NCLEX Mastery Volume 4 – 100 Practice
Questions with Rationales.
1.
A nurse is caring for a client with pneumonia who has a temperature of 103°F (39.4°C). Which
intervention is most important?
A) Offer warm blankets
B) Encourage increased oral fluids
C) Restrict physical activity completely
D) Place client on a cooling mattress
Answer: B) Encourage increased oral fluids
Rationale: Hydration helps reduce fever and prevent dehydration from insensible fluid loss.
2.
A client with diabetes mellitus reports dizziness, sweating, and tremors. What is the nurse’s
priority action?
A) Check the client’s temperature
B) Obtain a blood glucose level
C) Administer insulin
D) Call the provider immediately
Answer: B) Obtain a blood glucose level
Rationale: These are symptoms of hypoglycemia; confirm with glucose measurement
before intervention.
3.
The nurse administers furosemide. Which finding requires immediate follow-up?
A) Serum potassium 3.0 mEq/L
B) Blood pressure 120/70 mmHg
C) Output 1500 mL in 24 hours
D) Weight loss of 1 kg in a week
Answer: A) Serum potassium 3.0 mEq/L
Rationale: Hypokalemia can cause life-threatening arrhythmias and must be corrected.
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,4.
A nurse cares for a client 2 hours after a total hip replacement. Which action is appropriate?
A) Keep legs adducted tightly
B) Place a pillow between legs
C) Flex hip beyond 90 degrees
D) Place client in low Fowler’s position
Answer: B) Place a pillow between legs
Rationale: Prevents hip dislocation by maintaining abduction.
5.
Which client should the nurse see first?
A) Client on warfarin with INR of 4.5
B) Client with mild constipation
C) Client with blood glucose of 110 mg/dL
D) Client with blood pressure of 138/82 mmHg
Answer: A) Client on warfarin with INR of 4.5
Rationale: Elevated INR indicates high risk of bleeding, requiring urgent evaluation.
6.
A nurse is reinforcing teaching for a client prescribed nitroglycerin. Which statement indicates
correct understanding?
A) “I should chew the tablet for faster effect.”
B) “I will place the tablet under my tongue at the first sign of chest pain.”
C) “I can take it with food to prevent stomach upset.”
D) “I will stop taking it if I get a headache.”
Answer: B) “I will place the tablet under my tongue at the first sign of chest pain.”
Rationale: Sublingual administration provides rapid absorption. Headache is a common
side effect.
7.
A nurse observes a client with schizophrenia talking to themselves and laughing. What is the best
initial response?
A) “Stop laughing, there is nothing funny.”
B) “Are you hearing voices right now?”
C) “You need to take your medication now.”
D) “That behavior is inappropriate.”
For expert assistance contact us on WhatsApp: +254700486651
, Answer: B) “Are you hearing voices right now?”
Rationale: Assessing hallucinations promotes safety and therapeutic communication.
8.
Which newborn assessment requires immediate intervention?
A) Irregular respirations of 40/min
B) Acrocyanosis of hands and feet
C) Grunting with nasal flaring
D) Overlapping sutures of skull
Answer: C) Grunting with nasal flaring
Rationale: Signs of respiratory distress that require urgent evaluation.
9.
A nurse cares for a client post-thyroidectomy. Which finding is most concerning?
A) Voice hoarseness
B) Sore throat
C) Difficulty swallowing and stridor
D) Mild neck pain
Answer: C) Difficulty swallowing and stridor
Rationale: Suggests airway obstruction, which is a medical emergency.
10.
A client with chronic kidney disease is prescribed epoetin alfa. Which lab should the nurse
review first?
A) Platelet count
B) Hemoglobin level
C) Serum creatinine
D) White blood cell count
Answer: B) Hemoglobin level
Rationale: Epoetin increases hemoglobin; if >11 g/dL, risk of stroke increases.
11.
A client is prescribed lithium for bipolar disorder. Which finding requires immediate
intervention?
A) Fine hand tremor
For expert assistance contact us on WhatsApp: +254700486651
Questions with Rationales.
1.
A nurse is caring for a client with pneumonia who has a temperature of 103°F (39.4°C). Which
intervention is most important?
A) Offer warm blankets
B) Encourage increased oral fluids
C) Restrict physical activity completely
D) Place client on a cooling mattress
Answer: B) Encourage increased oral fluids
Rationale: Hydration helps reduce fever and prevent dehydration from insensible fluid loss.
2.
A client with diabetes mellitus reports dizziness, sweating, and tremors. What is the nurse’s
priority action?
A) Check the client’s temperature
B) Obtain a blood glucose level
C) Administer insulin
D) Call the provider immediately
Answer: B) Obtain a blood glucose level
Rationale: These are symptoms of hypoglycemia; confirm with glucose measurement
before intervention.
3.
The nurse administers furosemide. Which finding requires immediate follow-up?
A) Serum potassium 3.0 mEq/L
B) Blood pressure 120/70 mmHg
C) Output 1500 mL in 24 hours
D) Weight loss of 1 kg in a week
Answer: A) Serum potassium 3.0 mEq/L
Rationale: Hypokalemia can cause life-threatening arrhythmias and must be corrected.
For expert assistance contact us on WhatsApp: +254700486651
,4.
A nurse cares for a client 2 hours after a total hip replacement. Which action is appropriate?
A) Keep legs adducted tightly
B) Place a pillow between legs
C) Flex hip beyond 90 degrees
D) Place client in low Fowler’s position
Answer: B) Place a pillow between legs
Rationale: Prevents hip dislocation by maintaining abduction.
5.
Which client should the nurse see first?
A) Client on warfarin with INR of 4.5
B) Client with mild constipation
C) Client with blood glucose of 110 mg/dL
D) Client with blood pressure of 138/82 mmHg
Answer: A) Client on warfarin with INR of 4.5
Rationale: Elevated INR indicates high risk of bleeding, requiring urgent evaluation.
6.
A nurse is reinforcing teaching for a client prescribed nitroglycerin. Which statement indicates
correct understanding?
A) “I should chew the tablet for faster effect.”
B) “I will place the tablet under my tongue at the first sign of chest pain.”
C) “I can take it with food to prevent stomach upset.”
D) “I will stop taking it if I get a headache.”
Answer: B) “I will place the tablet under my tongue at the first sign of chest pain.”
Rationale: Sublingual administration provides rapid absorption. Headache is a common
side effect.
7.
A nurse observes a client with schizophrenia talking to themselves and laughing. What is the best
initial response?
A) “Stop laughing, there is nothing funny.”
B) “Are you hearing voices right now?”
C) “You need to take your medication now.”
D) “That behavior is inappropriate.”
For expert assistance contact us on WhatsApp: +254700486651
, Answer: B) “Are you hearing voices right now?”
Rationale: Assessing hallucinations promotes safety and therapeutic communication.
8.
Which newborn assessment requires immediate intervention?
A) Irregular respirations of 40/min
B) Acrocyanosis of hands and feet
C) Grunting with nasal flaring
D) Overlapping sutures of skull
Answer: C) Grunting with nasal flaring
Rationale: Signs of respiratory distress that require urgent evaluation.
9.
A nurse cares for a client post-thyroidectomy. Which finding is most concerning?
A) Voice hoarseness
B) Sore throat
C) Difficulty swallowing and stridor
D) Mild neck pain
Answer: C) Difficulty swallowing and stridor
Rationale: Suggests airway obstruction, which is a medical emergency.
10.
A client with chronic kidney disease is prescribed epoetin alfa. Which lab should the nurse
review first?
A) Platelet count
B) Hemoglobin level
C) Serum creatinine
D) White blood cell count
Answer: B) Hemoglobin level
Rationale: Epoetin increases hemoglobin; if >11 g/dL, risk of stroke increases.
11.
A client is prescribed lithium for bipolar disorder. Which finding requires immediate
intervention?
A) Fine hand tremor
For expert assistance contact us on WhatsApp: +254700486651
