2025 NCLEX-RN Test Bank: Latest Practice
Questions, Answers, and Rationales for
Exam Success
1. A nurse is assessing a client who has heart failure and is taking digoxin. Which finding
indicates digoxin toxicity?
A) Heart rate of 110 bpm
B) Nausea and blurred vision
C) Increased urine output
D) Hypertension
Correct Answer: B) Nausea and blurred vision
Rationale: Signs of digoxin toxicity include nausea, vomiting, blurred vision, and
bradycardia. The nurse should hold the dose and notify the provider.
2. A client with type 1 diabetes is experiencing diaphoresis, shakiness, and irritability.
What is the nurse’s priority action?
A) Administer glucagon IM
B) Check the client’s blood glucose
C) Give a long-acting carbohydrate
D) Start an insulin infusion
Correct Answer: B) Check the client’s blood glucose
Rationale: The symptoms indicate hypoglycemia, but the nurse should first confirm the
blood glucose level before treatment.
3. A nurse is preparing to administer warfarin to a client with atrial fibrillation. Which lab
value should the nurse review before giving the medication?
A) Potassium level
B) Hemoglobin level
C) INR
D) Creatinine level
Correct Answer: C) INR
Rationale: Warfarin (Coumadin) requires INR monitoring. A therapeutic INR for atrial
fibrillation is 2.0-3.0.
4. A nurse is caring for a child with epiglottitis. What action should the nurse take first?
A) Perform a throat culture
B) Have emergency airway equipment ready
C) Give oral antibiotics
D) Encourage oral fluids
Correct Answer: B) Have emergency airway equipment ready
Rationale: Epiglottitis causes severe airway obstruction. The nurse should never examine
,the throat due to the risk of complete obstruction.
5. A nurse is teaching a client about preventing osteoporosis. Which statement indicates a
need for further teaching?
A) "I will increase my calcium intake."
B) "I should perform weight-bearing exercises."
C) "I will drink more sodas instead of milk."
D) "I should get adequate vitamin D."
Correct Answer: C) "I will drink more sodas instead of milk."
Rationale: Sodas contain phosphoric acid, which can reduce calcium absorption and
increase osteoporosis risk.
6. A nurse is administering potassium chloride IV to a client with hypokalemia. What is the
safest way to give this medication?
A) As a rapid IV push
B) Diluted in IV fluid and given slowly
C) Undiluted through a central line
D) As an IM injection
Correct Answer: B) Diluted in IV fluid and given slowly
Rationale: IV potassium should never be given as a push or undiluted, as it can cause
fatal cardiac arrhythmias.
7. A nurse is assessing a client with increased intracranial pressure (ICP). Which finding is
most concerning?
A) Blood pressure of 170/60 mmHg
B) Pulse of 60 bpm
C) Irregular respiratory pattern
D) Hyperactive deep tendon reflexes
Correct Answer: C) Irregular respiratory pattern
Rationale: An irregular respiratory pattern is a sign of brainstem compression and
requires immediate intervention.
8. A nurse is teaching a client about dietary changes for hypertension. Which food should
the client avoid?
A) Grilled chicken
B) Canned soup
C) Fresh fruits
D) Whole grains
Correct Answer: B) Canned soup
Rationale: Canned foods contain high sodium, which can worsen hypertension.
9. A nurse is caring for a client with Cushing’s syndrome. Which finding should the nurse
expect?
A) Hypoglycemia
B) Hypotension
,C) Moon face and buffalo hump
D) Weight loss
Correct Answer: C) Moon face and buffalo hump
Rationale: Cushing’s syndrome causes fat redistribution, leading to a moon face and
buffalo hump.
10. A client with pneumonia is having difficulty breathing. What is the priority nursing
action?
A) Increase IV fluids
B) Encourage coughing and deep breathing
C) Perform postural drainage
D) Apply oxygen
Correct Answer: D) Apply oxygen
Rationale: Hypoxia is the priority concern in pneumonia. Oxygen should be given first to
maintain adequate oxygenation.
11. A nurse is caring for a client with deep vein thrombosis (DVT). What action should the
nurse take?
A) Massage the affected leg
B) Keep the leg elevated
C) Apply heat to the affected area
D) Encourage ambulation
Correct Answer: B) Keep the leg elevated
Rationale: Elevating the leg helps reduce swelling and prevents the clot from moving.
Massaging the leg could dislodge the clot, causing a pulmonary embolism.
12. A nurse is providing care to a client with suspected appendicitis. Which assessment
finding requires immediate intervention?
A) Severe RLQ pain
B) Sudden relief of pain
C) Low-grade fever
D) Nausea and vomiting
Correct Answer: B) Sudden relief of pain
Rationale: A sudden relief of pain may indicate appendix rupture, which is a medical
emergency.
13. A nurse is assessing a client’s IV site and notices redness, swelling, and warmth. What
is the priority action?
A) Apply a warm compress
B) Slow the IV infusion rate
C) Discontinue the IV line
D) Flush the IV site with normal saline
Correct Answer: C) Discontinue the IV line
Rationale: Redness, swelling, and warmth indicate phlebitis. The IV should be removed
immediately to prevent further complications.
, 14. A client is prescribed lithium for bipolar disorder. What dietary instruction should the
nurse give?
A) Avoid potassium-rich foods
B) Maintain a normal sodium intake
C) Follow a low-calcium diet
D) Increase vitamin K-rich foods
Correct Answer: B) Maintain a normal sodium intake
Rationale: Lithium levels are affected by sodium intake. Low sodium can increase
lithium toxicity, while high sodium can reduce lithium levels.
15. A nurse is assessing a client with compartment syndrome in the leg. What is the priority
action?
A) Apply heat packs
B) Elevate the leg above heart level
C) Loosen tight bandages
D) Administer pain medication
Correct Answer: C) Loosen tight bandages
Rationale: Compartment syndrome occurs when swelling restricts circulation. Loosening
tight bandages relieves pressure and prevents permanent damage.
16. A nurse is assessing a client who is post-op after hip surgery. Which finding requires
immediate intervention?
A) Redness at the surgical site
B) A shortened and externally rotated leg
C) Pain rated 5/10
D) Mild swelling in the affected leg
Correct Answer: B) A shortened and externally rotated leg
Rationale: This indicates a possible hip dislocation, which is a medical emergency requiring
immediate intervention.
17. A nurse is providing discharge teaching to a client with heart failure. Which statement
indicates a need for further teaching?
A) "I will weigh myself daily."
B) "I should notify my provider if I gain 3 pounds in 2 days."
C) "I will increase my sodium intake to prevent dehydration."
D) "I should take my prescribed diuretics in the morning."
Correct Answer: C) "I will increase my sodium intake to prevent dehydration."
Rationale: Clients with heart failure should limit sodium intake to prevent fluid retention
and worsening heart failure symptoms.
18. A nurse is assessing a client receiving magnesium sulfate for preeclampsia. Which
finding is most concerning?
A) Deep tendon reflexes of +1
B) Respiratory rate of 10 breaths per minute
Questions, Answers, and Rationales for
Exam Success
1. A nurse is assessing a client who has heart failure and is taking digoxin. Which finding
indicates digoxin toxicity?
A) Heart rate of 110 bpm
B) Nausea and blurred vision
C) Increased urine output
D) Hypertension
Correct Answer: B) Nausea and blurred vision
Rationale: Signs of digoxin toxicity include nausea, vomiting, blurred vision, and
bradycardia. The nurse should hold the dose and notify the provider.
2. A client with type 1 diabetes is experiencing diaphoresis, shakiness, and irritability.
What is the nurse’s priority action?
A) Administer glucagon IM
B) Check the client’s blood glucose
C) Give a long-acting carbohydrate
D) Start an insulin infusion
Correct Answer: B) Check the client’s blood glucose
Rationale: The symptoms indicate hypoglycemia, but the nurse should first confirm the
blood glucose level before treatment.
3. A nurse is preparing to administer warfarin to a client with atrial fibrillation. Which lab
value should the nurse review before giving the medication?
A) Potassium level
B) Hemoglobin level
C) INR
D) Creatinine level
Correct Answer: C) INR
Rationale: Warfarin (Coumadin) requires INR monitoring. A therapeutic INR for atrial
fibrillation is 2.0-3.0.
4. A nurse is caring for a child with epiglottitis. What action should the nurse take first?
A) Perform a throat culture
B) Have emergency airway equipment ready
C) Give oral antibiotics
D) Encourage oral fluids
Correct Answer: B) Have emergency airway equipment ready
Rationale: Epiglottitis causes severe airway obstruction. The nurse should never examine
,the throat due to the risk of complete obstruction.
5. A nurse is teaching a client about preventing osteoporosis. Which statement indicates a
need for further teaching?
A) "I will increase my calcium intake."
B) "I should perform weight-bearing exercises."
C) "I will drink more sodas instead of milk."
D) "I should get adequate vitamin D."
Correct Answer: C) "I will drink more sodas instead of milk."
Rationale: Sodas contain phosphoric acid, which can reduce calcium absorption and
increase osteoporosis risk.
6. A nurse is administering potassium chloride IV to a client with hypokalemia. What is the
safest way to give this medication?
A) As a rapid IV push
B) Diluted in IV fluid and given slowly
C) Undiluted through a central line
D) As an IM injection
Correct Answer: B) Diluted in IV fluid and given slowly
Rationale: IV potassium should never be given as a push or undiluted, as it can cause
fatal cardiac arrhythmias.
7. A nurse is assessing a client with increased intracranial pressure (ICP). Which finding is
most concerning?
A) Blood pressure of 170/60 mmHg
B) Pulse of 60 bpm
C) Irregular respiratory pattern
D) Hyperactive deep tendon reflexes
Correct Answer: C) Irregular respiratory pattern
Rationale: An irregular respiratory pattern is a sign of brainstem compression and
requires immediate intervention.
8. A nurse is teaching a client about dietary changes for hypertension. Which food should
the client avoid?
A) Grilled chicken
B) Canned soup
C) Fresh fruits
D) Whole grains
Correct Answer: B) Canned soup
Rationale: Canned foods contain high sodium, which can worsen hypertension.
9. A nurse is caring for a client with Cushing’s syndrome. Which finding should the nurse
expect?
A) Hypoglycemia
B) Hypotension
,C) Moon face and buffalo hump
D) Weight loss
Correct Answer: C) Moon face and buffalo hump
Rationale: Cushing’s syndrome causes fat redistribution, leading to a moon face and
buffalo hump.
10. A client with pneumonia is having difficulty breathing. What is the priority nursing
action?
A) Increase IV fluids
B) Encourage coughing and deep breathing
C) Perform postural drainage
D) Apply oxygen
Correct Answer: D) Apply oxygen
Rationale: Hypoxia is the priority concern in pneumonia. Oxygen should be given first to
maintain adequate oxygenation.
11. A nurse is caring for a client with deep vein thrombosis (DVT). What action should the
nurse take?
A) Massage the affected leg
B) Keep the leg elevated
C) Apply heat to the affected area
D) Encourage ambulation
Correct Answer: B) Keep the leg elevated
Rationale: Elevating the leg helps reduce swelling and prevents the clot from moving.
Massaging the leg could dislodge the clot, causing a pulmonary embolism.
12. A nurse is providing care to a client with suspected appendicitis. Which assessment
finding requires immediate intervention?
A) Severe RLQ pain
B) Sudden relief of pain
C) Low-grade fever
D) Nausea and vomiting
Correct Answer: B) Sudden relief of pain
Rationale: A sudden relief of pain may indicate appendix rupture, which is a medical
emergency.
13. A nurse is assessing a client’s IV site and notices redness, swelling, and warmth. What
is the priority action?
A) Apply a warm compress
B) Slow the IV infusion rate
C) Discontinue the IV line
D) Flush the IV site with normal saline
Correct Answer: C) Discontinue the IV line
Rationale: Redness, swelling, and warmth indicate phlebitis. The IV should be removed
immediately to prevent further complications.
, 14. A client is prescribed lithium for bipolar disorder. What dietary instruction should the
nurse give?
A) Avoid potassium-rich foods
B) Maintain a normal sodium intake
C) Follow a low-calcium diet
D) Increase vitamin K-rich foods
Correct Answer: B) Maintain a normal sodium intake
Rationale: Lithium levels are affected by sodium intake. Low sodium can increase
lithium toxicity, while high sodium can reduce lithium levels.
15. A nurse is assessing a client with compartment syndrome in the leg. What is the priority
action?
A) Apply heat packs
B) Elevate the leg above heart level
C) Loosen tight bandages
D) Administer pain medication
Correct Answer: C) Loosen tight bandages
Rationale: Compartment syndrome occurs when swelling restricts circulation. Loosening
tight bandages relieves pressure and prevents permanent damage.
16. A nurse is assessing a client who is post-op after hip surgery. Which finding requires
immediate intervention?
A) Redness at the surgical site
B) A shortened and externally rotated leg
C) Pain rated 5/10
D) Mild swelling in the affected leg
Correct Answer: B) A shortened and externally rotated leg
Rationale: This indicates a possible hip dislocation, which is a medical emergency requiring
immediate intervention.
17. A nurse is providing discharge teaching to a client with heart failure. Which statement
indicates a need for further teaching?
A) "I will weigh myself daily."
B) "I should notify my provider if I gain 3 pounds in 2 days."
C) "I will increase my sodium intake to prevent dehydration."
D) "I should take my prescribed diuretics in the morning."
Correct Answer: C) "I will increase my sodium intake to prevent dehydration."
Rationale: Clients with heart failure should limit sodium intake to prevent fluid retention
and worsening heart failure symptoms.
18. A nurse is assessing a client receiving magnesium sulfate for preeclampsia. Which
finding is most concerning?
A) Deep tendon reflexes of +1
B) Respiratory rate of 10 breaths per minute
