NSG 410 — NCLEX-RN Preparation exam
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1. A nurse is caring for a client who reports sudden crushing chest
pain radiating to the left arm. Which action should the nurse take
first?
A. Obtain a detailed health history
B. Administer prescribed oxygen if indicated and assess oxygen
saturation
C. Ask the client to rate the pain from 0 to 10
D. Prepare the client for discharge
Answer: B. Administer prescribed oxygen if indicated and assess
oxygen saturation
Rationale: A client with suspected acute coronary syndrome requires
immediate assessment and stabilization of airway, breathing, and
,circulation. Oxygen is administered when hypoxemia or respiratory
distress is present rather than routinely to every client with chest pain.
Rapid assessment of oxygenation and cardiovascular status helps
identify life-threatening deterioration.
2. A nurse is assessing a client with hypoglycemia. Which finding
should the nurse expect?
A. Warm, dry skin
B. Bradycardia
C. Tremors and diaphoresis
D. Deep, rapid respirations
Answer: C. Tremors and diaphoresis
Rationale: Hypoglycemia activates the sympathetic nervous system,
producing manifestations such as sweating, tremors, palpitations,
anxiety, and hunger. Severe hypoglycemia can progress to confusion,
seizures, and loss of consciousness. Warm, dry skin is more consistent
with hyperglycemia or other conditions, while deep, rapid respirations
are associated with metabolic acidosis such as diabetic ketoacidosis.
, 3. A client with heart failure suddenly develops severe dyspnea and
pink, frothy sputum. Which condition should the nurse suspect?
A. Pulmonary edema
B. Pneumothorax
C. Pleural effusion
D. Pulmonary embolism
Answer: A. Pulmonary edema
Rationale: Acute pulmonary edema occurs when fluid rapidly
accumulates in the alveoli, commonly because of severe left-sided
heart failure. Classic findings include severe dyspnea, crackles,
hypoxemia, anxiety, and pink or blood-tinged frothy sputum. This is
an emergency requiring rapid intervention to improve oxygenation
and reduce cardiac workload.
4. Which assessment finding in a postoperative client requires
immediate intervention?
A. Pain rated 6/10
B. Urine output of 20 mL over 2 hours
C. Temperature of 37.4°C (99.3°F)
D. Mild nausea after anesthesia
, Answer: B. Urine output of 20 mL over 2 hours
Rationale: Urine output below approximately 30 mL/hr in an adult
may indicate inadequate renal perfusion, hypovolemia, or acute
kidney injury. The nurse should promptly assess the client's
hemodynamic status and notify the appropriate provider if the finding
persists. Mild postoperative nausea, moderate pain, and a near-
normal temperature are generally less urgent.
5. A nurse is caring for a client receiving a blood transfusion. Fifteen
minutes after initiation, the client develops chills, fever, and low
back pain. What should the nurse do first?
A. Slow the transfusion rate
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another unit of blood
Answer: B. Stop the transfusion
Rationale: Fever, chills, and low back pain shortly after a transfusion
may indicate an acute hemolytic transfusion reaction. The transfusion
must be stopped immediately to prevent further exposure to the
incompatible blood product. The nurse should maintain IV access with
Questions and Correct Answers (Verified
Answers) Plus Rationale 2027 Q&A| Instant
Download Pdf
1. A nurse is caring for a client who reports sudden crushing chest
pain radiating to the left arm. Which action should the nurse take
first?
A. Obtain a detailed health history
B. Administer prescribed oxygen if indicated and assess oxygen
saturation
C. Ask the client to rate the pain from 0 to 10
D. Prepare the client for discharge
Answer: B. Administer prescribed oxygen if indicated and assess
oxygen saturation
Rationale: A client with suspected acute coronary syndrome requires
immediate assessment and stabilization of airway, breathing, and
,circulation. Oxygen is administered when hypoxemia or respiratory
distress is present rather than routinely to every client with chest pain.
Rapid assessment of oxygenation and cardiovascular status helps
identify life-threatening deterioration.
2. A nurse is assessing a client with hypoglycemia. Which finding
should the nurse expect?
A. Warm, dry skin
B. Bradycardia
C. Tremors and diaphoresis
D. Deep, rapid respirations
Answer: C. Tremors and diaphoresis
Rationale: Hypoglycemia activates the sympathetic nervous system,
producing manifestations such as sweating, tremors, palpitations,
anxiety, and hunger. Severe hypoglycemia can progress to confusion,
seizures, and loss of consciousness. Warm, dry skin is more consistent
with hyperglycemia or other conditions, while deep, rapid respirations
are associated with metabolic acidosis such as diabetic ketoacidosis.
, 3. A client with heart failure suddenly develops severe dyspnea and
pink, frothy sputum. Which condition should the nurse suspect?
A. Pulmonary edema
B. Pneumothorax
C. Pleural effusion
D. Pulmonary embolism
Answer: A. Pulmonary edema
Rationale: Acute pulmonary edema occurs when fluid rapidly
accumulates in the alveoli, commonly because of severe left-sided
heart failure. Classic findings include severe dyspnea, crackles,
hypoxemia, anxiety, and pink or blood-tinged frothy sputum. This is
an emergency requiring rapid intervention to improve oxygenation
and reduce cardiac workload.
4. Which assessment finding in a postoperative client requires
immediate intervention?
A. Pain rated 6/10
B. Urine output of 20 mL over 2 hours
C. Temperature of 37.4°C (99.3°F)
D. Mild nausea after anesthesia
, Answer: B. Urine output of 20 mL over 2 hours
Rationale: Urine output below approximately 30 mL/hr in an adult
may indicate inadequate renal perfusion, hypovolemia, or acute
kidney injury. The nurse should promptly assess the client's
hemodynamic status and notify the appropriate provider if the finding
persists. Mild postoperative nausea, moderate pain, and a near-
normal temperature are generally less urgent.
5. A nurse is caring for a client receiving a blood transfusion. Fifteen
minutes after initiation, the client develops chills, fever, and low
back pain. What should the nurse do first?
A. Slow the transfusion rate
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain another unit of blood
Answer: B. Stop the transfusion
Rationale: Fever, chills, and low back pain shortly after a transfusion
may indicate an acute hemolytic transfusion reaction. The transfusion
must be stopped immediately to prevent further exposure to the
incompatible blood product. The nurse should maintain IV access with
