NCLEX RN Comprehensive Practice
Exam 001 Questions And Correct
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Rationales 2026 Q&A | Instant
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Questions 1-10: Safe and Effective Care Environment
1. A nurse is preparing to administer a blood transfusion to a client with anemia.
Which action should the nurse take first?
A. Verify the client's identity using two identifiers
B. Obtain the client's vital signs
C. Start an intravenous line with normal saline
D. Check the blood product expiration date
Answer: A. Verify the client's identity using two identifiers
Rationale: Verification of client identity using two identifiers (such as name and
date of birth) is the priority action before initiating a blood transfusion to ensure
client safety and prevent transfusion errors. The Joint Commission requires two
patient identifiers before any procedure or blood product administration. While
checking expiration dates, vital signs, and starting an IV line are all important
steps in the transfusion process, identity verification must occur first to prevent
potentially fatal mismatched blood transfusions. The nurse should verify the
client's identification band matches the blood product tag and the provider's
order before proceeding with any other steps.
,2. A client is receiving continuous tube feeding through a nasogastric tube. The
nurse assesses the residual volume and finds 250 mL. Which action should the
nurse take?
A. Discard the residual and continue the feeding
B. Hold the feeding and notify the healthcare provider
C. Reinstill the residual and continue the feeding
D. Slow the feeding rate by half
Answer: B. Hold the feeding and notify the healthcare provider
Rationale: A residual volume of 250 mL exceeds the typical acceptable limit of
200 mL for tube feedings and indicates delayed gastric emptying, placing the
client at increased risk for aspiration. The nurse should hold the feeding and
notify the healthcare provider for further orders. Reinstilling the residual or
continuing the feeding could lead to gastric distension, nausea, vomiting, and
aspiration pneumonia. Slowing the rate does not address the underlying issue of
delayed gastric emptying. The healthcare provider may order a prokinetic
medication, change the feeding formula, or adjust the rate based on individual
client factors.
3. A nurse is caring for a client on fall precautions. Which intervention is most
effective in preventing falls?
A. Placing the bed in the lowest position
B. Using bed alarms for all clients
C. Keeping the call light within reach
D. Implementing a comprehensive fall prevention program
Answer: D. Implementing a comprehensive fall prevention program
Rationale: A comprehensive fall prevention program that includes multiple
interventions such as risk assessment, environmental modifications, staff
education, client and family education, and individualized care plans is most
effective in preventing falls. While placing beds in the lowest position, using bed
,alarms, and keeping call lights within reach are important components of fall
prevention, no single intervention is sufficient. Research demonstrates that
multifaceted approaches significantly reduce fall rates. The comprehensive
program should include regular risk assessments using validated tools, toileting
schedules, mobility assistance, medication reviews, and environmental safety
checks.
4. The nurse is preparing to administer medication to a client and notes that the
healthcare provider's order appears illegible. What is the nurse's best action?
A. Ask a colleague to interpret the order
B. Contact the healthcare provider for clarification
C. Administer the medication based on the client's previous dose
D. Consult the pharmacist for interpretation
Answer: B. Contact the healthcare provider for clarification
Rationale: The nurse should never administer a medication if the order is
illegible or unclear. The primary responsibility is to contact the healthcare
provider who wrote the order to obtain clarification. Asking a colleague to
interpret the order is not appropriate as it does not ensure accuracy and
bypasses the provider's responsibility. Administering based on previous doses is
unsafe because the order may have changed. While pharmacists are medication
experts, the prescribing provider must clarify their own order. The nurse should
document the clarification and follow the six rights of medication administration
once the order is verified.
5. A nurse is providing discharge teaching to a client who will be using a walker
at home. Which statement by the client indicates a need for further teaching?
A. "I will make sure my walker is adjusted to wrist height"
B. "I should place my walker slightly in front of me when walking"
, C. "I need to remove throw rugs from my home"
D. "I should use my walker to help me stand from a seated position"
Answer: D. "I should use my walker to help me stand from a seated position"
Rationale: Using a walker to pull up from a seated position is unsafe because it
can cause the walker to tip over, leading to falls and injury. Clients should be
taught to use the armrests of the chair or push off from the chair's seat to stand,
then grasp the walker once standing. Walker height should be adjusted to wrist
height when the arms are hanging down. The walker should be placed slightly in
front when walking for stability. Removing throw rugs is appropriate to prevent
tripping. The nurse should demonstrate proper transfer techniques and verify
client understanding before discharge.
6. A nurse is caring for a client with a new diagnosis of type 1 diabetes mellitus.
Which laboratory value requires immediate intervention?
A. Serum glucose of 180 mg/dL
B. Serum potassium of 3.8 mEq/L
C. Serum sodium of 135 mEq/L
D. Serum glucose of 55 mg/dL
Answer: D. Serum glucose of 55 mg/dL
Rationale: A serum glucose of 55 mg/dL indicates severe hypoglycemia and
requires immediate intervention with fast-acting carbohydrates or intravenous
dextrose to prevent neurological complications and potential loss of
consciousness. Hypoglycemia can cause confusion, seizures, coma, and death if
left untreated. A serum glucose of 180 mg/dL is elevated but not immediately
life-threatening, though it does require insulin administration. Serum potassium
of 3.8 mEq/L is within normal limits (3.5-5.0 mEq/L). Serum sodium of 135 mEq/L
is at the low end of normal (135-145 mEq/L) but does not require immediate
intervention.
Exam 001 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
Questions 1-10: Safe and Effective Care Environment
1. A nurse is preparing to administer a blood transfusion to a client with anemia.
Which action should the nurse take first?
A. Verify the client's identity using two identifiers
B. Obtain the client's vital signs
C. Start an intravenous line with normal saline
D. Check the blood product expiration date
Answer: A. Verify the client's identity using two identifiers
Rationale: Verification of client identity using two identifiers (such as name and
date of birth) is the priority action before initiating a blood transfusion to ensure
client safety and prevent transfusion errors. The Joint Commission requires two
patient identifiers before any procedure or blood product administration. While
checking expiration dates, vital signs, and starting an IV line are all important
steps in the transfusion process, identity verification must occur first to prevent
potentially fatal mismatched blood transfusions. The nurse should verify the
client's identification band matches the blood product tag and the provider's
order before proceeding with any other steps.
,2. A client is receiving continuous tube feeding through a nasogastric tube. The
nurse assesses the residual volume and finds 250 mL. Which action should the
nurse take?
A. Discard the residual and continue the feeding
B. Hold the feeding and notify the healthcare provider
C. Reinstill the residual and continue the feeding
D. Slow the feeding rate by half
Answer: B. Hold the feeding and notify the healthcare provider
Rationale: A residual volume of 250 mL exceeds the typical acceptable limit of
200 mL for tube feedings and indicates delayed gastric emptying, placing the
client at increased risk for aspiration. The nurse should hold the feeding and
notify the healthcare provider for further orders. Reinstilling the residual or
continuing the feeding could lead to gastric distension, nausea, vomiting, and
aspiration pneumonia. Slowing the rate does not address the underlying issue of
delayed gastric emptying. The healthcare provider may order a prokinetic
medication, change the feeding formula, or adjust the rate based on individual
client factors.
3. A nurse is caring for a client on fall precautions. Which intervention is most
effective in preventing falls?
A. Placing the bed in the lowest position
B. Using bed alarms for all clients
C. Keeping the call light within reach
D. Implementing a comprehensive fall prevention program
Answer: D. Implementing a comprehensive fall prevention program
Rationale: A comprehensive fall prevention program that includes multiple
interventions such as risk assessment, environmental modifications, staff
education, client and family education, and individualized care plans is most
effective in preventing falls. While placing beds in the lowest position, using bed
,alarms, and keeping call lights within reach are important components of fall
prevention, no single intervention is sufficient. Research demonstrates that
multifaceted approaches significantly reduce fall rates. The comprehensive
program should include regular risk assessments using validated tools, toileting
schedules, mobility assistance, medication reviews, and environmental safety
checks.
4. The nurse is preparing to administer medication to a client and notes that the
healthcare provider's order appears illegible. What is the nurse's best action?
A. Ask a colleague to interpret the order
B. Contact the healthcare provider for clarification
C. Administer the medication based on the client's previous dose
D. Consult the pharmacist for interpretation
Answer: B. Contact the healthcare provider for clarification
Rationale: The nurse should never administer a medication if the order is
illegible or unclear. The primary responsibility is to contact the healthcare
provider who wrote the order to obtain clarification. Asking a colleague to
interpret the order is not appropriate as it does not ensure accuracy and
bypasses the provider's responsibility. Administering based on previous doses is
unsafe because the order may have changed. While pharmacists are medication
experts, the prescribing provider must clarify their own order. The nurse should
document the clarification and follow the six rights of medication administration
once the order is verified.
5. A nurse is providing discharge teaching to a client who will be using a walker
at home. Which statement by the client indicates a need for further teaching?
A. "I will make sure my walker is adjusted to wrist height"
B. "I should place my walker slightly in front of me when walking"
, C. "I need to remove throw rugs from my home"
D. "I should use my walker to help me stand from a seated position"
Answer: D. "I should use my walker to help me stand from a seated position"
Rationale: Using a walker to pull up from a seated position is unsafe because it
can cause the walker to tip over, leading to falls and injury. Clients should be
taught to use the armrests of the chair or push off from the chair's seat to stand,
then grasp the walker once standing. Walker height should be adjusted to wrist
height when the arms are hanging down. The walker should be placed slightly in
front when walking for stability. Removing throw rugs is appropriate to prevent
tripping. The nurse should demonstrate proper transfer techniques and verify
client understanding before discharge.
6. A nurse is caring for a client with a new diagnosis of type 1 diabetes mellitus.
Which laboratory value requires immediate intervention?
A. Serum glucose of 180 mg/dL
B. Serum potassium of 3.8 mEq/L
C. Serum sodium of 135 mEq/L
D. Serum glucose of 55 mg/dL
Answer: D. Serum glucose of 55 mg/dL
Rationale: A serum glucose of 55 mg/dL indicates severe hypoglycemia and
requires immediate intervention with fast-acting carbohydrates or intravenous
dextrose to prevent neurological complications and potential loss of
consciousness. Hypoglycemia can cause confusion, seizures, coma, and death if
left untreated. A serum glucose of 180 mg/dL is elevated but not immediately
life-threatening, though it does require insulin administration. Serum potassium
of 3.8 mEq/L is within normal limits (3.5-5.0 mEq/L). Serum sodium of 135 mEq/L
is at the low end of normal (135-145 mEq/L) but does not require immediate
intervention.
