NCLEX Final Exam for 2025 Makeup 50 Q & A Rated A+ Make Up NCLEX Questions

1. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report? a. The client fell out of bed b. The client climbed over the side rails c. The client was found on the floor d. The client became restless and tried to get out of bed 2. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? a. Obtain a court order for the surgical procedure. b. Ask the EMS team to sign the informed consent. c. Transport the victim to the operating room for surgery. d. Call the police to identify the client and locate the family. 3. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action? a. Refuse to float to the ICU based on lack of unit orientation. b. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. c. Ask the nursing supervisor to review the hospital policy on floating. d. Submit a written protest to nursing administration, and then call the hospital lawyer. 4. A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? a. "I will sign as a witness to your signature." b. "You will need to find a witness on your own." c. "Whoever is available at the time will sign as a witness for you." d. "I will call the nursing supervisor to seek assistance regarding your request." 5. The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply. a. Complete and file an occurrence report. b. Right-click on the entry and modify it to reflect the correct information. c. Document the correct information and end with the nurse's signature and title. d. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. e. Document in a nurse's note in the client's record detailing the corrected information. 6. Which identifies accurate nursing documentation notation(s)? Select all that apply. a. The client slept through the night. b. Abdominal wound dressing is dry and intact without drainage. c. The client seemed angry when awakened for vital sign measurement. d. The client appears to become anxious when it is time for respiratory treatments. e. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. 7. A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? a. Performing a procedure without consent b. Threatening to give a client a medication c. Telling the client that he or she cannot leave the hospital d. Observing care provided to the client without the client's permission 8. Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort? a. Libel b. Slander c. Assault d. Negligence 9. An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response? a. "Oh, really? I will discuss this situation with your son." b. "Let's talk about the ways you can manage your time to prevent this from happening." c. "Do you have any friends who can help you out until you resolve these important issues with your son?" d. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." 10. The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take? a. Contact the nursing supervisor. b. Administer the dose prescribed. c. Hold the medication until the PHCP can be contacted. d. Administer the recommended dose until the PHCP can be located. 11. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? a. Call the police b. Cut up the photograph and throw it away. c. Call the nursing supervisor and report the occurrence. d. Call the laboratory and ask for the name of the individual who sent the photograph. 12. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? a. Each staff member is assigned a specific task for a group of clients. b. A staff member is assigned to determine the client's needs at home and begin discharge planning. c. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP). d. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients. 13. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? a. A client who is ambulatory demonstrating steady gait b. A postoperative client who has just received an opioid pain medication c. A client scheduled for physical therapy for the first crutch-walking session d. A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C 14. The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? a. Finish the bed bath and then administer the pain medication to the other client. b. Ask the AP to find out when the last pain medication was given to the client. c. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. d. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 15. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP? a. Ignore the resistance. b. Exert coercion on the AP. c. Provide a positive reward system for the AP. d. Confront the AP to encourage verbalization of feelings regarding the change. 16. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)? a. A client requiring a colostomy irrigation b. A client receiving continuous tube feedings c. A client who requires urine specimen collections d. A client with difficulty swallowing food and fluids 17. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply a. Open doors to client rooms. b. Move beds away from windows. c. Close window shades and curtains. d. Place blankets over clients who are confined to bed. e. Relocate ambulatory clients from the hallways back into their rooms. 18. The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? a. A client who requires a bed bath b. An older client requiring frequent ambulation c. A client who requires hourly vital sign measurements d. A client requiring abdominal wound irrigations and dressing changes every 3 hours 19. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. a. The acuity level of the clients b. Specific requests from the staff c. The clustering of the rooms on the unit d. The number of anticipated client discharges e. Client needs and workers' needs and abilities 20. Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. a. Obtain an intravenous (IV) infusion pump. b. Monitor urine output during administration. c. Prepare the medication for bolus administration d. Monitor the IV site for signs of infiltration or phlebitis. e. Ensure that the medication is diluted in the appropriate volume of fluid. f. Ensure that the bag is labeled so that it reads the volume of potassium in the solution. 21. The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? a. Respiratory acidosis from inadequate ventilation b. Respiratory alkalosis from anxiety and hyperventilation c. Metabolic acidosis from calcium loss due to broken bones d. Metabolic alkalosis from taking analgesics containing base products 22. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription? a. Adding a dose of heparin sodium b. Holding the next dose of warfarin c. Increasing the next dose of warfarin d. Administering the next dose of warfarin 23. A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? a. "I will be sure to ask my client what his pain level is on a scale of 0 to 10." b. "I know that I should follow up after giving medication to make sure it is effective." c. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." d. "I know that pain in the older client might manifest as sleep disturbances or depression." 24. A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? a. 3 mg/dL (1.08 mmol/L) b. 15 mg/dL (5.4 mmol/L) c. 29 mg/dL (10.44 mmol/L) d. 35 mg/dL (12.6 mmol/L) 25. The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? a. Taking a rectal temperature for a client who has undergone nasal surgery b. Taking an oral temperature for a client with a cough and nasal congestion c. Taking an axillary temperature for a client who has just consumed hot coffee d. Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic 26. The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? a. Document the finding. b. Check the mother's heart rate. c. Notify the obstetrician (OB). d. Tell the client that the fetal heart rate is normal. 27. The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? a. "You will need to bottle-feed your newborn." b. "You will need to feed your newborn by nasogastric tube feeding." c. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." d. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding." 28. The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? a. Urinary output has increased. b. Dependent edema has resolved. c. Blood pressure reading is at the prenatal baseline. d. The client complains of a headache and blurred vision. 29. A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? a. "What can I do for you?" b. "Now you have an angel in heaven." c. "Don't worry, there is nothing you could have done to prevent this from happening." d. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience." 30. The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? a. Enlargement of the breasts b. Complaints of feeling hot when the room is cool c. Periods of fetal movement followed by quiet periods d. Evidence of bleeding, such as in the gums, petechiae, and purpura 31. The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. a. A primigravida with abruptio placenta b. A primigravida who delivered a 10-lb infant 3 hours ago c. A gravida 2 who has just been diagnosed with dead fetus syndrome d. A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood e. A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension 32. The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? a. Hypertension b. Low-grade fever c. Generalized edema d. Increased pulse rate 33. The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? a. "I will need to increase my insulin dosage during the first 3 months of pregnancy." b. "My insulin dose will likely need to be increased during the second and third trimesters." c. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." d. "My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding." 34. A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? a. Therapeutic abortion is required. b. Isoniazid plus rifampin will be required for 9 months. c. She will have to stay at home until treatment is completed. d. Medication will not be started until after delivery of the fetus. 35. The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? a. "I should increase my sodium intake during pregnancy." b. "I should lower my blood volume by limiting my fluids." c. "I should maintain a low-calorie diet to prevent any weight gain." d. "I should drink adequate fluids and increase my intake of high-fiber foods." 36. The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. a. The client has a history of intravenous drug use. b. The client has a significant other who is heterosexual. c. The client has a history of sexually transmitted infections. d. The client has had one sexual partner for the past 10 years. e. The client has a previous history of gestational diabetes mellitus. 37. The nurse evaluates the ability of a hepatitis B–positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? a. The mother requests that the window be closed before feeding. b. The mother holds the newborn properly during feeding and burping. c. The mother tests the temperature of the formula before initiating feeding. d. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. 38. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? a. "I will watch to see if I pass any tissue." b. "I will maintain strict bed rest throughout the remainder of the pregnancy." c. "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." d. "I will avoid sexual intercourse until the bleeding has stopped and for 2 weeks following the last episode of bleeding." 39. The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. a. Bed rest as a necessary preventive measure may be prescribed. b. Administration of subcutaneous heparin postdelivery as prescribed. c. An overbed lift may be necessary if the client requires a cesarean section. d. Less frequent cleansing of a cesarean incision, if present, may be prescribed. e. Thromboembolism stockings or sequential compression devices may be prescribed. 40. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? a. Soft abdomen b. Uterine tenderness c. Absence of abdominal pain d. Painless, bright red vaginal bleeding 41. The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? a. Prepare the client for an ultrasound. b. Obtain equipment for a manual pelvic examination. c. Prepare to draw a hemoglobin and hematocrit blood sample. d. Obtain equipment for external electronic fetal heart rate monitoring. 42. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? a. Delivery of the fetus b. Strict monitoring of intake and output c. Complete bed rest for the remainder of the pregnancy d. The need for weekly monitoring of coagulation studies until the time of delivery 43. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? a. Infection b. Hemorrhage c. Chronic hypertension d. Disseminated intravascular coagulation 44. The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. a. Uterine rigidity b. Uterine tenderness c. Severe abdominal pain d. Bright red vaginal bleeding e. Soft, relaxed, nontender uterus f. Fundal height may be greater than expected for gestational age 45. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? a. Hemoglobin of 11 g/dL (110 mmol/L) b. Fetal heart rate of 180 beats per minute c. Maternal pulse rate of 85 beats per minute d. White blood cell count of 12,000/mm3 (12 × 109/L) 46. The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? a. Variability b. Accelerations c. Early decelerations d. Variable decelerations 47. A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? a. Supine position with a wedge under the right hip b. Trendelenburg's position with the legs in stirrups c. Prone position with the legs separated and elevated d. Semi-Fowler's position with a pillow under the knees 48. The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate? a. Notify the primary health care provider (PHCP). b. Continue monitoring the fetal heart rate. c. Encourage the client to continue pushing with each contraction. d. Instruct the client's coach to continue to encourage breathing techniques. 49. Which assessment finding after an amniotomy should be conducted first? a. Cervical dilation b. Bladder distention c. Fetal heart rate pattern d. Maternal blood pressure 50. The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action? a. Notify the primary health care provider. b. Discontinue the infusion of oxytocin. c. Place oxygen on at 8 to 10 L/minute via face mask. d. Contact the client's primary support person(s) if not currently present.