NCLEX-RN COMPREHENSIVE LICENSURE
EXAM/ ACTUAL EXAM QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES
GRADED A+ LATEST
1. A patient with congestive heart failure reports shortness of breath when
lying flat. The nurse documents orthopnea. Which intervention is best to
relieve symptoms immediately?
A. Administer oral furosemide now.
B. Raise the head of bed and offer oxygen.
C. Encourage slow, deep breathing while supine.
D. Teach pursed-lip breathing and ambulate.
Answer: B
Rationale: Elevating HOB improves ventilation/diaphragmatic excursion;
oxygen treats hypoxemia. IV/rapid diuresis may be needed but immediate
noninvasive measures first.
2. A post-op patient has a Foley drain with 100 mL urine output over 4 hours
and lower abdominal distention. What should nurse do first?
A. Increase IV fluids.
B. Check catheter tubing for kinks and reposition.
C. Notify surgeon for catheter replacement.
D. Palpate suprapubic area and attempt bladder scan.
Answer: B
Rationale: Low output with distention suggests obstruction—check tubing
and position immediately before escalating.
,3. A client with diabetic ketoacidosis has K+ 5.6 mEq/L. Which action does
nurse anticipate?
A. Administer IV potassium chloride.
B. Hold insulin until K+ falls.
C. Begin IV regular insulin infusion.
D. Give oral potassium binder.
Answer: C
Rationale: In DKA, insulin moves K+ into cells lowering serum K+.
Despite hyperkalemia, correcting acidosis and giving insulin is priority;
monitor K+ and replace later if needed.
4. A patient on warfarin (INR goal 2–3) has INR 5.2 with minor bruising.
Which is best?
A. Hold warfarin and give vitamin K orally.
B. Continue dose and recheck INR in one week.
C. Give IV vitamin K now.
D. Stop warfarin and start heparin infusion.
Answer: A
Rationale: INR >4.5–10 without major bleeding: hold warfarin and consider
low-dose oral vitamin K. IV vitamin K reserved for serious bleeding.
5. A newborn with suspected hip dysplasia has asymmetric gluteal folds. Nurse
should:
A. Apply Pavlik harness as ordered and educate parents.
B. Position newborn supine with legs extended.
C. Recommend casting at 6 months.
D. Reassure parents that this resolves spontaneously.
Answer: A
Rationale: Asymmetric folds suggest dysplasia — early Pavlik harness
stabilizes hip and is standard when ordered.
,6. A patient with COPD has PaO₂ 58 mmHg on room air and rests comfortably.
Which action is correct?
A. Start high-flow oxygen (10 L/min).
B. Administer low-flow oxygen to maintain SaO₂ 88–92%.
C. Encourage hyperventilation to raise PaO₂.
D. Immediately intubate for hypoxemia.
Answer: B
Rationale: COPD patients often target SaO₂ 88–92% to avoid CO₂
retention; moderate supplemental O₂ is appropriate.
7. A client receiving amphotericin B develops fever, chills, and hypotension
during infusion. Nurse should:
A. Continue infusion—these are mild expected effects.
B. Stop infusion and notify provider; administer antipyretic and fluids as
ordered.
C. Slow infusion rate only.
D. Give antihistamine and resume at same rate.
Answer: B
Rationale: Infusion reactions can be severe—stop, treat symptoms, and
notify prescriber.
8. A patient with Addison’s disease is vomiting and weak. Which IV order will
nurse question?
A. D5W at 75 mL/hr.
B. Hydrocortisone 100 mg IV bolus.
C. Normal saline with KCl.
D. Insulin infusion for hyperkalemia.
Answer: A
Rationale: Addisons risk hypotension and hyponatremia—D5W (free
water) can worsen hyponatremia; isotonic fluids are preferred.
, 9. A nurse counsels a patient starting isoniazid (INH) for latent TB. Which
teaching is essential?
A. Avoid sunlight exposure.
B. Take vitamin B6 (pyridoxine) to prevent neuropathy.
C. Expect brown urine discoloration.
D. Stop INH if slight abdominal discomfort occurs.
Answer: B
Rationale: INH can cause peripheral neuropathy; pyridoxine prophylaxis is
recommended. Rifampin causes orange discoloration.
10. During CPR, the nurse notes the monitor shows ventricular fibrillation.
What is priority?
A. Continue chest compressions and prepare defibrillation.
B. Administer epinephrine immediately.
C. Intubate then defibrillate.
D. Give IV amiodarone before shocks.
Answer: A
Rationale: VF is a shockable rhythm—deliver defibrillation as soon as
possible while CPR continues per ACLS.
11. A patient on lithium reports fine tremor and polyuria. Serum lithium is
therapeutic. Nurse should:
A. Suggest increased caffeine to reduce tremor.
B. Explain that mild tremor and polyuria are common and reassess.
C. Instruct to stop lithium immediately.
D. Hold next dose and bring in for lithium level check.
Answer: B
Rationale: Fine tremor and polyuria are common side effects at therapeutic
levels; assess severity and monitor.
EXAM/ ACTUAL EXAM QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES
GRADED A+ LATEST
1. A patient with congestive heart failure reports shortness of breath when
lying flat. The nurse documents orthopnea. Which intervention is best to
relieve symptoms immediately?
A. Administer oral furosemide now.
B. Raise the head of bed and offer oxygen.
C. Encourage slow, deep breathing while supine.
D. Teach pursed-lip breathing and ambulate.
Answer: B
Rationale: Elevating HOB improves ventilation/diaphragmatic excursion;
oxygen treats hypoxemia. IV/rapid diuresis may be needed but immediate
noninvasive measures first.
2. A post-op patient has a Foley drain with 100 mL urine output over 4 hours
and lower abdominal distention. What should nurse do first?
A. Increase IV fluids.
B. Check catheter tubing for kinks and reposition.
C. Notify surgeon for catheter replacement.
D. Palpate suprapubic area and attempt bladder scan.
Answer: B
Rationale: Low output with distention suggests obstruction—check tubing
and position immediately before escalating.
,3. A client with diabetic ketoacidosis has K+ 5.6 mEq/L. Which action does
nurse anticipate?
A. Administer IV potassium chloride.
B. Hold insulin until K+ falls.
C. Begin IV regular insulin infusion.
D. Give oral potassium binder.
Answer: C
Rationale: In DKA, insulin moves K+ into cells lowering serum K+.
Despite hyperkalemia, correcting acidosis and giving insulin is priority;
monitor K+ and replace later if needed.
4. A patient on warfarin (INR goal 2–3) has INR 5.2 with minor bruising.
Which is best?
A. Hold warfarin and give vitamin K orally.
B. Continue dose and recheck INR in one week.
C. Give IV vitamin K now.
D. Stop warfarin and start heparin infusion.
Answer: A
Rationale: INR >4.5–10 without major bleeding: hold warfarin and consider
low-dose oral vitamin K. IV vitamin K reserved for serious bleeding.
5. A newborn with suspected hip dysplasia has asymmetric gluteal folds. Nurse
should:
A. Apply Pavlik harness as ordered and educate parents.
B. Position newborn supine with legs extended.
C. Recommend casting at 6 months.
D. Reassure parents that this resolves spontaneously.
Answer: A
Rationale: Asymmetric folds suggest dysplasia — early Pavlik harness
stabilizes hip and is standard when ordered.
,6. A patient with COPD has PaO₂ 58 mmHg on room air and rests comfortably.
Which action is correct?
A. Start high-flow oxygen (10 L/min).
B. Administer low-flow oxygen to maintain SaO₂ 88–92%.
C. Encourage hyperventilation to raise PaO₂.
D. Immediately intubate for hypoxemia.
Answer: B
Rationale: COPD patients often target SaO₂ 88–92% to avoid CO₂
retention; moderate supplemental O₂ is appropriate.
7. A client receiving amphotericin B develops fever, chills, and hypotension
during infusion. Nurse should:
A. Continue infusion—these are mild expected effects.
B. Stop infusion and notify provider; administer antipyretic and fluids as
ordered.
C. Slow infusion rate only.
D. Give antihistamine and resume at same rate.
Answer: B
Rationale: Infusion reactions can be severe—stop, treat symptoms, and
notify prescriber.
8. A patient with Addison’s disease is vomiting and weak. Which IV order will
nurse question?
A. D5W at 75 mL/hr.
B. Hydrocortisone 100 mg IV bolus.
C. Normal saline with KCl.
D. Insulin infusion for hyperkalemia.
Answer: A
Rationale: Addisons risk hypotension and hyponatremia—D5W (free
water) can worsen hyponatremia; isotonic fluids are preferred.
, 9. A nurse counsels a patient starting isoniazid (INH) for latent TB. Which
teaching is essential?
A. Avoid sunlight exposure.
B. Take vitamin B6 (pyridoxine) to prevent neuropathy.
C. Expect brown urine discoloration.
D. Stop INH if slight abdominal discomfort occurs.
Answer: B
Rationale: INH can cause peripheral neuropathy; pyridoxine prophylaxis is
recommended. Rifampin causes orange discoloration.
10. During CPR, the nurse notes the monitor shows ventricular fibrillation.
What is priority?
A. Continue chest compressions and prepare defibrillation.
B. Administer epinephrine immediately.
C. Intubate then defibrillate.
D. Give IV amiodarone before shocks.
Answer: A
Rationale: VF is a shockable rhythm—deliver defibrillation as soon as
possible while CPR continues per ACLS.
11. A patient on lithium reports fine tremor and polyuria. Serum lithium is
therapeutic. Nurse should:
A. Suggest increased caffeine to reduce tremor.
B. Explain that mild tremor and polyuria are common and reassess.
C. Instruct to stop lithium immediately.
D. Hold next dose and bring in for lithium level check.
Answer: B
Rationale: Fine tremor and polyuria are common side effects at therapeutic
levels; assess severity and monitor.
