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NURSING CAPSTONE COMPREHENSIVE PRE-TEST NCLEX-RN® Readiness Assessment – Original
Questions with Answers & Rationales
SECTION 1: MEDICAL-SURGICAL NURSING
1. A nurse is caring for a patient with heart failure who reports a
weight gain of 3 pounds in 24 hours. The nurse's priority action
is to:
A) Document the finding and continue monitoring
B) Notify the healthcare provider and assess for other signs of
fluid overload
C) Encourage the patient to increase fluid intake
D) Administer a diuretic without an order
Answer: B
Rationale: Weight gain of 2–3 pounds in 24 hours indicates worsening fluid
retention and heart failure. The nurse should notify the provider and assess for
other signs (crackles, dyspnea, edema). Diuretics require an order.
2. A patient with type 1 diabetes presents with Kussmaul
respirations, fruity breath odor, and blood glucose of 480
mg/dL. The priority intervention is:
A) Administer oral hypoglycemics
B) Administer IV fluids and insulin per protocol
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C) Give the patient orange juice
D) Wait for the provider to arrive
Answer: B
Rationale: These findings indicate diabetic ketoacidosis (DKA). Priority treatment:
IV fluids, insulin infusion, and electrolyte management (especially potassium).
3. A patient receiving a blood transfusion develops chills, fever,
and back pain. The nurse's first action is:
A) Slow the transfusion
B) Stop the transfusion and maintain IV access with normal
saline
C) Administer antipyretics
D) Continue the transfusion and monitor closely
Answer: B
Rationale: These signs suggest a hemolytic transfusion reaction.
The transfusion must be stopped immediately, IV access
maintained with NS, and the provider notified.
4. A patient with chronic kidney disease has a serum potassium
of 6.8 mEq/L. The priority nursing action is:
A) Administer potassium supplements
B) Notify the provider and prepare for cardiac monitoring and
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potassium-lowering treatment
C) Encourage high-potassium foods
D) Document and reassess in 4 hours
Answer: B
Rationale: Severe hyperkalemia causes lethal arrhythmias. The
patient needs cardiac monitoring and urgent treatment
(calcium, insulin/glucose, dialysis).
5. A patient post-thyroidectomy develops stridor, hoarseness,
and difficulty breathing. The nurse suspects:
A) Normal postoperative swelling
B) Laryngeal edema or hematoma (airway emergency)
C) Anxiety
D) Infection only
Answer: B
Rationale: Stridor and breathing difficulty after thyroidectomy
suggest airway compromise from edema or hematoma—
requires emergency intervention.
6. A patient with cirrhosis develops confusion and asterixis
(flapping tremor). The nurse recognizes this as:
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A) Stroke
B) Hepatic encephalopathy
C) Meningitis
D) Seizure only
Answer: B
Rationale: Confusion and asterixis in cirrhosis indicate hepatic
encephalopathy from ammonia accumulation.
7. The first-line treatment for hepatic encephalopathy includes:
A) High-protein diet
B) Lactulose (to reduce ammonia) and addressing precipitating
factors
C) Antibiotics only
D) No treatment only
Answer: B
Rationale: Lactulose reduces ammonia absorption; treating
triggers (infection, GI bleeding) is essential.
8. A patient with a chest tube has continuous bubbling in the
water seal chamber. This indicates:
A) Normal function
B) An air leak
NURSING CAPSTONE COMPREHENSIVE PRE-TEST NCLEX-RN® Readiness Assessment – Original
Questions with Answers & Rationales
SECTION 1: MEDICAL-SURGICAL NURSING
1. A nurse is caring for a patient with heart failure who reports a
weight gain of 3 pounds in 24 hours. The nurse's priority action
is to:
A) Document the finding and continue monitoring
B) Notify the healthcare provider and assess for other signs of
fluid overload
C) Encourage the patient to increase fluid intake
D) Administer a diuretic without an order
Answer: B
Rationale: Weight gain of 2–3 pounds in 24 hours indicates worsening fluid
retention and heart failure. The nurse should notify the provider and assess for
other signs (crackles, dyspnea, edema). Diuretics require an order.
2. A patient with type 1 diabetes presents with Kussmaul
respirations, fruity breath odor, and blood glucose of 480
mg/dL. The priority intervention is:
A) Administer oral hypoglycemics
B) Administer IV fluids and insulin per protocol
, Page |2
C) Give the patient orange juice
D) Wait for the provider to arrive
Answer: B
Rationale: These findings indicate diabetic ketoacidosis (DKA). Priority treatment:
IV fluids, insulin infusion, and electrolyte management (especially potassium).
3. A patient receiving a blood transfusion develops chills, fever,
and back pain. The nurse's first action is:
A) Slow the transfusion
B) Stop the transfusion and maintain IV access with normal
saline
C) Administer antipyretics
D) Continue the transfusion and monitor closely
Answer: B
Rationale: These signs suggest a hemolytic transfusion reaction.
The transfusion must be stopped immediately, IV access
maintained with NS, and the provider notified.
4. A patient with chronic kidney disease has a serum potassium
of 6.8 mEq/L. The priority nursing action is:
A) Administer potassium supplements
B) Notify the provider and prepare for cardiac monitoring and
, Page |3
potassium-lowering treatment
C) Encourage high-potassium foods
D) Document and reassess in 4 hours
Answer: B
Rationale: Severe hyperkalemia causes lethal arrhythmias. The
patient needs cardiac monitoring and urgent treatment
(calcium, insulin/glucose, dialysis).
5. A patient post-thyroidectomy develops stridor, hoarseness,
and difficulty breathing. The nurse suspects:
A) Normal postoperative swelling
B) Laryngeal edema or hematoma (airway emergency)
C) Anxiety
D) Infection only
Answer: B
Rationale: Stridor and breathing difficulty after thyroidectomy
suggest airway compromise from edema or hematoma—
requires emergency intervention.
6. A patient with cirrhosis develops confusion and asterixis
(flapping tremor). The nurse recognizes this as:
, Page |4
A) Stroke
B) Hepatic encephalopathy
C) Meningitis
D) Seizure only
Answer: B
Rationale: Confusion and asterixis in cirrhosis indicate hepatic
encephalopathy from ammonia accumulation.
7. The first-line treatment for hepatic encephalopathy includes:
A) High-protein diet
B) Lactulose (to reduce ammonia) and addressing precipitating
factors
C) Antibiotics only
D) No treatment only
Answer: B
Rationale: Lactulose reduces ammonia absorption; treating
triggers (infection, GI bleeding) is essential.
8. A patient with a chest tube has continuous bubbling in the
water seal chamber. This indicates:
A) Normal function
B) An air leak
