GRADE A+ NCLEX-Style Questions with Rationales with ans 2025
Dizziness and weakness in IV fluids Check the client's blood pressure and heart rate
Shakiness and sweating in diabetes Give the client orange juice or glucose tablets
Pulse oximetry reading of 88% Increase oxygen flow rate as prescribed
Notify the healthcare provider for further assessment and possible
Severe pain post-operative
intervention
Blood pressure of 180/110 mm Hg Administer prescribed antihypertensive medication
Sign of hypokalemia Muscle weakness
Food to avoid while taking warfarin Leafy green vegetables like spinach and kale
Sudden pain and cessation of chest tube drainage Check the tubing for kinks or disconnection
Wheezing and shortness of breath in asthma Administer a prescribed bronchodilator
Serum sodium level of 125 mEq/L (Definition not provided in the notes)
Low sodium levels that can cause cerebral edema, requiring fluid
Hyponatremia
restriction and provider notification.
The best nursing action is to clean the skin around the stoma with
Colostomy skin irritation
mild soap and water and apply skin barrier cream.
The immediate nursing action is to call for emergency assistance
Chest pain with MI history
and prepare for possible transfer.
A slightly elevated blood pressure is a common finding due to
Normal finding in elderly clients
vascular changes with aging.
Proper inhaler technique includes exhaling fully before inhalation,
Inhaler use holding breath for about 10 seconds after inhaling, and rinsing the
mouth after using a corticosteroid inhaler.
The nurse should encourage consumption of leafy green vegeta-
Iron therapy for anemia
bles and lean meats, which are rich in iron.
The nurse should instruct the client to take the prescribed laxative
Colonoscopy preparation
the night before the procedure.
Decreased urine output The nurse's priority should be to check the client's hydration status
and kidney function.
Respiratory depression is a common side effect of opioid anal-
Opioid analgesics side effect
gesics that requires close monitoring.
Total parenteral nutrition (TPN) assessment Monitoring blood glucose levels is the most important assessment
for a client receiving TPN.
Hypothyroidism symptom Cold intolerance is a symptom most consistent with a diagnosis of
hypothyroidism.
The fetal position helps reduce abdominal tension and provides
Fetal position
comfort in pancreatitis.
Sudden cessation of tidaling and drainage may indicate a blocked
Sudden absence of tidaling and drainage
or dislodged tube, requiring immediate assessment.
Weight-bearing exercises Weight-bearing and resistance exercises promote bone density
and strength.
Potatoes are high in potassium, which should be limited in clients
Potatoes
with kidney disease.
DVT commonly presents with swelling, warmth, redness, and ten-
Well-demarcated erythema and swelling of the affected limb
derness in the affected limb.
The therapeutic range for digoxin is typically 0.5-2.0 ng/mL. Levels
2.4 ng/mL
above this indicate potential toxicity.
Exercise, weight management, and limiting sodium intake are
Regular aerobic exercise
effective lifestyle modifications for hypertension.
Rinse my mouth after using the inhaler Rinsing the mouth helps prevent fungal infections like oral thrush
caused by inhaled corticosteroids.
Ensure adequate rest and plan activities during peak energy times
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Dizziness and weakness in IV fluids Check the client's blood pressure and heart rate
Shakiness and sweating in diabetes Give the client orange juice or glucose tablets
Pulse oximetry reading of 88% Increase oxygen flow rate as prescribed
Notify the healthcare provider for further assessment and possible
Severe pain post-operative
intervention
Blood pressure of 180/110 mm Hg Administer prescribed antihypertensive medication
Sign of hypokalemia Muscle weakness
Food to avoid while taking warfarin Leafy green vegetables like spinach and kale
Sudden pain and cessation of chest tube drainage Check the tubing for kinks or disconnection
Wheezing and shortness of breath in asthma Administer a prescribed bronchodilator
Serum sodium level of 125 mEq/L (Definition not provided in the notes)
Low sodium levels that can cause cerebral edema, requiring fluid
Hyponatremia
restriction and provider notification.
The best nursing action is to clean the skin around the stoma with
Colostomy skin irritation
mild soap and water and apply skin barrier cream.
The immediate nursing action is to call for emergency assistance
Chest pain with MI history
and prepare for possible transfer.
A slightly elevated blood pressure is a common finding due to
Normal finding in elderly clients
vascular changes with aging.
Proper inhaler technique includes exhaling fully before inhalation,
Inhaler use holding breath for about 10 seconds after inhaling, and rinsing the
mouth after using a corticosteroid inhaler.
The nurse should encourage consumption of leafy green vegeta-
Iron therapy for anemia
bles and lean meats, which are rich in iron.
The nurse should instruct the client to take the prescribed laxative
Colonoscopy preparation
the night before the procedure.
Decreased urine output The nurse's priority should be to check the client's hydration status
and kidney function.
Respiratory depression is a common side effect of opioid anal-
Opioid analgesics side effect
gesics that requires close monitoring.
Total parenteral nutrition (TPN) assessment Monitoring blood glucose levels is the most important assessment
for a client receiving TPN.
Hypothyroidism symptom Cold intolerance is a symptom most consistent with a diagnosis of
hypothyroidism.
The fetal position helps reduce abdominal tension and provides
Fetal position
comfort in pancreatitis.
Sudden cessation of tidaling and drainage may indicate a blocked
Sudden absence of tidaling and drainage
or dislodged tube, requiring immediate assessment.
Weight-bearing exercises Weight-bearing and resistance exercises promote bone density
and strength.
Potatoes are high in potassium, which should be limited in clients
Potatoes
with kidney disease.
DVT commonly presents with swelling, warmth, redness, and ten-
Well-demarcated erythema and swelling of the affected limb
derness in the affected limb.
The therapeutic range for digoxin is typically 0.5-2.0 ng/mL. Levels
2.4 ng/mL
above this indicate potential toxicity.
Exercise, weight management, and limiting sodium intake are
Regular aerobic exercise
effective lifestyle modifications for hypertension.
Rinse my mouth after using the inhaler Rinsing the mouth helps prevent fungal infections like oral thrush
caused by inhaled corticosteroids.
Ensure adequate rest and plan activities during peak energy times
1/2
