NCLEX-RN Clinical Judgment Practice Exam
1. A nurse is assessing a client with heart failure. Which finding indicates a
worsening of the client's condition?
A. Weight loss of 1 kg (2.2 lb) in 24 hours
B. Heart rate of 88 beats per minute
C. Crackles audible at the lung bases
D. Urine output of 40 mL/hr
2. A client is prescribed digoxin. Which assessment finding should the nurse report
immediately?
A. Heart rate of 72 beats per minute
B. Heart rate of 52 beats per minute
C. Blood pressure of 128/80 mm Hg
D. Respiratory rate of 18 breaths per minute
3. The nurse is teaching a client about a low-sodium diet. Which food should the
client avoid?
A. Fresh apples
B. Canned soup
C. Plain rice
D. Grilled chicken breast
4. A nurse is caring for a client with a new colostomy. Which observation requires
immediate intervention?
A. The stoma is pink and moist.
B. The stoma is dark purple and dusky.
C. There is a small amount of bleeding when touched.
D. The client is reluctant to look at the stoma.
5. A client is receiving heparin therapy. Which laboratory value should the nurse
monitor?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
,C. International Normalized Ratio (INR)
D. Bleeding time
6. A nurse is preparing to administer a blood transfusion. Which action is the
priority?
A. Ensure the blood is warmed to body temperature.
B. Verify the client's identity and blood compatibility with another nurse.
C. Start the transfusion with a dextrose solution.
D. Administer the blood over 1 hour.
7. A client with diabetes mellitus is experiencing hypoglycemia. Which finding is
expected?
A. Polyuria
B. Polydipsia
C. Diaphoresis
D. Kussmaul respirations
8. A nurse is assessing a client with a suspected stroke. Which finding is a priority
to report?
A. Blood pressure of 150/90 mm Hg
B. Sudden onset of a severe headache
C. History of atrial fibrillation
D. Mild hand weakness
9. A client is on bed rest. Which intervention is most important to prevent
complications?
A. Provide a high-fiber diet.
B. Encourage range-of-motion exercises.
C. Administer a stool softener.
D. Keep the head of the bed flat.
10. A nurse is teaching a client about the use of an incentive spirometer. Which
instruction is correct?
A. "Inhale quickly and forcefully."
B. "Hold your breath for 3 seconds after inhaling."
C. "Exhale slowly through the mouthpiece."
D. "Use it only when you feel short of breath."
11. A client is prescribed warfarin. Which instruction should the nurse include in
the teaching plan?
A. "Increase your intake of green, leafy vegetables."
B. "Use a soft toothbrush and an electric razor."
,C. "Take aspirin for headaches."
D. "This medication will dissolve an existing clot."
12. A nurse is caring for a client with a chest tube. Which finding indicates a need
for immediate intervention?
A. Bubbling in the water seal chamber that is continuous.
B. Tidaling in the water seal chamber.
C. Drainage of 50 mL in the first hour.
D. The dressing is dry and intact.
13. A client is admitted with acute pancreatitis. Which intervention is a priority?
A. Administer a high-fat diet.
B. Maintain NPO status.
C. Place the client in a supine position.
D. Encourage ambulation.
14. A nurse is assessing a client with a head injury. Which finding is the earliest
sign of increased intracranial pressure (ICP)?
A. Decreased level of consciousness
B. Changes in level of consciousness
C. Dilated pupils
D. Decerebrate posturing
15. A client is receiving furosemide. Which laboratory value should the nurse
monitor closely?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
16. A nurse is teaching a new mother about newborn care. Which statement
indicates a need for further teaching?
A. "I will place my baby on their back to sleep."
B. "I will give my baby a bottle of water between feedings."
C. "I will support my baby's head when holding them."
D. "I will use a bulb syringe to clear my baby's nose."
17. A client with COPD is receiving oxygen therapy. Which oxygen delivery
method is most appropriate?
A. Nasal cannula at 6 L/min
B. Simple face mask at 8 L/min
, C. Venturi mask at 2 L/min
D. Non-rebreather mask at 10 L/min
18. A nurse is caring for a client in the immediate postoperative period. Which
assessment is the priority?
A. Pain level
B. Airway patency
C. Urinary output
D. Surgical site dressing
19. A client is diagnosed with major depressive disorder. Which symptom is a
priority for the nurse to assess?
A. Feelings of sadness
B. Suicidal ideation
C. Loss of appetite
D. Difficulty sleeping
20. A nurse is delegating tasks to a nursing assistant. Which task is appropriate to
delegate?
A. Administering oral medications
B. Assisting a client with a bed bath
C. Assessing a client's incision
D. Teaching a client about a new medication
21. A client is admitted with a diagnosis of syndrome of inappropriate antidiuretic
hormone (SIADH). Which finding is expected?
A. Polyuria
B. Hyponatremia
C. Hypernatremia
D. Decreased urine osmolality
22. A nurse is performing a focused assessment on a client with asthma. Which
finding indicates a severe exacerbation?
A. Wheezing
B. Silent chest
C. Use of accessory muscles
D. Respiratory rate of 24 breaths per minute
23. A client is prescribed lithium carbonate. Which instruction is essential for the
nurse to include?
A. "Take this medication on an empty stomach."
B. "Maintain a consistent fluid and sodium intake."
1. A nurse is assessing a client with heart failure. Which finding indicates a
worsening of the client's condition?
A. Weight loss of 1 kg (2.2 lb) in 24 hours
B. Heart rate of 88 beats per minute
C. Crackles audible at the lung bases
D. Urine output of 40 mL/hr
2. A client is prescribed digoxin. Which assessment finding should the nurse report
immediately?
A. Heart rate of 72 beats per minute
B. Heart rate of 52 beats per minute
C. Blood pressure of 128/80 mm Hg
D. Respiratory rate of 18 breaths per minute
3. The nurse is teaching a client about a low-sodium diet. Which food should the
client avoid?
A. Fresh apples
B. Canned soup
C. Plain rice
D. Grilled chicken breast
4. A nurse is caring for a client with a new colostomy. Which observation requires
immediate intervention?
A. The stoma is pink and moist.
B. The stoma is dark purple and dusky.
C. There is a small amount of bleeding when touched.
D. The client is reluctant to look at the stoma.
5. A client is receiving heparin therapy. Which laboratory value should the nurse
monitor?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPTT)
,C. International Normalized Ratio (INR)
D. Bleeding time
6. A nurse is preparing to administer a blood transfusion. Which action is the
priority?
A. Ensure the blood is warmed to body temperature.
B. Verify the client's identity and blood compatibility with another nurse.
C. Start the transfusion with a dextrose solution.
D. Administer the blood over 1 hour.
7. A client with diabetes mellitus is experiencing hypoglycemia. Which finding is
expected?
A. Polyuria
B. Polydipsia
C. Diaphoresis
D. Kussmaul respirations
8. A nurse is assessing a client with a suspected stroke. Which finding is a priority
to report?
A. Blood pressure of 150/90 mm Hg
B. Sudden onset of a severe headache
C. History of atrial fibrillation
D. Mild hand weakness
9. A client is on bed rest. Which intervention is most important to prevent
complications?
A. Provide a high-fiber diet.
B. Encourage range-of-motion exercises.
C. Administer a stool softener.
D. Keep the head of the bed flat.
10. A nurse is teaching a client about the use of an incentive spirometer. Which
instruction is correct?
A. "Inhale quickly and forcefully."
B. "Hold your breath for 3 seconds after inhaling."
C. "Exhale slowly through the mouthpiece."
D. "Use it only when you feel short of breath."
11. A client is prescribed warfarin. Which instruction should the nurse include in
the teaching plan?
A. "Increase your intake of green, leafy vegetables."
B. "Use a soft toothbrush and an electric razor."
,C. "Take aspirin for headaches."
D. "This medication will dissolve an existing clot."
12. A nurse is caring for a client with a chest tube. Which finding indicates a need
for immediate intervention?
A. Bubbling in the water seal chamber that is continuous.
B. Tidaling in the water seal chamber.
C. Drainage of 50 mL in the first hour.
D. The dressing is dry and intact.
13. A client is admitted with acute pancreatitis. Which intervention is a priority?
A. Administer a high-fat diet.
B. Maintain NPO status.
C. Place the client in a supine position.
D. Encourage ambulation.
14. A nurse is assessing a client with a head injury. Which finding is the earliest
sign of increased intracranial pressure (ICP)?
A. Decreased level of consciousness
B. Changes in level of consciousness
C. Dilated pupils
D. Decerebrate posturing
15. A client is receiving furosemide. Which laboratory value should the nurse
monitor closely?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
16. A nurse is teaching a new mother about newborn care. Which statement
indicates a need for further teaching?
A. "I will place my baby on their back to sleep."
B. "I will give my baby a bottle of water between feedings."
C. "I will support my baby's head when holding them."
D. "I will use a bulb syringe to clear my baby's nose."
17. A client with COPD is receiving oxygen therapy. Which oxygen delivery
method is most appropriate?
A. Nasal cannula at 6 L/min
B. Simple face mask at 8 L/min
, C. Venturi mask at 2 L/min
D. Non-rebreather mask at 10 L/min
18. A nurse is caring for a client in the immediate postoperative period. Which
assessment is the priority?
A. Pain level
B. Airway patency
C. Urinary output
D. Surgical site dressing
19. A client is diagnosed with major depressive disorder. Which symptom is a
priority for the nurse to assess?
A. Feelings of sadness
B. Suicidal ideation
C. Loss of appetite
D. Difficulty sleeping
20. A nurse is delegating tasks to a nursing assistant. Which task is appropriate to
delegate?
A. Administering oral medications
B. Assisting a client with a bed bath
C. Assessing a client's incision
D. Teaching a client about a new medication
21. A client is admitted with a diagnosis of syndrome of inappropriate antidiuretic
hormone (SIADH). Which finding is expected?
A. Polyuria
B. Hyponatremia
C. Hypernatremia
D. Decreased urine osmolality
22. A nurse is performing a focused assessment on a client with asthma. Which
finding indicates a severe exacerbation?
A. Wheezing
B. Silent chest
C. Use of accessory muscles
D. Respiratory rate of 24 breaths per minute
23. A client is prescribed lithium carbonate. Which instruction is essential for the
nurse to include?
A. "Take this medication on an empty stomach."
B. "Maintain a consistent fluid and sodium intake."
