NCLEX-RN EXAM REVIEW
1. A client receiving furosemide (Lasix) is being monitored. Which finding would be
most important to report to the healthcare provider?
A. Urine output of 2000 mL/day
B. Serum potassium level of 2.9 mEq/L
C. Weight loss of 1.5 kg in 2 days
D. Blood pressure of 110/70 mmHg
✅ Answer: B. Serum potassium level of 2.9 mEq/L
Rationale: Hypokalemia is a serious side effect of loop diuretics like furosemide. A
potassium level below 3.5 is dangerous and should be corrected immediately.
2. Which task can the RN safely delegate to the unlicensed assistive personnel
(UAP)?
A. Assessing a client with chest pain
B. Administering a tube feeding
C. Collecting a urine specimen
D. Teaching insulin injection
✅ Answer: C. Collecting a urine specimen
Rationale: UAPs can perform noninvasive tasks such as collecting specimens, but
cannot assess, teach, or administer medications.
3. A nurse is caring for a post-op client who suddenly develops tachypnea, chest
pain, and oxygen saturation of 84%. What is the priority action?
A. Call the Rapid Response Team
,B. Reassure the patient
C. Administer pain medication
D. Elevate the legs
✅ Answer: A. Call the Rapid Response Team
Rationale: These symptoms suggest a pulmonary embolism. Immediate intervention
is critical, and calling the RRT initiates a rapid assessment and treatment process.
4. Which intervention is the most effective in preventing hospital-acquired
pneumonia in a bedridden patient?
A. Increasing oral fluid intake
B. Encouraging use of incentive spirometer
C. Administering antibiotics prophylactically
D. Providing humidified oxygen
✅ Answer: B. Encouraging use of incentive spirometer
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis,
which reduces the risk of pneumonia.
5. A client with type 1 diabetes is found unconscious with cool, clammy skin. What is
the nurse’s first action?
A. Start an IV line
B. Check the blood glucose
C. Notify the provider
D. Administer insulin
✅ Answer: B. Check the blood glucose
Rationale: Hypoglycemia is suspected. Blood sugar must be checked before any
intervention. If low, glucose should be administered immediately.
6. A pregnant woman at 34 weeks gestation reports a headache and visual
disturbances. What condition is the nurse most concerned about?
,A. Gestational diabetes
B. Preterm labor
C. Preeclampsia
D. Urinary tract infection
✅ Answer: C. Preeclampsia
Rationale: Headache and visual changes are classic signs of preeclampsia, a serious
hypertensive disorder in pregnancy.
7. Which electrolyte imbalance is most likely to cause ECG changes such as peaked T
waves?
A. Hyponatremia
B. Hypokalemia
C. Hyperkalemia
D. Hypocalcemia
✅ Answer: C. Hyperkalemia
Rationale: Hyperkalemia is known to cause ECG changes like tall, peaked T waves
and can be life-threatening.
8. A client with COPD is receiving oxygen via nasal cannula at 4 L/min. The nurse
should:
A. Increase oxygen to 6 L/min if saturation drops
B. Encourage the client to use an incentive spirometer
C. Reduce oxygen to 2 L/min and notify provider
D. Discontinue oxygen and place in high Fowler’s position
✅ Answer: C. Reduce oxygen to 2 L/min and notify provider
Rationale: COPD patients rely on hypoxic drive to breathe; high O2 can suppress
respiration. Notify the provider and adjust accordingly.
, 9. A client with schizophrenia is pacing and muttering to themselves. What is the
nurse’s best initial response?
A. “Stop walking around; you’re upsetting others.”
B. “Would you like to talk about what you’re experiencing?”
C. “You need to go back to your room.”
D. “Here’s your medication. Take it now.”
✅ Answer: B. “Would you like to talk about what you’re experiencing?”
Rationale: This response is therapeutic and opens communication, especially when
the patient may be experiencing hallucinations or delusions.
10. A post-op client suddenly becomes confused and restless. What is the priority
nursing action?
A. Reorient the client
B. Check oxygen saturation
C. Restrain the client for safety
D. Administer pain medication
✅ Answer: B. Check oxygen saturation
Rationale: Confusion and restlessness are early signs of hypoxia. Assessing oxygen
saturation should be the first step.11. A nurse is caring for a client who is receiving a
blood transfusion. Which of the following signs indicates a hemolytic reaction?
A. Bradycardia and lethargy
B. Hypotension and low back pain
C. Fever and chills after 1 hour
D. Facial flushing and dry skin
✅ Answer: B. Hypotension and low back pain
Rationale: Hemolytic reactions usually present with fever, chills, hypotension, low
back pain, and hematuria. Immediate discontinuation of transfusion is required.
1. A client receiving furosemide (Lasix) is being monitored. Which finding would be
most important to report to the healthcare provider?
A. Urine output of 2000 mL/day
B. Serum potassium level of 2.9 mEq/L
C. Weight loss of 1.5 kg in 2 days
D. Blood pressure of 110/70 mmHg
✅ Answer: B. Serum potassium level of 2.9 mEq/L
Rationale: Hypokalemia is a serious side effect of loop diuretics like furosemide. A
potassium level below 3.5 is dangerous and should be corrected immediately.
2. Which task can the RN safely delegate to the unlicensed assistive personnel
(UAP)?
A. Assessing a client with chest pain
B. Administering a tube feeding
C. Collecting a urine specimen
D. Teaching insulin injection
✅ Answer: C. Collecting a urine specimen
Rationale: UAPs can perform noninvasive tasks such as collecting specimens, but
cannot assess, teach, or administer medications.
3. A nurse is caring for a post-op client who suddenly develops tachypnea, chest
pain, and oxygen saturation of 84%. What is the priority action?
A. Call the Rapid Response Team
,B. Reassure the patient
C. Administer pain medication
D. Elevate the legs
✅ Answer: A. Call the Rapid Response Team
Rationale: These symptoms suggest a pulmonary embolism. Immediate intervention
is critical, and calling the RRT initiates a rapid assessment and treatment process.
4. Which intervention is the most effective in preventing hospital-acquired
pneumonia in a bedridden patient?
A. Increasing oral fluid intake
B. Encouraging use of incentive spirometer
C. Administering antibiotics prophylactically
D. Providing humidified oxygen
✅ Answer: B. Encouraging use of incentive spirometer
Rationale: Incentive spirometry promotes lung expansion and prevents atelectasis,
which reduces the risk of pneumonia.
5. A client with type 1 diabetes is found unconscious with cool, clammy skin. What is
the nurse’s first action?
A. Start an IV line
B. Check the blood glucose
C. Notify the provider
D. Administer insulin
✅ Answer: B. Check the blood glucose
Rationale: Hypoglycemia is suspected. Blood sugar must be checked before any
intervention. If low, glucose should be administered immediately.
6. A pregnant woman at 34 weeks gestation reports a headache and visual
disturbances. What condition is the nurse most concerned about?
,A. Gestational diabetes
B. Preterm labor
C. Preeclampsia
D. Urinary tract infection
✅ Answer: C. Preeclampsia
Rationale: Headache and visual changes are classic signs of preeclampsia, a serious
hypertensive disorder in pregnancy.
7. Which electrolyte imbalance is most likely to cause ECG changes such as peaked T
waves?
A. Hyponatremia
B. Hypokalemia
C. Hyperkalemia
D. Hypocalcemia
✅ Answer: C. Hyperkalemia
Rationale: Hyperkalemia is known to cause ECG changes like tall, peaked T waves
and can be life-threatening.
8. A client with COPD is receiving oxygen via nasal cannula at 4 L/min. The nurse
should:
A. Increase oxygen to 6 L/min if saturation drops
B. Encourage the client to use an incentive spirometer
C. Reduce oxygen to 2 L/min and notify provider
D. Discontinue oxygen and place in high Fowler’s position
✅ Answer: C. Reduce oxygen to 2 L/min and notify provider
Rationale: COPD patients rely on hypoxic drive to breathe; high O2 can suppress
respiration. Notify the provider and adjust accordingly.
, 9. A client with schizophrenia is pacing and muttering to themselves. What is the
nurse’s best initial response?
A. “Stop walking around; you’re upsetting others.”
B. “Would you like to talk about what you’re experiencing?”
C. “You need to go back to your room.”
D. “Here’s your medication. Take it now.”
✅ Answer: B. “Would you like to talk about what you’re experiencing?”
Rationale: This response is therapeutic and opens communication, especially when
the patient may be experiencing hallucinations or delusions.
10. A post-op client suddenly becomes confused and restless. What is the priority
nursing action?
A. Reorient the client
B. Check oxygen saturation
C. Restrain the client for safety
D. Administer pain medication
✅ Answer: B. Check oxygen saturation
Rationale: Confusion and restlessness are early signs of hypoxia. Assessing oxygen
saturation should be the first step.11. A nurse is caring for a client who is receiving a
blood transfusion. Which of the following signs indicates a hemolytic reaction?
A. Bradycardia and lethargy
B. Hypotension and low back pain
C. Fever and chills after 1 hour
D. Facial flushing and dry skin
✅ Answer: B. Hypotension and low back pain
Rationale: Hemolytic reactions usually present with fever, chills, hypotension, low
back pain, and hematuria. Immediate discontinuation of transfusion is required.
