NCLEX Mastery Volume 10 – 100 Practice
Questions with Rationales.
Q1. A nurse is caring for a client with COPD who reports increased shortness of breath and a
productive cough with green sputum. Which action should the nurse take first?
A) Administer the scheduled bronchodilator
B) Obtain a sputum culture
C) Assess oxygen saturation
D) Encourage fluid intake
Answer: C) Assess oxygen saturation
Rationale: Airway and oxygenation take priority in COPD exacerbation. Immediate
assessment guides further interventions.
Q2. A client is admitted after a stroke and has right-sided weakness. Which task is appropriate to
delegate to the UAP?
A) Assessing neurological status
B) Assisting with feeding
C) Performing a swallow evaluation
D) Administering oral medications
Answer: B) Assisting with feeding
Rationale: UAP can safely assist with ADLs. Assessment and medication administration
require licensed personnel.
Q3. A client with heart failure has a BNP of 950 pg/mL. Which symptom should the nurse assess
first?
A) Peripheral edema
B) Shortness of breath
C) Weight gain
D) Fatigue
Answer: B) Shortness of breath
Rationale: Respiratory compromise is most urgent; BNP elevation indicates fluid overload.
Q4. A client on warfarin presents with bruising and gum bleeding. Which lab should the nurse
review immediately?
A) Platelet count
B) PT/INR
C) aPTT
D) Hemoglobin
Answer: B) PT/INR
Rationale: Warfarin affects clotting via PT/INR. Elevated values indicate bleeding risk.
For expert assistance contact us on WhatsApp: +254700486651
,Q5. A client is prescribed vancomycin IV. Which lab should the nurse monitor closely?
A) AST/ALT
B) BUN/Creatinine
C) Hemoglobin
D) Platelet count
Answer: B) BUN/Creatinine
Rationale: Vancomycin is nephrotoxic; renal function must be monitored to adjust dosing.
Q6. Which interventions are appropriate for a client with C. difficile diarrhea? (Select all that
apply)
A) Contact precautions
B) Handwashing with soap and water
C) Administer antidiarrheal medication as needed
D) Place client in a private room
E) Use alcohol-based hand sanitizer exclusively
Answer: A, B, D
Rationale: C. difficile spores require soap/water handwashing and isolation. Antidiarrheals
can worsen infection.
Q7. A client with diabetes presents with fruity breath, nausea, and Kussmaul respirations. Which
action should the nurse take first?
A) Start IV insulin
B) Check blood glucose
C) Administer oral fluids
D) Call the provider
Answer: B) Check blood glucose
Rationale: Confirming hyperglycemia is critical to guide immediate interventions for
diabetic ketoacidosis.
Q8. A nurse is planning care for a client with neutropenia. Which instructions are most important?
A) Avoid crowds and sick contacts
B) Use soft-bristled toothbrush
C) Limit protein intake
D) Schedule daily baths
Answer: A) Avoid crowds and sick contacts
Rationale: Neutropenic clients are highly susceptible to infection; avoiding exposure is
priority.
Q9. A client is receiving morphine for postoperative pain and becomes drowsy with a respiratory
rate of 8/min. Which action should the nurse take first?
A) Stimulate the client to breathe
B) Administer naloxone
C) Increase oxygen flow
D) Call the provider
Answer: A) Stimulate the client to breathe
For expert assistance contact us on WhatsApp: +254700486651
, Rationale: Immediate airway support and stimulation come first; naloxone is next if no
response.
Q10. A client with chronic kidney disease has hyperkalemia. Which intervention should the
nurse anticipate first?
A) Administer loop diuretics
B) Administer insulin with glucose
C) Restrict potassium in diet
D) Start dialysis
Answer: B) Administer insulin with glucose
Rationale: Insulin shifts potassium into cells quickly, reducing risk of life-threatening
arrhythmias.
Q11. A client with acute pancreatitis reports severe epigastric pain radiating to the back. Which
action should the nurse take first?
A) Administer IV morphine as prescribed
B) Encourage oral intake of clear fluids
C) Assess vital signs and oxygen saturation
D) Notify the provider of pain
Answer: C) Assess vital signs and oxygen saturation
Rationale: Assessing for hemodynamic stability and respiratory status takes priority before
interventions.
Q12. A nurse is caring for a post-op client who develops sudden shortness of breath and chest
pain. Which action is the highest priority?
A) Administer oxygen
B) Obtain vital signs
C) Notify the provider
D) Prepare for anticoagulant therapy
Answer: A) Administer oxygen
Rationale: Airway and oxygenation are always the first priority in potential pulmonary
embolism.
Q13. A client with atrial fibrillation is on digoxin and presents with nausea, vomiting, and visual
disturbances. Which action should the nurse take first?
A) Hold the digoxin
B) Check apical pulse
C) Notify the provider
D) Obtain serum digoxin level
Answer: B) Check apical pulse
Rationale: Bradycardia may indicate digoxin toxicity; assessing pulse guides immediate
safety interventions.
Q14. A client with an NG tube develops abdominal distention and vomiting. Which intervention
should the nurse implement first?
A) Reposition the tube
For expert assistance contact us on WhatsApp: +254700486651
Questions with Rationales.
Q1. A nurse is caring for a client with COPD who reports increased shortness of breath and a
productive cough with green sputum. Which action should the nurse take first?
A) Administer the scheduled bronchodilator
B) Obtain a sputum culture
C) Assess oxygen saturation
D) Encourage fluid intake
Answer: C) Assess oxygen saturation
Rationale: Airway and oxygenation take priority in COPD exacerbation. Immediate
assessment guides further interventions.
Q2. A client is admitted after a stroke and has right-sided weakness. Which task is appropriate to
delegate to the UAP?
A) Assessing neurological status
B) Assisting with feeding
C) Performing a swallow evaluation
D) Administering oral medications
Answer: B) Assisting with feeding
Rationale: UAP can safely assist with ADLs. Assessment and medication administration
require licensed personnel.
Q3. A client with heart failure has a BNP of 950 pg/mL. Which symptom should the nurse assess
first?
A) Peripheral edema
B) Shortness of breath
C) Weight gain
D) Fatigue
Answer: B) Shortness of breath
Rationale: Respiratory compromise is most urgent; BNP elevation indicates fluid overload.
Q4. A client on warfarin presents with bruising and gum bleeding. Which lab should the nurse
review immediately?
A) Platelet count
B) PT/INR
C) aPTT
D) Hemoglobin
Answer: B) PT/INR
Rationale: Warfarin affects clotting via PT/INR. Elevated values indicate bleeding risk.
For expert assistance contact us on WhatsApp: +254700486651
,Q5. A client is prescribed vancomycin IV. Which lab should the nurse monitor closely?
A) AST/ALT
B) BUN/Creatinine
C) Hemoglobin
D) Platelet count
Answer: B) BUN/Creatinine
Rationale: Vancomycin is nephrotoxic; renal function must be monitored to adjust dosing.
Q6. Which interventions are appropriate for a client with C. difficile diarrhea? (Select all that
apply)
A) Contact precautions
B) Handwashing with soap and water
C) Administer antidiarrheal medication as needed
D) Place client in a private room
E) Use alcohol-based hand sanitizer exclusively
Answer: A, B, D
Rationale: C. difficile spores require soap/water handwashing and isolation. Antidiarrheals
can worsen infection.
Q7. A client with diabetes presents with fruity breath, nausea, and Kussmaul respirations. Which
action should the nurse take first?
A) Start IV insulin
B) Check blood glucose
C) Administer oral fluids
D) Call the provider
Answer: B) Check blood glucose
Rationale: Confirming hyperglycemia is critical to guide immediate interventions for
diabetic ketoacidosis.
Q8. A nurse is planning care for a client with neutropenia. Which instructions are most important?
A) Avoid crowds and sick contacts
B) Use soft-bristled toothbrush
C) Limit protein intake
D) Schedule daily baths
Answer: A) Avoid crowds and sick contacts
Rationale: Neutropenic clients are highly susceptible to infection; avoiding exposure is
priority.
Q9. A client is receiving morphine for postoperative pain and becomes drowsy with a respiratory
rate of 8/min. Which action should the nurse take first?
A) Stimulate the client to breathe
B) Administer naloxone
C) Increase oxygen flow
D) Call the provider
Answer: A) Stimulate the client to breathe
For expert assistance contact us on WhatsApp: +254700486651
, Rationale: Immediate airway support and stimulation come first; naloxone is next if no
response.
Q10. A client with chronic kidney disease has hyperkalemia. Which intervention should the
nurse anticipate first?
A) Administer loop diuretics
B) Administer insulin with glucose
C) Restrict potassium in diet
D) Start dialysis
Answer: B) Administer insulin with glucose
Rationale: Insulin shifts potassium into cells quickly, reducing risk of life-threatening
arrhythmias.
Q11. A client with acute pancreatitis reports severe epigastric pain radiating to the back. Which
action should the nurse take first?
A) Administer IV morphine as prescribed
B) Encourage oral intake of clear fluids
C) Assess vital signs and oxygen saturation
D) Notify the provider of pain
Answer: C) Assess vital signs and oxygen saturation
Rationale: Assessing for hemodynamic stability and respiratory status takes priority before
interventions.
Q12. A nurse is caring for a post-op client who develops sudden shortness of breath and chest
pain. Which action is the highest priority?
A) Administer oxygen
B) Obtain vital signs
C) Notify the provider
D) Prepare for anticoagulant therapy
Answer: A) Administer oxygen
Rationale: Airway and oxygenation are always the first priority in potential pulmonary
embolism.
Q13. A client with atrial fibrillation is on digoxin and presents with nausea, vomiting, and visual
disturbances. Which action should the nurse take first?
A) Hold the digoxin
B) Check apical pulse
C) Notify the provider
D) Obtain serum digoxin level
Answer: B) Check apical pulse
Rationale: Bradycardia may indicate digoxin toxicity; assessing pulse guides immediate
safety interventions.
Q14. A client with an NG tube develops abdominal distention and vomiting. Which intervention
should the nurse implement first?
A) Reposition the tube
For expert assistance contact us on WhatsApp: +254700486651
