NCSBN NCLEX Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

NCSBN NCLEX Questions and Answers | Latest Version | 2025/2026 | Correct & Verified A nurse is caring for a client with congestive heart failure who reports shortness of breath and fatigue. Which intervention should the nurse implement first? a. Offer water b. Assist with ambulation c. Assess oxygen saturation and respiratory status d. Provide dietary teaching **Rationale:** Airway and oxygenation are always the priority in clients with CHF experiencing dyspnea. A client reports sudden dizziness after standing. Which action should the nurse take first? a. Encourage oral fluids b. Document the complaint c. Assist the client to sit or lie down d. Measure blood pressure later **Rationale:** Preventing falls is the immediate concern with dizziness or orthostatic hypotension. 2 A postoperative client develops a fever of 101.8°F. Which intervention should the nurse prioritize? a. Offer a warm blanket b. Assess for signs of infection at the surgical site c. Administer pain medication d. Encourage ambulation **Rationale:** Postoperative fever may indicate infection and requires immediate assessment. A client with diabetes reports feeling shaky and sweaty. Which action should the nurse take first? a. Check the client’s blood glucose b. Encourage a walk c. Administer insulin d. Provide oral fluids **Rationale:** Hypoglycemia is potentially life-threatening; rapid assessment of blood glucose is essential. The nurse is preparing to administer morning medications. Which client should be seen first? a. Client scheduled for daily wound care 3 b. Client with chest pain rating 8/10 c. Client requesting assistance with toileting d. Client with routine vital signs due **Rationale:** Chest pain may indicate myocardial infarction and requires immediate attention. A client receiving IV antibiotics reports a new rash and swelling of lips. Which is the nurse’s priority action? a. Document the findings b. Notify the dietary department c. Assess airway and prepare for possible anaphylaxis d. Administer antihistamines later **Rationale:** Airway compromise is life-threatening and must be addressed immediately. A client with chronic obstructive pulmonary disease (COPD) has increased shortness of breath and O2 saturation of 85%. Which intervention should the nurse implement first? a. Encourage coughing exercises b. Raise the head of the bed c. Administer supplemental oxygen as prescribed 4 d. Provide oral fluids **Rationale:** Hypoxia is a priority; oxygen therapy improves tissue oxygenation. A nurse is caring for multiple clients. Which one should the nurse assess first? a. Client requesting ice chips b. Client with sudden onset of slurred speech and facial droop c. Client needing assistance to the bathroom d. Client awaiting routine medication **Rationale:** Signs of stroke are time-sensitive and require immediate assessment. The nurse is preparing to administer medications. Which client should be seen first? a. Client needing scheduled vitamin supplement b. Client requesting a warm blanket c. Client with blood pressure 88/50 mmHg and dizziness d. Client awaiting routine vitals **Rationale:** Hypotension may indicate shock; safety and stability are the priority. A nurse notices that a client’s IV site is red, swollen, and painful. What is the nurse’s first action? 5 a. Apply a warm compress b. Discontinue the IV line c. Flush the IV line d. Elevate the arm **Rationale:** Phlebitis or infiltration requires immediate removal of the IV to prevent complications. A client reports sudden severe abdominal pain with nausea and vomiting. Which action is most important? a. Assess vital signs and pain location b. Offer oral fluids c. Encourage ambulation