NCLEX-RN Nursing — All Questions

A client experiencing a panic attack is hyperventilating and pacing. Which nursing action is most appropriate?

• a.Provide detailed teaching about the physiology of anxiety and its triggers
• b.Stay with the client and speak calmly using short, simple statements✓
• c.Leave the client alone in a quiet room until the hyperventilation stops
• d.Encourage the client to describe every worry in detail to release the tension

During a panic attack the nurse should stay with the client, remain calm, and use brief, clear communication. Complex teaching and detailed discussion overwhelm the client until the acute anxiety subsides.

A client with anorexia nervosa is admitted for treatment. Which finding is the priority concern?

• a.The client's preoccupation with calories
• b.The client's distorted body image
• c.The client's refusal to discuss feelings
• d.Bradycardia and electrolyte imbalance✓

Physiological instability such as bradycardia and electrolyte imbalance can be life-threatening in anorexia nervosa and takes priority over the important psychological issues.

A nurse uses therapeutic communication with a grieving client. Which technique best encourages the client to continue talking?

• a.Asking rapid closed-ended questions
• b.Offering personal opinions about the loss
• c.Reassuring the client that grief will pass quickly
• d.Using silence and attentive presence✓

Silence and attentive presence give the grieving client time to process and express feelings. Opinions, closed questions, and false reassurance interrupt therapeutic communication.

A client with schizophrenia says, 'The voices are telling me I am worthless.' Which response is most therapeutic?

• a.You should not listen to those voices, so keep your mind busy with the group activity
• b.Tell me what the voices sound like and try answering them aloud so that I can listen
• c.The voices are not real, so ignore them completely and they will soon stop bothering you
• d.I do not hear the voices, but I understand they seem real and upsetting to you✓

The nurse presents reality without arguing and acknowledges the client's experience and distress. Denying the client's perception or dismissing it damages trust.

A nurse is caring for a client in the manic phase of bipolar disorder. Which intervention supports the client's needs?

• a.Encourage participation in a competitive group game with peers
• b.Provide a calm, low-stimulation environment and finger foods✓
• c.Schedule several stimulating group activities back to back
• d.Serve large plated meals at a crowded communal table

During mania, clients are easily overstimulated and may not sit to eat. A low-stimulation environment and portable, high-calorie finger foods support rest and nutrition.

A client discloses a history of intimate partner violence. What is the nurse's priority action?

• a.Tell the client the abuse is not their fault and end the conversation
• b.Advise the client to leave the relationship immediately
• c.Assess the client's immediate safety and provide resources✓
• d.Contact the partner to discuss the situation

Assessing immediate safety and offering resources respects autonomy while protecting the client. Directing the client to leave or contacting the partner can increase danger.

A nurse is supporting a client through the stages of grief. A client who says, 'If I had only gone to the doctor sooner' is likely in which stage?

• a.Acceptance
• b.Bargaining✓
• c.Frustration
• d.Disbelief

Statements involving 'if only' and attempts to undo the loss reflect the bargaining stage of grief. Recognizing the stage helps the nurse respond supportively.

A client with alcohol use disorder is 12 hours into withdrawal. Which finding requires immediate attention?

• a.Mild hand tremors
• b.Requests for a cigarette
• c.Seizure activity✓
• d.Increased appetite

Seizures during alcohol withdrawal are a medical emergency and require immediate intervention. Mild tremors are common early findings but are less urgent.

A nurse is caring for a client experiencing acute confusion (delirium). Which intervention is most appropriate?

• a.Frequently reorient the client and provide familiar objects✓
• b.Restrain the client in bed to prevent wandering at night
• c.Keep the room dark and quiet at all times, even during the day
• d.Rotate caregivers each shift so the client gets variety

Frequent reorientation, familiar objects, and consistent caregivers reduce confusion in delirium. Restraints and frequent caregiver changes can worsen agitation.

A client is angry and shouting at the nurse about a delayed procedure. Which response best de-escalates the situation?

• a.You need to lower your voice right now or step out of the room
• b.If you keep yelling at me, I will have to leave the room until you calm down
• c.I can see you are frustrated. Let's talk about what is upsetting you✓
• d.There is nothing that I can do about the surgery schedule today

Acknowledging the client's feelings and inviting discussion de-escalates anger and builds rapport. Commanding or threatening the client escalates the conflict.

A nurse is assessing a client for postpartum depression. Which finding warrants further evaluation?

• a.Excitement about caring for and feeding the newborn at home each day
• b.Occasional tearfulness that resolves on its own within the first two weeks
• c.Persistent sadness and disinterest in the infant after three weeks✓
• d.Fatigue related to nighttime feedings that improves after a daytime nap

Persistent sadness and lack of interest in the infant beyond two weeks suggest postpartum depression rather than transient baby blues, and require further evaluation and support.

A nurse cares for a dying client's family. Which action best supports the family during end-of-life care?

• a.Providing privacy and encouraging expression of feelings✓
• b.Avoiding any discussion of the client's condition with the family
• c.Encouraging the family to stay positive in front of the client
• d.Limiting the family's visiting hours to reduce their fatigue

Providing privacy and encouraging the family to express feelings supports coping during end-of-life care. Restricting presence and avoiding honest discussion isolate the family.

A nurse is caring for a client at risk for pressure injuries. Which intervention is most effective for prevention?

• a.Keep the head of the bed elevated at 90 degrees continuously
• b.Use a doughnut-shaped cushion for sitting
• c.Reposition the client at least every two hours✓
• d.Massage bony prominences vigorously

Repositioning at least every two hours relieves pressure over bony prominences and prevents skin breakdown. Massaging bony areas and doughnut cushions can cause tissue damage.

A client has a new order for a clear liquid diet. Which item is appropriate?

• a.Melted vanilla ice cream
• b.Orange juice with pulp
• c.Cream of chicken soup
• d.Apple juice and gelatin✓

Clear liquids are transparent and leave little residue, such as apple juice and plain gelatin. Pulp, cream soups, and ice cream are not clear liquids.

A nurse is assisting a client with dysphagia to eat. Which action promotes safe swallowing?

• a.Position the client upright and encourage chin-tuck swallowing✓
• b.Encourage rapid eating so the meal is finished while food is warm
• c.Have the client lie flat while eating to relax the throat
• d.Offer thin liquids through a straw so that swallowing takes less effort

Sitting upright with a chin-tuck reduces aspiration risk in dysphagia. Lying flat, thin liquids, and rushing increase aspiration risk.

A nurse is providing oral care to an unconscious client. Which action is most important for safety?

• a.Use large amounts of water to rinse the mouth well
• b.Position the client side-lying to prevent aspiration✓
• c.Place the client supine with the head flat to see better
• d.Insert gloved fingers between the teeth to hold it open

A side-lying position allows secretions to drain and prevents aspiration during oral care in an unconscious client. Minimal fluid and safe technique protect the airway.

A nurse is caring for a client with a nasogastric tube for feeding. What action best confirms placement before feeding?

• a.Verify placement per facility protocol, often with pH testing or radiographic confirmation✓
• b.Ask the client whether the tube feels correctly placed before starting
• c.Auscultate over the stomach while injecting air through the tube with a syringe
• d.Place the end of the tube in a cup of water and watch for bubbles before feeding

Current standards rely on pH testing of aspirate and radiographic confirmation to verify tube placement. The auscultation and water-bubble methods are unreliable.

A client reports constipation. Which intervention should the nurse implement first?

• a.Restrict the client's oral intake to rest the bowel
• b.Administer a cleansing enema before trying other measures
• c.Increase fluid and fiber intake and encourage activity✓
• d.Request a prescription for a daily stimulant laxative first

Nonpharmacologic measures such as increasing fluids, fiber, and activity are first-line for constipation. Enemas and laxatives are used when conservative measures fail.

A nurse is measuring a client's urine output through an indwelling catheter. Which finding should be reported to the provider?

• a.Clear yellow urine totaling 60 mL over the past hour in a stable client
• b.Urine output of less than 30 mL per hour for two consecutive hours✓
• c.Slightly increased urine output an hour after a scheduled diuretic dose
• d.Pale straw-colored urine draining steadily into the closed drainage bag

Urine output below 30 mL per hour may indicate inadequate renal perfusion or obstruction and should be reported. Clear, adequate output is a normal finding.

A nurse is assisting a client to use crutches on level ground. Where should the top of the crutch rest?

• a.Directly under the axilla to bear the weight
• b.Level with the waist so the arms stay straight
• c.About two finger-widths below the axilla✓
• d.Against the mid-chest to steady the client

Crutch tops should rest about two finger-widths below the axilla to avoid pressure on the brachial nerves, with weight borne on the hands. Resting on the axillae can cause nerve damage.

A nurse is caring for a client on bed rest. Which intervention prevents venous thromboembolism?

• a.Placing pillows under the knees continuously to keep the legs supported
• b.Encouraging leg exercises and applying sequential compression devices✓
• c.Massaging the calves firmly to relieve stiffness and improve leg comfort
• d.Keeping the client's legs crossed at the ankles because it feels comfortable

Leg exercises and sequential compression devices promote venous return and prevent clot formation. Crossing the legs, calf massage, and continuous knee flexion impede circulation.

A nurse is providing perineal care for a female client with an indwelling catheter. Which technique is correct?

• a.Use the same section of the cloth for each stroke
• b.Apply powder around the catheter insertion site to keep it dry
• c.Clean from the urethra outward, away from the anus✓
• d.Clean from the anus toward the urethra with one stroke

Perineal care is performed from the cleanest area, the urethra, toward the anus to prevent introducing bacteria. A clean cloth section is used for each stroke.

A client is being repositioned to prevent complications of immobility. Which position best relieves pressure on the sacrum while maintaining alignment?

• a.Prone position for extended periods
• b.Supine with the head of the bed at 90 degrees
• c.The 30-degree lateral (side-lying) position✓
• d.High Fowler's position continuously

The 30-degree lateral position offloads the sacrum and trochanter while maintaining alignment. High Fowler's and prolonged supine positions increase shear and sacral pressure.

A nurse is caring for a client with a stage 2 pressure injury. Which description matches this stage?

• a.Intact, unbroken skin showing localized nonblanchable redness over a bony prominence
• b.Partial-thickness loss of the dermis presenting as a shallow open ulcer✓
• c.Skin loss covered entirely by eschar, so that the depth cannot be judged
• d.Full-thickness loss with exposed bone, tendon, or supporting muscle

A stage 2 pressure injury is partial-thickness skin loss involving the dermis, appearing as a shallow open ulcer or blister. Nonblanchable redness is stage 1 and exposed bone is stage 4.

A client who is NPO reports a dry mouth. Which comfort measure is appropriate?

• a.Offer frequent oral care and moisten the lips✓
• b.Encourage the client to drink small sips of juice
• c.Provide a large glass of water
• d.Give the client hard candy to suck

For an NPO client, oral care and lip moisture relieve dryness without violating the NPO status. Providing water, candy, or juice would break the NPO order.

A nurse is applying antiembolism stockings. Which action is correct?

• a.Apply the stockings while the client is lying down before rising✓
• b.Leave a few wrinkles in the stocking to allow for flexibility
• c.Apply the stockings after the client has been up walking in the hall
• d.Roll the top of the stocking down to create a snug, secure fit

Antiembolism stockings are applied before the client rises, while lying down, to prevent pooling of blood. Rolling the top or leaving wrinkles can create a tourniquet effect.

A client is prescribed warfarin. Which laboratory value is used to monitor its therapeutic effect?

• a.Prothrombin time and international normalized ratio (INR)✓
• b.Serum potassium and magnesium levels drawn before each dose
• c.Activated partial thromboplastin time (aPTT) drawn each morning
• d.Platelet count alone, repeated at weekly intervals during therapy

Warfarin is monitored using the prothrombin time and INR. The aPTT is used to monitor heparin, not warfarin.

A client receiving IV heparin has an aPTT far above the therapeutic range and is bleeding. Which medication is the antidote?

• a.Calcium gluconate
• b.Vitamin K injection
• c.Protamine sulfate✓
• d.Naloxone hydrochloride

Protamine sulfate reverses heparin. Vitamin K reverses warfarin, and naloxone reverses opioids.

A nurse is administering digoxin. Which finding requires the nurse to hold the dose and notify the provider?

• a.Temperature of 98.6 F (37 C)
• b.Respiratory rate of 16 breaths per minute
• c.Blood pressure of 118/72 mm Hg
• d.Apical heart rate of 52 beats per minute✓

Digoxin should be held for an apical heart rate below 60 beats per minute in adults because it can further slow the heart and may signal toxicity. The other vital signs are within normal limits.

A client is starting an angiotensin-converting enzyme (ACE) inhibitor. Which side effect should the nurse teach the client to report?

• a.Darkened urine that clears quickly
• b.Improved appetite
• c.Increased salivation
• d.A persistent dry cough✓

ACE inhibitors commonly cause a persistent dry cough due to bradykinin accumulation. Clients should report it, and angioedema, though rare, is an emergency.

A nurse prepares to administer an aminoglycoside antibiotic. Which parameters are most important to monitor?

• a.Renal function and drug peak and trough levels✓
• b.Serum calcium and serum phosphate levels each morning
• c.Thyroid hormone levels and the basal metabolic rate
• d.Blood glucose and hemoglobin A1c measured before each dose

Aminoglycosides are nephrotoxic and ototoxic, so renal function and peak and trough serum levels must be monitored to ensure safety and efficacy.

A client is prescribed 250 mg of a medication. The pharmacy supplies 125 mg tablets. How many tablets should the nurse administer?

• a.Four tablets
• b.Half a tablet
• c.One tablet
• d.Two tablets✓

Using desired over available, 250 mg divided by 125 mg per tablet equals two tablets. Accurate dose calculation prevents a medication error.

A nurse teaches a client taking an oral corticosteroid long term. Which instruction is correct?

• a.Take the medication on an empty stomach for best absorption
• b.Avoid monitoring blood glucose, since steroids do not affect it
• c.Do not stop the medication suddenly; taper as directed✓
• d.Stop the medication abruptly once symptoms improve

Long-term corticosteroids must be tapered to avoid adrenal insufficiency. They should be taken with food, and blood glucose should be monitored because they raise glucose.

A client is receiving IV furosemide. Which electrolyte imbalance should the nurse monitor for?

• a.Hypernatremia
• b.Hypercalcemia
• c.Hyperkalemia
• d.Hypokalemia✓

Loop diuretics such as furosemide promote potassium excretion and can cause hypokalemia. The nurse monitors potassium and watches for muscle weakness and cardiac dysrhythmias.

A client taking a monoamine oxidase inhibitor (MAOI) for depression requires dietary teaching. Which food should be avoided?

• a.Freshly steamed carrots
• b.Plain steamed white rice
• c.Fresh apples and pears
• d.Aged cheese and cured meats✓

Tyramine-rich foods such as aged cheese and cured meats can trigger a hypertensive crisis in clients taking MAOIs and must be avoided.

A nurse administers insulin lispro, a rapid-acting insulin. When should the nurse ensure the client is ready to eat?

• a.Meal timing does not matter with lispro
• b.About two hours after the injection
• c.Within about 15 minutes of the injection✓
• d.Only at bedtime with a light snack

Rapid-acting insulin such as lispro begins working within about 15 minutes, so food should be available promptly to prevent hypoglycemia.

A client is prescribed morphine for pain. Which assessment is most important before and after administration?

• a.Deep tendon reflexes and hand grip strength
• b.Skin turgor and oral mucous membrane color
• c.Respiratory rate and level of sedation✓
• d.Bowel sounds in all four quadrants

Opioids such as morphine can cause respiratory depression and sedation, so respiratory rate and sedation level must be assessed before and after administration.

A client taking phenytoin for seizures needs teaching. Which instruction is appropriate?

• a.Stop the drug if a rash appears without contacting the provider
• b.Expect the urine to turn blue
• c.Maintain good oral hygiene because of gum overgrowth risk✓
• d.Skip doses if you feel well

Phenytoin commonly causes gingival hyperplasia, so meticulous oral hygiene is important. Doses should not be skipped, and any rash should be reported because it may signal a serious reaction.

A nurse is administering a beta-blocker such as metoprolol. Which parameter should be checked before administration?

• a.Urine specific gravity and color
• b.Serum bilirubin and albumin levels
• c.Total white blood cell count
• d.Apical heart rate and blood pressure✓

Beta-blockers lower heart rate and blood pressure, so both should be assessed before administration and the dose held for significant bradycardia or hypotension per parameters.

A client on lithium for bipolar disorder reports vomiting, coarse tremors, and confusion. What does the nurse suspect?

• a.Normal side effects that require no action
• b.A therapeutic drug response
• c.A common cold
• d.Lithium toxicity✓

Vomiting, coarse tremors, and confusion are signs of lithium toxicity. The narrow therapeutic range makes level monitoring and adequate hydration essential.

A client is prescribed an oral tetracycline antibiotic. Which instruction is correct?

• a.Take it with milk or antacids to reduce stomach upset
• b.Take each dose only with grapefruit juice for absorption
• c.Double the next dose whenever a dose is missed to catch up
• d.Avoid dairy products and antacids near the time of the dose✓

Calcium in dairy and antacids binds tetracycline and reduces its absorption, so they should be separated from the dose. Doses should not be doubled if missed.

A nurse is preparing to administer a medication and notes the client has a documented allergy to it. What is the nurse's action?

• a.Hold the medication and notify the prescriber✓
• b.Give a smaller dose to test tolerance
• c.Give the medication and monitor closely
• d.Administer with an antihistamine to prevent a reaction

A documented allergy is a contraindication. The nurse holds the drug and notifies the prescriber to clarify or change the order, preventing a potentially life-threatening reaction.

A client is receiving an IV infusion of potassium chloride. Which action is essential for safety?

• a.Stop cardiac monitoring during the infusion to reduce alarms
• b.Administer the potassium by rapid IV push to correct the level
• c.Infuse diluted potassium slowly using an infusion pump✓
• d.Give the potassium undiluted so that it takes effect faster

IV potassium must always be diluted and infused slowly with a pump; it is never given by IV push because rapid administration can cause fatal cardiac arrest. Cardiac monitoring is important.

A client taking an opioid reports no bowel movement for three days. Which intervention should the nurse anticipate?

• a.Initiating a bowel regimen with a stool softener and increased fluids✓
• b.Discontinuing the opioid without consulting the provider who prescribed it
• c.Withholding oral fluids until the client passes a bowel movement alone
• d.Restricting all dietary fiber to rest the bowel until stooling returns

Opioids commonly cause constipation, so a prophylactic bowel regimen with stool softeners, fluids, and fiber is appropriate. Fluids and fiber should be increased, not restricted.

A nurse reviews a client's laboratory results. Which serum potassium value is within the normal range?

• a.7.2 mEq/L
• b.6.5 mEq/L
• c.2.8 mEq/L
• d.4.0 mEq/L✓

The normal serum potassium range is approximately 3.5 to 5.0 mEq/L, so 4.0 mEq/L is normal. Values of 6.5 and 7.2 indicate hyperkalemia, and 2.8 indicates hypokalemia.

A client with heart failure gains 3 pounds in two days and has new crackles in the lungs. Which condition does the nurse suspect?

• a.Fluid volume overload✓
• b.Severe hypokalemia
• c.Acute dehydration
• d.Metabolic alkalosis

Rapid weight gain and pulmonary crackles indicate fluid volume overload, common in a heart failure exacerbation. Prompt recognition allows diuretic and fluid management.

A nurse is caring for a client with diabetic ketoacidosis. Which arterial blood gas finding is expected?

• a.Metabolic alkalosis
• b.Respiratory acidosis
• c.Metabolic acidosis✓
• d.Respiratory alkalosis

Diabetic ketoacidosis produces excess ketoacids, causing metabolic acidosis with a low pH and low bicarbonate. Kussmaul respirations develop as compensation.

A client with chronic obstructive pulmonary disease has an oxygen saturation of 90%. Which oxygen delivery approach is appropriate?

• a.Administer high-flow oxygen at 10 L/min to raise the saturation
• b.Place the client on a nonrebreather mask as the routine choice
• c.Withhold oxygen entirely so the respiratory drive is preserved
• d.Provide low-flow oxygen and titrate to the target saturation✓

Clients with COPD are given controlled low-flow oxygen titrated to a target saturation, often around 88 to 92 percent, to avoid suppressing respiratory drive while treating hypoxemia.

A nurse assesses a client with hypocalcemia. Which finding is expected?

• a.Constipation, lethargy, and thirst
• b.Diminished deep tendon reflexes throughout
• c.Warm, dry, and flushed skin and face
• d.Positive Trousseau and Chvostek signs✓

Hypocalcemia increases neuromuscular excitability, producing positive Trousseau and Chvostek signs, muscle cramps, and tingling. Hypercalcemia causes the opposite findings.

A client presents with slurred speech, facial droop, and right-sided weakness. What is the nurse's priority action?

• a.Activate the stroke protocol and note the time of symptom onset✓
• b.Give the client oral fluids to check the swallowing reflex
• c.Administer aspirin immediately, before any brain imaging is done
• d.Encourage the client to rest and reassess in about an hour

These signs suggest an acute stroke. Rapid activation of the stroke protocol and documenting the symptom onset time are critical because treatment such as thrombolytics is time-dependent.