Lippincott-Style NCLEX Questions with
Rationales | 100 Comprehensive Q&A |
Grade A | 100%Correct -The Ultimate
Guide for Yr. (2026/2027)
Question 1: A nurse is caring for a client with heart failure who is receiving furosemide.
Which assessment finding requires immediate action? (Variation 12) (Select all that apply)
A. Potassium level of 3.0 mEq/L
B. Blood pressure of 110/70 mmHg
C. Heart rate of 80 bpm
D. Reports of nausea
Correct Answer: A. Potassium level of 3.0 mEq/L, B. Blood pressure of 110/70 mmHg
Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0
mEq/L, B. Blood pressure of 110/70 mmHg is correct because it prevents complications and ensures
safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows
hierarchy.
Question 2: A nurse is educating a client on warfarin therapy. Which statement indicates a
need for further teaching? (Variation 8)
A. 'I will avoid green leafy vegetables.'
B. 'I will use an electric razor to shave.'
C. 'I will take ibuprofen for headaches.'
D. 'I will have regular blood tests to monitor my INR.'
Correct Answer: C. 'I will take ibuprofen for headaches.'
Rationale: Rationale: The correct answer aligns with nursing standards. C. 'I will take ibuprofen for
headaches.' is correct because it prevents complications and ensures safe client care. Nursing
priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 3: A nurse is caring for a client with heart failure who is receiving furosemide.
Which assessment finding requires immediate action? (Variation 18)
A. Potassium level of 3.0 mEq/L
B. Blood pressure of 110/70 mmHg
C. Heart rate of 80 bpm
D. Reports of nausea
,Correct Answer: A. Potassium level of 3.0 mEq/L
Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0
mEq/L is correct because it prevents complications and ensures safe client care. Nursing priorities
follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 4: A client with diabetes mellitus reports shakiness and confusion. The nurse should
first: (Variation 1) (Select all that apply)
A. Check the client's blood glucose
B. Administer insulin
C. Give a high-protein snack
D. Encourage fluids
Correct Answer: A. Check the client's blood glucose, B. Administer insulin
Rationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's blood
glucose, B. Administer insulin is correct because it prevents complications and ensures safe client
care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 5: A nurse is assessing a client with chronic obstructive pulmonary disease
(COPD). Which finding is most concerning? (Variation 5)
A. Barrel-shaped chest
B. Clubbing of fingers
C. Oxygen saturation of 88%
D. Respiratory rate of 22 breaths/min
Correct Answer: B. Clubbing of fingers
Rationale: Rationale: The correct answer aligns with nursing standards. B. Clubbing of fingers is
correct because it prevents complications and ensures safe client care. Nursing priorities follow the
ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 6: A nurse is caring for a client with pneumonia. Which nursing intervention is the
priority? (Variation 9) (Which intervention is the priority?)
A. Encourage oral fluids
B. Obtain a sputum culture
C. Administer oxygen therapy
D. Monitor temperature
Correct Answer: C. Administer oxygen therapy
Rationale: Rationale: The correct answer aligns with nursing standards. C. Administer oxygen therapy
is correct because it prevents complications and ensures safe client care. Nursing priorities follow the
ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 7: A nurse is assessing a client with chronic obstructive pulmonary disease
(COPD). Which finding is most concerning? (Variation 8) (Select all that apply)
A. Barrel-shaped chest
B. Clubbing of fingers
, C. Oxygen saturation of 88%
D. Respiratory rate of 22 breaths/min
Correct Answer: A. Barrel-shaped chest, B. Clubbing of fingers
Rationale: Rationale: The correct answer aligns with nursing standards. A. Barrel-shaped chest, B.
Clubbing of fingers is correct because it prevents complications and ensures safe client care.
Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 8: A nurse is educating a client on warfarin therapy. Which statement indicates a
need for further teaching? (Variation 6) (Which task should the nurse delegate?)
A. 'I will avoid green leafy vegetables.'
B. 'I will use an electric razor to shave.'
C. 'I will take ibuprofen for headaches.'
D. 'I will have regular blood tests to monitor my INR.'
Correct Answer: C. 'I will take ibuprofen for headaches.'
Rationale: Rationale: The correct answer aligns with nursing standards. C. 'I will take ibuprofen for
headaches.' is correct because it prevents complications and ensures safe client care. Nursing
priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 9: A nurse is assessing a client with chronic obstructive pulmonary disease
(COPD). Which finding is most concerning? (Variation 19)
A. Barrel-shaped chest
B. Clubbing of fingers
C. Oxygen saturation of 88%
D. Respiratory rate of 22 breaths/min
Correct Answer: B. Clubbing of fingers
Rationale: Rationale: The correct answer aligns with nursing standards. B. Clubbing of fingers is
correct because it prevents complications and ensures safe client care. Nursing priorities follow the
ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 10: A nurse is educating a client on warfarin therapy. Which statement indicates a
need for further teaching? (Variation 12) (Select all that apply)
A. 'I will avoid green leafy vegetables.'
B. 'I will use an electric razor to shave.'
C. 'I will take ibuprofen for headaches.'
D. 'I will have regular blood tests to monitor my INR.'
Correct Answer: A. 'I will avoid green leafy vegetables.', B. 'I will use an electric razor to shave.'
Rationale: Rationale: The correct answer aligns with nursing standards. A. 'I will avoid green leafy
vegetables.', B. 'I will use an electric razor to shave.' is correct because it prevents complications and
ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and
Maslows hierarchy.
Rationales | 100 Comprehensive Q&A |
Grade A | 100%Correct -The Ultimate
Guide for Yr. (2026/2027)
Question 1: A nurse is caring for a client with heart failure who is receiving furosemide.
Which assessment finding requires immediate action? (Variation 12) (Select all that apply)
A. Potassium level of 3.0 mEq/L
B. Blood pressure of 110/70 mmHg
C. Heart rate of 80 bpm
D. Reports of nausea
Correct Answer: A. Potassium level of 3.0 mEq/L, B. Blood pressure of 110/70 mmHg
Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0
mEq/L, B. Blood pressure of 110/70 mmHg is correct because it prevents complications and ensures
safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows
hierarchy.
Question 2: A nurse is educating a client on warfarin therapy. Which statement indicates a
need for further teaching? (Variation 8)
A. 'I will avoid green leafy vegetables.'
B. 'I will use an electric razor to shave.'
C. 'I will take ibuprofen for headaches.'
D. 'I will have regular blood tests to monitor my INR.'
Correct Answer: C. 'I will take ibuprofen for headaches.'
Rationale: Rationale: The correct answer aligns with nursing standards. C. 'I will take ibuprofen for
headaches.' is correct because it prevents complications and ensures safe client care. Nursing
priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 3: A nurse is caring for a client with heart failure who is receiving furosemide.
Which assessment finding requires immediate action? (Variation 18)
A. Potassium level of 3.0 mEq/L
B. Blood pressure of 110/70 mmHg
C. Heart rate of 80 bpm
D. Reports of nausea
,Correct Answer: A. Potassium level of 3.0 mEq/L
Rationale: Rationale: The correct answer aligns with nursing standards. A. Potassium level of 3.0
mEq/L is correct because it prevents complications and ensures safe client care. Nursing priorities
follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 4: A client with diabetes mellitus reports shakiness and confusion. The nurse should
first: (Variation 1) (Select all that apply)
A. Check the client's blood glucose
B. Administer insulin
C. Give a high-protein snack
D. Encourage fluids
Correct Answer: A. Check the client's blood glucose, B. Administer insulin
Rationale: Rationale: The correct answer aligns with nursing standards. A. Check the client's blood
glucose, B. Administer insulin is correct because it prevents complications and ensures safe client
care. Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 5: A nurse is assessing a client with chronic obstructive pulmonary disease
(COPD). Which finding is most concerning? (Variation 5)
A. Barrel-shaped chest
B. Clubbing of fingers
C. Oxygen saturation of 88%
D. Respiratory rate of 22 breaths/min
Correct Answer: B. Clubbing of fingers
Rationale: Rationale: The correct answer aligns with nursing standards. B. Clubbing of fingers is
correct because it prevents complications and ensures safe client care. Nursing priorities follow the
ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 6: A nurse is caring for a client with pneumonia. Which nursing intervention is the
priority? (Variation 9) (Which intervention is the priority?)
A. Encourage oral fluids
B. Obtain a sputum culture
C. Administer oxygen therapy
D. Monitor temperature
Correct Answer: C. Administer oxygen therapy
Rationale: Rationale: The correct answer aligns with nursing standards. C. Administer oxygen therapy
is correct because it prevents complications and ensures safe client care. Nursing priorities follow the
ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 7: A nurse is assessing a client with chronic obstructive pulmonary disease
(COPD). Which finding is most concerning? (Variation 8) (Select all that apply)
A. Barrel-shaped chest
B. Clubbing of fingers
, C. Oxygen saturation of 88%
D. Respiratory rate of 22 breaths/min
Correct Answer: A. Barrel-shaped chest, B. Clubbing of fingers
Rationale: Rationale: The correct answer aligns with nursing standards. A. Barrel-shaped chest, B.
Clubbing of fingers is correct because it prevents complications and ensures safe client care.
Nursing priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 8: A nurse is educating a client on warfarin therapy. Which statement indicates a
need for further teaching? (Variation 6) (Which task should the nurse delegate?)
A. 'I will avoid green leafy vegetables.'
B. 'I will use an electric razor to shave.'
C. 'I will take ibuprofen for headaches.'
D. 'I will have regular blood tests to monitor my INR.'
Correct Answer: C. 'I will take ibuprofen for headaches.'
Rationale: Rationale: The correct answer aligns with nursing standards. C. 'I will take ibuprofen for
headaches.' is correct because it prevents complications and ensures safe client care. Nursing
priorities follow the ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 9: A nurse is assessing a client with chronic obstructive pulmonary disease
(COPD). Which finding is most concerning? (Variation 19)
A. Barrel-shaped chest
B. Clubbing of fingers
C. Oxygen saturation of 88%
D. Respiratory rate of 22 breaths/min
Correct Answer: B. Clubbing of fingers
Rationale: Rationale: The correct answer aligns with nursing standards. B. Clubbing of fingers is
correct because it prevents complications and ensures safe client care. Nursing priorities follow the
ABCs (airway, breathing, circulation) and Maslows hierarchy.
Question 10: A nurse is educating a client on warfarin therapy. Which statement indicates a
need for further teaching? (Variation 12) (Select all that apply)
A. 'I will avoid green leafy vegetables.'
B. 'I will use an electric razor to shave.'
C. 'I will take ibuprofen for headaches.'
D. 'I will have regular blood tests to monitor my INR.'
Correct Answer: A. 'I will avoid green leafy vegetables.', B. 'I will use an electric razor to shave.'
Rationale: Rationale: The correct answer aligns with nursing standards. A. 'I will avoid green leafy
vegetables.', B. 'I will use an electric razor to shave.' is correct because it prevents complications and
ensures safe client care. Nursing priorities follow the ABCs (airway, breathing, circulation) and
Maslows hierarchy.
