ALVON
NCLEX PAST
1. A client is prescribed furosemide (Lasix). Which laboratory value requires priority
follow-up?
A. Sodium 139 mEq/L
B. Potassium 2.9 mEq/L
C. Magnesium 1.9 mg/dL
D. Calcium 9.1 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Hypokalemia is a dangerous side effect of loop diuretics like furosemide
and can lead to cardiac arrhythmias.
2. A nurse is caring for a client with a new colostomy. What is the priority nursing
diagnosis?
A. Risk for impaired skin integrity
B. Risk for infection
C. Disturbed body image
D. Impaired urinary elimination
Answer: A. Risk for impaired skin integrity
Rationale: Peristomal skin is at high risk for breakdown from fecal matter exposure.
3. A client with schizophrenia says, “The government is watching me.” What is the
best response by the nurse?
A. “That’s not true.”
B. “Tell me more about what you are thinking.”
,ALVON
C. “Why do you think that?”
D. “You’re just paranoid.”
Answer: B. “Tell me more about what you are thinking.”
Rationale: Encouraging the client to express feelings promotes therapeutic
communication without confirming or denying delusions.
4. Which action should the nurse take when administering a blood transfusion?
A. Infuse over 8 hours
B. Use a 16-gauge needle
C. Start with D5W
D. Check vital signs every 4 hours
Answer: B. Use a 16-gauge needle
Rationale: Large-bore needles reduce the risk of hemolysis. Normal saline (0.9% NS)
should be used, not D5W.
5. A pregnant client at 36 weeks reports a severe headache, visual changes, and
epigastric pain. What is the nurse’s priority action?
A. Perform a nonstress test
B. Assess deep tendon reflexes
C. Notify the health care provider immediately
D. Offer the client acetaminophen
Answer: C. Notify the health care provider immediately
Rationale: These symptoms suggest preeclampsia, a medical emergency requiring
immediate evaluation.
6. A 3-year-old is hospitalized with croup. What is the priority nursing intervention?
A. Administer oral antibiotics
B. Encourage fluids by mouth
C. Provide cool mist humidification
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D. Place in prone position
Answer: C. Provide cool mist humidification
Rationale: Cool mist helps reduce laryngeal inflammation and ease breathing.
7. A client is taking warfarin (Coumadin). Which instruction should the nurse
include?
A. “Eat more leafy green vegetables.”
B. “Use a soft toothbrush.”
C. “Avoid all dairy products.”
D. “You will not need regular blood tests.”
Answer: B. “Use a soft toothbrush.”
Rationale: Clients on anticoagulants should avoid anything that may cause bleeding.
Vitamin K (leafy greens) intake should be consistent, not avoided entirely.
8. A post-op client’s wound eviscerates. What is the nurse’s priority action?
A. Push organs back in
B. Cover with dry gauze
C. Place client in high Fowler’s
D. Cover with sterile saline-soaked gauze
Answer: D. Cover with sterile saline-soaked gauze
Rationale: Moist dressings prevent tissue drying until surgery.
9. A client is prescribed lithium. Which finding requires immediate action?
A. Tremors
B. Nausea
C. Diarrhea
D. Slurred speech
Answer: D. Slurred speech
, ALVON
Rationale: Signs of lithium toxicity include slurred speech, ataxia, and confusion.
Normal side effects include mild tremors or GI upset.
10. A nurse finds a patient on the floor, not breathing, and without a pulse. What is
the first action?
A. Start chest compressions
B. Check the client’s airway
C. Call the rapid response team
D. Check for responsiveness
Answer: D. Check for responsiveness
Rationale: According to BLS protocol, confirm unresponsiveness before initiating
CPR.11. A nurse is caring for a client who is receiving total parenteral nutrition (TPN).
Which laboratory value requires immediate intervention?
A. Glucose: 250 mg/dL
B. Sodium: 138 mEq/L
C. Potassium: 4.0 mEq/L
D. Chloride: 100 mEq/L
Answer: A. Glucose: 250 mg/dL
Rationale: TPN can cause hyperglycemia, especially when newly initiated. A glucose
level >200 should be reported.
12. A client is admitted with myasthenia gravis. What is the nurse’s priority
assessment?
A. Muscle cramps
B. Reflexes
C. Respiratory status
D. Vision loss
Answer: C. Respiratory status
NCLEX PAST
1. A client is prescribed furosemide (Lasix). Which laboratory value requires priority
follow-up?
A. Sodium 139 mEq/L
B. Potassium 2.9 mEq/L
C. Magnesium 1.9 mg/dL
D. Calcium 9.1 mg/dL
Answer: B. Potassium 2.9 mEq/L
Rationale: Hypokalemia is a dangerous side effect of loop diuretics like furosemide
and can lead to cardiac arrhythmias.
2. A nurse is caring for a client with a new colostomy. What is the priority nursing
diagnosis?
A. Risk for impaired skin integrity
B. Risk for infection
C. Disturbed body image
D. Impaired urinary elimination
Answer: A. Risk for impaired skin integrity
Rationale: Peristomal skin is at high risk for breakdown from fecal matter exposure.
3. A client with schizophrenia says, “The government is watching me.” What is the
best response by the nurse?
A. “That’s not true.”
B. “Tell me more about what you are thinking.”
,ALVON
C. “Why do you think that?”
D. “You’re just paranoid.”
Answer: B. “Tell me more about what you are thinking.”
Rationale: Encouraging the client to express feelings promotes therapeutic
communication without confirming or denying delusions.
4. Which action should the nurse take when administering a blood transfusion?
A. Infuse over 8 hours
B. Use a 16-gauge needle
C. Start with D5W
D. Check vital signs every 4 hours
Answer: B. Use a 16-gauge needle
Rationale: Large-bore needles reduce the risk of hemolysis. Normal saline (0.9% NS)
should be used, not D5W.
5. A pregnant client at 36 weeks reports a severe headache, visual changes, and
epigastric pain. What is the nurse’s priority action?
A. Perform a nonstress test
B. Assess deep tendon reflexes
C. Notify the health care provider immediately
D. Offer the client acetaminophen
Answer: C. Notify the health care provider immediately
Rationale: These symptoms suggest preeclampsia, a medical emergency requiring
immediate evaluation.
6. A 3-year-old is hospitalized with croup. What is the priority nursing intervention?
A. Administer oral antibiotics
B. Encourage fluids by mouth
C. Provide cool mist humidification
,ALVON
D. Place in prone position
Answer: C. Provide cool mist humidification
Rationale: Cool mist helps reduce laryngeal inflammation and ease breathing.
7. A client is taking warfarin (Coumadin). Which instruction should the nurse
include?
A. “Eat more leafy green vegetables.”
B. “Use a soft toothbrush.”
C. “Avoid all dairy products.”
D. “You will not need regular blood tests.”
Answer: B. “Use a soft toothbrush.”
Rationale: Clients on anticoagulants should avoid anything that may cause bleeding.
Vitamin K (leafy greens) intake should be consistent, not avoided entirely.
8. A post-op client’s wound eviscerates. What is the nurse’s priority action?
A. Push organs back in
B. Cover with dry gauze
C. Place client in high Fowler’s
D. Cover with sterile saline-soaked gauze
Answer: D. Cover with sterile saline-soaked gauze
Rationale: Moist dressings prevent tissue drying until surgery.
9. A client is prescribed lithium. Which finding requires immediate action?
A. Tremors
B. Nausea
C. Diarrhea
D. Slurred speech
Answer: D. Slurred speech
, ALVON
Rationale: Signs of lithium toxicity include slurred speech, ataxia, and confusion.
Normal side effects include mild tremors or GI upset.
10. A nurse finds a patient on the floor, not breathing, and without a pulse. What is
the first action?
A. Start chest compressions
B. Check the client’s airway
C. Call the rapid response team
D. Check for responsiveness
Answer: D. Check for responsiveness
Rationale: According to BLS protocol, confirm unresponsiveness before initiating
CPR.11. A nurse is caring for a client who is receiving total parenteral nutrition (TPN).
Which laboratory value requires immediate intervention?
A. Glucose: 250 mg/dL
B. Sodium: 138 mEq/L
C. Potassium: 4.0 mEq/L
D. Chloride: 100 mEq/L
Answer: A. Glucose: 250 mg/dL
Rationale: TPN can cause hyperglycemia, especially when newly initiated. A glucose
level >200 should be reported.
12. A client is admitted with myasthenia gravis. What is the nurse’s priority
assessment?
A. Muscle cramps
B. Reflexes
C. Respiratory status
D. Vision loss
Answer: C. Respiratory status
