GRADE A+ nclex style questions with rationales 2025
A patient with glaucoma reports sudden eye pain and loss of
vision. What is the nurse's priority action?
C. Notify the healthcare provider immediately.
A. Reassess vision in 15 minutes.
Acute angle-closure glaucoma is a medical emergency that can
B. Administer prescribed eye drops.
cause permanent vision loss if not treated immediately.
C. Notify the healthcare provider immediately.
D. Document and continue monitoring.
The nurse is delegating care for a client with a feeding tube. Which
task is appropriate to assign to a UAP?
B. Position the client with the head of bed elevated at least 30
A. Check the residual volume.
degrees.
B. Position the client with the head of bed elevated at least 30
UAPs can assist with positioning to prevent aspiration, which is a
degrees.
safety concern.
C. Flush the feeding tube with water.
D. Adjust the feeding rate.
Which client should the nurse assess first?
A. A patient with presbycusis who reports difficulty hearing dis- A. A patient with presbycusis who reports difficulty hearing dis-
charge instructions. charge instructions.
B. A client with cataracts who uses glasses. Addressing communication barriers is a priority for safety and
C. A stable patient requesting water. understanding care instructions.
D. A patient waiting for discharge paperwork.
The nurse receives the following report. Which client should be
seen first?
D. A patient who had bariatric surgery and is reporting shoulder
A. A patient with a history of cataracts requesting glasses.
pain.
B. A patient who is 2 days post-op reporting fatigue.
Shoulder pain could be referred pain from an anastomotic leak, a
C. A patient who had clear liquids for lunch.
serious post-op complication.
D. A patient who had bariatric surgery and is reporting shoulder
pain.
Which task can the nurse delegate to an LPN/LVN?
A. Developing a teaching plan on nutrition. C. Administering enteral feedings to a stable patient.
B. Starting a new IV for TPN. LPNs can administer enteral feedings to stable patients but cannot
C. Administering enteral feedings to a stable patient. assess or create teaching plans.
D. Performing an initial assessment.
Which action by the nurse best promotes patient safety for a client
with peripheral neuropathy?
A. Assess the feet daily for signs of injury.
A. Assess the feet daily for signs of injury.
Peripheral neuropathy reduces sensation, increasing the risk of
B. Encourage barefoot walking at home.
unnoticed injuries.
C. Apply lotion between the toes.
D. Limit foot inspection to once per week.
A nurse is planning care for a client at risk of malnutrition. Which
intervention takes priority?
D. Assess the client's ability to swallow.
A. Offer protein shakes.
Swallowing difficulties increase the risk of aspiration and must be
B. Weigh the patient weekly.
assessed before feeding.
C. Encourage intake of fluids.
D. Assess the client's ability to swallow.
Which task should the nurse delegate to a UAP when caring for a
client with impaired vision?
B. Orienting the patient to the location of the call bell and personal
A. Feed the patient lunch.
items.
B. Orient the patient to the location of the call bell and personal
UAPs can help ensure the environment is safe and accessible,
items.
reducing fall risk.
C. Check pupillary response.
D. Evaluate visual acuity.
The nurse is reviewing orders for a client with stress-related
insomnia. Which action is the highest priority?
A. Ensure a quiet and dark environment during the night.
A. Administer a sleep aid.
A restful environment supports sleep and reduces the risk of
B. Offer caffeinated beverages.
further cognitive decline.
C. Leave a light on all night.
D. Ensure a quiet and dark environment during the night.
A nurse is caring for a client on a mechanical soft diet. What is the
priority safety intervention?
A. Encourage the patient to chew slowly.
1/9
, GRADE A+ nclex style questions with rationales 2025
B. Give thin liquids with meals. C. Monitor for choking during meals.
C. Monitor for choking during meals. Clients on soft diets may still have chewing or swallowing difficul-
D. Serve hard foods for stimulation. ties, putting them at risk for aspiration.
Which of the following clients requires immediate intervention by
the nurse?
B. A patient with new-onset confusion and disorientation.
A. A patient requesting a snack.
New-onset confusion could indicate acute illness such as infection
B. A patient with new-onset confusion and disorientation.
or stroke and needs prompt assessment.
C. A patient asking for pain meds.
D. A patient who is stable post-op.
A nurse is supervising a UAP assisting a visually impaired client
with ambulation. Which action requires intervention?
D. Walking several steps ahead of the patient.
A. Holding the patient's hand tightly while walking.
The UAP should walk slightly ahead and to the side, offering an
B. Standing directly behind the patient.
arm—not far ahead where guidance is lost.
C. Offering the patient a walker instead of a cane.
D. Walking several steps ahead of the patient.
Which patient care task should be assigned to an experienced
LPN?
A. Reinforcing dietary teaching for a patient with hypertension.
A. Performing an initial head-to-toe assessment.
LPNs can reinforce teaching initiated by RNs, especially on stable
B. Educating on medication side effects.
conditions like hypertension.
C. Reinforcing dietary teaching for a patient with hypertension.
D. Creating a care plan for a newly diagnosed diabetic.
A nurse observes a caregiver providing care to a client with
dementia. Which action requires immediate correction?
C. Leaving the client alone during meals.
A. Allowing the client to feed themselves.
Clients with dementia are at increased risk of choking and require
B. Placing the call light within reach.
supervision during meals.
C. Leaving the client alone during meals.
D. Encouraging the client to sit upright during meals.
Which intervention should be prioritized for a malnourished pa-
tient with dysphagia?
D. Consult the speech-language pathologist.
A. Encourage high-calorie snacks.
SLPs assess swallowing ability and recommend appropriate di-
B. Administer tube feeding.
etary modifications to prevent aspiration.
C. Offer fluids with meals.
D. Consult the speech-language pathologist.
A nurse is assigning tasks for the day. Which task is appropriate
for a UAP?
C. Measuring intake and output for a stable post-op patient. UAPs
A. Administer IV medications.
can measure and record I&O, which is a routine, non-complex
B. Evaluate dietary intake.
task.
C. Measuring intake and output for a stable post-op patient.
D. Develop a care plan.
Which patient is most at risk for injury and requires immediate fall
precautions?
A. An elderly patient with macular degeneration and unsteady gait.
A. A young adult with asthma requesting inhaler.
Visual impairment and mobility issues increase fall risk and require
B. A patient with arthritis requesting a cane.
immediate intervention.
C. A patient with visual impairment and unsteady gait.
D. A middle-aged patient asking for discharge instructions.
What is the priority action when a patient refuses to eat due to
taste changes from chemotherapy?
B. Offer flavorful, high-protein snacks the patient prefers. Tailoring
A. Explain the importance of eating despite the taste.
nutrition strategies to patient preferences can promote intake and
B. Offer flavorful, high-protein snacks the patient prefers.
prevent malnutrition.
C. Refer to psychiatry.
D. Request a feeding tube order.
Which of the following situations requires the RN to personally
assess the client before delegating further care?
D. A newly admitted client with a history of sleep apnea.
A. A patient who needs a flu shot.
New admissions must be assessed by the RN before any delega-
B. A patient scheduled for a routine lab draw.
tion occurs.
C. A patient requesting water.
D. A newly admitted client with a history of sleep apnea.
What is the priority safety action for a patient receiving enteral
feedings via PEG tube?
2/9
A patient with glaucoma reports sudden eye pain and loss of
vision. What is the nurse's priority action?
C. Notify the healthcare provider immediately.
A. Reassess vision in 15 minutes.
Acute angle-closure glaucoma is a medical emergency that can
B. Administer prescribed eye drops.
cause permanent vision loss if not treated immediately.
C. Notify the healthcare provider immediately.
D. Document and continue monitoring.
The nurse is delegating care for a client with a feeding tube. Which
task is appropriate to assign to a UAP?
B. Position the client with the head of bed elevated at least 30
A. Check the residual volume.
degrees.
B. Position the client with the head of bed elevated at least 30
UAPs can assist with positioning to prevent aspiration, which is a
degrees.
safety concern.
C. Flush the feeding tube with water.
D. Adjust the feeding rate.
Which client should the nurse assess first?
A. A patient with presbycusis who reports difficulty hearing dis- A. A patient with presbycusis who reports difficulty hearing dis-
charge instructions. charge instructions.
B. A client with cataracts who uses glasses. Addressing communication barriers is a priority for safety and
C. A stable patient requesting water. understanding care instructions.
D. A patient waiting for discharge paperwork.
The nurse receives the following report. Which client should be
seen first?
D. A patient who had bariatric surgery and is reporting shoulder
A. A patient with a history of cataracts requesting glasses.
pain.
B. A patient who is 2 days post-op reporting fatigue.
Shoulder pain could be referred pain from an anastomotic leak, a
C. A patient who had clear liquids for lunch.
serious post-op complication.
D. A patient who had bariatric surgery and is reporting shoulder
pain.
Which task can the nurse delegate to an LPN/LVN?
A. Developing a teaching plan on nutrition. C. Administering enteral feedings to a stable patient.
B. Starting a new IV for TPN. LPNs can administer enteral feedings to stable patients but cannot
C. Administering enteral feedings to a stable patient. assess or create teaching plans.
D. Performing an initial assessment.
Which action by the nurse best promotes patient safety for a client
with peripheral neuropathy?
A. Assess the feet daily for signs of injury.
A. Assess the feet daily for signs of injury.
Peripheral neuropathy reduces sensation, increasing the risk of
B. Encourage barefoot walking at home.
unnoticed injuries.
C. Apply lotion between the toes.
D. Limit foot inspection to once per week.
A nurse is planning care for a client at risk of malnutrition. Which
intervention takes priority?
D. Assess the client's ability to swallow.
A. Offer protein shakes.
Swallowing difficulties increase the risk of aspiration and must be
B. Weigh the patient weekly.
assessed before feeding.
C. Encourage intake of fluids.
D. Assess the client's ability to swallow.
Which task should the nurse delegate to a UAP when caring for a
client with impaired vision?
B. Orienting the patient to the location of the call bell and personal
A. Feed the patient lunch.
items.
B. Orient the patient to the location of the call bell and personal
UAPs can help ensure the environment is safe and accessible,
items.
reducing fall risk.
C. Check pupillary response.
D. Evaluate visual acuity.
The nurse is reviewing orders for a client with stress-related
insomnia. Which action is the highest priority?
A. Ensure a quiet and dark environment during the night.
A. Administer a sleep aid.
A restful environment supports sleep and reduces the risk of
B. Offer caffeinated beverages.
further cognitive decline.
C. Leave a light on all night.
D. Ensure a quiet and dark environment during the night.
A nurse is caring for a client on a mechanical soft diet. What is the
priority safety intervention?
A. Encourage the patient to chew slowly.
1/9
, GRADE A+ nclex style questions with rationales 2025
B. Give thin liquids with meals. C. Monitor for choking during meals.
C. Monitor for choking during meals. Clients on soft diets may still have chewing or swallowing difficul-
D. Serve hard foods for stimulation. ties, putting them at risk for aspiration.
Which of the following clients requires immediate intervention by
the nurse?
B. A patient with new-onset confusion and disorientation.
A. A patient requesting a snack.
New-onset confusion could indicate acute illness such as infection
B. A patient with new-onset confusion and disorientation.
or stroke and needs prompt assessment.
C. A patient asking for pain meds.
D. A patient who is stable post-op.
A nurse is supervising a UAP assisting a visually impaired client
with ambulation. Which action requires intervention?
D. Walking several steps ahead of the patient.
A. Holding the patient's hand tightly while walking.
The UAP should walk slightly ahead and to the side, offering an
B. Standing directly behind the patient.
arm—not far ahead where guidance is lost.
C. Offering the patient a walker instead of a cane.
D. Walking several steps ahead of the patient.
Which patient care task should be assigned to an experienced
LPN?
A. Reinforcing dietary teaching for a patient with hypertension.
A. Performing an initial head-to-toe assessment.
LPNs can reinforce teaching initiated by RNs, especially on stable
B. Educating on medication side effects.
conditions like hypertension.
C. Reinforcing dietary teaching for a patient with hypertension.
D. Creating a care plan for a newly diagnosed diabetic.
A nurse observes a caregiver providing care to a client with
dementia. Which action requires immediate correction?
C. Leaving the client alone during meals.
A. Allowing the client to feed themselves.
Clients with dementia are at increased risk of choking and require
B. Placing the call light within reach.
supervision during meals.
C. Leaving the client alone during meals.
D. Encouraging the client to sit upright during meals.
Which intervention should be prioritized for a malnourished pa-
tient with dysphagia?
D. Consult the speech-language pathologist.
A. Encourage high-calorie snacks.
SLPs assess swallowing ability and recommend appropriate di-
B. Administer tube feeding.
etary modifications to prevent aspiration.
C. Offer fluids with meals.
D. Consult the speech-language pathologist.
A nurse is assigning tasks for the day. Which task is appropriate
for a UAP?
C. Measuring intake and output for a stable post-op patient. UAPs
A. Administer IV medications.
can measure and record I&O, which is a routine, non-complex
B. Evaluate dietary intake.
task.
C. Measuring intake and output for a stable post-op patient.
D. Develop a care plan.
Which patient is most at risk for injury and requires immediate fall
precautions?
A. An elderly patient with macular degeneration and unsteady gait.
A. A young adult with asthma requesting inhaler.
Visual impairment and mobility issues increase fall risk and require
B. A patient with arthritis requesting a cane.
immediate intervention.
C. A patient with visual impairment and unsteady gait.
D. A middle-aged patient asking for discharge instructions.
What is the priority action when a patient refuses to eat due to
taste changes from chemotherapy?
B. Offer flavorful, high-protein snacks the patient prefers. Tailoring
A. Explain the importance of eating despite the taste.
nutrition strategies to patient preferences can promote intake and
B. Offer flavorful, high-protein snacks the patient prefers.
prevent malnutrition.
C. Refer to psychiatry.
D. Request a feeding tube order.
Which of the following situations requires the RN to personally
assess the client before delegating further care?
D. A newly admitted client with a history of sleep apnea.
A. A patient who needs a flu shot.
New admissions must be assessed by the RN before any delega-
B. A patient scheduled for a routine lab draw.
tion occurs.
C. A patient requesting water.
D. A newly admitted client with a history of sleep apnea.
What is the priority safety action for a patient receiving enteral
feedings via PEG tube?
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