NCLEX Mastery Volume 2 – 100 Practice
Questions with Rationales.
1.
A client with pneumonia is receiving IV antibiotics. Which finding indicates the treatment is
effective?
A) White blood cell count 15,000/mm³
B) Temperature 37.2°C (99°F)
C) Productive cough with green sputum
D) Oxygen saturation 88%
Answer: B) Temperature 37.2°C (99°F)
Rationale: A normalizing temperature shows improvement. The other findings indicate
infection or hypoxia.
2.
A nurse prepares to insert an indwelling urinary catheter. Which action prevents infection?
A) Wearing clean gloves during insertion
B) Lubricating the catheter tip with sterile water
C) Using sterile gloves and maintaining asepsis
D) Anchoring the catheter to the inner thigh
Answer: C) Using sterile gloves and maintaining asepsis
Rationale: Catheter insertion requires strict aseptic technique to prevent urinary tract
infections.
3.
A client with type 1 diabetes is sweating, anxious, and has tremors. Which intervention is
priority?
A) Administer insulin subcutaneously
B) Give orange juice
C) Notify the provider
D) Start an IV infusion of normal saline
Answer: B) Give orange juice
Rationale: The client is hypoglycemic; fast-acting carbohydrates are the immediate
treatment.
For expert assistance contact us on WhatsApp: +254700486651
,4.
Which action is appropriate when caring for a client with a chest tube?
A) Clamp the tube to check for air leaks
B) Keep the drainage system below chest level
C) Empty the drainage chamber every shift
D) Strip the tubing to maintain patency
Answer: B) Keep the drainage system below chest level
Rationale: This prevents backflow of fluid into the pleural space. Stripping and clamping
increase risks.
5.
A nurse receives a client from PACU who is drowsy but arousable. What is the priority
assessment?
A) Surgical dressing
B) Blood pressure
C) Airway and breathing
D) Urine output
Answer: C) Airway and breathing
Rationale: Airway and breathing always take priority postoperatively.
6.
A client with chronic kidney disease has serum potassium of 6.2 mEq/L. Which order should the
nurse question?
A) Administer sodium polystyrene sulfonate
B) Provide low-potassium diet
C) Administer spironolactone
D) Monitor cardiac rhythm
Answer: C) Administer spironolactone
Rationale: Spironolactone is potassium-sparing and contraindicated in hyperkalemia.
7.
Which finding requires immediate intervention in a client receiving a blood transfusion?
A) Temperature rise of 0.5°C
B) Mild headache
C) Back pain and dark urine
D) Sore throat after infusion
For expert assistance contact us on WhatsApp: +254700486651
,Answer: C) Back pain and dark urine
Rationale: These are signs of acute hemolytic transfusion reaction, a medical emergency.
8.
A client is prescribed lithium for bipolar disorder. Which statement indicates a need for further
teaching?
A) “I should drink 2–3 liters of fluid daily.”
B) “I will avoid low-sodium diets.”
C) “I can take ibuprofen for headaches.”
D) “I will have regular blood tests.”
Answer: C) “I can take ibuprofen for headaches.”
Rationale: NSAIDs increase lithium toxicity. Acetaminophen is safer.
9.
The nurse cares for a client with a tracheostomy. Which intervention is priority?
A) Suction every 4 hours routinely
B) Keep an obturator and spare tracheostomy tube at bedside
C) Deflate the cuff when giving oral fluids
D) Perform deep suctioning for at least 30 seconds
Answer: B) Keep an obturator and spare tracheostomy tube at bedside
Rationale: This ensures immediate replacement if accidental decannulation occurs.
10.
Which client should the nurse assess first?
A) Asthma client with wheezes and O₂ sat 92%
B) Post-op client with pain level 8/10
C) COPD client with clubbing of fingers
D) Heart failure client with 1+ ankle edema
Answer: A) Asthma client with wheezes and O₂ sat 92%
Rationale: Airway and breathing are priority; this client is at risk of acute distress.
11.
A postoperative client who had abdominal surgery reports sudden shortness of breath and
pleuritic chest pain while ambulating. The client is tachycardic and has unilateral calf swelling.
What should the nurse suspect and do first?
A) Atelectasis; encourage deep breathing
B) Pulmonary embolism; call for immediate evaluation and give oxygen
For expert assistance contact us on WhatsApp: +254700486651
, C) Myocardial infarction; obtain a 12-lead ECG
D) Pneumonia; start antibiotics
Answer: B) Pulmonary embolism; call for immediate evaluation and give oxygen
Rationale: Sudden dyspnea, pleuritic pain, tachycardia, and unilateral calf swelling suggest
PE — urgent oxygenation and evaluation required.
12.
A client with chronic heart failure is placed on a low-sodium diet and furosemide. The client
complains of muscle weakness and palpitations. Which lab should the nurse check first?
A) Serum magnesium
B) Serum sodium
C) Serum potassium
D) Serum calcium
Answer: C) Serum potassium
Rationale: Loop diuretics cause potassium wasting; hypokalemia can cause muscle
weakness and palpitations.
13.
A diabetic client is admitted with confusion and fruity breath; glucose is 420 mg/dL, and urine
ketones are positive. Which condition is most likely and what is initial nursing priority?
A) Hyperosmolar hyperglycemic state; give oral glucose
B) Diabetic ketoacidosis; start IV fluids and insulin therapy per protocol
C) Hypoglycemia; give IV dextrose
D) Lactic acidosis; administer sodium bicarbonate
Answer: B) Diabetic ketoacidosis; start IV fluids and insulin therapy per protocol
Rationale: High glucose + ketones + fruity breath indicate DKA; initial treatment includes
fluid resuscitation and insulin.
14.
A client on warfarin therapy presents with new bruising and an INR of 5.8. Which action should
the nurse expect?
A) Continue current dose and recheck in 2 weeks
B) Administer vitamin K as ordered and hold warfarin
C) Increase warfarin dose to stabilize INR
D) Start aspirin concomitantly
Answer: B) Administer vitamin K as ordered and hold warfarin
Rationale: High INR with bleeding risk warrants reversal (vitamin K) and holding
warfarin per protocol.
For expert assistance contact us on WhatsApp: +254700486651
Questions with Rationales.
1.
A client with pneumonia is receiving IV antibiotics. Which finding indicates the treatment is
effective?
A) White blood cell count 15,000/mm³
B) Temperature 37.2°C (99°F)
C) Productive cough with green sputum
D) Oxygen saturation 88%
Answer: B) Temperature 37.2°C (99°F)
Rationale: A normalizing temperature shows improvement. The other findings indicate
infection or hypoxia.
2.
A nurse prepares to insert an indwelling urinary catheter. Which action prevents infection?
A) Wearing clean gloves during insertion
B) Lubricating the catheter tip with sterile water
C) Using sterile gloves and maintaining asepsis
D) Anchoring the catheter to the inner thigh
Answer: C) Using sterile gloves and maintaining asepsis
Rationale: Catheter insertion requires strict aseptic technique to prevent urinary tract
infections.
3.
A client with type 1 diabetes is sweating, anxious, and has tremors. Which intervention is
priority?
A) Administer insulin subcutaneously
B) Give orange juice
C) Notify the provider
D) Start an IV infusion of normal saline
Answer: B) Give orange juice
Rationale: The client is hypoglycemic; fast-acting carbohydrates are the immediate
treatment.
For expert assistance contact us on WhatsApp: +254700486651
,4.
Which action is appropriate when caring for a client with a chest tube?
A) Clamp the tube to check for air leaks
B) Keep the drainage system below chest level
C) Empty the drainage chamber every shift
D) Strip the tubing to maintain patency
Answer: B) Keep the drainage system below chest level
Rationale: This prevents backflow of fluid into the pleural space. Stripping and clamping
increase risks.
5.
A nurse receives a client from PACU who is drowsy but arousable. What is the priority
assessment?
A) Surgical dressing
B) Blood pressure
C) Airway and breathing
D) Urine output
Answer: C) Airway and breathing
Rationale: Airway and breathing always take priority postoperatively.
6.
A client with chronic kidney disease has serum potassium of 6.2 mEq/L. Which order should the
nurse question?
A) Administer sodium polystyrene sulfonate
B) Provide low-potassium diet
C) Administer spironolactone
D) Monitor cardiac rhythm
Answer: C) Administer spironolactone
Rationale: Spironolactone is potassium-sparing and contraindicated in hyperkalemia.
7.
Which finding requires immediate intervention in a client receiving a blood transfusion?
A) Temperature rise of 0.5°C
B) Mild headache
C) Back pain and dark urine
D) Sore throat after infusion
For expert assistance contact us on WhatsApp: +254700486651
,Answer: C) Back pain and dark urine
Rationale: These are signs of acute hemolytic transfusion reaction, a medical emergency.
8.
A client is prescribed lithium for bipolar disorder. Which statement indicates a need for further
teaching?
A) “I should drink 2–3 liters of fluid daily.”
B) “I will avoid low-sodium diets.”
C) “I can take ibuprofen for headaches.”
D) “I will have regular blood tests.”
Answer: C) “I can take ibuprofen for headaches.”
Rationale: NSAIDs increase lithium toxicity. Acetaminophen is safer.
9.
The nurse cares for a client with a tracheostomy. Which intervention is priority?
A) Suction every 4 hours routinely
B) Keep an obturator and spare tracheostomy tube at bedside
C) Deflate the cuff when giving oral fluids
D) Perform deep suctioning for at least 30 seconds
Answer: B) Keep an obturator and spare tracheostomy tube at bedside
Rationale: This ensures immediate replacement if accidental decannulation occurs.
10.
Which client should the nurse assess first?
A) Asthma client with wheezes and O₂ sat 92%
B) Post-op client with pain level 8/10
C) COPD client with clubbing of fingers
D) Heart failure client with 1+ ankle edema
Answer: A) Asthma client with wheezes and O₂ sat 92%
Rationale: Airway and breathing are priority; this client is at risk of acute distress.
11.
A postoperative client who had abdominal surgery reports sudden shortness of breath and
pleuritic chest pain while ambulating. The client is tachycardic and has unilateral calf swelling.
What should the nurse suspect and do first?
A) Atelectasis; encourage deep breathing
B) Pulmonary embolism; call for immediate evaluation and give oxygen
For expert assistance contact us on WhatsApp: +254700486651
, C) Myocardial infarction; obtain a 12-lead ECG
D) Pneumonia; start antibiotics
Answer: B) Pulmonary embolism; call for immediate evaluation and give oxygen
Rationale: Sudden dyspnea, pleuritic pain, tachycardia, and unilateral calf swelling suggest
PE — urgent oxygenation and evaluation required.
12.
A client with chronic heart failure is placed on a low-sodium diet and furosemide. The client
complains of muscle weakness and palpitations. Which lab should the nurse check first?
A) Serum magnesium
B) Serum sodium
C) Serum potassium
D) Serum calcium
Answer: C) Serum potassium
Rationale: Loop diuretics cause potassium wasting; hypokalemia can cause muscle
weakness and palpitations.
13.
A diabetic client is admitted with confusion and fruity breath; glucose is 420 mg/dL, and urine
ketones are positive. Which condition is most likely and what is initial nursing priority?
A) Hyperosmolar hyperglycemic state; give oral glucose
B) Diabetic ketoacidosis; start IV fluids and insulin therapy per protocol
C) Hypoglycemia; give IV dextrose
D) Lactic acidosis; administer sodium bicarbonate
Answer: B) Diabetic ketoacidosis; start IV fluids and insulin therapy per protocol
Rationale: High glucose + ketones + fruity breath indicate DKA; initial treatment includes
fluid resuscitation and insulin.
14.
A client on warfarin therapy presents with new bruising and an INR of 5.8. Which action should
the nurse expect?
A) Continue current dose and recheck in 2 weeks
B) Administer vitamin K as ordered and hold warfarin
C) Increase warfarin dose to stabilize INR
D) Start aspirin concomitantly
Answer: B) Administer vitamin K as ordered and hold warfarin
Rationale: High INR with bleeding risk warrants reversal (vitamin K) and holding
warfarin per protocol.
For expert assistance contact us on WhatsApp: +254700486651
