NCLEX-RN NEXT GENERATION QUESTIONS AND ANSWERS |
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
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1. A nurse on a medical-surgical unit receives a change-of-shift report for four clients.
Which client should the nurse assess first?
A. A client with type 2 diabetes mellitus whose morning fingerstick blood glucose level is 185
mg/dL.
B. A client with heart failure who has 2+ bilateral pitting pedal edema and a weight gain of 1 lb
in 24 hours.
C. A client 1 day postoperative following a total hip replacement who reports 6/10 incisional
pain.
D. A client with asthma who has a silent chest on auscultation and an oxygen saturation of
88% on room air.
A silent chest in an asthmatic client indicates severe airway obstruction and impending
respiratory arrest because air movement is insufficient to generate wheezing. This represents
an immediate threat to the airway and oxygenation, requiring urgent intervention under
airway, breathing, and circulation (ABCs) prioritization. Elevated blood glucose, mild fluid
retention, and expected postoperative pain are less urgent priorities.
2. A nurse is caring for a client receiving a continuous IV infusion of heparin for a deep
vein thrombosis. The nurse reviews the laboratory results and notes an activated partial
thromboplastin time (aPTT) of 110 seconds. What is the nurse's priority action?
A. Administer the prescribed dose of protamine sulfate immediately.
B. Stop the heparin infusion and notify the primary healthcare provider.
C. Decrease the heparin infusion rate by 50% according to protocol.
D. Re-draw the blood sample to confirm the laboratory accuracy.
The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5 times the control
baseline (50 to 70 seconds). An aPTT of 110 seconds indicates critical anticoagulation and a
severe risk for hemorrhage. The primary action is to stop the heparin infusion to prevent
further bleeding risks and promptly notify the provider. Protamine sulfate is the antidote but is
reserved for overt, life-threatening bleeding under provider direction.
3. A primary care nurse is reviewing prescriptions for a client diagnosed with heart failure
who is initiated on lisinopril therapy. Which baseline client assessment finding requires
immediate clarification with the prescribing healthcare provider?
A. Serum potassium level of 5.6 mEq/L.
B. Blood pressure of 132/84 mmHg.
,C. Serum sodium level of 138 mEq/L.
D. Heart rate of 68 beats per minute.
Angiotensin-converting enzyme (ACE) inhibitors like lisinopril inhibit aldosterone secretion,
leading to potassium retention. Administering an ACE inhibitor to a client with pre-existing
hyperkalemia (potassium greater than 5.0 mEq/L) significantly increases the risk of fatal
cardiac dysrhythmias. The nurse must withhold the medication and clarify the prescription.
Blood pressure, sodium, and heart rate are within acceptable limits.
4. A home health nurse visits a client with chronic obstructive pulmonary disease (COPD)
who is receiving continuous supplemental oxygen at 2 L/min via nasal cannula. The client
reports increased fatigue and shortness of breath. Which assessment finding should the
nurse address first?
A. Clubbing of the fingers and toes.
B. An oxygen saturation of 89% on nasal cannula.
C. Respiratory rate of 32 breaths per minute with intercostal retractions.
D. Barrel chest appearance on inspection.
Tachypnea accompanied by intercostal retractions signals acute respiratory distress and
increased work of breathing. While clubbing, barrel chest, and mild hypoxemia (SpO2 88-
92%) are chronic manifestations of COPD, active respiratory muscle fatigue requires
immediate priority intervention to prevent impending respiratory failure.
5. A emergency department nurse triages a client who presented with chest pain radiating
to the left jaw. The nurse obtains an electrocardiogram (ECG) showing ST-segment
elevation in leads II, III, and aVF. Which intervention should the nurse anticipate
implementing first?
A. Administer sublingual nitroglycerin every 5 minutes up to 3 doses.
B. Obtain blood specimens for cardiac troponin levels.
C. Administer chewable aspirin 325 mg unless contraindicated.
D. Prepare the client for an immediate chest X-ray.
In acute coronary syndrome with ST-segment elevation (STEMI), chewable aspirin is the
priority immediate pharmacological intervention because it inhibits platelet aggregation and
limits thrombus expansion. While sublingual nitroglycerin, cardiac markers, and chest
radiographs are standard diagnostic and therapeutic steps, immediate antiplatelet action with
chewable aspirin reduces overall cardiac mortality.
6. A pediatric nurse receives report on four assigned pediatric clients. Which child should
the nurse evaluate first?
A. A 2-year-old child with croup who has mild inspiratory stridor only when crying.
B. A 4-year-old child with suspected epiglottitis who is drooling, sitting in a tripod
position, and anxious.
,C. A 6-year-old child with asthma who has a peak expiratory flow rate in the yellow zone.
D. An 8-year-old child with cystic fibrosis who has thick greenish sputum production.
Epiglottitis is a life-threatening medical emergency causing severe airway edema and rapid
respiratory occlusion. Drooling, tripod positioning, and anxiety are classic signs of critical
airway compromise. The nurse must refrain from examining the throat and immediately
prepare for emergency airway protection. The other clients represent stable or managed
respiratory conditions.
7. A nurse in a medical clinic is educating a client who has been newly prescribed
levothyroxine for primary hypothyroidism. Which instruction should the nurse emphasize
regarding administration?
A. Take the medication at bedtime with a light snack to avoid gastric distress.
B. Take the medication in the morning on an empty stomach with a full glass of water.
C. Take the medication along with daily calcium and iron supplements.
D. Double the daily dose if a previous dose is accidentally omitted.
Levothyroxine absorption is maximized when taken in the morning on an empty stomach at
least 30 to 60 minutes before breakfast. Calcium and iron supplements significantly impair
levothyroxine absorption and should be taken at least 4 hours apart. Doses should never be
doubled without primary provider orders.
8. A charge nurse in an intensive care unit is delegating duties to an experienced licensed
practical nurse (LPN). Which client care task is appropriate to assign to the LPN?
A. Performing the initial nursing assessment on a newly admitted postoperative vascular surgery
client.
B. Administering subcutaneous insulin glargine to a stable client with diabetes mellitus.
C. Developing the formal discharge education plan for a client recovering from heart failure.
D. Titrating an intravenous vasoactive drip based on mean arterial pressure parameters.
Administration of subcutaneous medications to stable clients falls within the scope of practice
for an LPN. Initial assessment, complex titrations, and formal nursing care plan development
require advanced clinical judgment reserved exclusively for the registered nurse (RN).
9. A nurse is caring for a client admitted with acute pancreatitis. Which clinical assessment
finding is consistent with severe pancreatic necrosis and retroperitoneal hemorrhage?
A. Presence of positive Trousseau and Chvostek signs.
B. Bluish discoloration around the umbilicus (Cullen sign).
C. Sharp right upper quadrant pain radiating to the right shoulder (Murphy sign).
D. Rebound tenderness at McBurney point.
Cullen sign (periumbilical ecchymosis) and Grey Turner sign (flank ecchymosis) indicate
retroperitoneal blood extravasation associated with severe necrotizing pancreatitis. Positive
, Trousseau/Chvostek signs reflect hypocalcemia. Murphy sign indicates cholecystitis, and
McBurney point tenderness indicates appendicitis.
10. A mental health nurse is evaluating a client diagnosed with major depressive disorder
who was started on fluoxetine 3 weeks ago. The client reports feeling significantly more
energized but remains passive regarding treatment goals. What is the nurse's priority
concern?
A. Development of serotonin syndrome due to drug accumulation.
B. Increased risk for suicide due to increased physical energy while depressive thoughts
persist.
C. Emergence of extrapyramidal side effects from selective serotonin reuptake inhibitors.
D. Development of hypertensive crisis from dietary tyramine interactions.
During the initial 2 to 4 weeks of antidepressant therapy, clients often experience increased
physical energy and motivation before psychological mood elevation occurs. This transitional
phase places the client at heightened risk for executing suicidal plans. Serum monitoring and
suicide precautions are vital safety priorities.
11. A surgical nurse cares for a client who underwent an abdominal hysterectomy 12 hours
ago. On assessment, the nurse notes that the client's surgical dressing is saturated with
bright red blood. Which action should the nurse perform first?
A. Reinforce the dressing with sterile gauze and re-evaluate in 1 hour.
B. Assess the client's vital signs and palpate the abdomen.
C. Notify the surgical team immediately of active hemorrhage.
D. Draw blood for a stat hemoglobin and hematocrit laboratory test.
Before notifying the provider or reinforcing dressings, the nurse must quickly perform a
baseline physiological evaluation (vital signs, abdominal palpation for rigidity/distension) to
establish hemodynamic stability and determine the extent of active hemorrhage. Assessment
always precedes intervention unless immediate resuscitation is required.
12. A nurse is reviewing cardiac monitor tracings for a client admitted with acute
myocardial infarction. The monitor reveals a chaotic, irregular waveform without
recognizable P waves, QRS complexes, or T waves. The client is unresponsive and
pulseless. What is the immediate priority action?
A. Administer IV epinephrine 1 mg push.
B. Perform immediate unsynchronized cardioversion.
C. Initiate high-quality CPR and prepare for immediate defibrillation.
D. Place an advanced airway and deliver 100% oxygen.
The monitor rhythm describes ventricular fibrillation (VF), a lethal pulseless dysrhythmia.
The definitive treatment for VF is immediate chest compressions (CPR) combined with rapid
electrical defibrillation. Unsynchronized cardioversion is used for unstable tachyarrhythmias
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST| DOWNLOAD INSTANT PDF
1. A nurse on a medical-surgical unit receives a change-of-shift report for four clients.
Which client should the nurse assess first?
A. A client with type 2 diabetes mellitus whose morning fingerstick blood glucose level is 185
mg/dL.
B. A client with heart failure who has 2+ bilateral pitting pedal edema and a weight gain of 1 lb
in 24 hours.
C. A client 1 day postoperative following a total hip replacement who reports 6/10 incisional
pain.
D. A client with asthma who has a silent chest on auscultation and an oxygen saturation of
88% on room air.
A silent chest in an asthmatic client indicates severe airway obstruction and impending
respiratory arrest because air movement is insufficient to generate wheezing. This represents
an immediate threat to the airway and oxygenation, requiring urgent intervention under
airway, breathing, and circulation (ABCs) prioritization. Elevated blood glucose, mild fluid
retention, and expected postoperative pain are less urgent priorities.
2. A nurse is caring for a client receiving a continuous IV infusion of heparin for a deep
vein thrombosis. The nurse reviews the laboratory results and notes an activated partial
thromboplastin time (aPTT) of 110 seconds. What is the nurse's priority action?
A. Administer the prescribed dose of protamine sulfate immediately.
B. Stop the heparin infusion and notify the primary healthcare provider.
C. Decrease the heparin infusion rate by 50% according to protocol.
D. Re-draw the blood sample to confirm the laboratory accuracy.
The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5 times the control
baseline (50 to 70 seconds). An aPTT of 110 seconds indicates critical anticoagulation and a
severe risk for hemorrhage. The primary action is to stop the heparin infusion to prevent
further bleeding risks and promptly notify the provider. Protamine sulfate is the antidote but is
reserved for overt, life-threatening bleeding under provider direction.
3. A primary care nurse is reviewing prescriptions for a client diagnosed with heart failure
who is initiated on lisinopril therapy. Which baseline client assessment finding requires
immediate clarification with the prescribing healthcare provider?
A. Serum potassium level of 5.6 mEq/L.
B. Blood pressure of 132/84 mmHg.
,C. Serum sodium level of 138 mEq/L.
D. Heart rate of 68 beats per minute.
Angiotensin-converting enzyme (ACE) inhibitors like lisinopril inhibit aldosterone secretion,
leading to potassium retention. Administering an ACE inhibitor to a client with pre-existing
hyperkalemia (potassium greater than 5.0 mEq/L) significantly increases the risk of fatal
cardiac dysrhythmias. The nurse must withhold the medication and clarify the prescription.
Blood pressure, sodium, and heart rate are within acceptable limits.
4. A home health nurse visits a client with chronic obstructive pulmonary disease (COPD)
who is receiving continuous supplemental oxygen at 2 L/min via nasal cannula. The client
reports increased fatigue and shortness of breath. Which assessment finding should the
nurse address first?
A. Clubbing of the fingers and toes.
B. An oxygen saturation of 89% on nasal cannula.
C. Respiratory rate of 32 breaths per minute with intercostal retractions.
D. Barrel chest appearance on inspection.
Tachypnea accompanied by intercostal retractions signals acute respiratory distress and
increased work of breathing. While clubbing, barrel chest, and mild hypoxemia (SpO2 88-
92%) are chronic manifestations of COPD, active respiratory muscle fatigue requires
immediate priority intervention to prevent impending respiratory failure.
5. A emergency department nurse triages a client who presented with chest pain radiating
to the left jaw. The nurse obtains an electrocardiogram (ECG) showing ST-segment
elevation in leads II, III, and aVF. Which intervention should the nurse anticipate
implementing first?
A. Administer sublingual nitroglycerin every 5 minutes up to 3 doses.
B. Obtain blood specimens for cardiac troponin levels.
C. Administer chewable aspirin 325 mg unless contraindicated.
D. Prepare the client for an immediate chest X-ray.
In acute coronary syndrome with ST-segment elevation (STEMI), chewable aspirin is the
priority immediate pharmacological intervention because it inhibits platelet aggregation and
limits thrombus expansion. While sublingual nitroglycerin, cardiac markers, and chest
radiographs are standard diagnostic and therapeutic steps, immediate antiplatelet action with
chewable aspirin reduces overall cardiac mortality.
6. A pediatric nurse receives report on four assigned pediatric clients. Which child should
the nurse evaluate first?
A. A 2-year-old child with croup who has mild inspiratory stridor only when crying.
B. A 4-year-old child with suspected epiglottitis who is drooling, sitting in a tripod
position, and anxious.
,C. A 6-year-old child with asthma who has a peak expiratory flow rate in the yellow zone.
D. An 8-year-old child with cystic fibrosis who has thick greenish sputum production.
Epiglottitis is a life-threatening medical emergency causing severe airway edema and rapid
respiratory occlusion. Drooling, tripod positioning, and anxiety are classic signs of critical
airway compromise. The nurse must refrain from examining the throat and immediately
prepare for emergency airway protection. The other clients represent stable or managed
respiratory conditions.
7. A nurse in a medical clinic is educating a client who has been newly prescribed
levothyroxine for primary hypothyroidism. Which instruction should the nurse emphasize
regarding administration?
A. Take the medication at bedtime with a light snack to avoid gastric distress.
B. Take the medication in the morning on an empty stomach with a full glass of water.
C. Take the medication along with daily calcium and iron supplements.
D. Double the daily dose if a previous dose is accidentally omitted.
Levothyroxine absorption is maximized when taken in the morning on an empty stomach at
least 30 to 60 minutes before breakfast. Calcium and iron supplements significantly impair
levothyroxine absorption and should be taken at least 4 hours apart. Doses should never be
doubled without primary provider orders.
8. A charge nurse in an intensive care unit is delegating duties to an experienced licensed
practical nurse (LPN). Which client care task is appropriate to assign to the LPN?
A. Performing the initial nursing assessment on a newly admitted postoperative vascular surgery
client.
B. Administering subcutaneous insulin glargine to a stable client with diabetes mellitus.
C. Developing the formal discharge education plan for a client recovering from heart failure.
D. Titrating an intravenous vasoactive drip based on mean arterial pressure parameters.
Administration of subcutaneous medications to stable clients falls within the scope of practice
for an LPN. Initial assessment, complex titrations, and formal nursing care plan development
require advanced clinical judgment reserved exclusively for the registered nurse (RN).
9. A nurse is caring for a client admitted with acute pancreatitis. Which clinical assessment
finding is consistent with severe pancreatic necrosis and retroperitoneal hemorrhage?
A. Presence of positive Trousseau and Chvostek signs.
B. Bluish discoloration around the umbilicus (Cullen sign).
C. Sharp right upper quadrant pain radiating to the right shoulder (Murphy sign).
D. Rebound tenderness at McBurney point.
Cullen sign (periumbilical ecchymosis) and Grey Turner sign (flank ecchymosis) indicate
retroperitoneal blood extravasation associated with severe necrotizing pancreatitis. Positive
, Trousseau/Chvostek signs reflect hypocalcemia. Murphy sign indicates cholecystitis, and
McBurney point tenderness indicates appendicitis.
10. A mental health nurse is evaluating a client diagnosed with major depressive disorder
who was started on fluoxetine 3 weeks ago. The client reports feeling significantly more
energized but remains passive regarding treatment goals. What is the nurse's priority
concern?
A. Development of serotonin syndrome due to drug accumulation.
B. Increased risk for suicide due to increased physical energy while depressive thoughts
persist.
C. Emergence of extrapyramidal side effects from selective serotonin reuptake inhibitors.
D. Development of hypertensive crisis from dietary tyramine interactions.
During the initial 2 to 4 weeks of antidepressant therapy, clients often experience increased
physical energy and motivation before psychological mood elevation occurs. This transitional
phase places the client at heightened risk for executing suicidal plans. Serum monitoring and
suicide precautions are vital safety priorities.
11. A surgical nurse cares for a client who underwent an abdominal hysterectomy 12 hours
ago. On assessment, the nurse notes that the client's surgical dressing is saturated with
bright red blood. Which action should the nurse perform first?
A. Reinforce the dressing with sterile gauze and re-evaluate in 1 hour.
B. Assess the client's vital signs and palpate the abdomen.
C. Notify the surgical team immediately of active hemorrhage.
D. Draw blood for a stat hemoglobin and hematocrit laboratory test.
Before notifying the provider or reinforcing dressings, the nurse must quickly perform a
baseline physiological evaluation (vital signs, abdominal palpation for rigidity/distension) to
establish hemodynamic stability and determine the extent of active hemorrhage. Assessment
always precedes intervention unless immediate resuscitation is required.
12. A nurse is reviewing cardiac monitor tracings for a client admitted with acute
myocardial infarction. The monitor reveals a chaotic, irregular waveform without
recognizable P waves, QRS complexes, or T waves. The client is unresponsive and
pulseless. What is the immediate priority action?
A. Administer IV epinephrine 1 mg push.
B. Perform immediate unsynchronized cardioversion.
C. Initiate high-quality CPR and prepare for immediate defibrillation.
D. Place an advanced airway and deliver 100% oxygen.
The monitor rhythm describes ventricular fibrillation (VF), a lethal pulseless dysrhythmia.
The definitive treatment for VF is immediate chest compressions (CPR) combined with rapid
electrical defibrillation. Unsynchronized cardioversion is used for unstable tachyarrhythmias
