NCLEX Mastery Volume 1 – 100 Practice
Questions with Rationales.
Q1. A nurse is caring for a client with heart failure who is receiving furosemide. Which
finding requires immediate intervention?
A) Blood pressure 118/76 mmHg
B) Serum potassium 2.9 mEq/L
C) 1+ pitting edema in ankles
D) Urine output 1500 mL/24 hr
Answer: B) Serum potassium 2.9 mEq/L
Rationale: Hypokalemia (<3.5 mEq/L) increases the risk of arrhythmias and is the priority
concern.
Q2. A client receiving morphine sulfate develops respiratory depression. Which medication
should the nurse prepare to administer?
A) Naloxone
B) Flumazenil
C) Protamine sulfate
D) Atropine
Answer: A) Naloxone
Rationale: Naloxone is the opioid antagonist that reverses respiratory depression caused by
opioids.
Q3. A nurse is reinforcing teaching with a client prescribed warfarin. Which statement
indicates understanding?
A) “I will increase intake of green leafy vegetables.”
B) “I should use an electric razor when shaving.”
C) “I will take aspirin if I have a headache.”
D) “I do not need blood tests while on this medication.”
Answer: B) “I should use an electric razor when shaving.”
Rationale: Warfarin increases bleeding risk; clients should use safety precautions like an
electric razor.
Q4. Which isolation precautions are appropriate for a client with tuberculosis?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions only
For expert assistance contact us on WhatsApp: +254700486651
,Answer: C) Airborne precautions
Rationale: TB requires airborne precautions including N95 mask and negative-pressure
room.
Q5. A nurse is reviewing lab results for a client receiving digoxin. Which finding indicates
risk for digoxin toxicity?
A) Sodium 142 mEq/L
B) Potassium 3.0 mEq/L
C) Digoxin level 1.5 ng/mL
D) Hemoglobin 13 g/dL
Answer: B) Potassium 3.0 mEq/L
Rationale: Hypokalemia increases sensitivity to digoxin and risk of toxicity.
Q6. A nurse finds a patient experiencing a tonic-clonic seizure. What is the nurse’s priority
action?
A) Insert a tongue blade
B) Restrain the patient’s arms
C) Turn the patient to the side
D) Give lorazepam IV
Answer: C) Turn the patient to the side
Rationale: Turning the patient prevents aspiration; airway and safety take precedence.
Q7. A client with type 1 diabetes is sweating, shaky, and has blood glucose of 52 mg/dL.
What is the nurse’s first action?
A) Notify the provider
B) Give 4 oz orange juice
C) Start IV dextrose
D) Check urine ketones
Answer: B) Give 4 oz orange juice
Rationale: For mild hypoglycemia in a conscious patient, give fast-acting oral
carbohydrates.
Q8. A client with COPD is receiving oxygen at 6 L/min via nasal cannula. Which action
should the nurse take?
A) Maintain flow as ordered
B) Lower oxygen to 2 L/min
C) Switch to non-rebreather mask
D) Discontinue oxygen
For expert assistance contact us on WhatsApp: +254700486651
, Answer: B) Lower oxygen to 2 L/min
Rationale: High oxygen flow can suppress hypoxic respiratory drive in some COPD
patients; low flow (≤2 L/min) may be safer unless prescribed otherwise.
Q9. A nurse prepares to insert an indwelling urinary catheter in a female patient. Which
step is correct?
A) Place the catheter in the urethral opening, then inflate balloon immediately
B) Insert catheter until urine flows, then advance 2–3 inches more
C) Clean the perineum with circular motions from back to front
D) Touch the catheter with sterile gloves only after insertion
Answer: B) Insert catheter until urine flows, then advance 2–3 inches more
Rationale: Advancing a bit after urine return ensures the catheter is well within the
bladder before inflating the balloon.
Q10. Which finding in a post-op patient requires immediate intervention?
A) Pain score of 7/10
B) Small amount of serosanguinous drainage
C) Absent bowel sounds for 12 hours
D) Saturated dressing with bright red blood
Answer: D) Saturated dressing with bright red blood
Rationale: A saturated dressing with bright red blood suggests active hemorrhage and
requires immediate action.
Q11. A nurse is teaching a client with hypertension about diet. Which statement indicates
correct understanding?
A) “I will eat canned soups for convenience.”
B) “I will increase fresh fruits and vegetables.”
C) “I will use salt substitutes freely.”
D) “I will eat bacon daily for protein.”
Answer: B) “I will increase fresh fruits and vegetables.”
Rationale: Diets rich in fruits/vegetables and low sodium (DASH diet) help control
hypertension.
Q12. Which newborn assessment finding requires immediate intervention?
A) Capillary refill <2 seconds
B) Respiratory rate 28 breaths/min
C) Nasal flaring with grunting
D) Acrocyanosis of hands and feet
For expert assistance contact us on WhatsApp: +254700486651
Questions with Rationales.
Q1. A nurse is caring for a client with heart failure who is receiving furosemide. Which
finding requires immediate intervention?
A) Blood pressure 118/76 mmHg
B) Serum potassium 2.9 mEq/L
C) 1+ pitting edema in ankles
D) Urine output 1500 mL/24 hr
Answer: B) Serum potassium 2.9 mEq/L
Rationale: Hypokalemia (<3.5 mEq/L) increases the risk of arrhythmias and is the priority
concern.
Q2. A client receiving morphine sulfate develops respiratory depression. Which medication
should the nurse prepare to administer?
A) Naloxone
B) Flumazenil
C) Protamine sulfate
D) Atropine
Answer: A) Naloxone
Rationale: Naloxone is the opioid antagonist that reverses respiratory depression caused by
opioids.
Q3. A nurse is reinforcing teaching with a client prescribed warfarin. Which statement
indicates understanding?
A) “I will increase intake of green leafy vegetables.”
B) “I should use an electric razor when shaving.”
C) “I will take aspirin if I have a headache.”
D) “I do not need blood tests while on this medication.”
Answer: B) “I should use an electric razor when shaving.”
Rationale: Warfarin increases bleeding risk; clients should use safety precautions like an
electric razor.
Q4. Which isolation precautions are appropriate for a client with tuberculosis?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Standard precautions only
For expert assistance contact us on WhatsApp: +254700486651
,Answer: C) Airborne precautions
Rationale: TB requires airborne precautions including N95 mask and negative-pressure
room.
Q5. A nurse is reviewing lab results for a client receiving digoxin. Which finding indicates
risk for digoxin toxicity?
A) Sodium 142 mEq/L
B) Potassium 3.0 mEq/L
C) Digoxin level 1.5 ng/mL
D) Hemoglobin 13 g/dL
Answer: B) Potassium 3.0 mEq/L
Rationale: Hypokalemia increases sensitivity to digoxin and risk of toxicity.
Q6. A nurse finds a patient experiencing a tonic-clonic seizure. What is the nurse’s priority
action?
A) Insert a tongue blade
B) Restrain the patient’s arms
C) Turn the patient to the side
D) Give lorazepam IV
Answer: C) Turn the patient to the side
Rationale: Turning the patient prevents aspiration; airway and safety take precedence.
Q7. A client with type 1 diabetes is sweating, shaky, and has blood glucose of 52 mg/dL.
What is the nurse’s first action?
A) Notify the provider
B) Give 4 oz orange juice
C) Start IV dextrose
D) Check urine ketones
Answer: B) Give 4 oz orange juice
Rationale: For mild hypoglycemia in a conscious patient, give fast-acting oral
carbohydrates.
Q8. A client with COPD is receiving oxygen at 6 L/min via nasal cannula. Which action
should the nurse take?
A) Maintain flow as ordered
B) Lower oxygen to 2 L/min
C) Switch to non-rebreather mask
D) Discontinue oxygen
For expert assistance contact us on WhatsApp: +254700486651
, Answer: B) Lower oxygen to 2 L/min
Rationale: High oxygen flow can suppress hypoxic respiratory drive in some COPD
patients; low flow (≤2 L/min) may be safer unless prescribed otherwise.
Q9. A nurse prepares to insert an indwelling urinary catheter in a female patient. Which
step is correct?
A) Place the catheter in the urethral opening, then inflate balloon immediately
B) Insert catheter until urine flows, then advance 2–3 inches more
C) Clean the perineum with circular motions from back to front
D) Touch the catheter with sterile gloves only after insertion
Answer: B) Insert catheter until urine flows, then advance 2–3 inches more
Rationale: Advancing a bit after urine return ensures the catheter is well within the
bladder before inflating the balloon.
Q10. Which finding in a post-op patient requires immediate intervention?
A) Pain score of 7/10
B) Small amount of serosanguinous drainage
C) Absent bowel sounds for 12 hours
D) Saturated dressing with bright red blood
Answer: D) Saturated dressing with bright red blood
Rationale: A saturated dressing with bright red blood suggests active hemorrhage and
requires immediate action.
Q11. A nurse is teaching a client with hypertension about diet. Which statement indicates
correct understanding?
A) “I will eat canned soups for convenience.”
B) “I will increase fresh fruits and vegetables.”
C) “I will use salt substitutes freely.”
D) “I will eat bacon daily for protein.”
Answer: B) “I will increase fresh fruits and vegetables.”
Rationale: Diets rich in fruits/vegetables and low sodium (DASH diet) help control
hypertension.
Q12. Which newborn assessment finding requires immediate intervention?
A) Capillary refill <2 seconds
B) Respiratory rate 28 breaths/min
C) Nasal flaring with grunting
D) Acrocyanosis of hands and feet
For expert assistance contact us on WhatsApp: +254700486651
