NCLEX-Style Nursing Exam
Mastery: Top 100 Frequently
Tested Questions with
Rationales”---
**1.** A nurse is caring for a client with heart failure who has crackles
in the lungs and an SpO₂ of 88%. Which action should the nurse take
first?
A. Administer furosemide IV push
B. Place the client in high Fowler’s position
C. Notify the healthcare provider
D. Prepare for intubation
> **Answer:** B – High Fowler’s position uses gravity to improve lung
expansion and oxygenation. Airway/breathing always comes first.
**2.** A client on warfarin has an INR of 4.5. Which medication should
the nurse anticipate administering?
A. Protamine sulfate
,B. Vitamin K
C. Andexanet alfa
D. Aminocaproic acid
> **Answer:** B – Vitamin K reverses warfarin’s anticoagulation.
Protamine is for heparin.
**3.** Which finding in a postpartum client requires immediate
intervention?
A. Lochia rubra on day 4
B. Fundus at umbilicus
C. Heavy, constant vaginal bleeding
D. Afterpains during breastfeeding
> **Answer:** C – Heavy constant bleeding suggests uterine atony or
laceration; lochia rubra is normal for 3–5 days.
**4.** A nurse is preparing to administer potassium chloride IV. Which
action is essential?
A. Give as a rapid IV push
B. Dilute and use an infusion pump
C. Mix in a lactated Ringer’s bag
D. Warm the solution to body temperature
,> **Answer:** B – IV potassium must be diluted and given via pump to
prevent cardiac arrest; never given as a push.
**5.** A client with major depressive disorder says, “Life isn’t worth
living anymore.” What is the nurse’s priority response?
A. “Why do you feel that way?”
B. “Have you thought about how you would hurt yourself?”
C. “You have so much to live for.”
D. “Let’s talk about your medications.”
> **Answer:** B – Directly assess for suicidal ideation, plan, means,
and intent. Safety first.
**6.** A child with cystic fibrosis presents with a barrel chest and
clubbing. The nurse understands these are due to:
A. Chronic hypoxemia
B. Cardiac failure
C. Liver cirrhosis
D. Renal failure
> **Answer:** A – Chronic hypoxemia from lung disease causes
clubbing and barrel chest from air trapping.
, **7.** A nurse finds a client on the floor after a fall. What is the first
action?
A. Call the healthcare provider
B. Assess the client’s vital signs and level of consciousness
C. Fill out an incident report
D. Help the client back to bed
> **Answer:** B – Assess for injury first, then notify provider, then
complete incident report.
**8.** Which lab value indicates that heparin therapy is therapeutic?
A. INR 2.0–3.0
B. aPTT 1.5–2.5 times normal
C. Platelets 150,000
D. PT 12–14 seconds
> **Answer:** B – aPTT is monitored for heparin; INR for warfarin.
**9.** A nurse is providing discharge teaching for a client with a new
colostomy. Which statement by the client indicates understanding?
A. “I can only wear pouches with a belt.”
B. “I will change the entire appliance every day.”
Mastery: Top 100 Frequently
Tested Questions with
Rationales”---
**1.** A nurse is caring for a client with heart failure who has crackles
in the lungs and an SpO₂ of 88%. Which action should the nurse take
first?
A. Administer furosemide IV push
B. Place the client in high Fowler’s position
C. Notify the healthcare provider
D. Prepare for intubation
> **Answer:** B – High Fowler’s position uses gravity to improve lung
expansion and oxygenation. Airway/breathing always comes first.
**2.** A client on warfarin has an INR of 4.5. Which medication should
the nurse anticipate administering?
A. Protamine sulfate
,B. Vitamin K
C. Andexanet alfa
D. Aminocaproic acid
> **Answer:** B – Vitamin K reverses warfarin’s anticoagulation.
Protamine is for heparin.
**3.** Which finding in a postpartum client requires immediate
intervention?
A. Lochia rubra on day 4
B. Fundus at umbilicus
C. Heavy, constant vaginal bleeding
D. Afterpains during breastfeeding
> **Answer:** C – Heavy constant bleeding suggests uterine atony or
laceration; lochia rubra is normal for 3–5 days.
**4.** A nurse is preparing to administer potassium chloride IV. Which
action is essential?
A. Give as a rapid IV push
B. Dilute and use an infusion pump
C. Mix in a lactated Ringer’s bag
D. Warm the solution to body temperature
,> **Answer:** B – IV potassium must be diluted and given via pump to
prevent cardiac arrest; never given as a push.
**5.** A client with major depressive disorder says, “Life isn’t worth
living anymore.” What is the nurse’s priority response?
A. “Why do you feel that way?”
B. “Have you thought about how you would hurt yourself?”
C. “You have so much to live for.”
D. “Let’s talk about your medications.”
> **Answer:** B – Directly assess for suicidal ideation, plan, means,
and intent. Safety first.
**6.** A child with cystic fibrosis presents with a barrel chest and
clubbing. The nurse understands these are due to:
A. Chronic hypoxemia
B. Cardiac failure
C. Liver cirrhosis
D. Renal failure
> **Answer:** A – Chronic hypoxemia from lung disease causes
clubbing and barrel chest from air trapping.
, **7.** A nurse finds a client on the floor after a fall. What is the first
action?
A. Call the healthcare provider
B. Assess the client’s vital signs and level of consciousness
C. Fill out an incident report
D. Help the client back to bed
> **Answer:** B – Assess for injury first, then notify provider, then
complete incident report.
**8.** Which lab value indicates that heparin therapy is therapeutic?
A. INR 2.0–3.0
B. aPTT 1.5–2.5 times normal
C. Platelets 150,000
D. PT 12–14 seconds
> **Answer:** B – aPTT is monitored for heparin; INR for warfarin.
**9.** A nurse is providing discharge teaching for a client with a new
colostomy. Which statement by the client indicates understanding?
A. “I can only wear pouches with a belt.”
B. “I will change the entire appliance every day.”
