NCLEX Question Bank with Rationales 2025
A nurse is planning care for a patient with anorexia nervosa. Which goal is most appropriate for
the initial plan of care?
A) The patient will express satisfaction with body image within one week.
B) The patient will engage in social activities with peers during meal times.
C) The patient will independently plan and prepare all meals.
D) The patient will gain a specified amount of weight each week as agreed upon by the
healthcare team. - correct answer
After a transfusion, the body reacts by destroying the transfused red blood cells. What is this
reaction?
A) Rh negative
B) antihistamine
C) hemolytic
D) antibody - correct answer C) Hemolytic
RATIONALE: A hemolytic reaction occurs when the body destroys transfused red blood cells.
The nurse prepares to perform the initial assessment on a school-age client. The client has an
open wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which
precaution will the nurse take?
A. Wear gloves only.
B. Wear gown and gloves.
C. Wear gown, gloves, and mask.
D. No precautions are necessary. - correct answer B. Wear gown and gloves.
RATIONALE: MRSA requires contact precautions. The nurse should wear clean, nonsterile gloves
and gown when entering the client?s room and when having any contact with the client or with
surfaces that the client touches.
The nurse has four phone messages. Which message does the nurse return first?
,A) An older adult client undergoing bowel prep and reporting watery diarrhea.
B) A client with a newborn and experiencing breast engorgement.
C) A client who had a cataract extraction 3 days ago and reporting nausea.
D) A client diagnosed with a C6 spinal cord injury and reporting a headache. - correct answer
D) A client diagnosed with a C6 spinal cord injury and reporting a headache.
RATIONALE:
A severe headache is indicative of autonomic dysreflexia in the client who has sustained a high-
level spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood
pressure, and, if untreated, can result in intracranial bleeding and death. This client is the most
unstable and is experiencing a potentially life-threatening issue that needs to be addressed
immediately by the nurse.
The adult grandchild of a client diagnosed with Parkinson disease tells the nurse about
proposed gift ideas for the grandparent's birthday in 2 weeks. The grandchild asks the nurse
which idea is best. Which option is the best gift for the nurse to recommend?
A)Perfume and makeup.
B)Hearing aid with batteries.
C)Warming tray for food.
D)Quilt and soft pillow. - correct answer C) Warming tray for food
RATIONALE: Warming trays can keep food hot, safe, and appealing during the slow eating
process of the client diagnosed with Parkinson disease. Eating is slow because of overall slowed
body movement, tremors, difficulty chewing and swallowing, fatigue, and need for rest periods.
This choice directly addresses a physiologic need.
The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with
asthma about preventative care. Which statement by the parent indicates to the nurse that
further teaching is necessary?
A. "My child likes sleeping on the top bunk when visiting grandparents."
B. "My child sleeps on a zippered covered pillow and mattress."
C. "My child changes his clothes after playing outside."
,D. "My child wears a mask while I vacuum the carpets." - correct answer A."My child likes
sleeping on the top bunk when visiting grandparents."
RATIONALE:
Dust mites are a trigger for asthma. Fabric from bedding on the upper bunk can harbor dust
mites. The child is not to sleep or lie down on upholstered furniture. Use furniture that can be
wiped with a damp cloth such as wood, plastic, vinyl, or leather.
The home care nurse evaluates a client diagnosed with tuberculosis and receiving isoniazid,
rifampin, and pyrazinamide. Which client statement requires further assessment by the nurse?
A) "I have gained 5 pounds since I started taking the medication."
B) "I cover my nose and mouth when I cough or sneeze."
C) "I drink a glass of wine with dinner each night."
D) "I have stopped eating tuna salad sandwiches." - correct answer C) "I drink a glass of wine
with dinner each night."
RATIONALE:
An adverse reaction of isoniazid is hepatitis. Instruct a client to avoid ingesting alcohol when
taking the medication.
RATIONALE FOR INCORRECT ANSWER S:
"I have gained 5 pounds since I started taking the medication."
Weight loss is a symptom of TB. Gaining weight indicates the client is able to eat and is having
minimal GI upset due to the medications.
"I cover my nose and mouth when I cough or sneeze."
Covering the mouth and nose when coughing or sneezing is good hygiene and prevents the
spread of disease.
"I have stopped eating tuna salad sandwiches."
, A client taking these medications should avoid tuna, aged cheese, red wine, and yeast extracts,
as they may cause the adverse effects of flushing, hypotension, palpitations, and diaphoresis.
The nurse in the emergency department assesses a client diagnosed with burns. Which
observation most concerns the nurse?
A) Redness and swelling with fluid-filled vesicles noted on right arm.
B) Charred, waxy, white appearance of skin on the left leg.
C) Reddened blotchy painful areas noted on the trunk.
D) Blistering and blanching of the skin noted on the back. - correct answer B) Charred, waxy,
white appearance of skin on the left leg.
RATIONALE:
This describes a full-thickness burn. All the skin is destroyed and the muscle and bone may be
involved. The substance that remains is called eschar and is dry to the touch. Full-thickness
burns do not heal spontaneously and require grafting. All functions of the skin are lost.
RATIONALE FOR INCORRECT ANSWER S:
A) This describes a partial-thickness burn. Only part of the skin is damaged or destroyed. Large,
thick-walled blisters develop, and the underlying tissue is deep red and appears wet and shiny.
The damaged skin is painful with increased sensitivity to heat. Healing occurs by evolution of
undamaged basal cells and takes about 21 to 22 days.
C) This describes a superficial burn. The skin appears pink and has increased sensitivity to heat.
Healing occurs without treatment.
D)This describes a partial-thickness burn.
The nurse providing care for clients with diabetes mellitus receives report. Which client does
the nurse see first?
A) A female client who reports urinary frequency and burning with urination.
B) A client with a BP of 90/60 mm Hg and whose skin is hot and dry to touch.
C) A client with a BP of 120/50 mm Hg and who reports frequent urination and thirst.
D) A client who reports experiencing constant hunger. - correct answer B) A client with a BP of
90/60 mm Hg and whose skin is hot and dry to touch.
RATIONALE:
A nurse is planning care for a patient with anorexia nervosa. Which goal is most appropriate for
the initial plan of care?
A) The patient will express satisfaction with body image within one week.
B) The patient will engage in social activities with peers during meal times.
C) The patient will independently plan and prepare all meals.
D) The patient will gain a specified amount of weight each week as agreed upon by the
healthcare team. - correct answer
After a transfusion, the body reacts by destroying the transfused red blood cells. What is this
reaction?
A) Rh negative
B) antihistamine
C) hemolytic
D) antibody - correct answer C) Hemolytic
RATIONALE: A hemolytic reaction occurs when the body destroys transfused red blood cells.
The nurse prepares to perform the initial assessment on a school-age client. The client has an
open wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which
precaution will the nurse take?
A. Wear gloves only.
B. Wear gown and gloves.
C. Wear gown, gloves, and mask.
D. No precautions are necessary. - correct answer B. Wear gown and gloves.
RATIONALE: MRSA requires contact precautions. The nurse should wear clean, nonsterile gloves
and gown when entering the client?s room and when having any contact with the client or with
surfaces that the client touches.
The nurse has four phone messages. Which message does the nurse return first?
,A) An older adult client undergoing bowel prep and reporting watery diarrhea.
B) A client with a newborn and experiencing breast engorgement.
C) A client who had a cataract extraction 3 days ago and reporting nausea.
D) A client diagnosed with a C6 spinal cord injury and reporting a headache. - correct answer
D) A client diagnosed with a C6 spinal cord injury and reporting a headache.
RATIONALE:
A severe headache is indicative of autonomic dysreflexia in the client who has sustained a high-
level spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood
pressure, and, if untreated, can result in intracranial bleeding and death. This client is the most
unstable and is experiencing a potentially life-threatening issue that needs to be addressed
immediately by the nurse.
The adult grandchild of a client diagnosed with Parkinson disease tells the nurse about
proposed gift ideas for the grandparent's birthday in 2 weeks. The grandchild asks the nurse
which idea is best. Which option is the best gift for the nurse to recommend?
A)Perfume and makeup.
B)Hearing aid with batteries.
C)Warming tray for food.
D)Quilt and soft pillow. - correct answer C) Warming tray for food
RATIONALE: Warming trays can keep food hot, safe, and appealing during the slow eating
process of the client diagnosed with Parkinson disease. Eating is slow because of overall slowed
body movement, tremors, difficulty chewing and swallowing, fatigue, and need for rest periods.
This choice directly addresses a physiologic need.
The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with
asthma about preventative care. Which statement by the parent indicates to the nurse that
further teaching is necessary?
A. "My child likes sleeping on the top bunk when visiting grandparents."
B. "My child sleeps on a zippered covered pillow and mattress."
C. "My child changes his clothes after playing outside."
,D. "My child wears a mask while I vacuum the carpets." - correct answer A."My child likes
sleeping on the top bunk when visiting grandparents."
RATIONALE:
Dust mites are a trigger for asthma. Fabric from bedding on the upper bunk can harbor dust
mites. The child is not to sleep or lie down on upholstered furniture. Use furniture that can be
wiped with a damp cloth such as wood, plastic, vinyl, or leather.
The home care nurse evaluates a client diagnosed with tuberculosis and receiving isoniazid,
rifampin, and pyrazinamide. Which client statement requires further assessment by the nurse?
A) "I have gained 5 pounds since I started taking the medication."
B) "I cover my nose and mouth when I cough or sneeze."
C) "I drink a glass of wine with dinner each night."
D) "I have stopped eating tuna salad sandwiches." - correct answer C) "I drink a glass of wine
with dinner each night."
RATIONALE:
An adverse reaction of isoniazid is hepatitis. Instruct a client to avoid ingesting alcohol when
taking the medication.
RATIONALE FOR INCORRECT ANSWER S:
"I have gained 5 pounds since I started taking the medication."
Weight loss is a symptom of TB. Gaining weight indicates the client is able to eat and is having
minimal GI upset due to the medications.
"I cover my nose and mouth when I cough or sneeze."
Covering the mouth and nose when coughing or sneezing is good hygiene and prevents the
spread of disease.
"I have stopped eating tuna salad sandwiches."
, A client taking these medications should avoid tuna, aged cheese, red wine, and yeast extracts,
as they may cause the adverse effects of flushing, hypotension, palpitations, and diaphoresis.
The nurse in the emergency department assesses a client diagnosed with burns. Which
observation most concerns the nurse?
A) Redness and swelling with fluid-filled vesicles noted on right arm.
B) Charred, waxy, white appearance of skin on the left leg.
C) Reddened blotchy painful areas noted on the trunk.
D) Blistering and blanching of the skin noted on the back. - correct answer B) Charred, waxy,
white appearance of skin on the left leg.
RATIONALE:
This describes a full-thickness burn. All the skin is destroyed and the muscle and bone may be
involved. The substance that remains is called eschar and is dry to the touch. Full-thickness
burns do not heal spontaneously and require grafting. All functions of the skin are lost.
RATIONALE FOR INCORRECT ANSWER S:
A) This describes a partial-thickness burn. Only part of the skin is damaged or destroyed. Large,
thick-walled blisters develop, and the underlying tissue is deep red and appears wet and shiny.
The damaged skin is painful with increased sensitivity to heat. Healing occurs by evolution of
undamaged basal cells and takes about 21 to 22 days.
C) This describes a superficial burn. The skin appears pink and has increased sensitivity to heat.
Healing occurs without treatment.
D)This describes a partial-thickness burn.
The nurse providing care for clients with diabetes mellitus receives report. Which client does
the nurse see first?
A) A female client who reports urinary frequency and burning with urination.
B) A client with a BP of 90/60 mm Hg and whose skin is hot and dry to touch.
C) A client with a BP of 120/50 mm Hg and who reports frequent urination and thirst.
D) A client who reports experiencing constant hunger. - correct answer B) A client with a BP of
90/60 mm Hg and whose skin is hot and dry to touch.
RATIONALE:
