NCLEX Mastery Volume 3 – 100 Practice
Questions with Rationales.
1.
A nurse is caring for a client admitted with heart failure who reports shortness of breath when
lying flat. Which intervention should the nurse implement first?
A) Administer prescribed diuretic
B) Place the client in high-Fowler’s position
C) Notify the healthcare provider
D) Restrict oral fluids
Answer: B) Place the client in high-Fowler’s position
Rationale: Positioning immediately improves ventilation and reduces dyspnea while
preparing for further interventions like diuretics.
2.
The nurse prepares to administer morning medications to a client with a nasogastric tube
attached to suction. What action is appropriate?
A) Crush all medications and give together
B) Flush the tube, clamp for 30 minutes, then reconnect suction
C) Administer with feeding formula to save time
D) Give medications directly into suction tubing
Answer: B) Flush the tube, clamp for 30 minutes, then reconnect suction
Rationale: Medications need absorption time; clamping ensures effectiveness.
3.
A client receiving heparin infusion has an aPTT of 120 seconds (normal: 25–35). What is the
nurse’s priority action?
A) Continue infusion at same rate
B) Stop infusion and prepare protamine sulfate
C) Increase infusion rate
D) Document as expected result
Answer: B) Stop infusion and prepare protamine sulfate
Rationale: aPTT is dangerously high, increasing bleeding risk. Antidote may be needed.
For expert assistance contact us on WhatsApp: +254700486651
,4.
A nurse is teaching a new mother about umbilical cord care. Which statement indicates correct
understanding?
A) “I will apply petroleum jelly to keep it moist.”
B) “I should clean it with alcohol after every diaper change.”
C) “I will keep the area clean and dry until it falls off.”
D) “I should pull on it gently after one week.”
Answer: C) “I will keep the area clean and dry until it falls off.”
Rationale: The cord should be kept clean and dry; it falls off naturally in 1–2 weeks.
5.
The nurse cares for a client receiving digoxin. Which finding requires immediate intervention?
A) Heart rate 58 bpm
B) Serum potassium 2.9 mEq/L
C) Client reports mild fatigue
D) Apical pulse regular
Answer: B) Serum potassium 2.9 mEq/L
Rationale: Hypokalemia increases the risk of digoxin toxicity and requires prompt
correction.
6.
A child with sickle cell crisis is admitted. Which nursing intervention is priority?
A) Encourage ambulation
B) Administer IV fluids
C) Apply cold compresses
D) Restrict oral intake
Answer: B) Administer IV fluids
Rationale: Hydration reduces sickling and helps relieve vaso-occlusion.
7.
A nurse receives report on four clients. Which should be assessed first?
A) COPD client with O₂ sat of 90%
B) Heart failure client with 3+ edema
C) Post-op client with 150 mL bright red drainage in the past hour
D) Client with diabetes whose blood glucose is 180 mg/dL
Answer: C) Post-op client with 150 mL bright red drainage in the past hour
For expert assistance contact us on WhatsApp: +254700486651
, Rationale: This suggests hemorrhage, which is life-threatening and requires immediate
attention.
8.
A client with depression is started on sertraline. Which statement shows the need for further
teaching?
A) “It may take several weeks before I feel better.”
B) “I should avoid alcohol while taking this medication.”
C) “If I develop suicidal thoughts, I should stop the medication immediately.”
D) “I may notice some nausea at first.”
Answer: C) “If I develop suicidal thoughts, I should stop the medication immediately.”
Rationale: Suicidal thoughts require immediate provider notification, not abrupt
discontinuation.
9.
A client receiving IV vancomycin develops flushing, rash, and hypotension. What is the nurse’s
priority action?
A) Stop the infusion immediately
B) Administer diphenhydramine
C) Slow the infusion rate
D) Call the provider after completion
Answer: A) Stop the infusion immediately
Rationale: These are signs of “red man syndrome”; infusion must be stopped first.
10.
A nurse cares for a client with suspected appendicitis. Which action is contraindicated?
A) Keeping client NPO
B) Applying heat to the abdomen
C) Administering IV fluids
D) Monitoring pain level
Answer: B) Applying heat to the abdomen
Rationale: Heat increases risk of perforation; cold compresses are safer.
Q11. A client returns from colonoscopy with moderate abdominal cramping and a small amount
of bloody-tinged stool. What is the nurse’s best action?
A) Encourage vigorous ambulation immediately
B) Apply ice to the abdomen and continue to monitor
C) Notify the provider for emergent surgery
For expert assistance contact us on WhatsApp: +254700486651
Questions with Rationales.
1.
A nurse is caring for a client admitted with heart failure who reports shortness of breath when
lying flat. Which intervention should the nurse implement first?
A) Administer prescribed diuretic
B) Place the client in high-Fowler’s position
C) Notify the healthcare provider
D) Restrict oral fluids
Answer: B) Place the client in high-Fowler’s position
Rationale: Positioning immediately improves ventilation and reduces dyspnea while
preparing for further interventions like diuretics.
2.
The nurse prepares to administer morning medications to a client with a nasogastric tube
attached to suction. What action is appropriate?
A) Crush all medications and give together
B) Flush the tube, clamp for 30 minutes, then reconnect suction
C) Administer with feeding formula to save time
D) Give medications directly into suction tubing
Answer: B) Flush the tube, clamp for 30 minutes, then reconnect suction
Rationale: Medications need absorption time; clamping ensures effectiveness.
3.
A client receiving heparin infusion has an aPTT of 120 seconds (normal: 25–35). What is the
nurse’s priority action?
A) Continue infusion at same rate
B) Stop infusion and prepare protamine sulfate
C) Increase infusion rate
D) Document as expected result
Answer: B) Stop infusion and prepare protamine sulfate
Rationale: aPTT is dangerously high, increasing bleeding risk. Antidote may be needed.
For expert assistance contact us on WhatsApp: +254700486651
,4.
A nurse is teaching a new mother about umbilical cord care. Which statement indicates correct
understanding?
A) “I will apply petroleum jelly to keep it moist.”
B) “I should clean it with alcohol after every diaper change.”
C) “I will keep the area clean and dry until it falls off.”
D) “I should pull on it gently after one week.”
Answer: C) “I will keep the area clean and dry until it falls off.”
Rationale: The cord should be kept clean and dry; it falls off naturally in 1–2 weeks.
5.
The nurse cares for a client receiving digoxin. Which finding requires immediate intervention?
A) Heart rate 58 bpm
B) Serum potassium 2.9 mEq/L
C) Client reports mild fatigue
D) Apical pulse regular
Answer: B) Serum potassium 2.9 mEq/L
Rationale: Hypokalemia increases the risk of digoxin toxicity and requires prompt
correction.
6.
A child with sickle cell crisis is admitted. Which nursing intervention is priority?
A) Encourage ambulation
B) Administer IV fluids
C) Apply cold compresses
D) Restrict oral intake
Answer: B) Administer IV fluids
Rationale: Hydration reduces sickling and helps relieve vaso-occlusion.
7.
A nurse receives report on four clients. Which should be assessed first?
A) COPD client with O₂ sat of 90%
B) Heart failure client with 3+ edema
C) Post-op client with 150 mL bright red drainage in the past hour
D) Client with diabetes whose blood glucose is 180 mg/dL
Answer: C) Post-op client with 150 mL bright red drainage in the past hour
For expert assistance contact us on WhatsApp: +254700486651
, Rationale: This suggests hemorrhage, which is life-threatening and requires immediate
attention.
8.
A client with depression is started on sertraline. Which statement shows the need for further
teaching?
A) “It may take several weeks before I feel better.”
B) “I should avoid alcohol while taking this medication.”
C) “If I develop suicidal thoughts, I should stop the medication immediately.”
D) “I may notice some nausea at first.”
Answer: C) “If I develop suicidal thoughts, I should stop the medication immediately.”
Rationale: Suicidal thoughts require immediate provider notification, not abrupt
discontinuation.
9.
A client receiving IV vancomycin develops flushing, rash, and hypotension. What is the nurse’s
priority action?
A) Stop the infusion immediately
B) Administer diphenhydramine
C) Slow the infusion rate
D) Call the provider after completion
Answer: A) Stop the infusion immediately
Rationale: These are signs of “red man syndrome”; infusion must be stopped first.
10.
A nurse cares for a client with suspected appendicitis. Which action is contraindicated?
A) Keeping client NPO
B) Applying heat to the abdomen
C) Administering IV fluids
D) Monitoring pain level
Answer: B) Applying heat to the abdomen
Rationale: Heat increases risk of perforation; cold compresses are safer.
Q11. A client returns from colonoscopy with moderate abdominal cramping and a small amount
of bloody-tinged stool. What is the nurse’s best action?
A) Encourage vigorous ambulation immediately
B) Apply ice to the abdomen and continue to monitor
C) Notify the provider for emergent surgery
For expert assistance contact us on WhatsApp: +254700486651
