What is the NCLEX-RN Exam?
The NCLEX-RN (National Council Licensure Examination for Registered Nurses) is a standardized exam that assesses the knowledge, skills, and abilities required to become a licensed registered nurse (RN) in the United States. This exam is designed to evaluate a nurse’s capability to provide safe and effective care to patients in a variety of healthcare settings. It is administered by the National Council of State Boards of Nursing (NCSBN) and is a crucial step in the process of becoming a licensed RN.
The NCLEX-RN exam tests candidates on a wide range of topics, including safe and effective care environment, health promotion and maintenance, psychosocial integrity, and physiological integrity. These categories are designed to evaluate both the theoretical knowledge and practical application that nurses need in real-world clinical environments. The exam covers everything from basic patient care, disease prevention, and administering medications to more complex scenarios like managing critical patients and navigating ethical dilemmas.
The exam is computer-adaptive, meaning that the difficulty of the questions adjusts based on the test taker’s previous answers. This ensures that the exam is appropriately challenging for each candidate. The exam may consist of between 75 and 265 questions, depending on how well the candidate answers questions. The total testing time can range from 2 to 6 hours. The results are typically available within a few days after the exam.
Preparing for the NCLEX-RN exam is vital for future nurses, as it determines their eligibility to practice as registered nurses. Effective preparation includes studying the key content areas, understanding the exam format, and practicing with realistic test questions.
By completing the NCLEX-RN exam, nurses demonstrate their ability to provide safe, competent, and ethical care, ensuring they are well-equipped to handle the responsibilities that come with being a registered nurse. For More NCLEX Exam visit: https://examsage.com/downloads/category/nclex-quiz/
NCLEX RN Test Free Questions
A client with congestive heart failure is receiving furosemide. Which electrolyte should the nurse monitor most closely?
Sodium
B. Potassium
C. Calcium
D. Magnesium
Answer: B. Potassium
Explanation: Furosemide is a loop diuretic that increases the excretion of potassium, putting the client at risk for hypokalemia. Monitoring potassium is essential to prevent complications like arrhythmias.
The nurse is assessing a client who just received morphine. Which assessment is the highest priority?
Bowel sounds
B. Respiratory rate
C. Blood pressure
D. Pain level
Answer: B. Respiratory rate
Explanation: Morphine is an opioid analgesic and can cause respiratory depression. Monitoring respiration is the highest priority to ensure safety.
Which intervention is appropriate for a client experiencing a tonic-clonic seizure?
Restrain the client
B. Insert an oral airway
C. Turn the client to the side
D. Apply a cool compress
Answer: C. Turn the client to the side
Explanation: Turning the client to the side helps maintain airway patency and reduces the risk of aspiration. Never restrain or insert objects in the mouth during a seizure.
A client with diabetes reports shakiness, sweating, and irritability. What is the nurse’s initial action?
Administer insulin
B. Notify the healthcare provider
C. Give 4 oz of orange juice
D. Recheck blood glucose in 30 minutes
Answer: C. Give 4 oz of orange juice
Explanation: These are signs of hypoglycemia. The nurse should provide a quick source of glucose, like juice, to raise blood sugar levels.
A postpartum client complains of calf pain and warmth. What is the nurse’s priority action?
Massage the calf
B. Encourage ambulation
C. Elevate the leg
D. Notify the healthcare provider
Answer: D. Notify the healthcare provider
Explanation: These are signs of a possible deep vein thrombosis (DVT). Massaging the leg could dislodge a clot. Immediate provider notification is necessary.
The nurse is caring for a child with epiglottitis. Which action is most appropriate?
Obtain throat culture
B. Inspect the throat with a tongue blade
C. Prepare for possible intubation
D. Encourage oral fluids
Answer: C. Prepare for possible intubation
Explanation: Epiglottitis can cause airway obstruction. Throat inspection or culture may worsen the obstruction. Emergency airway management must be available.
A client is prescribed lithium. Which statement indicates the need for further teaching?
“I will drink plenty of fluids each day.”
B. “I can continue taking ibuprofen for headaches.”
C. “I will have my blood levels checked regularly.”
D. “I should avoid becoming dehydrated.”
Answer: B. “I can continue taking ibuprofen for headaches.”
Explanation: NSAIDs like ibuprofen can increase lithium levels and cause toxicity. The client should consult the provider before using such medications.
What is the primary concern when caring for a client with a nasogastric (NG) tube to suction?
Risk of constipation
B. Risk of dehydration
C. Risk of electrolyte imbalance
D. Risk of gastric bleeding
Answer: C. Risk of electrolyte imbalance
Explanation: NG suction removes stomach contents, leading to loss of electrolytes like potassium and chloride, increasing the risk of imbalances.
The nurse is teaching a client with a new colostomy. Which action shows understanding?
Eating a low-fiber diet for life
B. Cleaning the stoma with alcohol
C. Using soap and water to clean around the stoma
D. Changing the appliance every 10 days
Answer: C. Using soap and water to clean around the stoma
Explanation: Soap and water are safe and effective for cleaning around the stoma. Alcohol is too harsh and can cause irritation.
A client is having a panic attack. What is the nurse’s best initial response?
“You’re going to be fine. Just relax.”
B. “Tell me what caused this.”
C. “Focus on taking slow, deep breaths with me.”
D. “Let’s figure out what you’re afraid of.”
Answer: C. “Focus on taking slow, deep breaths with me.”
Explanation: During a panic attack, helping the client regulate breathing can reduce symptoms. Exploring the cause can come later.
Which condition is a contraindication for administering a live vaccine?
Pregnancy
B. Hypertension
C. Asthma
D. Diabetes
Answer: A. Pregnancy
Explanation: Live vaccines (e.g., MMR, varicella) are contraindicated in pregnancy due to risk of fetal infection.
The nurse assesses a client with crackles in the lungs and pink, frothy sputum. What condition is most likely?
Pneumonia
B. Pulmonary embolism
C. Pulmonary edema
D. Chronic bronchitis
Answer: C. Pulmonary edema
Explanation: Pink, frothy sputum and crackles are hallmark signs of pulmonary edema, often associated with heart failure.
Which finding indicates that a client with COPD needs immediate attention?
Oxygen saturation of 89%
B. Productive cough
C. Clubbing of the fingers
D. Confusion and restlessness
Answer: D. Confusion and restlessness
Explanation: These are signs of hypoxia and may indicate respiratory failure. Immediate intervention is required.
Which instruction should be given to a client taking warfarin?
Increase intake of leafy greens
B. Avoid grapefruit juice
C. Use a soft toothbrush
D. Take on an empty stomach
Answer: C. Use a soft toothbrush
Explanation: Warfarin increases bleeding risk. Clients should avoid trauma, including brushing teeth too vigorously.
Which client is at greatest risk for developing pressure injuries?
A mobile elderly client
B. A client with incontinence and limited mobility
C. A teenager in a leg cast
D. A postpartum mother
Answer: B. A client with incontinence and limited mobility
Explanation: Immobility and moisture from incontinence increase the risk for skin breakdown.
The nurse observes a student nurse preparing to administer ear drops to an adult. Which action needs correction?
Washing hands
B. Pulling the ear down and back
C. Warming the medication
D. Wearing gloves
Answer: B. Pulling the ear down and back
Explanation: For adults, the ear should be pulled up and back. Down and back is correct for children under 3.
What is the nurse’s best action after a client with a central venous catheter reports chest pain and shortness of breath during flushing?
Reposition the client
B. Continue flushing slowly
C. Stop the procedure and notify the provider
D. Elevate the client’s head
Answer: C. Stop the procedure and notify the provider
Explanation: Symptoms suggest a possible air embolism or catheter complication. Stop immediately and seek help.
A nurse is teaching a client with hypertension about diet. Which food should be avoided?
Baked chicken
B. Canned soup
C. Steamed broccoli
D. Brown rice
Answer: B. Canned soup
Explanation: Canned soups are high in sodium and can worsen hypertension.
A client with cirrhosis has an elevated ammonia level. What symptom should the nurse monitor for?
Confusion
B. Diarrhea
C. Chest pain
D. Hypotension
Answer: A. Confusion
Explanation: High ammonia levels affect the brain, leading to hepatic encephalopathy, which causes confusion and altered mental status.
A pregnant client is Rh-negative and her baby is Rh-positive. What intervention is expected?
Administration of folic acid
B. Administration of Rho(D) immune globulin
C. Cesarean delivery
D. High protein diet
Answer: B. Administration of Rho(D) immune globulin
Explanation: Rh-negative mothers need Rho(D) immune globulin to prevent sensitization to Rh-positive fetal blood.
A nurse is preparing to administer digoxin to a pediatric client. Which finding would require holding the medication?
Heart rate of 120 bpm
B. Blood pressure of 90/60 mmHg
C. Heart rate of 68 bpm
D. Respiratory rate of 20
Answer: C. Heart rate of 68 bpm
Explanation: In children, a heart rate below 70 bpm is typically a contraindication for digoxin. It can lead to bradycardia and heart block. Always check apical pulse before giving.
A client is prescribed metformin. Which lab value requires immediate attention before administering the drug?
Hemoglobin: 12.4 g/dL
B. Creatinine: 2.1 mg/dL
C. Potassium: 4.8 mEq/L
D. Glucose: 160 mg/dL
Answer: B. Creatinine: 2.1 mg/dL
Explanation: Metformin is contraindicated in renal impairment due to the risk of lactic acidosis. A creatinine >1.5 mg/dL (men) or >1.4 mg/dL (women) is concerning.
What is a priority nursing action after a client has a lumbar puncture?
Ambulate the client to prevent clots
B. Keep the client NPO for 12 hours
C. Encourage high protein diet
D. Keep the client flat for several hours
Answer: D. Keep the client flat for several hours
Explanation: Keeping the client in a flat position prevents post-lumbar puncture headache by minimizing CSF leakage.
A nurse is caring for a client in Buck’s traction. Which action is most appropriate?
Remove the traction every 2 hours
B. Elevate the head of the bed 45 degrees
C. Ensure the weights hang freely
D. Place weights on the floor during repositioning
Answer: C. Ensure the weights hang freely
Explanation: Buck’s traction requires continuous traction with freely hanging weights to maintain proper alignment and effectiveness.
What is a concerning finding in a newborn 1 hour after delivery?
Respiratory rate of 50 bpm
B. Acrocyanosis
C. Grunting and nasal flaring
D. Positive Moro reflex
Answer: C. Grunting and nasal flaring
Explanation: These are signs of respiratory distress and should be addressed immediately. Acrocyanosis is normal in the first 24 hours.
A nurse is reviewing lab values. Which finding is most concerning in a client taking heparin?
Platelets: 90,000/mm³
B. INR: 1.1
C. Hemoglobin: 14.0 g/dL
D. WBC: 10,000/mm³
Answer: A. Platelets: 90,000/mm³
Explanation: Heparin-induced thrombocytopenia (HIT) can occur. A drop in platelets below 100,000 is alarming and requires stopping the medication.
A nurse is educating a client about methotrexate for rheumatoid arthritis. Which teaching is most important?
Take with high doses of vitamin C
B. Avoid live vaccines
C. Expect mild weight gain
D. Discontinue folic acid
Answer: B. Avoid live vaccines
Explanation: Methotrexate is an immunosuppressant. Live vaccines pose a risk of infection and should be avoided.
Which client should the nurse see first during shift change?
A client with a stage 1 pressure injury
B. A client scheduled for discharge
C. A client with an oxygen saturation of 84%
D. A client with a resolved nosebleed
Answer: C. A client with an oxygen saturation of 84%
Explanation: This is a critical oxygenation issue requiring immediate intervention. Airway and breathing always take top priority.
Which behavior indicates that a client with schizophrenia is experiencing a command hallucination?
Laughing to themselves
B. Saying “The TV is talking to me”
C. Staring at the wall silently
D. Whispering, “He said I should hurt myself”
Answer: D. Whispering, “He said I should hurt myself”
Explanation: Command hallucinations involve voices instructing the person to act, often dangerously. Safety is the priority in this case.
A nurse is teaching a newly diagnosed client with heart failure. Which statement indicates effective understanding?
“I’ll drink at least 3 liters of fluid daily.”
B. “I will weigh myself once a week.”
C. “I will report if I gain more than 2 pounds in a day.”
D. “I should increase my salt intake to stay hydrated.”
Answer: C. “I will report if I gain more than 2 pounds in a day.”
Explanation: Rapid weight gain is a sign of fluid retention and worsening heart failure. Clients should monitor daily and report sudden increases.
31. A nurse is preparing to administer insulin lispro to a client with type 1 diabetes. When should the nurse administer this medication?
30 minutes before meals
B. At bedtime
C. Immediately after meals
D. Within 15 minutes of starting a meal
Answer: D. Within 15 minutes of starting a meal
Explanation: Insulin lispro is rapid-acting and should be administered within 15 minutes of eating to prevent hypoglycemia and mimic natural insulin response to meals.
32. Which finding indicates that a client with chronic kidney disease (CKD) needs dietary teaching?
Eats bananas and baked potatoes daily
B. Avoids processed foods
C. Limits dairy intake
D. Drinks water instead of soda
Answer: A. Eats bananas and baked potatoes daily
Explanation: Bananas and potatoes are high in potassium, which should be restricted in CKD to avoid hyperkalemia.
33. A nurse is caring for a client receiving a blood transfusion. The client suddenly reports chills, back pain, and shortness of breath. What is the nurse’s priority action?
Document the reaction
B. Stop the transfusion
C. Call the healthcare provider
D. Administer diphenhydramine
Answer: B. Stop the transfusion
Explanation: These symptoms suggest an acute hemolytic reaction. The transfusion must be stopped immediately to prevent further complications.
34. What is a normal expected finding in a healthy newborn 2 hours after birth?
Heart rate of 80 bpm
B. Respiratory rate of 20 breaths/min
C. Presence of a positive Babinski reflex
D. Absence of rooting reflex
Answer: C. Presence of a positive Babinski reflex
Explanation: A positive Babinski reflex is normal in infants up to 1 year. It indicates neurological integrity in newborns.
35. A nurse assesses a client 24 hours post abdominal surgery. Which finding requires immediate attention?
Pain score of 6/10
B. Absent bowel sounds
C. Temperature of 101.5°F (38.6°C)
D. 100 mL of serosanguineous drainage from the incision
Answer: C. Temperature of 101.5°F (38.6°C)
Explanation: This may indicate infection. Post-op fevers >101°F warrant prompt investigation and possible intervention.
36. A client with liver cirrhosis has a serum ammonia level of 98 mcg/dL. Which assessment is most concerning?
Confusion and difficulty answering questions
B. Complaints of nausea
C. Occasional hiccups
D. Yellowing of the eyes
Answer: A. Confusion and difficulty answering questions
Explanation: High ammonia levels can cause hepatic encephalopathy, leading to mental status changes, which are an emergency.
37. A nurse is reinforcing teaching to a client taking warfarin. Which statement indicates a need for further teaching?
“I’ll use an electric razor to shave.”
B. “I’ll eat more broccoli and spinach to stay healthy.”
C. “I’ll get my INR checked regularly.”
D. “I’ll report any unusual bleeding to my provider.”
Answer: B. “I’ll eat more broccoli and spinach to stay healthy.”
Explanation: Foods high in vitamin K can interfere with warfarin’s effectiveness. Clients should maintain a consistent intake, not increase it suddenly.
38. Which task is appropriate for the nurse to delegate to a licensed practical nurse (LPN)?
Developing a care plan
B. Administering IV push morphine
C. Teaching insulin self-administration
D. Performing wound dressing change
Answer: D. Performing wound dressing change
Explanation: LPNs can perform routine procedures such as wound care. Teaching, planning, and IV push meds are the responsibility of RNs.
39. A nurse is reviewing morning labs. Which finding requires notifying the provider immediately?
Potassium 3.4 mEq/L
B. Sodium 147 mEq/L
C. Magnesium 1.0 mg/dL
D. Calcium 9.0 mg/dL
Answer: C. Magnesium 1.0 mg/dL
Explanation: This is below normal (1.5–2.5 mg/dL) and can lead to arrhythmias and seizures. It requires urgent intervention.
40. A nurse is caring for a client post thyroidectomy. Which finding indicates a potential complication?
Hoarseness for the first few hours
B. Complaints of sore throat
C. Positive Chvostek’s sign
D. Mild neck edema
Answer: C. Positive Chvostek’s sign
Explanation: This indicates hypocalcemia, a complication due to potential parathyroid injury. It requires immediate calcium replacement.
41. A nurse is caring for a client receiving total parenteral nutrition (TPN). Which action is most appropriate?
Shake the TPN bag vigorously before use
B. Check blood glucose levels every 6 hours
C. Infuse TPN through a peripheral IV line
D. Discontinue TPN abruptly when feeding starts
Answer: B. Check blood glucose levels every 6 hours
Explanation: TPN contains high levels of glucose, requiring regular monitoring to prevent hyperglycemia or hypoglycemia.
42. A client receiving furosemide reports muscle cramps. What is the nurse’s priority action?
Encourage ambulation
B. Offer fluids
C. Check potassium level
D. Elevate the legs
Answer: C. Check potassium level
Explanation: Furosemide can cause hypokalemia, leading to muscle cramps and cardiac arrhythmias. Monitor electrolyte levels closely.
43. A nurse assesses a client with a chest tube. Which finding requires immediate intervention?
Gentle bubbling in the suction chamber
B. Intermittent bubbling in the water seal chamber
C. Drainage of 100 mL over 4 hours
D. Continuous bubbling in the water seal chamber
Answer: D. Continuous bubbling in the water seal chamber
Explanation: This may indicate an air leak in the system, which can compromise lung re-expansion and requires prompt action.
44. A client is diagnosed with a deep vein thrombosis (DVT). Which is the nurse’s priority?
Massage the leg to reduce pain
B. Elevate the affected limb
C. Apply warm compresses
D. Encourage ambulation
Answer: B. Elevate the affected limb
Explanation: Elevation reduces swelling and promotes venous return. Massaging can dislodge the clot and is contraindicated.
45. A nurse is caring for a client with myasthenia gravis. Which meal plan is most appropriate?
Large meals twice a day
B. Frequent snacks
C. Small, frequent meals with rest before eating
D. High-fat meals to improve energy
Answer: C. Small, frequent meals with rest before eating
Explanation: Muscle fatigue affects chewing and swallowing. Frequent, small meals and resting before meals help prevent aspiration.
46. Which medication should the nurse question for a client with asthma?
Albuterol
B. Fluticasone
C. Propranolol
D. Montelukast
Answer: C. Propranolol
Explanation: Beta-blockers like propranolol can cause bronchoconstriction and worsen asthma symptoms.
47. A nurse is assessing a client with a history of heart failure. Which symptom suggests fluid volume overload?
Dry mucous membranes
B. Weak peripheral pulses
C. Crackles in the lungs
D. Low blood pressure
Answer: C. Crackles in the lungs
Explanation: Crackles are a sign of pulmonary congestion due to fluid buildup, a common complication of heart failure.
48. What is the most important instruction for a client newly prescribed phenytoin?
Avoid dairy products
B. Expect increased urination
C. Maintain good oral hygiene
D. Take with grapefruit juice
Answer: C. Maintain good oral hygiene
Explanation: Phenytoin can cause gingival hyperplasia. Proper dental care is essential to prevent complications.
49. A client with a C6 spinal cord injury suddenly develops a severe headache, flushed skin, and hypertension. What should the nurse do first?
Lower the client’s head
B. Check for bladder distention
C. Administer antihypertensive medication
D. Notify the provider
Answer: B. Check for bladder distention
Explanation: Autonomic dysreflexia is often caused by a full bladder or bowel. Address the cause first before other actions.
50. A nurse is caring for a client with a new tracheostomy. Which action takes priority?
Provide humidified oxygen
B. Suction as needed using sterile technique
C. Clean the stoma daily
D. Change the trach ties every shift
Answer: B. Suction as needed using sterile technique
Explanation: Maintaining a clear airway is critical. Suctioning with sterile technique prevents infection and obstruction.
51. A client with peptic ulcer disease is prescribed omeprazole. What is the mechanism of action?
Neutralizes stomach acid
B. Coats the ulcer surface
C. Decreases gastric acid secretion
D. Increases gastric motility
Answer: C. Decreases gastric acid secretion
Explanation: Omeprazole is a proton pump inhibitor that blocks acid production, promoting ulcer healing.
52. Which laboratory value is most important to monitor in a client taking enoxaparin?
INR
B. Platelet count
C. Sodium
D. Hemoglobin A1C
Answer: B. Platelet count
Explanation: Enoxaparin can cause heparin-induced thrombocytopenia (HIT). Monitoring platelets helps detect this adverse effect.
53. What is the primary purpose of administering lactulose to a client with liver disease?
Stimulate bile flow
B. Lower blood glucose
C. Reduce ammonia levels
D. Relieve constipation only
Answer: C. Reduce ammonia levels
Explanation: Lactulose traps ammonia in the gut and helps excrete it, preventing hepatic encephalopathy.
54. A nurse assesses a client after thyroidectomy and notes hoarseness. What is the priority action?
Document the finding
B. Notify the provider
C. Assess for stridor
D. Encourage vocal rest
Answer: C. Assess for stridor
Explanation: Hoarseness is expected, but stridor indicates airway obstruction, which is life-threatening.
55. A client with type 2 diabetes has fasting blood glucose of 300 mg/dL and is lethargic. What should the nurse do first?
Administer sliding-scale insulin
B. Encourage oral fluids
C. Check ketone levels
D. Call the provider
Answer: C. Check ketone levels
Explanation: A high glucose with lethargy may indicate diabetic ketoacidosis. Ketone testing helps determine the next step.
56. Which of the following is an early sign of increased intracranial pressure (ICP)?
Bradycardia
B. Projectile vomiting
C. Restlessness and irritability
D. Fixed and dilated pupils
Answer: C. Restlessness and irritability
Explanation: These are early neurologic signs of rising ICP and should be addressed before progression.
57. A nurse is educating a pregnant client about iron supplements. What instruction should be included?
Take iron with dairy products
B. Take with orange juice
C. Expect diarrhea
D. Take on a full stomach
Answer: B. Take with orange juice
Explanation: Vitamin C enhances iron absorption. Dairy can inhibit absorption and should be avoided at the same time.
58. A nurse reviews the lab results of a client with pancreatitis. Which finding is expected?
Elevated lipase
B. Decreased amylase
C. Elevated potassium
D. Increased hemoglobin
Answer: A. Elevated lipase
Explanation: Lipase and amylase are pancreatic enzymes that increase during pancreatitis due to inflammation.
59. A client receiving chemotherapy reports sore mouth and difficulty eating. What is the best nursing intervention?
Encourage salty snacks
B. Provide a firm-bristled toothbrush
C. Offer cool, bland foods
D. Suggest lemon-flavored lozenges
Answer: C. Offer cool, bland foods
Explanation: Oral mucositis is common with chemotherapy. Bland, non-irritating foods reduce discomfort and promote intake.
60. Which of the following indicates the client understands how to use a metered-dose inhaler (MDI)?
“I’ll exhale while spraying the inhaler.”
B. “I’ll hold my breath after inhaling.”
C. “I’ll inhale as quickly as possible.”
D. “I don’t need to shake the inhaler before use.”
Answer: B. “I’ll hold my breath after inhaling.”
Explanation: Holding the breath for 10 seconds allows the medication to reach deeper into the lungs for better absorption.
✅ 61. A nurse is teaching a newly diagnosed type 1 diabetic about insulin administration. Which statement indicates correct understanding?
“I’ll inject the insulin into my thigh before jogging.”
B. “I’ll rotate injection sites to prevent lipodystrophy.”
C. “I’ll massage the site after injecting the insulin.”
D. “I’ll always inject at the same site for faster absorption.”
Answer: B. “I’ll rotate injection sites to prevent lipodystrophy.”
Explanation: Rotating injection sites prevents tissue damage and ensures proper insulin absorption.
✅ 62. Which symptom should the nurse report immediately in a client taking clozapine?
Drowsiness
B. Dry mouth
C. Sore throat and fever
D. Increased appetite
Answer: C. Sore throat and fever
Explanation: These may indicate agranulocytosis, a serious adverse effect of clozapine requiring immediate attention.
✅ 63. The nurse is caring for a client in the emergency department after a motor vehicle crash. The client has a rigid abdomen and absent bowel sounds. What is the priority action?
Administer pain medication
B. Insert a nasogastric tube
C. Prepare for emergency surgery
D. Obtain a urine specimen
Answer: C. Prepare for emergency surgery
Explanation: A rigid abdomen and absent bowel sounds may indicate peritonitis or internal bleeding — life-threatening surgical emergencies.
✅ 64. Which of the following clients is at highest risk for developing hospital-acquired pneumonia (HAP)?
A young adult recovering from appendectomy
B. An older adult on mechanical ventilation
C. A client on long-term beta blockers
D. A pediatric patient receiving antibiotics
Answer: B. An older adult on mechanical ventilation
Explanation: Mechanical ventilation significantly increases the risk of ventilator-associated pneumonia (VAP).
✅ 65. A nurse receives morning report. Which client should the nurse assess first?
A post-op client complaining of incisional pain
B. A diabetic client with blood glucose of 65 mg/dL
C. A heart failure client with 2+ peripheral edema
D. A client awaiting discharge instructions
Answer: B. A diabetic client with blood glucose of 65 mg/dL
Explanation: Hypoglycemia is potentially life-threatening and requires immediate intervention.
✅ 66. A nurse prepares to administer digoxin. The client’s apical pulse is 56 bpm. What should the nurse do next?
Administer the medication
B. Notify the provider
C. Check blood pressure
D. Wait 30 minutes and reassess
Answer: B. Notify the provider
Explanation: Digoxin is held if the apical pulse is <60 bpm in adults to prevent bradycardia and toxicity.
✅ 67. Which finding in a client with cirrhosis requires immediate intervention?
Ascites
B. Spider angiomas
C. Confusion
D. Jaundice
Answer: C. Confusion
Explanation: Confusion may indicate hepatic encephalopathy, a potentially fatal complication of liver failure.
✅ 68. Which task can the RN delegate to an experienced UAP?
Assessing pain in a post-op client
B. Administering a fleet enema
C. Ambulating a stable client 24 hours post-op
D. Teaching incentive spirometry use
Answer: C. Ambulating a stable client 24 hours post-op
Explanation: UAPs can assist with ambulation for stable clients under RN supervision.
✅ 69. A nurse is preparing to administer a blood transfusion. What is the priority action?
Check the client’s vital signs after 30 minutes
B. Start the infusion quickly to avoid clotting
C. Verify the client’s identity and blood product with another RN
D. Use a 22-gauge IV catheter
Answer: C. Verify the client’s identity and blood product with another RN
Explanation: Two-person verification prevents fatal ABO incompatibility errors.
✅ 70. A client on warfarin has an INR of 5.5. What should the nurse do first?
Administer vitamin K
B. Continue warfarin as prescribed
C. Recheck INR in 6 hours
D. Encourage a high-vitamin K diet
Answer: A. Administer vitamin K
Explanation: INR > 5 indicates bleeding risk; vitamin K is the antidote to reduce INR.
✅ 71. Which finding in a 6-month-old infant is most concerning?
Unable to sit with support
B. Posterior fontanel is closed
C. Babbles and coos
D. Has a strong palmar grasp reflex
Answer: A. Unable to sit with support
Explanation: By 6 months, infants should be able to sit with support. Delay suggests developmental concern.
✅ 72. A nurse is caring for a client receiving vancomycin IV. Which is the most important assessment?
Capillary refill
B. White blood cell count
C. Renal function
D. Pupil reaction
Answer: C. Renal function
Explanation: Vancomycin is nephrotoxic; monitor creatinine and BUN regularly.
✅ 73. A nurse is teaching a client about preventing urinary tract infections. Which statement requires further teaching?
“I should wipe from front to back.”
B. “I’ll avoid bubble baths.”
C. “I’ll drink 6–8 glasses of water daily.”
D. “I’ll void only when I feel full.”
Answer: D. “I’ll void only when I feel full.”
Explanation: Holding urine can lead to bacterial growth. Clients should void regularly.
✅ 74. A nurse finds a client seizing. What is the priority action?
Insert a tongue blade
B. Restrain the client
C. Turn the client on their side
D. Administer IV lorazepam
Answer: C. Turn the client on their side
Explanation: Positioning prevents aspiration during seizures. Medication is administered after airway safety is ensured.
✅ 75. Which client behavior after discharge teaching on wound care indicates proper understanding?
“I’ll wash the wound with hydrogen peroxide daily.”
B. “I’ll change the dressing only if it looks dirty.”
C. “I’ll wash my hands before and after dressing changes.”
D. “I’ll soak the wound to remove scabs.”
Answer: C. “I’ll wash my hands before and after dressing changes.”
Explanation: Hand hygiene is the most effective infection prevention step.
✅ 76. A nurse is assessing a client with COPD. Which finding requires immediate intervention?
Clubbing of fingers
B. Use of accessory muscles
C. Respiratory rate of 10
D. Barrel-shaped chest
Answer: C. Respiratory rate of 10
Explanation: A low respiratory rate may indicate impending respiratory failure, which requires urgent intervention.
✅ 77. A client is prescribed lisinopril. Which side effect should the nurse report immediately?
Dizziness
B. Headache
C. Dry cough
D. Swelling of the tongue
Answer: D. Swelling of the tongue
Explanation: This may be a sign of angioedema, a life-threatening reaction to ACE inhibitors.
✅ 78. Which client should the nurse assess first?
A client with nausea and vomiting
B. A client who reports new onset chest pain
C. A client who is requesting pain medication
D. A client with a temperature of 100.2°F (37.9°C)
Answer: B. A client who reports new onset chest pain
Explanation: New chest pain suggests a possible myocardial infarction and requires immediate attention.
✅ 79. A postpartum client is experiencing heavy lochia and a boggy uterus. What is the priority nursing intervention?
Notify the healthcare provider
B. Massage the uterus
C. Increase IV fluids
D. Insert a Foley catheter
Answer: B. Massage the uterus
Explanation: A boggy uterus is likely due to uterine atony; massage helps stimulate contractions and reduce bleeding.
✅ 80. A nurse is caring for a client with C. difficile. Which infection control measure is appropriate?
Wear an N95 respirator
B. Use alcohol-based hand sanitizer
C. Don gloves and gown before entering the room
D. Dispose of linens in a red biohazard bag
Answer: C. Don gloves and gown before entering the room
Explanation: Contact precautions are required; soap and water must be used for hand hygiene, not alcohol-based sanitizer.
✅ 81. Which electrolyte imbalance is most likely in a client with renal failure?
Hypokalemia
B. Hypocalcemia
C. Hypernatremia
D. Hyperkalemia
Answer: D. Hyperkalemia
Explanation: Renal failure leads to decreased potassium excretion, causing hyperkalemia, a dangerous cardiac risk.
✅ 82. A client with a head injury has a fixed and dilated pupil on the left side. What is the nurse’s priority action?
Check the client’s blood glucose
B. Elevate the head of the bed
C. Notify the healthcare provider immediately
D. Recheck the pupils in 15 minutes
Answer: C. Notify the healthcare provider immediately
Explanation: This suggests increased intracranial pressure and possibly brain herniation, which is life-threatening.
✅ 83. What is the best position for a client receiving tube feedings via a nasogastric tube?
Supine
B. High Fowler’s
C. Prone
D. Left side-lying
Answer: B. High Fowler’s
Explanation: High Fowler’s position reduces the risk of aspiration during feedings.
✅ 84. A nurse is caring for a child with epiglottitis. What is the priority action?
Administer oral antibiotics
B. Inspect the throat with a tongue depressor
C. Keep the child calm and avoid airway manipulation
D. Give a throat lozenge
Answer: C. Keep the child calm and avoid airway manipulation
Explanation: Airway obstruction can occur suddenly. Inspection may trigger laryngospasm.
✅ 85. A client with diabetes has a blood glucose of 40 mg/dL. What symptom is expected?
Polyuria
B. Diaphoresis
C. Flushed skin
D. Slow heart rate
Answer: B. Diaphoresis
Explanation: Signs of hypoglycemia include sweating, shakiness, and confusion.
✅ 86. What assessment finding is expected in a client with right-sided heart failure?
Pulmonary crackles
B. Jugular vein distention
C. Orthopnea
D. Dyspnea on exertion
Answer: B. Jugular vein distention
Explanation: Right-sided heart failure causes systemic venous congestion, leading to JVD and peripheral edema.
✅ 87. A client taking lithium reports nausea, vomiting, and tremors. What is the nurse’s next step?
Hold the next dose and notify the provider
B. Encourage fluids and give antiemetics
C. Continue the medication and reassess in 2 hours
D. Administer diphenhydramine
Answer: A. Hold the next dose and notify the provider
Explanation: These are signs of lithium toxicity, which requires immediate provider notification.
✅ 88. Which client is most at risk for developing a pressure ulcer?
A confused client ambulating independently
B. A mobile client with a BMI of 29
C. A bed-bound client with fecal incontinence
D. A client on a low-fat diet
Answer: C. A bed-bound client with fecal incontinence
Explanation: Immobility and moisture are high-risk factors for skin breakdown.
✅ 89. A client on furosemide develops muscle cramps. What lab result should the nurse review?
Hemoglobin
B. Potassium
C. Sodium
D. Calcium
Answer: B. Potassium
Explanation: Furosemide (a loop diuretic) causes potassium loss, which may lead to muscle cramps or arrhythmias.
✅ 90. What is the priority nursing diagnosis for a client experiencing alcohol withdrawal?
Risk for injury
B. Ineffective coping
C. Disturbed sleep pattern
D. Impaired social interaction
Answer: A. Risk for injury
Explanation: Alcohol withdrawal can cause seizures or delirium tremens, posing immediate risk to safety.
✅ 91. A nurse is preparing to administer insulin to a client with type 1 diabetes before breakfast. The blood glucose is 80 mg/dL. What should the nurse do?
Hold the insulin and notify the provider
B. Administer insulin as prescribed
C. Give half the prescribed insulin
D. Provide orange juice and reassess in 15 minutes
Answer: B. Administer insulin as prescribed
Explanation: A blood glucose of 80 mg/dL is within normal pre-meal range. Administering insulin as prescribed is appropriate.
✅ 92. Which laboratory result is most important to monitor for a client receiving warfarin?
aPTT
B. INR
C. Hemoglobin
D. Platelet count
Answer: B. INR
Explanation: INR is the key lab test for monitoring warfarin therapy to maintain therapeutic range and avoid bleeding.
✅ 93. A nurse is caring for a client with pneumonia who is restless and confused. What should the nurse do first?
Administer pain medication
B. Assess oxygen saturation
C. Notify the provider
D. Reorient the client
Answer: B. Assess oxygen saturation
Explanation: Confusion and restlessness can be early signs of hypoxia.
✅ 94. What is the priority action for a nurse caring for a client receiving a blood transfusion who reports back pain and chills?
Continue the transfusion and monitor
B. Recheck the client’s blood type
C. Stop the transfusion and notify the provider
D. Slow the rate of transfusion
Answer: C. Stop the transfusion and notify the provider
Explanation: These are signs of a hemolytic transfusion reaction, which is life-threatening.
✅ 95. A nurse is caring for a client with Alzheimer’s disease. Which intervention is most appropriate to reduce confusion?
Encourage frequent naps
B. Use a consistent daily routine
C. Limit verbal communication
D. Offer new activities daily
Answer: B. Use a consistent daily routine
Explanation: Routine and structure reduce confusion and agitation in clients with dementia.
✅ 96. A client has an NG tube with low intermittent suction. Which finding should the nurse report?
Green drainage from the tube
B. Nausea and abdominal distention
C. Hypoactive bowel sounds
D. Loud suctioning sounds
Answer: B. Nausea and abdominal distention
Explanation: These are signs that the tube may not be functioning properly, leading to a potential bowel obstruction.
✅ 97. A nurse is providing discharge teaching for a client prescribed digoxin. Which statement requires further teaching?
“I will take my pulse every day before taking the medication.”
B. “If I feel nauseated, I’ll skip a dose.”
C. “I will report any vision changes.”
D. “I’ll keep my follow-up lab appointments.”
Answer: B. “If I feel nauseated, I’ll skip a dose.”
Explanation: Nausea may be a sign of digoxin toxicity, and skipping a dose without guidance is inappropriate.
✅ 98. Which assessment finding indicates dehydration in an infant?
Moist mucous membranes
B. Bulging fontanelles
C. Capillary refill time of 4 seconds
D. Increased urine output
Answer: C. Capillary refill time of 4 seconds
Explanation: Prolonged cap refill suggests hypovolemia and dehydration.
✅ 99. A nurse is teaching a client how to use a metered-dose inhaler (MDI). Which statement indicates proper use?
“I will exhale immediately after spraying.”
B. “I will hold my breath for 5–10 seconds after inhaling.”
C. “I will shake the inhaler after each puff.”
D. “I’ll use the inhaler while lying flat.”
Answer: B. “I will hold my breath for 5–10 seconds after inhaling.”
Explanation: This maximizes drug absorption in the lungs.
✅ 100. What is the priority nursing diagnosis for a client with a new tracheostomy?
Risk for impaired mobility
B. Risk for infection
C. Ineffective airway clearance
D. Disturbed body image
Answer: C. Ineffective airway clearance
Explanation: Airway patency is the top priority in tracheostomy care.
✅ 121. A nurse is preparing to administer 20 mEq of potassium chloride IV to a client. What is the safest administration guideline?
Dilute in 100 mL and infuse over 15 minutes
B. Administer as a rapid IV push in a central line
C. Infuse slowly via IV pump over 1 hour
D. Mix with dextrose and infuse over 4 hours
Answer: C. Infuse slowly via IV pump over 1 hour
Explanation: IV potassium must be diluted and administered slowly to avoid cardiac arrhythmias.
✅ 122. A client is prescribed lisinopril. Which electrolyte imbalance is most important to monitor?
Hypokalemia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
Answer: B. Hyperkalemia
Explanation: ACE inhibitors like lisinopril can cause potassium retention, leading to hyperkalemia.
✅ 123. Which of the following is a priority assessment after administering morphine?
Blood pressure
B. Respiratory rate
C. Pain scale
D. Temperature
Answer: B. Respiratory rate
Explanation: Morphine can cause respiratory depression, making respiratory rate the priority.
✅ 124. A client receiving chemotherapy reports mouth sores and difficulty eating. What is the appropriate intervention?
Encourage spicy foods
B. Use alcohol-based mouthwash
C. Provide oral care with a soft toothbrush
D. Offer citrus juices
Answer: C. Provide oral care with a soft toothbrush
Explanation: This minimizes trauma to oral mucosa and helps manage mucositis.
✅ 125. A nurse is assessing a client for compartment syndrome. Which finding is most concerning?
Warm skin at the site
B. Capillary refill of less than 2 seconds
C. Pain unrelieved by medication
D. Decreased swelling
Answer: C. Pain unrelieved by medication
Explanation: Severe pain out of proportion is an early sign of compartment syndrome.
✅ 126. A nurse is caring for a postpartum client with uterine atony. Which medication should the nurse anticipate?
Oxytocin
B. Magnesium sulfate
C. Methotrexate
D. Rho(D) immune globulin
Answer: A. Oxytocin
Explanation: Oxytocin promotes uterine contractions to treat uterine atony and bleeding.
✅ 127. Which finding is expected in a newborn with fetal alcohol syndrome?
Large head circumference
B. Smooth philtrum
C. High birth weight
D. Long palpebral fissures
Answer: B. Smooth philtrum
Explanation: Characteristic features include a smooth philtrum, thin upper lip, and growth retardation.
✅ 128. A nurse is reviewing lab results for a client with chronic kidney disease. Which value requires immediate attention?
BUN 35 mg/dL
B. Potassium 6.2 mEq/L
C. Hemoglobin 9.8 g/dL
D. Creatinine 3.1 mg/dL
Answer: B. Potassium 6.2 mEq/L
Explanation: Hyperkalemia poses a serious risk for cardiac arrhythmias and needs urgent treatment.
✅ 129. A client is diagnosed with C. difficile. What isolation precautions are required?
Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions only
Answer: B. Contact precautions
Explanation: C. diff requires contact precautions, including gloves and gowns.
✅ 130. A nurse is caring for a client receiving IV vancomycin. Which assessment is most important?
Temperature
B. Bowel sounds
C. Creatinine level
D. Mental status
Answer: C. Creatinine level
Explanation: Vancomycin is nephrotoxic, so renal function must be monitored.
✅ 151. A nurse is caring for a client receiving total parenteral nutrition (TPN). Which laboratory value is most important to monitor?
Serum albumin
B. Potassium
C. Blood glucose
D. White blood cell count
Answer: C. Blood glucose
Explanation: TPN increases the risk for hyperglycemia due to high glucose content.
✅ 152. A nurse is preparing to administer an opioid analgesic to a client with pain. Which assessment is a priority?
Blood pressure
B. Respiratory rate
C. Urine output
D. Heart rate
Answer: B. Respiratory rate
Explanation: Opioids can cause respiratory depression, making it essential to assess the respiratory rate.
✅ 153. A nurse is caring for a client with a chest tube. Which finding should be reported to the provider?
Bubbling in the water-seal chamber
B. Continuous gentle suction
C. Drainage greater than 70 mL per hour
D. Fluctuation of water in the tubing with respiration
Answer: C. Drainage greater than 70 mL per hour
Explanation: Excessive drainage may indicate hemorrhage and requires immediate attention.
✅ 154. Which of the following is a sign of dehydration in a 2-year-old child?
Moist mucous membranes
B. Increased tears
C. Sunken fontanelles
D. Decreased heart rate
Answer: C. Sunken fontanelles
Explanation: Fontanelle depression is an indicator of dehydration in infants and young children.
✅ 155. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?
Apply cold compresses to the affected leg
B. Ambulate the client frequently
C. Administer aspirin as prescribed
D. Elevate the affected leg above the level of the heart
Answer: D. Elevate the affected leg above the level of the heart
Explanation: Elevating the leg helps reduce swelling and prevents complications.
✅ 156. A client is receiving a blood transfusion and reports chills and back pain. What is the nurse’s first action?
Stop the transfusion and notify the provider
B. Slow the transfusion rate
C. Administer acetaminophen for pain
D. Increase the infusion rate
Answer: A. Stop the transfusion and notify the provider
Explanation: Chills and back pain are signs of a hemolytic reaction and require immediate action.
✅ 157. A nurse is assessing a client with left-sided heart failure. Which finding is most concerning?
Edema in the lower extremities
B. Shortness of breath when lying flat
C. Frothy pink sputum
D. Weight gain of 2 pounds in 24 hours
Answer: C. Frothy pink sputum
Explanation: Frothy pink sputum is a sign of pulmonary edema, a life-threatening complication of heart failure.
✅ 158. A nurse is teaching a client with asthma about using a peak flow meter. Which statement indicates proper use?
“I will use the meter when I feel short of breath.”
B. “I will perform the test before taking my medication.”
C. “I should blow out slowly and steadily.”
D. “I will repeat the test three times and record the highest number.”
Answer: D. “I will repeat the test three times and record the highest number.”
Explanation: The peak flow test should be repeated three times, and the highest value is recorded for accuracy.
✅ 159. A nurse is caring for a client with a history of chronic alcohol use. Which lab result is most important to monitor?
Serum albumin
B. Blood glucose
C. Liver enzymes
D. White blood cell count
Answer: C. Liver enzymes
Explanation: Chronic alcohol use increases the risk of liver damage, making liver enzymes critical to monitor.
✅ 160. A nurse is teaching a client with hypertension about managing their condition. Which statement requires further teaching?
“I will follow a low-sodium diet.”
B. “I will monitor my blood pressure at home regularly.”
C. “I will avoid taking my medication if I feel fine.”
D. “I will exercise regularly and maintain a healthy weight.”
Answer: C. “I will avoid taking my medication if I feel fine.”
Explanation: Hypertension requires continuous medication adherence, even if the client feels well.
✅ 161. Which of the following is a priority intervention for a client with a history of anaphylaxis who has received a bee sting?
Administer a dose of epinephrine
B. Monitor the client’s vital signs
C. Apply a cold compress to the sting site
D. Elevate the affected limb
Answer: A. Administer a dose of epinephrine
Explanation: Epinephrine is the first-line treatment for anaphylaxis and should be administered immediately.
✅ 162. A client with cirrhosis develops ascites. Which nursing intervention is most appropriate?
Restrict fluid intake
B. Place the client in a low Fowler’s position
C. Encourage increased protein intake
D. Measure abdominal girth daily
Answer: D. Measure abdominal girth daily
Explanation: Abdominal girth measurement helps monitor the progression of ascites.
✅ 163. A nurse is caring for a client with a history of stroke. Which of the following is a priority when assessing for complications?
Monitor for changes in level of consciousness
B. Assess for a rash on the chest
C. Monitor for muscle weakness on one side
D. Observe for fever and chills
Answer: A. Monitor for changes in level of consciousness
Explanation: Changes in LOC may indicate increased intracranial pressure or stroke complications.
✅ 164. A nurse is caring for a client with a urinary tract infection (UTI). Which symptom should the nurse expect?
Fever, chills, and dysuria
B. Low-grade fever and anorexia
C. Nausea, vomiting, and diarrhea
D. Sudden onset of severe lower abdominal pain
Answer: A. Fever, chills, and dysuria
Explanation: Common symptoms of UTI include fever, chills, and painful urination (dysuria).
✅ 165. A nurse is teaching a client with rheumatoid arthritis about joint protection. Which statement indicates proper understanding?
“I should avoid using splints for joint support.”
B. “I should perform repetitive movements of the joints regularly.”
C. “I should apply heat to the joints when they are stiff.”
D. “I should rest the joints when they are inflamed.”
Answer: D. “I should rest the joints when they are inflamed.”
Explanation: Resting inflamed joints can reduce swelling and pain.
✅ 166. A client with a history of myocardial infarction is prescribed a beta-blocker. What is the priority nursing assessment?
Respiratory rate
B. Heart rate
C. Blood pressure
D. Bowel sounds
Answer: B. Heart rate
Explanation: Beta-blockers can lower the heart rate, so it’s important to assess this regularly.
✅ 167. A nurse is preparing a client for a lumbar puncture. Which position should the client be in?
Supine with the head elevated
B. Lying on the left side with the knees drawn up
C. Prone with the feet elevated
D. Supine with the legs extended
Answer: B. Lying on the left side with the knees drawn up
Explanation: This position helps widen the space between vertebrae for easier access.
✅ 168. A nurse is caring for a client with a diagnosis of acute pancreatitis. Which intervention should the nurse implement first?
Administer pain medication
B. Begin IV fluids as ordered
C. Monitor vital signs every 4 hours
D. Encourage oral intake of clear liquids
Answer: B. Begin IV fluids as ordered
Explanation: Fluid resuscitation is essential for managing acute pancreatitis and preventing hypovolemia.
✅ 169. A nurse is teaching a client with diabetes about foot care. Which statement indicates proper understanding?
“I will soak my feet in hot water every night.”
B. “I will wear tight-fitting shoes to prevent blisters.”
C. “I will inspect my feet daily for cuts or blisters.”
D. “I will use lotion between my toes to prevent dryness.”
Answer: C. “I will inspect my feet daily for cuts or blisters.”
Explanation: Clients with diabetes need to monitor their feet for wounds or infections due to impaired circulation and sensation.
✅ 170. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following is most important?
Maintain oxygen saturation between 90%–95%
B. Administer high-flow oxygen to prevent hypoxia
C. Monitor for signs of respiratory alkalosis
D. Encourage deep breathing exercises
Answer: A. Maintain oxygen saturation between 90%–95%
Explanation: Maintaining adequate oxygenation while avoiding hyperoxia is crucial for COPD patients.
✅ 181. A nurse is caring for a client with a diagnosis of pneumonia. Which finding requires immediate intervention?
Increased respiratory rate
B. Fever of 100.4°F (38°C)
C. Diminished breath sounds on auscultation
D. Use of accessory muscles during respiration
Answer: D. Use of accessory muscles during respiration
Explanation: Use of accessory muscles indicates respiratory distress, which requires immediate intervention.
✅ 182. A nurse is caring for a client who has just received a dose of morphine for pain. Which assessment should the nurse prioritize?
Oxygen saturation
B. Blood pressure
C. Heart rate
D. Pain level
Answer: A. Oxygen saturation
Explanation: Morphine can cause respiratory depression, making oxygen saturation a priority assessment.
✅ 183. A nurse is teaching a client with type 2 diabetes about diet management. Which statement by the client indicates a need for further teaching?
“I will monitor my blood sugar levels regularly.”
B. “I will avoid eating sweets and sugary foods.”
C. “I can eat as much fruit as I want.”
D. “I will balance my meals with protein and carbohydrates.”
Answer: C. “I can eat as much fruit as I want.”
Explanation: While fruit is healthy, it contains sugar and should be eaten in moderation.
✅ 184. A nurse is caring for a client receiving hemodialysis. Which finding is the most concerning?
Weight gain of 3 pounds in 3 days
B. Blood pressure of 160/90 mm Hg
C. Complaints of fatigue
D. Ankle edema
Answer: A. Weight gain of 3 pounds in 3 days
Explanation: Rapid weight gain can indicate fluid retention, which is a concern for clients undergoing hemodialysis.
✅ 185. A nurse is assessing a client with a history of stroke. Which finding requires immediate attention?
Slurred speech
B. Weakness in the arm
C. Sudden onset of a headache
D. Decreased sensation on one side of the body
Answer: C. Sudden onset of a headache
Explanation: A sudden, severe headache could indicate increased intracranial pressure or a recurrent stroke.
✅ 186. A nurse is administering an intravenous (IV) medication to a client. Which action is correct when preparing the IV medication?
Verify the medication against the client’s ID band
B. Mix the medication with any available IV fluid
C. Use the same needle for both drawing up and administering the medication
D. Check the medication expiration date after administration
Answer: A. Verify the medication against the client’s ID band
Explanation: ID verification is crucial to ensure the correct medication is given to the correct patient.
✅ 187. A nurse is caring for a client who has a new prescription for warfarin. Which instruction should the nurse include in the teaching plan?
“Limit your intake of leafy green vegetables.”
B. “Take an antacid if you experience indigestion.”
C. “You can eat grapefruit in moderation.”
D. “Use an electric razor to shave.”
Answer: D. “Use an electric razor to shave.”
Explanation: Warfarin increases the risk for bleeding, so clients should avoid activities that could lead to cuts or injuries.
✅ 188. A nurse is caring for a client with a burn injury. Which of the following should the nurse assess first?
Fluid balance
B. Pain level
C. Oxygen saturation
D. Blood pressure
Answer: C. Oxygen saturation
Explanation: Respiratory compromise is the priority in burn victims, particularly if the burn is to the face or chest.
✅ 189. A nurse is caring for a client receiving a blood transfusion. Which of the following is a priority?
Monitor for signs of a transfusion reaction
B. Check the client’s blood pressure every 30 minutes
C. Administer a diuretic to prevent fluid overload
D. Begin the transfusion at a rapid rate
Answer: A. Monitor for signs of a transfusion reaction
Explanation: Transfusion reactions can occur unexpectedly, so monitoring the client closely is critical.
✅ 190. A nurse is preparing a client for a colonoscopy. Which instruction should the nurse provide?
“You will be awake during the procedure and can resume normal activities immediately after.”
B. “Avoid eating solid foods for 24 hours before the procedure.”
C. “You will need to drink a large amount of clear liquids before the procedure.”
D. “A full liquid diet is required 48 hours before the procedure.”
Answer: C. “You will need to drink a large amount of clear liquids before the procedure.”
Explanation: Preparation for a colonoscopy often includes a clear liquid diet and laxative use to clear the bowel.
✅ 191. A nurse is caring for a client with a new diagnosis of diabetes. Which statement by the client indicates a need for further teaching?
“I will check my blood sugar before meals.”
B. “I will exercise regularly to control my blood sugar.”
C. “I will increase my intake of sugary foods to prevent hypoglycemia.”
D. “I will take my insulin as prescribed.”
Answer: C. “I will increase my intake of sugary foods to prevent hypoglycemia.”
Explanation: Excessive sugary foods can increase blood glucose and should not be used to manage hypoglycemia.
✅ 192. A nurse is caring for a client with a history of seizures. Which of the following is the priority intervention during a seizure?
Place a tongue depressor in the client’s mouth
B. Place the client in a prone position
C. Protect the client from injury
D. Restrain the client’s movements
Answer: C. Protect the client from injury
Explanation: The priority during a seizure is to ensure the client’s safety by protecting them from falls or injury.
✅ 193. A nurse is caring for a client with hyperthyroidism. Which of the following is most likely to be observed?
Bradycardia
B. Weight gain
C. Increased appetite
D. Cold intolerance
Answer: C. Increased appetite
Explanation: Hyperthyroidism causes an increase in metabolism, leading to symptoms such as increased appetite and weight loss.
✅ 194. A nurse is teaching a client with a history of myocardial infarction about lifestyle changes. Which statement by the client indicates understanding?
“I will follow a low-fat diet and exercise regularly.”
B. “I can resume smoking once my symptoms improve.”
C. “I will avoid taking my medication if I feel fine.”
D. “I can eat red meat once a week.”
Answer: A. “I will follow a low-fat diet and exercise regularly.”
Explanation: Lifestyle changes such as a low-fat diet and regular exercise are essential in managing heart disease.
✅ 195. A nurse is caring for a client who is receiving intravenous (IV) fluids. Which of the following is a sign of fluid overload?
Decreased blood pressure
B. Swelling in the ankles
C. Increased heart rate
D. Dry skin
Answer: B. Swelling in the ankles
Explanation: Fluid overload can cause edema, especially in the lower extremities.
✅ 196. A nurse is assessing a newborn infant. Which finding requires immediate intervention?
Mild tremors in the hands
B. Respiratory rate of 50 breaths per minute
C. Cyanosis of the hands and feet
D. Apnea for 20 seconds
Answer: D. Apnea for 20 seconds
Explanation: Apnea lasting longer than 20 seconds in a newborn may indicate a serious respiratory issue and requires immediate intervention.
✅ 197. A nurse is caring for a client with a history of hypertension. Which of the following is a priority action?
Monitor blood pressure regularly
B. Administer antihypertensive medications as prescribed
C. Encourage increased fluid intake
D. Promote a high-sodium diet
Answer: B. Administer antihypertensive medications as prescribed
Explanation: Medications to control blood pressure are critical for reducing the risk of cardiovascular complications.
✅ 198. A nurse is preparing to administer a medication to a client. Which of the following is an example of the “rights” of medication administration?
Right documentation
B. Right therapeutic effect
C. Right outcome
D. Right diagnosis
Answer: A. Right documentation
Explanation: Proper documentation is part of the rights of medication administration to ensure correct delivery and accountability.
✅ 199. A nurse is caring for a client who is postoperative. Which finding is most concerning?
Blood pressure of 110/60 mm Hg
B. Pain level of 6/10
C. Clear, non-odorous urine
D. Red, warm incision site
Answer: D. Red, warm incision site
Explanation: A red and warm incision site could indicate infection and should be assessed further.
✅ 200. A nurse is caring for a client with a history of asthma. Which of the following is most important to include in the plan of care?
Teach the client to use a spacer with inhaler use
B. Encourage frequent aerobic exercise
C. Limit fluid intake during an asthma attack
D. Avoid all allergens, including pets
Answer: A. Teach the client to use a spacer with inhaler use
Explanation: A spacer improves the delivery of medication to the lungs and is essential for effective inhaler use.
✅ 211. A nurse is assessing a client who is postoperative and experiencing confusion. Which intervention should the nurse prioritize?
Administer a sedative
B. Encourage deep breathing exercises
C. Assess for signs of hypoxia
D. Provide a calming environment
Answer: C. Assess for signs of hypoxia
Explanation: Confusion in a postoperative client can be caused by hypoxia, so it’s important to assess oxygen levels.
✅ 212. A nurse is preparing to administer a medication that can cause sedation. Which action should the nurse take first?
Ensure the client is lying down
B. Verify the client’s identity
C. Assess the client’s level of consciousness
D. Ensure the client has a meal before taking the medication
Answer: C. Assess the client’s level of consciousness
Explanation: Assessing the level of consciousness is essential to ensure the client can tolerate the sedative without adverse effects.
✅ 213. A nurse is caring for a client with heart failure. Which symptom is most indicative of worsening heart failure?
Increased appetite
B. Decreased urinary output
C. Weight loss
D. Cold extremities
Answer: B. Decreased urinary output
Explanation: Decreased urinary output can indicate fluid retention, which is a sign of worsening heart failure.
✅ 214. A nurse is teaching a client about self-monitoring blood glucose levels. Which statement by the client indicates a need for further teaching?
“I will check my blood sugar before meals and at bedtime.”
B. “I should use the same finger each time I check my blood sugar.”
C. “I will record my blood sugar results regularly.”
D. “I will contact my provider if my blood sugar readings are consistently high.”
Answer: B. “I should use the same finger each time I check my blood sugar.”
Explanation: It is important to rotate fingers to avoid soreness and ensure accurate readings.
✅ 215. A nurse is caring for a client receiving chemotherapy. Which of the following is a priority assessment?
Nutritional intake
B. Signs of infection
C. Skin integrity
D. Hair loss
Answer: B. Signs of infection
Explanation: Chemotherapy can suppress the immune system, increasing the risk of infection, which should be closely monitored.
✅ 216. A nurse is administering an opioid analgesic to a client. Which of the following is a priority assessment?
Respiratory rate
B. Blood pressure
C. Pain level
D. Oxygen saturation
Answer: A. Respiratory rate
Explanation: Opioids can cause respiratory depression, so the respiratory rate should be monitored closely.
✅ 217. A nurse is caring for a client who is receiving a blood transfusion. The client develops chills and back pain. Which action should the nurse take first?
Notify the healthcare provider
B. Stop the transfusion immediately
C. Administer pain medication
D. Take the client’s vital signs
Answer: B. Stop the transfusion immediately
Explanation: These symptoms may indicate a transfusion reaction, so the transfusion should be stopped immediately to prevent complications.
✅ 218. A nurse is assessing a client who is receiving potassium supplements. Which of the following findings is the most concerning?
Increased urine output
B. Muscle weakness
C. Increased appetite
D. Mild nausea
Answer: B. Muscle weakness
Explanation: Muscle weakness can indicate hyperkalemia, which is a serious side effect of potassium supplementation.
✅ 219. A nurse is caring for a client who is receiving a continuous IV infusion of normal saline. Which of the following findings should the nurse report immediately?
Blood pressure of 120/70 mm Hg
B. Swelling in the ankles
C. Oxygen saturation of 98%
D. Heart rate of 80 beats per minute
Answer: B. Swelling in the ankles
Explanation: Swelling in the ankles could indicate fluid overload, which should be addressed immediately.
✅ 220. A nurse is preparing a client for a lumbar puncture. Which of the following is the most important nursing intervention?
Explain the procedure to the client
B. Monitor the client’s blood pressure
C. Keep the client in a flat position after the procedure
D. Administer antibiotics before the procedure
Answer: A. Explain the procedure to the client
Explanation: Ensuring the client understands the procedure helps alleviate anxiety and promotes cooperation.
✅ 221. A nurse is caring for a client with a diagnosis of acute pancreatitis. Which of the following findings is most concerning?
Increased heart rate
B. Elevated blood pressure
C. Abdominal distention
D. Decreased oxygen saturation
Answer: D. Decreased oxygen saturation
Explanation: Decreased oxygen saturation can indicate respiratory distress or complications such as hypovolemic shock related to pancreatitis.
✅ 222. A nurse is teaching a client with hypertension about lifestyle changes. Which statement by the client indicates a need for further teaching?
“I will reduce my sodium intake.”
B. “I will lose weight and exercise regularly.”
C. “I will start drinking two cups of coffee every morning.”
D. “I will monitor my blood pressure at home.”
Answer: C. “I will start drinking two cups of coffee every morning.”
Explanation: Caffeine can elevate blood pressure, so it should be consumed in moderation.
✅ 223. A nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). Which of the following interventions is most important?
Encourage the client to increase fluid intake
B. Instruct the client to perform deep breathing exercises
C. Teach the client to use a spacer with inhalers
D. Administer oxygen as prescribed
Answer: D. Administer oxygen as prescribed
Explanation: Oxygen therapy is crucial for COPD clients to maintain adequate oxygen levels and prevent hypoxia.
✅ 224. A nurse is caring for a client who has a history of alcohol use disorder. Which of the following is the most important assessment?
Nutritional intake
B. Liver function
C. Blood glucose levels
D. Respiratory rate
Answer: B. Liver function
Explanation: Alcohol abuse can lead to liver dysfunction, so monitoring liver function is a priority.
✅ 225. A nurse is teaching a client who is starting antipsychotic medication. Which of the following instructions should the nurse include?
“You may experience drowsiness or dizziness.”
B. “Avoid drinking alcohol while on this medication.”
C. “You can stop taking this medication when you feel better.”
D. “You should take the medication only when you feel anxious.”
Answer: B. “Avoid drinking alcohol while on this medication.”
Explanation: Alcohol can interfere with the effectiveness of antipsychotic medications and increase the risk of side effects.
✅ 226. A nurse is caring for a client with a history of asthma. Which of the following should be included in the discharge plan?
Encourage smoking cessation
B. Teach the client to increase fluid intake
C. Avoid exposure to cold air
D. Limit exercise to prevent exacerbations
Answer: A. Encourage smoking cessation
Explanation: Smoking cessation is crucial for preventing asthma exacerbations and improving lung function.
✅ 227. A nurse is caring for a client who is receiving a blood transfusion. Which of the following is the most important initial action?
Obtain the client’s vital signs
B. Assess the client for any signs of transfusion reactions
C. Check the client’s blood type and the donor blood type
D. Administer a pre-transfusion medication
Answer: C. Check the client’s blood type and the donor blood type
Explanation: Ensuring that the blood types match is the most important step in preventing a transfusion reaction.
✅ 228. A nurse is caring for a client with a history of peptic ulcer disease. Which of the following is a priority assessment?
Pain level
B. Heart rate
C. Bowel sounds
D. Blood pressure
Answer: A. Pain level
Explanation: Pain is a primary symptom of peptic ulcer disease and requires prompt assessment and management.
✅ 229. A nurse is caring for a client with tuberculosis. Which of the following should be included in the client’s plan of care?
Provide a private room with negative airflow
B. Place the client in a room with other clients with tuberculosis
C. Administer high-dose antibiotics to prevent reinfection
D. Encourage the client to drink alcohol to reduce symptoms
Answer: A. Provide a private room with negative airflow
Explanation: Tuberculosis (TB) is highly contagious, so the client should be placed in a private room with negative airflow to prevent the spread of infection.
✅ 230. A nurse is caring for a client with a wound infection. Which of the following is the most important intervention?
Administer prescribed antibiotics
B. Provide a high-protein diet
C. Monitor vital signs
D. Change the wound dressing regularly
Answer: A. Administer prescribed antibiotics
Explanation: Antibiotic therapy is essential to treat the wound infection and prevent complications.
✅ 231. A nurse is caring for a client with a chest tube following thoracic surgery. Which finding should the nurse report immediately?
Bright red blood in the chest tube
B. Drainage of 100 mL of serous fluid in 8 hours
C. Air bubbles in the water-seal chamber during inspiration
D. Sudden cessation of drainage from the chest tube
Answer: A. Bright red blood in the chest tube
Explanation: Bright red blood may indicate hemorrhage and should be reported immediately.
✅ 232. A nurse is teaching a client about the use of a metered-dose inhaler (MDI). Which of the following is an appropriate instruction?
“Exhale through your nose before using the inhaler.”
B. “Hold your breath for 5 seconds after inhaling the medication.”
C. “Inhale deeply and forcefully while using the inhaler.”
D. “Shake the inhaler only once before use.”
Answer: B. “Hold your breath for 5 seconds after inhaling the medication.”
Explanation: Holding the breath for 5-10 seconds after inhalation helps maximize medication absorption in the lungs.
✅ 233. A nurse is caring for a client with a history of depression. Which of the following statements indicates that the client is at risk for suicide?
“I’ve been feeling sad lately.”
B. “I’m just so tired all the time.”
C. “I don’t think I can take this anymore.”
D. “I’m worried about my family.”
Answer: C. “I don’t think I can take this anymore.”
Explanation: This statement reflects a desire to end life, indicating a risk for suicide that requires immediate attention.
✅ 234. A nurse is caring for a client with a history of kidney stones. Which of the following dietary changes should the nurse recommend?
Increase calcium intake
B. Limit fluid intake
C. Decrease sodium intake
D. Increase protein intake
Answer: C. Decrease sodium intake
Explanation: Excess sodium can increase calcium excretion, contributing to the formation of kidney stones. The client should decrease sodium intake.
✅ 235. A nurse is caring for a client with a recent diagnosis of heart failure. Which of the following findings is most concerning?
Weight loss of 2 pounds in a week
B. Fatigue on exertion
C. Decreased urinary output
D. Pulse rate of 80 beats per minute
Answer: C. Decreased urinary output
Explanation: Decreased urinary output may indicate fluid retention, which can worsen heart failure.
✅ 241. A nurse is caring for a client who is receiving chemotherapy. The client is experiencing nausea and vomiting. Which intervention is most appropriate?
Offer small, frequent meals
B. Administer antiemetics before meals
C. Encourage the client to eat a high-fat diet
D. Discourage the client from drinking fluids during meals
Answer: B. Administer antiemetics before meals
Explanation: Antiemetic medications should be given before meals to prevent nausea and vomiting associated with chemotherapy.
✅ 242. A nurse is teaching a client with osteoarthritis about joint protection. Which of the following is the best advice?
“Use your hands to lift heavy objects whenever possible.”
B. “Perform range-of-motion exercises to strengthen the joints.”
C. “Take frequent rest periods throughout the day.”
D. “Apply ice to the joints only during flare-ups.”
Answer: C. “Take frequent rest periods throughout the day.”
Explanation: Resting joints during the day can help reduce the risk of fatigue and prevent further damage in osteoarthritis.
✅ 243. A nurse is teaching a client about dietary changes for managing diabetes. Which statement by the client indicates a need for further teaching?
“I will choose whole-grain foods instead of refined grains.”
B. “I will limit my intake of sugar and high-fat foods.”
C. “I will eat more frequent meals to prevent blood sugar spikes.”
D. “I will include more processed foods in my diet for variety.”
Answer: D. “I will include more processed foods in my diet for variety.”
Explanation: Processed foods often contain added sugars, unhealthy fats, and preservatives that can negatively affect blood sugar control.
✅ 244. A nurse is caring for a client with a history of seizures. Which of the following interventions is most important to prevent injury during a seizure?
Place a tongue depressor in the client’s mouth
B. Hold the client’s head during the seizure
C. Place the client on their side
D. Restrain the client’s limbs to prevent movement
Answer: C. Place the client on their side
Explanation: Placing the client on their side helps prevent aspiration of saliva and reduces the risk of injury during a seizure.
✅ 245. A nurse is caring for a client with chronic kidney disease. Which of the following findings is most concerning?
Increased urination
B. Shortness of breath
C. Increased appetite
D. Weight loss
Answer: B. Shortness of breath
Explanation: Shortness of breath can indicate fluid overload, a common complication of chronic kidney disease that needs immediate attention.
✅ 246. A nurse is assessing a client with a history of a stroke. The nurse notes that the client has difficulty with speech. Which area of the brain is most likely affected?
Temporal lobe
B. Frontal lobe
C. Parietal lobe
D. Cerebellum
Answer: A. Temporal lobe
Explanation: The temporal lobe, specifically the Broca’s area, is responsible for speech production. Damage to this area may cause speech difficulties.
✅ 247. A nurse is teaching a client with asthma how to use a peak flow meter. Which instruction should the nurse include?
“Blow out forcefully and quickly when using the peak flow meter.”
B. “Use the peak flow meter only during asthma attacks.”
C. “Hold your breath for 10 seconds after using the peak flow meter.”
D. “Use the peak flow meter only once a week.”
Answer: A. “Blow out forcefully and quickly when using the peak flow meter.”
Explanation: A forceful exhale helps measure the peak expiratory flow rate, which is essential for assessing asthma control.
✅ 248. A nurse is caring for a client who is receiving a blood transfusion. The nurse notices that the client is experiencing chills and fever. Which action should the nurse take first?
Stop the transfusion immediately
B. Increase the rate of the transfusion
C. Administer acetaminophen for fever
D. Take the client’s vital signs
Answer: A. Stop the transfusion immediately
Explanation: Chills and fever can indicate an acute transfusion reaction, so the nurse should stop the transfusion immediately to prevent further complications.
✅ 249. A nurse is caring for a client who is on a low-sodium diet. Which of the following foods should the nurse recommend?
Canned soup
B. Fresh fruit
C. Processed cheese
D. Frozen meals
Answer: B. Fresh fruit
Explanation: Fresh fruit is naturally low in sodium and a healthy choice for clients on a low-sodium diet.
✅ 250. A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) how to use a nebulizer. Which statement by the client indicates a need for further teaching?
“I will inhale slowly and deeply during the treatment.”
B. “I will keep my mouthpiece between my teeth during the treatment.”
C. “I will use the nebulizer only when I feel short of breath.”
D. “I will clean the nebulizer equipment regularly.”
Answer: C. “I will use the nebulizer only when I feel short of breath.”
Explanation: The nebulizer should be used regularly as prescribed, not just when symptoms occur, to prevent exacerbations of COPD.
✅ 251. A nurse is caring for a client who has a wound infection. The client is receiving antibiotics. Which of the following findings indicates that the antibiotic therapy is effective?
Decrease in white blood cell count
B. Decreased pain at the wound site
C. Elevated blood pressure
D. Increased appetite
Answer: B. Decreased pain at the wound site
Explanation: Decreased pain indicates that the infection is responding to antibiotic treatment.
✅ 252. A nurse is assessing a client who is recovering from surgery. The client is complaining of leg pain and swelling. Which of the following actions should the nurse take first?
Elevate the client’s leg
B. Apply warm compresses to the leg
C. Measure the client’s calf circumference
D. Administer pain medication
Answer: C. Measure the client’s calf circumference
Explanation: Leg pain and swelling could indicate a deep vein thrombosis (DVT). Measuring the calf circumference can help assess for this complication.
✅ 253. A nurse is caring for a client with a history of chronic alcoholism. Which of the following is the priority assessment?
Blood pressure
B. Liver function
C. Nutritional status
D. Respiratory rate
Answer: B. Liver function
Explanation: Chronic alcoholism can cause liver damage, so monitoring liver function is a priority.
✅ 254. A nurse is caring for a client with acute pancreatitis. Which of the following findings is most concerning?
Pain in the upper abdomen
B. Nausea and vomiting
C. Fever and elevated white blood cell count
D. Decreased urinary output
Answer: D. Decreased urinary output
Explanation: Decreased urinary output can indicate hypovolemia or kidney failure, which are serious complications of acute pancreatitis.
✅ 255. A nurse is assessing a client with a history of diabetes. Which of the following findings is most concerning?
Fasting blood glucose of 120 mg/dL
B. Blood pressure of 140/90 mm Hg
C. A1C of 7.5%
D. Foot ulcers
Answer: D. Foot ulcers
Explanation: Foot ulcers are a common complication of diabetes and require prompt treatment to prevent infection and complications.
✅ 256. A nurse is caring for a client who has been diagnosed with depression. Which of the following is a priority action?
Encourage the client to attend support groups
B. Assess the client’s risk for suicide
C. Educate the client about lifestyle changes
D. Encourage the client to express their feelings
Answer: B. Assess the client’s risk for suicide
Explanation: Suicide risk assessment is the priority when caring for a client with depression, as they may have thoughts of harming themselves.
✅ 257. A nurse is caring for a client with tuberculosis. Which of the following interventions is most important?
Administer prescribed antitubercular medications
B. Encourage deep breathing exercises
C. Monitor vital signs
D. Provide high-protein meals
Answer: A. Administer prescribed antitubercular medications
Explanation: Antitubercular medications are the cornerstone of tuberculosis treatment and should be administered as prescribed.
✅ 258. A nurse is caring for a client who is post-appendectomy. Which of the following actions should the nurse take to prevent complications?
Encourage deep breathing and coughing
B. Apply a heating pad to the abdomen
C. Provide a high-fat diet
D. Restrict fluid intake to prevent bloating
Answer: A. Encourage deep breathing and coughing
Explanation: Deep breathing and coughing exercises help prevent atelectasis and promote lung expansion following surgery.
✅ 259. A nurse is caring for a client with a history of asthma. Which of the following interventions should the nurse prioritize?
Administer inhaled corticosteroids
B. Encourage fluid intake
C. Monitor blood oxygen levels
D. Instruct the client to avoid triggers
Answer: A. Administer inhaled corticosteroids
Explanation: Inhaled corticosteroids help control inflammation and are a key component of managing asthma.
✅ 260. A nurse is teaching a client with hypertension about lifestyle modifications. Which statement by the client indicates a need for further teaching?
“I will reduce my salt intake.”
B. “I will stop drinking alcohol.”
C. “I will engage in regular physical activity.”
D. “I will start taking calcium supplements.”
Answer: D. “I will start taking calcium supplements.”
Explanation: There is no evidence that calcium supplements directly affect blood pressure control, and other lifestyle changes should take priority.
✅ 271. A nurse is caring for a client who is post-operative and has a nasogastric (NG) tube in place. Which of the following actions should the nurse take to prevent complications associated with the NG tube?
Flush the NG tube with water every 4 hours
B. Ensure the client is in a high Fowler’s position during tube feedings
C. Keep the NG tube clamped during periods of feeding
D. Use a soft diet to prevent clogging of the NG tube
Answer: B. Ensure the client is in a high Fowler’s position during tube feedings
Explanation: High Fowler’s position during feedings helps prevent aspiration and gastroesophageal reflux.
✅ 272. A nurse is assessing a client with an oxygen mask. Which of the following findings indicates a complication?
The mask fits snugly and does not allow air to escape
B. The oxygen flow rate is set at 6 L/min
C. The client has dry nasal passages
D. The client has a slight sensation of discomfort
Answer: C. The client has dry nasal passages
Explanation: Dry nasal passages may indicate that the oxygen flow rate is too high or the mask is not providing adequate moisture, leading to discomfort and potential complications.
✅ 273. A nurse is caring for a client with a history of congestive heart failure (CHF). The nurse notes that the client is experiencing peripheral edema. Which of the following interventions should the nurse prioritize?
Administer a diuretic as prescribed
B. Encourage the client to drink more fluids
C. Increase the client’s dietary intake of sodium
D. Apply a compression stocking to the affected leg
Answer: A. Administer a diuretic as prescribed
Explanation: Diuretics help reduce fluid retention and are often prescribed to manage peripheral edema in clients with CHF.
✅ 274. A nurse is caring for a client who is receiving a blood transfusion. The client suddenly develops fever and chills. What is the nurse’s first action?
Slow the rate of the transfusion
B. Stop the transfusion immediately
C. Administer an antipyretic medication
D. Take the client’s vital signs
Answer: B. Stop the transfusion immediately
Explanation: Fever and chills during a blood transfusion can indicate a transfusion reaction, and the nurse should stop the transfusion immediately to prevent further complications.
✅ 275. A nurse is caring for a client with a deep vein thrombosis (DVT). Which of the following actions should the nurse take to prevent further complications?
Massage the affected leg to promote circulation
B. Apply heat to the affected leg
C. Keep the client on bed rest with the affected leg elevated
D. Encourage the client to walk frequently
Answer: C. Keep the client on bed rest with the affected leg elevated
Explanation: Bed rest and elevation of the affected leg help reduce the risk of embolism and promote circulation in clients with DVT.
✅ 276. A nurse is caring for a client with a history of myocardial infarction. Which of the following findings is most concerning?
Mild shortness of breath
B. Decreased exercise tolerance
C. Chest pain upon exertion
D. Heart rate of 80 beats per minute
Answer: C. Chest pain upon exertion
Explanation: Chest pain upon exertion could indicate angina or the risk of another myocardial infarction and requires immediate evaluation.
✅ 277. A nurse is teaching a client with hypertension about lifestyle modifications. Which of the following changes should the nurse prioritize?
Reducing alcohol intake
B. Increasing dietary sodium
C. Starting a high-fat diet
D. Reducing physical activity
Answer: A. Reducing alcohol intake
Explanation: Excessive alcohol consumption can raise blood pressure, so reducing alcohol intake is a key modification for managing hypertension.
✅ 278. A nurse is assessing a client who is on a mechanical ventilator. Which of the following findings should the nurse report immediately?
Positive end-expiratory pressure (PEEP) of 5 cm H2O
B. Respiratory rate of 16 breaths per minute
C. Blood pressure of 92/60 mm Hg
D. Oxygen saturation of 89%
Answer: D. Oxygen saturation of 89%
Explanation: An oxygen saturation of 89% is below the normal range and indicates that the client may not be receiving adequate oxygenation, requiring immediate attention.
✅ 279. A nurse is caring for a client with a history of hypoglycemia. Which of the following actions should the nurse prioritize?
Check the client’s blood glucose level
B. Administer insulin as prescribed
C. Provide a high-carbohydrate meal
D. Encourage the client to drink more fluids
Answer: A. Check the client’s blood glucose level
Explanation: Blood glucose should be checked first to confirm whether the client is hypoglycemic before administering any treatment.
✅ 280. A nurse is assessing a client who is experiencing shortness of breath. The nurse notes that the client has an elevated heart rate and jugular venous distension. Which of the following conditions is most likely?
Asthma
B. Heart failure
C. Pneumonia
D. Pulmonary embolism
Answer: B. Heart failure
Explanation: Jugular venous distension and elevated heart rate are classic signs of heart failure, which causes fluid buildup in the lungs and other parts of the body.
✅ 281. A nurse is caring for a client who is post-operative and is complaining of severe pain. The nurse administers the prescribed pain medication, but the client continues to report pain. What is the next step?
Increase the dosage of pain medication
B. Reassess the client’s pain and provide additional interventions
C. Withhold further pain medication
D. Notify the healthcare provider immediately
Answer: B. Reassess the client’s pain and provide additional interventions
Explanation: It is important to reassess the client’s pain to determine if further interventions, such as adjusting the medication or using alternative pain management strategies, are needed.
✅ 282. A nurse is teaching a client with epilepsy about medication management. Which of the following statements indicates the need for further teaching?
“I will take my medication at the same time every day.”
B. “I will notify my healthcare provider if I miss a dose.”
C. “I can stop taking my medication when I feel better.”
D. “I will avoid alcohol while taking my medication.”
Answer: C. “I can stop taking my medication when I feel better.”
Explanation: Antiepileptic medications should be taken as prescribed, even if the client feels better, to prevent seizures from recurring.
✅ 283. A nurse is assessing a client with a history of gastrointestinal bleeding. The client’s stool is black and tarry. What should the nurse suspect?
Peptic ulcer disease
B. Gastrointestinal reflux disease
C. Upper gastrointestinal bleeding
D. Colon cancer
Answer: C. Upper gastrointestinal bleeding
Explanation: Black, tarry stools (melena) are a classic sign of upper gastrointestinal bleeding due to the presence of digested blood.
✅ 284. A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about breathing techniques. Which of the following is the most appropriate technique to teach the client?
Pursed-lip breathing
B. Diaphragmatic breathing
C. Chest breathing
D. Abdominal breathing
Answer: A. Pursed-lip breathing
Explanation: Pursed-lip breathing helps maintain airway patency and reduces the work of breathing for clients with COPD.
✅ 285. A nurse is caring for a client who is post-operative following a mastectomy. The nurse notes that the client’s arm on the surgical side is swollen. Which of the following actions should the nurse take first?
Elevate the client’s arm above the heart
B. Apply a cold compress to the arm
C. Encourage the client to exercise the arm
D. Massage the arm gently
Answer: A. Elevate the client’s arm above the heart
Explanation: Elevation helps reduce swelling and promotes lymphatic drainage after mastectomy.
✅ 286. A nurse is caring for a client with a history of asthma. The nurse notes that the client is using their rescue inhaler more frequently. What action should the nurse take?
Encourage the client to use the inhaler more often
B. Assess the client for potential triggers or worsening symptoms
C. Increase the dosage of the inhaler
D. Administer oxygen therapy immediately
Answer: B. Assess the client for potential triggers or worsening symptoms
Explanation: Increased use of a rescue inhaler indicates worsening asthma or exposure to triggers and requires immediate assessment.
✅ 287. A nurse is caring for a client with chronic kidney disease. The client’s potassium level is 5.6 mEq/L. Which of the following actions should the nurse take?
Administer potassium supplements as prescribed
B. Restrict potassium-rich foods
C. Increase the client’s fluid intake
D. Administer an intravenous potassium bolus
Answer: B. Restrict potassium-rich foods
Explanation: A potassium level of 5.6 mEq/L is above normal, so the nurse should restrict potassium-rich foods to prevent hyperkalemia.
✅ 288. A nurse is caring for a client who is receiving an intravenous (IV) infusion of 0.9% sodium chloride. The nurse notices redness and warmth at the IV insertion site. What is the most likely cause of this finding?
Infection
B. Infiltration
C. Phlebitis
D. Fluid overload
Answer: C. Phlebitis
Explanation: Redness and warmth at the IV site are common signs of phlebitis, which is inflammation of the vein caused by the IV catheter.
✅ 289. A nurse is caring for a client who is taking warfarin. Which of the following laboratory tests is most important to monitor?
Hemoglobin and hematocrit
B. Prothrombin time (PT) and International Normalized Ratio (INR)
C. Platelet count
D. Complete blood count (CBC)
Answer: B. Prothrombin time (PT) and International Normalized Ratio (INR)
Explanation: Warfarin therapy affects blood clotting, so it is important to monitor PT and INR to assess the effectiveness of the medication.
✅ 290. A nurse is caring for a client with schizophrenia who has been prescribed haloperidol. Which of the following side effects should the nurse monitor for?
Bradycardia
B. Tardive dyskinesia
C. Hypoglycemia
D. Hyperkalemia
Answer: B. Tardive dyskinesia
Explanation: Tardive dyskinesia is a serious and irreversible side effect of antipsychotic medications like haloperidol.
🩺 Preparing for the NCLEX exam? Explore our NCLEX Exam Practice Tests to sharpen your skills and increase your chances of passing.