1
NCLEX RN EXAM 2025 BRAND NEW
ACTUAL EXAM TEST BANK
COMPLETE 800 QUESTIONS WITH
DETAILED VERIFIED ANSWERS AND
RATIONALES (VERSION A AND B)
/A+ STUDY MATERIAL // BRAND
NEW!!
VERSION A
The nurse is admitting a client who is diagnosed with
syndrome of inappropriate antidiuretic hormone secretion
(SIADH) and has serum sodium of 118 mEq/L (118
mmol/L). Which primary health care provider
1
, 2
prescriptions should the nurse anticipate receiving? Select
all that apply.
A. Initiate an infusion of 3% NaCl.
B. Administer intravenous furosemide.
C. Restrict fluids to 800 mL over 24 hours.
D. Elevate the head of the bed to high-Fowler's.
E. Administer a vasopressin antagonist as prescribed. -
....ANSWER...A, C, E
Rationale:
Clients with SIADH experience excess secretion of
antidiuretic hormone (ADH), which leads to excess
intravascular volume, a declining serum osmolarity, and
dilutional hyponatremia. Management is directed at
correcting the hyponatremia and preventing cerebral
edema. Hypertonic saline is prescribed when the
hyponatremia is severe, less than 120 mEq/L (120
mmol/L). When furosemide is used, potassium
supplementation should also occur and serum potassium
levels should be monitored. To promote venous return, the
head of the bed should not be raised more than 10 degrees
for the client with SIADH. Maximizing venous return
2
, 3
helps avoid stimulating stretch receptors in the heart that
signal to the pituitary that more ADH is needed.
A client is admitted to an emergency department, and a
diagnosis of myxedema coma is made. Which action
should the nurse prepare to carry out initially?
A. Warm the client.
B. Maintain a patent airway.
C. Administer thyroid hormone.
D. Administer fluid replacement. - ....ANSWER...B
Rationale:
Myxedema coma is a rare but serious disorder that results
from persistently low thyroid production. Coma can be
precipitated by acute illness, rapid withdrawal of thyroid
medication, anesthesia and surgery, hypothermia, and the
use of sedatives and opioid analgesics. In myxedema coma,
the initial nursing action is to maintain a patent airway.
Oxygen should be administered, followed by fluid
replacement, keeping the client warm, monitoring vital
signs, and administering thyroid hormones by the
intravenous route.
3
, 4
The nurse is caring for a client admitted to the emergency
department with diabetic ketoacidosis (DKA). In the
acute phase, the nurse plans for which priority
intervention?
A. Correct the acidosis.
B. Administer 5% dextrose intravenously.
C. Apply a monitor for an electrocardiogram.
D. Administer short-duration insulin intravenously. -
....ANSWER...D
Rationale:
Lack of insulin (absolute or relative) is the primary cause
of DKA. Treatment consists of insulin administration
(short- or rapid-acting), intravenous fluid administration
(normal saline initially, not 5% dextrose), and potassium
replacement, followed by correcting acidosis. Cardiac
monitoring is important due to alterations in potassium
levels associated with DKA and its treatment, but
applying an electrocardiogram monitor is not the priority
action.
4
NCLEX RN EXAM 2025 BRAND NEW
ACTUAL EXAM TEST BANK
COMPLETE 800 QUESTIONS WITH
DETAILED VERIFIED ANSWERS AND
RATIONALES (VERSION A AND B)
/A+ STUDY MATERIAL // BRAND
NEW!!
VERSION A
The nurse is admitting a client who is diagnosed with
syndrome of inappropriate antidiuretic hormone secretion
(SIADH) and has serum sodium of 118 mEq/L (118
mmol/L). Which primary health care provider
1
, 2
prescriptions should the nurse anticipate receiving? Select
all that apply.
A. Initiate an infusion of 3% NaCl.
B. Administer intravenous furosemide.
C. Restrict fluids to 800 mL over 24 hours.
D. Elevate the head of the bed to high-Fowler's.
E. Administer a vasopressin antagonist as prescribed. -
....ANSWER...A, C, E
Rationale:
Clients with SIADH experience excess secretion of
antidiuretic hormone (ADH), which leads to excess
intravascular volume, a declining serum osmolarity, and
dilutional hyponatremia. Management is directed at
correcting the hyponatremia and preventing cerebral
edema. Hypertonic saline is prescribed when the
hyponatremia is severe, less than 120 mEq/L (120
mmol/L). When furosemide is used, potassium
supplementation should also occur and serum potassium
levels should be monitored. To promote venous return, the
head of the bed should not be raised more than 10 degrees
for the client with SIADH. Maximizing venous return
2
, 3
helps avoid stimulating stretch receptors in the heart that
signal to the pituitary that more ADH is needed.
A client is admitted to an emergency department, and a
diagnosis of myxedema coma is made. Which action
should the nurse prepare to carry out initially?
A. Warm the client.
B. Maintain a patent airway.
C. Administer thyroid hormone.
D. Administer fluid replacement. - ....ANSWER...B
Rationale:
Myxedema coma is a rare but serious disorder that results
from persistently low thyroid production. Coma can be
precipitated by acute illness, rapid withdrawal of thyroid
medication, anesthesia and surgery, hypothermia, and the
use of sedatives and opioid analgesics. In myxedema coma,
the initial nursing action is to maintain a patent airway.
Oxygen should be administered, followed by fluid
replacement, keeping the client warm, monitoring vital
signs, and administering thyroid hormones by the
intravenous route.
3
, 4
The nurse is caring for a client admitted to the emergency
department with diabetic ketoacidosis (DKA). In the
acute phase, the nurse plans for which priority
intervention?
A. Correct the acidosis.
B. Administer 5% dextrose intravenously.
C. Apply a monitor for an electrocardiogram.
D. Administer short-duration insulin intravenously. -
....ANSWER...D
Rationale:
Lack of insulin (absolute or relative) is the primary cause
of DKA. Treatment consists of insulin administration
(short- or rapid-acting), intravenous fluid administration
(normal saline initially, not 5% dextrose), and potassium
replacement, followed by correcting acidosis. Cardiac
monitoring is important due to alterations in potassium
levels associated with DKA and its treatment, but
applying an electrocardiogram monitor is not the priority
action.
4
