NCLEX Mastery Volume 8 – 100 Practice
Questions with Rationales.
Q1 (Priority). A 68-year-old patient with chronic atrial fibrillation on warfarin presents to the
ED with sudden onset right-sided weakness and slurred speech that began 45 minutes ago. The
ED nurse must act quickly. Which is the nurse’s first action?
A) Obtain an immediate CT scan of the head
B) Give vitamin K to reverse warfarin
C) Prepare for emergent thrombolytic therapy (tPA) administration
D) Start a heparin infusion
Answer: A) Obtain an immediate CT scan of the head
Rationale: Before tPA, CT is required to exclude hemorrhagic stroke; imaging is the first
priority.
Q2 (SATA). A post-op patient (abdominal surgery, POD1) has an order for a nurse assistant
(NA) to help with care. Which tasks may be delegated to the NA? (Select all that apply.)
A) Assist the patient to ambulate to the bedside commode
B) Assess the surgical incision for signs of infection
C) Measure and record intake and output
D) Teach deep-breathing and coughing technique
Answer: A) Assist the patient to ambulate to the bedside commode, C) Measure and record
intake and output
Rationale: Ambulation assistance and I&O are appropriate UAP tasks; assessment and
teaching are RN responsibilities.
Q3 (Long stem). A 54-year-old with COPD is admitted with shortness of breath. He uses
accessory muscles and has an ABG: pH 7.30, PaCO₂ 55 mmHg, HCO₃⁻ 24 mEq/L. O₂ sat 86%
on room air. Which intervention should the nurse perform first?
A) Start high-flow oxygen (10 L/min) by nonrebreather mask
B) Initiate controlled low-flow oxygen (1–2 L/min) and monitor closely
C) Prepare for immediate endotracheal intubation
D) Administer IV furosemide
Answer: B) Initiate controlled low-flow oxygen (1–2 L/min) and monitor closely
Rationale: COPD with chronic CO₂ retention needs controlled O₂ to avoid suppressing
hypoxic drive; start low-flow O₂ and monitor.
For expert assistance contact us on WhatsApp: +254700486651
,Q4 (SATA). A 72-year-old on multiple meds is being discharged. Which instructions should the
nurse include for safe medication management at home? (Select all that apply.)
A) Use a single pillbox and organize weekly doses
B) Stop one medication if you feel dizzy after taking it
C) Bring all medications to follow-up appointments for reconciliation
D) Store all pills in the bathroom medicine cabinet
Answer: A) Use a single pillbox and organize weekly doses, C) Bring all medications to
follow-up appointments for reconciliation
Rationale: Pillboxes and med reconciliation reduce errors; stopping meds without
consulting provider and humid bathroom storage are unsafe.
Q5 (Prioritization). Four patients on your med-surg unit need assessment. Who do you see first?
A) Post-op day 1 patient with saturated dressing but stable vitals
B) COPD patient with O₂ sat 90% on 2 L but increased work of breathing
C) Diabetic with scheduled PO metformin and blood glucose 220 mg/dL
D) Patient requesting pain med for chronic back pain, pain 6/10
Answer: B) COPD patient with O₂ sat 90% on 2 L but increased work of breathing
Rationale: Worsening respiratory effort signals potential decompensation — highest risk.
Q6 (SATA). A patient receiving chemo reports new mouth sores, diarrhea, and low-grade fever.
Which nursing interventions apply? (Select all that apply.)
A) Encourage saline mouth rinses and soft diet
B) Start broad-spectrum antibiotics immediately without cultures
C) Obtain WBC and ANC and implement neutropenic precautions if ANC low
D) Recommend OTC viscous lidocaine for oral ulcers without provider consult
Answer: A) Encourage saline mouth rinses and soft diet, C) Obtain WBC and ANC and
implement neutropenic precautions if ANC low
Rationale: Oral care and assessing neutropenia/infection risk are appropriate;
antibiotics/meds require provider orders.
Q7 (Complex scenario). A patient with end-stage renal disease on hemodialysis arrives with K⁺
6.8 mEq/L and peaked T waves on ECG. Orders: IV calcium gluconate, insulin with dextrose,
kayexalate, and urgent dialysis. Which should the nurse implement first?
A) Administer IV calcium gluconate
B) Start insulin with dextrose infusion
C) Administer kayexalate per protocol
D) Contact dialysis team and prepare for immediate dialysis
Answer: A) Administer IV calcium gluconate
Rationale: Calcium stabilizes myocardial membranes immediately to reduce arrhythmia
risk — highest immediate priority while arranging definitive removal (dialysis).
For expert assistance contact us on WhatsApp: +254700486651
,Q8 (SATA). A woman at 36 weeks’ gestation reports decreased fetal movement for 12 hours.
Which actions should the nurse take? (Select all that apply.)
A) Instruct to perform daily kick counts at home and report if fewer than 10 in 2 hours
B) Obtain NST (nonstress test) and/or biophysical profile per protocol
C) Reassure that decreased movement is normal late in pregnancy
D) Instruct to hydrate and rest, then reassess fetal movement
Answer: B) Obtain NST (nonstress test) and/or biophysical profile per protocol, D) Instruct
to hydrate and rest, then reassess fetal movement
Rationale: Immediate fetal assessment is required; hydration/rest can transiently increase
movements — daily kick counts are preventative education but NST is priority now.
Q9 (Prioritization). In the ED, four patients are triaged: (1) chest pain, vomiting; (2) laceration
with bright arterial bleeding; (3) migraine with photophobia; (4) ankle sprain. Which patient is
priority?
A) Chest pain with vomiting
B) Laceration with arterial bleeding
C) Migraine
D) Ankle sprain
Answer: B) Laceration with arterial bleeding
Rationale: Active arterial bleeding threatens life — immediate control is top priority.
Q10 (SATA). A nurse is counseling a patient on newly prescribed ACE inhibitor (lisinopril).
Which statements are correct teaching points? (Select all that apply.)
A) You may develop a dry cough — report if bothersome
B) Avoid potassium-containing salt substitutes
C) It’s safe to become pregnant while taking ACE inhibitors
D) Monitor for facial swelling or difficulty breathing and seek urgent care
Answer: A) You may develop a dry cough — report if bothersome, B) Avoid potassium-
containing salt substitutes, D) Monitor for facial swelling or difficulty breathing and seek
urgent care
Rationale: ACE inhibitors cause cough, hyperkalemia risk, and angioedema — pregnancy
is contraindicated (so C is incorrect).
Q11 (Long scenario). A patient with septic shock is on norepinephrine via peripheral line due to
lack of central access. The infusion pump alarms and you notice swelling at the IV site and cool,
pale skin distal to the site. What are your immediate actions in order of priority? (Select the
correct sequence.)
A) Stop infusion, aspirate drug from line, elevate limb, notify provider, prepare antidote
For expert assistance contact us on WhatsApp: +254700486651
, (phentolamine)
B) Decrease infusion rate, document, call pharmacy, apply warm compress
C) Clamp line and remove IV, start new peripheral line in same extremity, continue infusion
D) Leave line in place and cover with sterile dressing, notify provider
Answer: A) Stop infusion, aspirate drug from line, elevate limb, notify provider, prepare
antidote (phentolamine)
Rationale: Vasopressor extravasation causes ischemia — stop infusion, attempt to limit
tissue exposure, elevate, and follow protocol for antidote; prompt action reduces tissue
necrosis.
Q12 (SATA). A patient on warfarin has INR 5.8 with minor nosebleed. Which interventions are
appropriate? (Select all that apply.)
A) Hold warfarin and notify provider
B) Apply direct pressure to nose and monitor bleeding
C) Give vitamin K per provider order if bleeding persists or risk high
D) Increase warfarin dose to overcome variability
Answer: A) Hold warfarin and notify provider, B) Apply direct pressure to nose and
monitor bleeding, C) Give vitamin K per provider order if bleeding persists or risk high
Rationale: Hold anticoagulant, control bleeding, and consult provider about reversal
therapy; increasing warfarin is unsafe.
Q13 (Complex). A 3-day post-op abdominal surgery patient develops sudden shortness of breath,
pleuritic chest pain, tachycardia, and hemoptysis. Vitals: HR 125, BP 100/60, SpO₂ 88% on RA.
What is the nurse’s immediate priority?
A) Obtain stat CT pulmonary angiography
B) Give subcutaneous heparin per standing order
C) Administer supplemental oxygen and prepare for potential thrombolysis after diagnosis
D) Send for portable chest x-ray
Answer: C) Administer supplemental oxygen and prepare for potential thrombolysis after
diagnosis
Rationale: Immediate oxygenation is essential while arranging diagnostics and treatment
for suspected PE; CT is needed but oxygen is the first bedside action.
Q14 (SATA). A clinic nurse gives immunization counseling. Which vaccines are contraindicated
in pregnant women? (Select all that apply.)
A) Inactivated influenza (IIV)
B) Live attenuated influenza (LAIV, nasal)
C) MMR (measles–mumps–rubella)
D) Tdap (tetanus–diphtheria–acellular pertussis)
Answer: B) Live attenuated influenza (LAIV, nasal), C) MMR (measles–mumps–rubella)
For expert assistance contact us on WhatsApp: +254700486651
Questions with Rationales.
Q1 (Priority). A 68-year-old patient with chronic atrial fibrillation on warfarin presents to the
ED with sudden onset right-sided weakness and slurred speech that began 45 minutes ago. The
ED nurse must act quickly. Which is the nurse’s first action?
A) Obtain an immediate CT scan of the head
B) Give vitamin K to reverse warfarin
C) Prepare for emergent thrombolytic therapy (tPA) administration
D) Start a heparin infusion
Answer: A) Obtain an immediate CT scan of the head
Rationale: Before tPA, CT is required to exclude hemorrhagic stroke; imaging is the first
priority.
Q2 (SATA). A post-op patient (abdominal surgery, POD1) has an order for a nurse assistant
(NA) to help with care. Which tasks may be delegated to the NA? (Select all that apply.)
A) Assist the patient to ambulate to the bedside commode
B) Assess the surgical incision for signs of infection
C) Measure and record intake and output
D) Teach deep-breathing and coughing technique
Answer: A) Assist the patient to ambulate to the bedside commode, C) Measure and record
intake and output
Rationale: Ambulation assistance and I&O are appropriate UAP tasks; assessment and
teaching are RN responsibilities.
Q3 (Long stem). A 54-year-old with COPD is admitted with shortness of breath. He uses
accessory muscles and has an ABG: pH 7.30, PaCO₂ 55 mmHg, HCO₃⁻ 24 mEq/L. O₂ sat 86%
on room air. Which intervention should the nurse perform first?
A) Start high-flow oxygen (10 L/min) by nonrebreather mask
B) Initiate controlled low-flow oxygen (1–2 L/min) and monitor closely
C) Prepare for immediate endotracheal intubation
D) Administer IV furosemide
Answer: B) Initiate controlled low-flow oxygen (1–2 L/min) and monitor closely
Rationale: COPD with chronic CO₂ retention needs controlled O₂ to avoid suppressing
hypoxic drive; start low-flow O₂ and monitor.
For expert assistance contact us on WhatsApp: +254700486651
,Q4 (SATA). A 72-year-old on multiple meds is being discharged. Which instructions should the
nurse include for safe medication management at home? (Select all that apply.)
A) Use a single pillbox and organize weekly doses
B) Stop one medication if you feel dizzy after taking it
C) Bring all medications to follow-up appointments for reconciliation
D) Store all pills in the bathroom medicine cabinet
Answer: A) Use a single pillbox and organize weekly doses, C) Bring all medications to
follow-up appointments for reconciliation
Rationale: Pillboxes and med reconciliation reduce errors; stopping meds without
consulting provider and humid bathroom storage are unsafe.
Q5 (Prioritization). Four patients on your med-surg unit need assessment. Who do you see first?
A) Post-op day 1 patient with saturated dressing but stable vitals
B) COPD patient with O₂ sat 90% on 2 L but increased work of breathing
C) Diabetic with scheduled PO metformin and blood glucose 220 mg/dL
D) Patient requesting pain med for chronic back pain, pain 6/10
Answer: B) COPD patient with O₂ sat 90% on 2 L but increased work of breathing
Rationale: Worsening respiratory effort signals potential decompensation — highest risk.
Q6 (SATA). A patient receiving chemo reports new mouth sores, diarrhea, and low-grade fever.
Which nursing interventions apply? (Select all that apply.)
A) Encourage saline mouth rinses and soft diet
B) Start broad-spectrum antibiotics immediately without cultures
C) Obtain WBC and ANC and implement neutropenic precautions if ANC low
D) Recommend OTC viscous lidocaine for oral ulcers without provider consult
Answer: A) Encourage saline mouth rinses and soft diet, C) Obtain WBC and ANC and
implement neutropenic precautions if ANC low
Rationale: Oral care and assessing neutropenia/infection risk are appropriate;
antibiotics/meds require provider orders.
Q7 (Complex scenario). A patient with end-stage renal disease on hemodialysis arrives with K⁺
6.8 mEq/L and peaked T waves on ECG. Orders: IV calcium gluconate, insulin with dextrose,
kayexalate, and urgent dialysis. Which should the nurse implement first?
A) Administer IV calcium gluconate
B) Start insulin with dextrose infusion
C) Administer kayexalate per protocol
D) Contact dialysis team and prepare for immediate dialysis
Answer: A) Administer IV calcium gluconate
Rationale: Calcium stabilizes myocardial membranes immediately to reduce arrhythmia
risk — highest immediate priority while arranging definitive removal (dialysis).
For expert assistance contact us on WhatsApp: +254700486651
,Q8 (SATA). A woman at 36 weeks’ gestation reports decreased fetal movement for 12 hours.
Which actions should the nurse take? (Select all that apply.)
A) Instruct to perform daily kick counts at home and report if fewer than 10 in 2 hours
B) Obtain NST (nonstress test) and/or biophysical profile per protocol
C) Reassure that decreased movement is normal late in pregnancy
D) Instruct to hydrate and rest, then reassess fetal movement
Answer: B) Obtain NST (nonstress test) and/or biophysical profile per protocol, D) Instruct
to hydrate and rest, then reassess fetal movement
Rationale: Immediate fetal assessment is required; hydration/rest can transiently increase
movements — daily kick counts are preventative education but NST is priority now.
Q9 (Prioritization). In the ED, four patients are triaged: (1) chest pain, vomiting; (2) laceration
with bright arterial bleeding; (3) migraine with photophobia; (4) ankle sprain. Which patient is
priority?
A) Chest pain with vomiting
B) Laceration with arterial bleeding
C) Migraine
D) Ankle sprain
Answer: B) Laceration with arterial bleeding
Rationale: Active arterial bleeding threatens life — immediate control is top priority.
Q10 (SATA). A nurse is counseling a patient on newly prescribed ACE inhibitor (lisinopril).
Which statements are correct teaching points? (Select all that apply.)
A) You may develop a dry cough — report if bothersome
B) Avoid potassium-containing salt substitutes
C) It’s safe to become pregnant while taking ACE inhibitors
D) Monitor for facial swelling or difficulty breathing and seek urgent care
Answer: A) You may develop a dry cough — report if bothersome, B) Avoid potassium-
containing salt substitutes, D) Monitor for facial swelling or difficulty breathing and seek
urgent care
Rationale: ACE inhibitors cause cough, hyperkalemia risk, and angioedema — pregnancy
is contraindicated (so C is incorrect).
Q11 (Long scenario). A patient with septic shock is on norepinephrine via peripheral line due to
lack of central access. The infusion pump alarms and you notice swelling at the IV site and cool,
pale skin distal to the site. What are your immediate actions in order of priority? (Select the
correct sequence.)
A) Stop infusion, aspirate drug from line, elevate limb, notify provider, prepare antidote
For expert assistance contact us on WhatsApp: +254700486651
, (phentolamine)
B) Decrease infusion rate, document, call pharmacy, apply warm compress
C) Clamp line and remove IV, start new peripheral line in same extremity, continue infusion
D) Leave line in place and cover with sterile dressing, notify provider
Answer: A) Stop infusion, aspirate drug from line, elevate limb, notify provider, prepare
antidote (phentolamine)
Rationale: Vasopressor extravasation causes ischemia — stop infusion, attempt to limit
tissue exposure, elevate, and follow protocol for antidote; prompt action reduces tissue
necrosis.
Q12 (SATA). A patient on warfarin has INR 5.8 with minor nosebleed. Which interventions are
appropriate? (Select all that apply.)
A) Hold warfarin and notify provider
B) Apply direct pressure to nose and monitor bleeding
C) Give vitamin K per provider order if bleeding persists or risk high
D) Increase warfarin dose to overcome variability
Answer: A) Hold warfarin and notify provider, B) Apply direct pressure to nose and
monitor bleeding, C) Give vitamin K per provider order if bleeding persists or risk high
Rationale: Hold anticoagulant, control bleeding, and consult provider about reversal
therapy; increasing warfarin is unsafe.
Q13 (Complex). A 3-day post-op abdominal surgery patient develops sudden shortness of breath,
pleuritic chest pain, tachycardia, and hemoptysis. Vitals: HR 125, BP 100/60, SpO₂ 88% on RA.
What is the nurse’s immediate priority?
A) Obtain stat CT pulmonary angiography
B) Give subcutaneous heparin per standing order
C) Administer supplemental oxygen and prepare for potential thrombolysis after diagnosis
D) Send for portable chest x-ray
Answer: C) Administer supplemental oxygen and prepare for potential thrombolysis after
diagnosis
Rationale: Immediate oxygenation is essential while arranging diagnostics and treatment
for suspected PE; CT is needed but oxygen is the first bedside action.
Q14 (SATA). A clinic nurse gives immunization counseling. Which vaccines are contraindicated
in pregnant women? (Select all that apply.)
A) Inactivated influenza (IIV)
B) Live attenuated influenza (LAIV, nasal)
C) MMR (measles–mumps–rubella)
D) Tdap (tetanus–diphtheria–acellular pertussis)
Answer: B) Live attenuated influenza (LAIV, nasal), C) MMR (measles–mumps–rubella)
For expert assistance contact us on WhatsApp: +254700486651
