NCLEX-RN, FOCUSING ON MED-SURG, MATERNAL-NEWBORN, PEDIATRICS,
PHARMACOLOGY, AND SAFETY WITH MULTIPLE-CHOICE QUESTIONS,
RATIONALES, AND CORRECT ANSWER INDICATORS.
1. A nurse is caring for a client with congestive heart failure. Which of the following
findings should the nurse report immediately?
A. Mild peripheral edema
B. Crackles in the lungs
C. Weight gain of 1 lb in a week
D. Slight fatigue with activity
Answer: ✔ B. Crackles in the lungs
Rationale: Crackles indicate fluid accumulation in the lungs, suggesting worsening
pulmonary edema, which requires immediate intervention.
2. The nurse is teaching a client with diabetes mellitus about foot care. Which statement
by the client indicates a need for further teaching?
A. “I will inspect my feet daily.”
B. “I can soak my feet in hot water.”
C. “I will wear socks without holes.”
D. “I will trim my toenails straight across.”
Answer: ✔ B. “I can soak my feet in hot water.”
Rationale: Soaking feet in hot water can cause burns due to reduced sensation from
neuropathy.
3. A client with schizophrenia is prescribed risperidone. Which side effect should the
nurse monitor for?
A. Hyperglycemia
B. Extrapyramidal symptoms
C. Hypertension
D. Insomnia
, Answer: ✔ B. Extrapyramidal symptoms
Rationale: Risperidone is an atypical antipsychotic that can cause EPS, including
tremors, rigidity, and dystonia.
4. Which action should the nurse take first for a client experiencing an acute asthma
attack?
A. Administer albuterol via nebulizer
B. Assess oxygen saturation
C. Obtain a chest x-ray
D. Encourage deep breathing exercises
Answer: ✔ A. Administer albuterol via nebulizer
Rationale: Albuterol is a fast-acting bronchodilator, and rapid intervention is critical in
acute asthma exacerbation.
5. A postpartum client has a temperature of 38.5°C (101.3°F). What is the priority
nursing action?
A. Encourage oral fluids
B. Assess for signs of infection
C. Administer acetaminophen
D. Reassure the client that mild fever is normal
Answer: ✔ B. Assess for signs of infection
Rationale: Fever postpartum may indicate infection (e.g., endometritis), which requires
prompt assessment.
6. Which lab result is most important for the nurse to report in a client receiving
heparin?
A. Hemoglobin 12 g/dL
B. Platelet count 50,000/mm³
C. Sodium 138 mEq/L
PHARMACOLOGY, AND SAFETY WITH MULTIPLE-CHOICE QUESTIONS,
RATIONALES, AND CORRECT ANSWER INDICATORS.
1. A nurse is caring for a client with congestive heart failure. Which of the following
findings should the nurse report immediately?
A. Mild peripheral edema
B. Crackles in the lungs
C. Weight gain of 1 lb in a week
D. Slight fatigue with activity
Answer: ✔ B. Crackles in the lungs
Rationale: Crackles indicate fluid accumulation in the lungs, suggesting worsening
pulmonary edema, which requires immediate intervention.
2. The nurse is teaching a client with diabetes mellitus about foot care. Which statement
by the client indicates a need for further teaching?
A. “I will inspect my feet daily.”
B. “I can soak my feet in hot water.”
C. “I will wear socks without holes.”
D. “I will trim my toenails straight across.”
Answer: ✔ B. “I can soak my feet in hot water.”
Rationale: Soaking feet in hot water can cause burns due to reduced sensation from
neuropathy.
3. A client with schizophrenia is prescribed risperidone. Which side effect should the
nurse monitor for?
A. Hyperglycemia
B. Extrapyramidal symptoms
C. Hypertension
D. Insomnia
, Answer: ✔ B. Extrapyramidal symptoms
Rationale: Risperidone is an atypical antipsychotic that can cause EPS, including
tremors, rigidity, and dystonia.
4. Which action should the nurse take first for a client experiencing an acute asthma
attack?
A. Administer albuterol via nebulizer
B. Assess oxygen saturation
C. Obtain a chest x-ray
D. Encourage deep breathing exercises
Answer: ✔ A. Administer albuterol via nebulizer
Rationale: Albuterol is a fast-acting bronchodilator, and rapid intervention is critical in
acute asthma exacerbation.
5. A postpartum client has a temperature of 38.5°C (101.3°F). What is the priority
nursing action?
A. Encourage oral fluids
B. Assess for signs of infection
C. Administer acetaminophen
D. Reassure the client that mild fever is normal
Answer: ✔ B. Assess for signs of infection
Rationale: Fever postpartum may indicate infection (e.g., endometritis), which requires
prompt assessment.
6. Which lab result is most important for the nurse to report in a client receiving
heparin?
A. Hemoglobin 12 g/dL
B. Platelet count 50,000/mm³
C. Sodium 138 mEq/L
