NCLEX-RN TEST WITH NGN| ALL QUESTIONS & CORRECT
VERIFIED ANSWERS 100% VERIFIED RATIONALES LATEST
UPDATE 2025
1. The nurse witnesses the collapse of a child while outdoors. The child is
not breathing and has a pulse of 50/min. The nurse calls emergency services
and initiates rescue breathing. After 2 minutes of rescue breaths, the child is
still not breathing and is pale with a pulse of 30/min. What is the nurse's next
action? ANS : 1. Initiate chest compressions
RATIONALE Rescue breathing is performed at a rate of 1 breath every 2-3
seconds. If the pulse remains <60/min and there are signs of poor perfusion (skin
pallor), the nurse should initiate chest compressions and reassess the pulse every
2 minutes
2. The charger nurse is responsible for making room assignments multiple
clients. Which pari of client assignments to a shared room is appropriate?
ANS : 3. Client who had a bowel resection 1 day ago and client with asthma
exacerbation.
When making room assignments, it is important to remember that a client with an
active or suspected infection should not be paired with a client who has a fresh
surgical wound or is immunocompromised. A client having an asthma exacerbation
does not have an infection and is not at risk for spreading infection to a client who
had a recent bowel resection surgery.
3. The clinic nurse is assessing a client who is being treated for depression
and suicidal ideation. Which client statement best indicates that the client is
not currently at risk for suicide? ANS : 2. "I plan to attend my grandchild's
graduation next month"
Clients receiving treatment for depression and suicidal ideation must be carefully
monitored for indications of increasing suicidal intent. During a client interview, the
nurse should assess ANS :
- Access to psychiatric medications
https://www.stuvia.com/user/Mboffin
, - Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less likely
to attempt death by suicide
4. The nurse is caring for a client who had an anterior wall myocardial infarc-
tion 2 days ago. The telemetry technician notifies the nurse at 8 ANS : 30 AM
that the client is in ventricular trigeminy. What is the nurse's priority
intervention? ANS : 1. Administer potassium supplement
https://www.stuvia.com/user/Mboffin
, In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third
heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to
ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ven-
tricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte
imbalances, emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L
[3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the
ectopy by administering the prescribed potassium replacement (Option 1). Health
care providers (HCPs) often prescribe electrolyte replacement algorithms to clients
at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a
contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight
<99.2 lb [45 kg]).
5. The nurse cares for a client with a terminal disease who created a do
not attempt resuscitation (DNAR) directive. The client stops breathing and
loses their pulse. The client's adult child states, "Please, do whatever you
can to save them!" Which intervention is appropriate? ANS : 3. Explain the
client's resuscitation directive to the client's child
Clients can create a do not attempt resuscitation (DNAR) directive instructing that
CPR and other life-saving measures be withheld. With an advance directive in place,
the client's wishes should be followed, even if they conflict with the wishes of loved
ones
6. The nurse in the cardiac intensive care unit receives report on 4 clients.
Which client should the nurse assess first? ANS : 2. Client who underwent
coronary artery stent placement via femoral approach 3 hours ago and is
reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary
stent placement using the femoral approach is at increased risk for retroperitoneal
hemorrhage. Administration of antithrombotic drugs before, during, and after PCI
can exacerbate potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma forma-
tion, and diminished distal pulses can be early signs of bleeding into the retroperi-
toneal space and require immediate intervention (eg, notify health care provider,
serial complete blood count, CT scan of the abdomen)
https://www.stuvia.com/user/Mboffin
, 7. The nurse is reviewing the medical history of a client who has sustained a
right tibia/fibula fracture from a fall. The nurse identifies which finding as most
likely to hinder healing? ANS : 4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate circulation,
and age. A client with peripheral arterial disease has decreased perfusion to the ex-
tremities due to atherosclerotic changes in the arteries. Without adequate perfusion,
the bone is not supplied with the oxygen and nutrients required for healing
8. Based on the nursing assessment progress notes, what is the correct stag-
ing of the client's pressure injury? Click on the exhibit button for additional
information. ANS : WRONG
2. Stage 2 ANS : Stage 2 pressure injuries have partial-thickness skin loss
(abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and
the area around the sore may be red and irritated. (shallow, open ulcer, red-pink
wound with no sloughing and possible intact or ruptured blister)
Stage 1 ANS : Intact skin with nonblanchable redness
Stage 2 ANS : Partial-thickness skin loss (abrasion, blister, or shallow crater)
involving the dermis or epidermis; the wound bed is red or pink and may be shiny
or dry
Stage 3 ANS : Full-thickness skin loss; subcutaneous fat is visible but not tendon,
muscle, or bone; tunneling may be present
Stage 4 ANS : Full-thickness skin loss with visible tendon, muscle, or bone;
slough or eschar (scabbing, dead tissue) may be present; undermining and
tunneling may be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
9. A client with type 1 diabetes mellitus has prescriptions for NPH insulin and
regular insulin. At 0730, the client's blood glucose level is 322 mg/dL (17.9
mmol/L), and the breakfast tray has arrived. What action should the nurse
take? Click the exhibit button for additional information. ANS : 4. Administer
37 units of insulin ANS : 25 units of NPH mixed with 12 units of regular insulin in
the same syringe, drawing up the regular insulin first
Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular)
and rapid-acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should
be drawn into the syringe before intermediate-acting insulin to avoid cross-contam-
inating multidose vials (mnemonic - RN ANS : Regular before NPH).
https://www.stuvia.com/user/Mboffin
VERIFIED ANSWERS 100% VERIFIED RATIONALES LATEST
UPDATE 2025
1. The nurse witnesses the collapse of a child while outdoors. The child is
not breathing and has a pulse of 50/min. The nurse calls emergency services
and initiates rescue breathing. After 2 minutes of rescue breaths, the child is
still not breathing and is pale with a pulse of 30/min. What is the nurse's next
action? ANS : 1. Initiate chest compressions
RATIONALE Rescue breathing is performed at a rate of 1 breath every 2-3
seconds. If the pulse remains <60/min and there are signs of poor perfusion (skin
pallor), the nurse should initiate chest compressions and reassess the pulse every
2 minutes
2. The charger nurse is responsible for making room assignments multiple
clients. Which pari of client assignments to a shared room is appropriate?
ANS : 3. Client who had a bowel resection 1 day ago and client with asthma
exacerbation.
When making room assignments, it is important to remember that a client with an
active or suspected infection should not be paired with a client who has a fresh
surgical wound or is immunocompromised. A client having an asthma exacerbation
does not have an infection and is not at risk for spreading infection to a client who
had a recent bowel resection surgery.
3. The clinic nurse is assessing a client who is being treated for depression
and suicidal ideation. Which client statement best indicates that the client is
not currently at risk for suicide? ANS : 2. "I plan to attend my grandchild's
graduation next month"
Clients receiving treatment for depression and suicidal ideation must be carefully
monitored for indications of increasing suicidal intent. During a client interview, the
nurse should assess ANS :
- Access to psychiatric medications
https://www.stuvia.com/user/Mboffin
, - Availability of help during a crisis (counselor, family)
- Future goals and plans
- Home and environment risks
- Overall affect and level of energy
- Possible access to weapons
Clients who articulate long-term personal goals and family milestones are less likely
to attempt death by suicide
4. The nurse is caring for a client who had an anterior wall myocardial infarc-
tion 2 days ago. The telemetry technician notifies the nurse at 8 ANS : 30 AM
that the client is in ventricular trigeminy. What is the nurse's priority
intervention? ANS : 1. Administer potassium supplement
https://www.stuvia.com/user/Mboffin
, In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third
heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to
ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ven-
tricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte
imbalances, emotional stress, stimulants, fever, and exercise.
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L
[3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the
ectopy by administering the prescribed potassium replacement (Option 1). Health
care providers (HCPs) often prescribe electrolyte replacement algorithms to clients
at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a
contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight
<99.2 lb [45 kg]).
5. The nurse cares for a client with a terminal disease who created a do
not attempt resuscitation (DNAR) directive. The client stops breathing and
loses their pulse. The client's adult child states, "Please, do whatever you
can to save them!" Which intervention is appropriate? ANS : 3. Explain the
client's resuscitation directive to the client's child
Clients can create a do not attempt resuscitation (DNAR) directive instructing that
CPR and other life-saving measures be withheld. With an advance directive in place,
the client's wishes should be followed, even if they conflict with the wishes of loved
ones
6. The nurse in the cardiac intensive care unit receives report on 4 clients.
Which client should the nurse assess first? ANS : 2. Client who underwent
coronary artery stent placement via femoral approach 3 hours ago and is
reporting severe back pain
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary
stent placement using the femoral approach is at increased risk for retroperitoneal
hemorrhage. Administration of antithrombotic drugs before, during, and after PCI
can exacerbate potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma forma-
tion, and diminished distal pulses can be early signs of bleeding into the retroperi-
toneal space and require immediate intervention (eg, notify health care provider,
serial complete blood count, CT scan of the abdomen)
https://www.stuvia.com/user/Mboffin
, 7. The nurse is reviewing the medical history of a client who has sustained a
right tibia/fibula fracture from a fall. The nurse identifies which finding as most
likely to hinder healing? ANS : 4. Peripheral arterial disease
Bone healing depends on multiple factors, including nutrition, adequate circulation,
and age. A client with peripheral arterial disease has decreased perfusion to the ex-
tremities due to atherosclerotic changes in the arteries. Without adequate perfusion,
the bone is not supplied with the oxygen and nutrients required for healing
8. Based on the nursing assessment progress notes, what is the correct stag-
ing of the client's pressure injury? Click on the exhibit button for additional
information. ANS : WRONG
2. Stage 2 ANS : Stage 2 pressure injuries have partial-thickness skin loss
(abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and
the area around the sore may be red and irritated. (shallow, open ulcer, red-pink
wound with no sloughing and possible intact or ruptured blister)
Stage 1 ANS : Intact skin with nonblanchable redness
Stage 2 ANS : Partial-thickness skin loss (abrasion, blister, or shallow crater)
involving the dermis or epidermis; the wound bed is red or pink and may be shiny
or dry
Stage 3 ANS : Full-thickness skin loss; subcutaneous fat is visible but not tendon,
muscle, or bone; tunneling may be present
Stage 4 ANS : Full-thickness skin loss with visible tendon, muscle, or bone;
slough or eschar (scabbing, dead tissue) may be present; undermining and
tunneling may be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
9. A client with type 1 diabetes mellitus has prescriptions for NPH insulin and
regular insulin. At 0730, the client's blood glucose level is 322 mg/dL (17.9
mmol/L), and the breakfast tray has arrived. What action should the nurse
take? Click the exhibit button for additional information. ANS : 4. Administer
37 units of insulin ANS : 25 units of NPH mixed with 12 units of regular insulin in
the same syringe, drawing up the regular insulin first
Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular)
and rapid-acting (eg, lispro, aspart) insulins in one syringe. Regular insulin should
be drawn into the syringe before intermediate-acting insulin to avoid cross-contam-
inating multidose vials (mnemonic - RN ANS : Regular before NPH).
https://www.stuvia.com/user/Mboffin
