risk. Clients should report signs of bleeding
immediately. Consistent—not increased—vitamin K intake is recommended, aspirin should
be avoided unless prescribed, and INR monitoring is required.
,6. A nurse is caring for a client with a serum potassium level of 2.9 mEq/L.
Which finding should the nurse anticipate?
A. Peaked T waves
B. Muscle weakness
C. Hyperactive bowel sounds only
D. Increased respiratory effort
Correct Answer: B. Muscle weakness
Rationale: Hypokalemia commonly causes muscle weakness, fatigue, dysrhythmias, and
decreased gastrointestinal motility. Peaked T waves are associated with hyperkalemia.
7. A nurse is assessing a newborn immediately after birth. Which finding
requires immediate intervention?
A. Heart rate of 140/min
B. Acrocyanosis
C. Respiratory rate of 68/min with grunting
D. Flexed extremities
Correct Answer: C. Respiratory rate of 68/min with grunting
Rationale: Grunting is a sign of respiratory distress and requires immediate evaluation.
Acrocyanosis, flexed extremities, and a heart rate of 140/min are generally expected
findings in a healthy newborn.
8. A nurse is caring for a client receiving morphine intravenously. Which
assessment finding requires immediate action?
A. Pain level decreased from 8/10 to 3/10
B. Respiratory rate of 8/min
C. Blood pressure 128/74 mm Hg
D. Mild drowsiness
Correct Answer: B. Respiratory rate of 8/min
Rationale: Respiratory depression is a serious adverse effect of opioid administration. A
respiratory rate below 12/min requires prompt assessment and intervention.
9. A nurse is reviewing laboratory results for a client. Which result should
be reported to the provider immediately?
, A. Hemoglobin 13.8 g/dL
B. Sodium 140 mEq/L
C. Blood glucose 58 mg/dL
D. White blood cell count 8,000/mm³
Correct Answer: C. Blood glucose 58 mg/dL
Rationale: A blood glucose level of 58 mg/dL indicates hypoglycemia, which can rapidly
progress to seizures, loss of consciousness, or other serious complications if untreated.
10. A nurse is caring for a client who suddenly becomes unresponsive.
What is the nurse's priority action?
A. Notify the provider
B. Document the event
C. Assess responsiveness and activate emergency response procedures
D. Obtain a full set of vital signs
Correct Answer: C. Assess responsiveness and activate emergency response
procedures
Rationale: According to emergency response priorities, the nurse must first assess
responsiveness and initiate emergency procedures to ensure rapid intervention and support
of airway, breathing, and circulation.
11. A nurse is caring for a client who is 12 hours postoperative following
abdominal surgery. Which finding requires immediate intervention?
A. Temperature of 37.6°C (99.7°F)
B. Pain rating of 6/10 at the incision site
C. Oxygen saturation of 88% on room air
D. Hypoactive bowel sounds
Correct Answer: C. Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates inadequate oxygenation and requires
immediate assessment and intervention. Airway and breathing concerns take priority over
pain, mild postoperative temperature elevations, and hypoactive bowel sounds.
12. A nurse is teaching a client with heart failure about daily weight
monitoring. Which statement by the client indicates understanding?
A. "I will weigh myself once a week."
B. "I will weigh myself at the same time each morning."
Style Practice Questions, Detailed Rationales,
Nursing Prioritization & Clinical Judgment
Review
1. A nurse is caring for a client who is experiencing hypoglycemia. Which
assessment finding should the nurse expect?
A. Bradycardia
B. Cool, clammy skin
C. Decreased hunger
D. Deep, slow respirations
Correct Answer: B. Cool, clammy skin
Rationale: Hypoglycemia activates the sympathetic nervous system, causing diaphoresis,
cool clammy skin, tachycardia, tremors, and anxiety. Bradycardia is not expected. Hunger
typically increases rather than decreases. Deep respirations are more commonly associated
with diabetic ketoacidosis.
2. A nurse is assessing a client who may have increased intracranial
pressure (ICP). Which finding requires immediate intervention?
A. Headache rated 4/10
B. Restlessness and confusion
C. Pupils equal and reactive
D. Blood pressure 118/76 mm Hg
Correct Answer: B. Restlessness and confusion
Rationale: Restlessness and confusion are often early signs of increased ICP and
decreased cerebral perfusion. Early recognition is critical because neurological
deterioration can progress rapidly.
3. A nurse is preparing to administer a blood transfusion. Which action
should the nurse take first?
,A. Start the transfusion at the prescribed rate
B. Verify the client's identity with another licensed nurse
C. Obtain post-transfusion vital signs
D. Administer acetaminophen
Correct Answer: B. Verify the client's identity with another licensed nurse
Rationale: Client identification and verification of the blood product with another licensed
nurse are critical safety steps before initiating a transfusion. Incorrect identification can
result in life-threatening transfusion reactions.
4. A nurse is caring for four clients. Which client should the nurse assess
first?
A. A client with chronic heart failure reporting fatigue
B. A client one day postoperative reporting incisional pain of 5/10
C. A client with asthma who has wheezing and increasing shortness of breath
D. A client awaiting discharge instructions
Correct Answer: C. A client with asthma who has wheezing and increasing
shortness of breath
Rationale: Using the ABC framework (Airway, Breathing, Circulation), breathing
difficulties take priority. Increasing shortness of breath and wheezing may indicate
worsening respiratory compromise requiring immediate intervention.
5. A nurse is teaching a client about warfarin therapy. Which statement by
the client indicates understanding of the teaching?
A. "I should increase my intake of leafy green vegetables."
B. "I will take aspirin daily unless instructed otherwise."
C. "I will notify my provider if I notice unusual bleeding."
D. "I do not need regular laboratory monitoring."
Correct Answer: C. "I will notify my provider if I notice unusual
bleeding."
Rationale: Warfarin increases bleeding risk. Clients should report signs of bleeding
immediately. Consistent—not increased—vitamin K intake is recommended, aspirin should
be avoided unless prescribed, and INR monitoring is required.
,6. A nurse is caring for a client with a serum potassium level of 2.9 mEq/L.
Which finding should the nurse anticipate?
A. Peaked T waves
B. Muscle weakness
C. Hyperactive bowel sounds only
D. Increased respiratory effort
Correct Answer: B. Muscle weakness
Rationale: Hypokalemia commonly causes muscle weakness, fatigue, dysrhythmias, and
decreased gastrointestinal motility. Peaked T waves are associated with hyperkalemia.
7. A nurse is assessing a newborn immediately after birth. Which finding
requires immediate intervention?
A. Heart rate of 140/min
B. Acrocyanosis
C. Respiratory rate of 68/min with grunting
D. Flexed extremities
Correct Answer: C. Respiratory rate of 68/min with grunting
Rationale: Grunting is a sign of respiratory distress and requires immediate evaluation.
Acrocyanosis, flexed extremities, and a heart rate of 140/min are generally expected
findings in a healthy newborn.
8. A nurse is caring for a client receiving morphine intravenously. Which
assessment finding requires immediate action?
A. Pain level decreased from 8/10 to 3/10
B. Respiratory rate of 8/min
C. Blood pressure 128/74 mm Hg
D. Mild drowsiness
Correct Answer: B. Respiratory rate of 8/min
Rationale: Respiratory depression is a serious adverse effect of opioid administration. A
respiratory rate below 12/min requires prompt assessment and intervention.
9. A nurse is reviewing laboratory results for a client. Which result should
be reported to the provider immediately?
, A. Hemoglobin 13.8 g/dL
B. Sodium 140 mEq/L
C. Blood glucose 58 mg/dL
D. White blood cell count 8,000/mm³
Correct Answer: C. Blood glucose 58 mg/dL
Rationale: A blood glucose level of 58 mg/dL indicates hypoglycemia, which can rapidly
progress to seizures, loss of consciousness, or other serious complications if untreated.
10. A nurse is caring for a client who suddenly becomes unresponsive.
What is the nurse's priority action?
A. Notify the provider
B. Document the event
C. Assess responsiveness and activate emergency response procedures
D. Obtain a full set of vital signs
Correct Answer: C. Assess responsiveness and activate emergency response
procedures
Rationale: According to emergency response priorities, the nurse must first assess
responsiveness and initiate emergency procedures to ensure rapid intervention and support
of airway, breathing, and circulation.
11. A nurse is caring for a client who is 12 hours postoperative following
abdominal surgery. Which finding requires immediate intervention?
A. Temperature of 37.6°C (99.7°F)
B. Pain rating of 6/10 at the incision site
C. Oxygen saturation of 88% on room air
D. Hypoactive bowel sounds
Correct Answer: C. Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates inadequate oxygenation and requires
immediate assessment and intervention. Airway and breathing concerns take priority over
pain, mild postoperative temperature elevations, and hypoactive bowel sounds.
12. A nurse is teaching a client with heart failure about daily weight
monitoring. Which statement by the client indicates understanding?
A. "I will weigh myself once a week."
B. "I will weigh myself at the same time each morning."
