NCLEX Mastery Volume 9 – 100 Practice
Questions with Rationales.
Q1. A 72-year-old with atrial fibrillation is admitted with left-arm weakness that began 30
minutes ago. Which is the nurse’s first action?
A) Administer aspirin per protocol
B) Obtain CT of head STAT
C) Start heparin infusion
D) Give tissue plasminogen activator (tPA) immediately
Answer: B) Obtain CT of head STAT
Rationale: CT is required first to differentiate ischemic vs hemorrhagic stroke before
reperfusion therapy.
Q2 (SATA). Which tasks may be delegated to a UAP for a stable med-surg patient? (Select all
that apply.)
A) Measure and record intake and output
B) Assist with ambulation to bathroom
C) Teach a new diabetic how to inject insulin
D) Obtain routine vital signs
Answer: A, B, D
Rationale: UAPs can collect data and assist with ADLs; teaching is an RN responsibility.
Q3. A client on warfarin has INR 5.6 and is asymptomatic. Which action should the nurse take
first?
A) Give vitamin K per protocol and hold warfarin
B) Continue warfarin and retest in a week
C) Start low-molecular-weight heparin
D) Discharge with instructions to avoid green leafy vegetables
Answer: A) Give vitamin K per protocol and hold warfarin
Rationale: INR >5 increases bleeding risk; reversal and holding anticoagulant per policy is
required.
Q4. A patient receiving IV potassium reports burning at the IV site and the IV is infiltrated.
What is the immediate action?
A) Slow the infusion and continue monitoring
B) Stop the infusion and disconnect the IV
For expert assistance contact us on WhatsApp: +254700486651
,C) Apply heat and restart infusion in same site
D) Increase infusion rate to finish quickly
Answer: B) Stop the infusion and disconnect the IV
Rationale: Infiltrated potassium can cause tissue injury; stop immediately and follow
extravasation protocol.
Q5 (Prioritization). You have four patients: (1) chest pain 6/10, stable vitals; (2) postoperative
temp 101.8°F and purulent wound drainage; (3) newly admitted with acute confusion and
possible stroke; (4) routine med refill. Who to see first?
A) #1
B) #2
C) #3
D) #4
Answer: C) #3
Rationale: Acute neurological change potentially time-sensitive—assess for stroke first.
Q6 (SATA). A chemo patient with mucositis needs mouth care. Which are appropriate? (Select
all that apply.)
A) Use soft toothbrush or foam sponges
B) Rinse with warm saline frequently
C) Use commercial alcohol mouthwash for antisepsis
D) Avoid lemon glycerin swabs
Answer: A, B, D
Rationale: Gentle non-alcohol rinses and soft brushes help mucositis; alcohol and lemon
glycerin can irritate mucosa.
Q7. A post-op patient has a sudden drop in urine output to 10 mL/hr and BP 86/48. What is the
nurse’s first action?
A) Document; continue monitoring
B) Increase IV maintenance fluids per order or notify provider for bolus
C) Encourage oral fluid intake
D) Apply warm compress to extremities
Answer: B) Increase IV maintenance fluids per order or notify provider for bolus
Rationale: Oliguria with hypotension suggests hypovolemia → restore perfusion urgently.
Q8. A ventilated patient’s ventilator alarms high-pressure and the patient becomes desaturated.
What should you check first?
A) Suction for airway secretions and inspect tubing for kink/displacement
For expert assistance contact us on WhatsApp: +254700486651
, B) Increase FiO₂ by 10% immediately
C) Disconnect the ventilator and place on T-piece without checking tube
D) Administer bronchodilator via nebulizer
Answer: A) Suction for airway secretions and inspect tubing for kink/displacement
Rationale: High pressure is often due to obstruction (secretions, kink); suction and tubing
check are immediate.
Q9 (SATA). A client with CHF is discharged on furosemide, lisinopril, and spironolactone.
What teaching points should you include? (Select all that apply.)
A) Monitor daily weights and report rapid gains
B) Use salt substitutes liberally (potassium chloride)
C) Rise slowly to avoid dizziness
D) Report muscle weakness or palpitations
Answer: A, C, D
Rationale: Daily weights, orthostatic precautions, and reporting
hypokalemia/hyperkalemia symptoms are vital; avoid K⁺ salt substitutes with K-sparing
meds.
Q10. A postpartum patient has a boggy fundus and heavy bleeding. What is the first nursing
action?
A) Massage the uterus firmly
B) Insert Foley catheter
C) Call the provider and await orders
D) Apply ice packs to abdomen
Answer: A) Massage the uterus firmly
Rationale: Uterine atony is most common cause of postpartum hemorrhage—massage to
promote contraction immediately.
Q11 (SATA). Which measures reduce ventilator-associated pneumonia risk? (Select all that
apply.)
A) Elevate head of bed 30–45°
B) Daily sedation interruption and assessment for readiness to extubate
C) Routine prophylactic antibiotics for ventilated patients
D) Oral care with chlorhexidine
Answer: A, B, D
Rationale: Evidence supports HOB elevation, daily sedation vacation, and oral antiseptic
care; routine prophylactic antibiotics are not routinely recommended.
For expert assistance contact us on WhatsApp: +254700486651
Questions with Rationales.
Q1. A 72-year-old with atrial fibrillation is admitted with left-arm weakness that began 30
minutes ago. Which is the nurse’s first action?
A) Administer aspirin per protocol
B) Obtain CT of head STAT
C) Start heparin infusion
D) Give tissue plasminogen activator (tPA) immediately
Answer: B) Obtain CT of head STAT
Rationale: CT is required first to differentiate ischemic vs hemorrhagic stroke before
reperfusion therapy.
Q2 (SATA). Which tasks may be delegated to a UAP for a stable med-surg patient? (Select all
that apply.)
A) Measure and record intake and output
B) Assist with ambulation to bathroom
C) Teach a new diabetic how to inject insulin
D) Obtain routine vital signs
Answer: A, B, D
Rationale: UAPs can collect data and assist with ADLs; teaching is an RN responsibility.
Q3. A client on warfarin has INR 5.6 and is asymptomatic. Which action should the nurse take
first?
A) Give vitamin K per protocol and hold warfarin
B) Continue warfarin and retest in a week
C) Start low-molecular-weight heparin
D) Discharge with instructions to avoid green leafy vegetables
Answer: A) Give vitamin K per protocol and hold warfarin
Rationale: INR >5 increases bleeding risk; reversal and holding anticoagulant per policy is
required.
Q4. A patient receiving IV potassium reports burning at the IV site and the IV is infiltrated.
What is the immediate action?
A) Slow the infusion and continue monitoring
B) Stop the infusion and disconnect the IV
For expert assistance contact us on WhatsApp: +254700486651
,C) Apply heat and restart infusion in same site
D) Increase infusion rate to finish quickly
Answer: B) Stop the infusion and disconnect the IV
Rationale: Infiltrated potassium can cause tissue injury; stop immediately and follow
extravasation protocol.
Q5 (Prioritization). You have four patients: (1) chest pain 6/10, stable vitals; (2) postoperative
temp 101.8°F and purulent wound drainage; (3) newly admitted with acute confusion and
possible stroke; (4) routine med refill. Who to see first?
A) #1
B) #2
C) #3
D) #4
Answer: C) #3
Rationale: Acute neurological change potentially time-sensitive—assess for stroke first.
Q6 (SATA). A chemo patient with mucositis needs mouth care. Which are appropriate? (Select
all that apply.)
A) Use soft toothbrush or foam sponges
B) Rinse with warm saline frequently
C) Use commercial alcohol mouthwash for antisepsis
D) Avoid lemon glycerin swabs
Answer: A, B, D
Rationale: Gentle non-alcohol rinses and soft brushes help mucositis; alcohol and lemon
glycerin can irritate mucosa.
Q7. A post-op patient has a sudden drop in urine output to 10 mL/hr and BP 86/48. What is the
nurse’s first action?
A) Document; continue monitoring
B) Increase IV maintenance fluids per order or notify provider for bolus
C) Encourage oral fluid intake
D) Apply warm compress to extremities
Answer: B) Increase IV maintenance fluids per order or notify provider for bolus
Rationale: Oliguria with hypotension suggests hypovolemia → restore perfusion urgently.
Q8. A ventilated patient’s ventilator alarms high-pressure and the patient becomes desaturated.
What should you check first?
A) Suction for airway secretions and inspect tubing for kink/displacement
For expert assistance contact us on WhatsApp: +254700486651
, B) Increase FiO₂ by 10% immediately
C) Disconnect the ventilator and place on T-piece without checking tube
D) Administer bronchodilator via nebulizer
Answer: A) Suction for airway secretions and inspect tubing for kink/displacement
Rationale: High pressure is often due to obstruction (secretions, kink); suction and tubing
check are immediate.
Q9 (SATA). A client with CHF is discharged on furosemide, lisinopril, and spironolactone.
What teaching points should you include? (Select all that apply.)
A) Monitor daily weights and report rapid gains
B) Use salt substitutes liberally (potassium chloride)
C) Rise slowly to avoid dizziness
D) Report muscle weakness or palpitations
Answer: A, C, D
Rationale: Daily weights, orthostatic precautions, and reporting
hypokalemia/hyperkalemia symptoms are vital; avoid K⁺ salt substitutes with K-sparing
meds.
Q10. A postpartum patient has a boggy fundus and heavy bleeding. What is the first nursing
action?
A) Massage the uterus firmly
B) Insert Foley catheter
C) Call the provider and await orders
D) Apply ice packs to abdomen
Answer: A) Massage the uterus firmly
Rationale: Uterine atony is most common cause of postpartum hemorrhage—massage to
promote contraction immediately.
Q11 (SATA). Which measures reduce ventilator-associated pneumonia risk? (Select all that
apply.)
A) Elevate head of bed 30–45°
B) Daily sedation interruption and assessment for readiness to extubate
C) Routine prophylactic antibiotics for ventilated patients
D) Oral care with chlorhexidine
Answer: A, B, D
Rationale: Evidence supports HOB elevation, daily sedation vacation, and oral antiseptic
care; routine prophylactic antibiotics are not routinely recommended.
For expert assistance contact us on WhatsApp: +254700486651
