NCLEX Mastery Volume 5 – 100 Practice
Questions with Rationales.
1.
A client with chronic kidney disease is prescribed a low-protein diet. What is the primary reason
for this restriction?
A) Prevent fluid overload
B) Reduce risk of infection
C) Limit nitrogenous waste accumulation
D) Improve appetite
Answer: C
Rationale: Protein breakdown produces nitrogenous waste; restriction slows uremia
progression.
2.
The nurse prepares to administer NPH insulin at 0800. When is the client most at risk for
hypoglycemia?
A) 0900
B) 1400
C) 2000
D) 2200
Answer: B
Rationale: NPH peaks in 6–8 hours; risk of hypoglycemia occurs mid-afternoon.
3.
Which newborn finding is abnormal?
A) Positive Babinski reflex
B) Acrocyanosis of hands and feet
C) Bulging fontanel at rest
D) Irregular respirations
Answer: C
Rationale: Bulging fontanel at rest suggests increased ICP or hydrocephalus.
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,4.
A client with a chest tube suddenly shows no tidaling in the water seal chamber. What should the
nurse do first?
A) Call provider
B) Assess for kinks or obstruction in tubing
C) Remove chest tube
D) Increase suction
Answer: B
Rationale: Absence of tidaling may mean obstruction; tubing should be checked first.
5.
The nurse cares for a client receiving TPN (total parenteral nutrition). Which complication is
priority?
A) Hypertension
B) Constipation
C) Hyperglycemia
D) Hypothermia
Answer: C
Rationale: TPN has high dextrose concentration, risk of hyperglycemia.
6.
Which is the best snack for a client with iron-deficiency anemia?
A) Cheese and crackers
B) Spinach salad with orange slices
C) Yogurt with granola
D) Ice cream sundae
Answer: B
Rationale: Spinach provides iron, and vitamin C enhances absorption.
7.
The nurse is caring for a client with Cushing’s syndrome. Which finding is expected?
A) Hypotension
B) Weight loss
C) Moon face and truncuous obesity
D) Low blood glucose
Answer: C
Rationale: Excess cortisol causes characteristic fat distribution.
For expert assistance contact us on WhatsApp: +254700486651
, 8.
Which intervention is most important for a client on neutropenic precautions?
A) Limit fluid intake
B) Strict hand hygiene
C) Encourage group activities
D) Place in negative pressure room
Answer: B
Rationale: Infection prevention through hand hygiene is priority.
9.
A client with a tracheostomy has thick secretions. What action is best?
A) Increase suction frequency
B) Humidify inspired air
C) Restrict fluids
D) Keep cuff inflated at all times
Answer: B
Rationale: Humidity thins secretions and prevents plugging.
10.
Which task can the nurse safely delegate to a UAP (unlicensed assistive personnel)?
A) Assessing wound drainage
B) Teaching deep breathing exercises
C) Measuring vital signs
D) Evaluating pain relief
Answer: C
Rationale: UAP may collect basic data such as vitals but cannot assess or teach.
11.
A client is receiving amphotericin B IV. The nurse monitors closely for:
A) Nephrotoxicity
B) Hypotension
C) Hyperglycemia
D) Constipation
Answer: A
Rationale: Amphotericin B is nephrotoxic; kidney function must be monitored.
For expert assistance contact us on WhatsApp: +254700486651
Questions with Rationales.
1.
A client with chronic kidney disease is prescribed a low-protein diet. What is the primary reason
for this restriction?
A) Prevent fluid overload
B) Reduce risk of infection
C) Limit nitrogenous waste accumulation
D) Improve appetite
Answer: C
Rationale: Protein breakdown produces nitrogenous waste; restriction slows uremia
progression.
2.
The nurse prepares to administer NPH insulin at 0800. When is the client most at risk for
hypoglycemia?
A) 0900
B) 1400
C) 2000
D) 2200
Answer: B
Rationale: NPH peaks in 6–8 hours; risk of hypoglycemia occurs mid-afternoon.
3.
Which newborn finding is abnormal?
A) Positive Babinski reflex
B) Acrocyanosis of hands and feet
C) Bulging fontanel at rest
D) Irregular respirations
Answer: C
Rationale: Bulging fontanel at rest suggests increased ICP or hydrocephalus.
For expert assistance contact us on WhatsApp: +254700486651
,4.
A client with a chest tube suddenly shows no tidaling in the water seal chamber. What should the
nurse do first?
A) Call provider
B) Assess for kinks or obstruction in tubing
C) Remove chest tube
D) Increase suction
Answer: B
Rationale: Absence of tidaling may mean obstruction; tubing should be checked first.
5.
The nurse cares for a client receiving TPN (total parenteral nutrition). Which complication is
priority?
A) Hypertension
B) Constipation
C) Hyperglycemia
D) Hypothermia
Answer: C
Rationale: TPN has high dextrose concentration, risk of hyperglycemia.
6.
Which is the best snack for a client with iron-deficiency anemia?
A) Cheese and crackers
B) Spinach salad with orange slices
C) Yogurt with granola
D) Ice cream sundae
Answer: B
Rationale: Spinach provides iron, and vitamin C enhances absorption.
7.
The nurse is caring for a client with Cushing’s syndrome. Which finding is expected?
A) Hypotension
B) Weight loss
C) Moon face and truncuous obesity
D) Low blood glucose
Answer: C
Rationale: Excess cortisol causes characteristic fat distribution.
For expert assistance contact us on WhatsApp: +254700486651
, 8.
Which intervention is most important for a client on neutropenic precautions?
A) Limit fluid intake
B) Strict hand hygiene
C) Encourage group activities
D) Place in negative pressure room
Answer: B
Rationale: Infection prevention through hand hygiene is priority.
9.
A client with a tracheostomy has thick secretions. What action is best?
A) Increase suction frequency
B) Humidify inspired air
C) Restrict fluids
D) Keep cuff inflated at all times
Answer: B
Rationale: Humidity thins secretions and prevents plugging.
10.
Which task can the nurse safely delegate to a UAP (unlicensed assistive personnel)?
A) Assessing wound drainage
B) Teaching deep breathing exercises
C) Measuring vital signs
D) Evaluating pain relief
Answer: C
Rationale: UAP may collect basic data such as vitals but cannot assess or teach.
11.
A client is receiving amphotericin B IV. The nurse monitors closely for:
A) Nephrotoxicity
B) Hypotension
C) Hyperglycemia
D) Constipation
Answer: A
Rationale: Amphotericin B is nephrotoxic; kidney function must be monitored.
For expert assistance contact us on WhatsApp: +254700486651
