NCLEX-RN NGN TEST BANK (2025/2026) ACTUAL EXAM
QUESTIONS AND 100% CORRECT ANSWERS WITH VERIFIED
EXPLANATIONS.
1. A nurse is caring for a client with heart failure who suddenly develops
dyspnea and pink frothy sputum. What is the nurse’s priority action?
A. Administer oral diuretics
B. Place the client in a high-Fowler’s position
C. Encourage fluid intake
D. Obtain a chest X-ray
Correct Answer: B
Explanation: High-Fowler’s position promotes lung expansion and
decreases venous return, improving oxygenation. Oral diuretics act
slowly, fluid intake worsens condition, and diagnostics are not priority
over airway and breathing.
2. A client with diabetes mellitus has a blood glucose level of 48 mg/dL.
Which intervention should the nurse perform first?
A. Administer insulin
B. Give 15 g of fast-acting carbohydrate
C. Start IV fluids
D. Notify the provider
Correct Answer: B
Explanation: Hypoglycemia requires immediate correction with fast-
acting carbohydrates. Insulin would worsen hypoglycemia, IV fluids
are not first-line, and notification follows stabilization.
3. A nurse is assessing a postoperative client. Which finding requires
immediate intervention?
A. Pain rating of 6/10
B. Urine output of 20 mL/hr
C. Temperature of 37.8°C (100°F)
D. Mild nausea
Correct Answer: B
Explanation: Urine output <30 mL/hr indicates possible renal
hypoperfusion or shock. Pain, mild fever, and nausea are expected
postoperative findings.
,4. A client receiving heparin therapy has an aPTT of 120 seconds. What is
the nurse’s priority action?
A. Continue infusion
B. Increase dose
C. Stop infusion
D. Administer vitamin K
Correct Answer: C
Explanation: Elevated aPTT indicates risk of bleeding; heparin should
be stopped. Vitamin K is for warfarin reversal.
5. A nurse is caring for a client with COPD. Which oxygen delivery method
is most appropriate?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 1–2 L/min
C. Venturi mask at 10 L/min
D. Simple mask at 8 L/min
Correct Answer: B
Explanation: Low-flow oxygen prevents suppression of respiratory
drive in COPD. High oxygen levels can cause CO₂ retention.
6. A client develops sudden unilateral weakness and slurred speech. What is
the nurse’s priority action?
A. Check blood glucose
B. Call rapid response team
C. Administer aspirin
D. Position client flat
Correct Answer: B
Explanation: Stroke symptoms require immediate emergency response.
Rapid response ensures timely intervention such as thrombolytics.
7. A nurse is administering digoxin. Which finding requires withholding the
medication?
A. Heart rate of 58 bpm
B. Blood pressure of 130/80 mmHg
C. Potassium level of 4.0 mEq/L
D. Respiratory rate of 18/min
, Correct Answer: A
Explanation: Digoxin should be withheld if heart rate is below 60 bpm
due to risk of bradycardia.
8. A client with a spinal cord injury at T6 is experiencing severe headache
and hypertension. What condition does the nurse suspect?
A. Hypovolemic shock
B. Autonomic dysreflexia
C. Neurogenic shock
D. Sepsis
Correct Answer: B
Explanation: Autonomic dysreflexia presents with hypertension and
headache due to noxious stimuli below injury level.
9. A nurse is caring for a client receiving morphine. Which assessment is
the priority?
A. Pain level
B. Respiratory rate
C. Blood pressure
D. Temperature
Correct Answer: B
Explanation: Morphine can cause respiratory depression, making
respiratory rate the priority assessment.
10.A client with hyperkalemia shows peaked T waves on ECG. What
intervention is expected?
A. Administer calcium gluconate
B. Give sodium chloride
C. Restrict fluids
D. Provide potassium supplements
Correct Answer: A
Explanation: Calcium gluconate stabilizes cardiac membranes in
hyperkalemia. Potassium supplements worsen condition.
11.A nurse is teaching a client about warfarin therapy. Which statement
indicates understanding?
, A. “I will avoid leafy greens.”
B. “I will double doses if missed.”
C. “I will stop medication if I feel better.”
D. “I will take aspirin for headaches.”
Correct Answer: A
Explanation: Leafy greens contain vitamin K, which reduces warfarin
effectiveness. Other options are unsafe practices.
12.A nurse identifies a medication error after administration. What is the
first action?
A. Notify the provider
B. Document the error
C. Assess the client
D. Inform the supervisor
Correct Answer: C
Explanation: Client assessment ensures safety before reporting or
documentation.
13.A client with asthma is experiencing wheezing and shortness of breath.
Which medication is given first?
A. Inhaled bronchodilator
B. Oral corticosteroid
C. Antibiotic
D. Antihistamine
Correct Answer: A
Explanation: Bronchodilators provide rapid airway relief in acute
asthma exacerbation.
14.A nurse is caring for a client with increased intracranial pressure. Which
position is appropriate?
A. Flat supine
B. Trendelenburg
C. Head elevated 30 degrees
D. Prone position
Correct Answer: C
Explanation: Elevating head promotes venous drainage and reduces
ICP.
QUESTIONS AND 100% CORRECT ANSWERS WITH VERIFIED
EXPLANATIONS.
1. A nurse is caring for a client with heart failure who suddenly develops
dyspnea and pink frothy sputum. What is the nurse’s priority action?
A. Administer oral diuretics
B. Place the client in a high-Fowler’s position
C. Encourage fluid intake
D. Obtain a chest X-ray
Correct Answer: B
Explanation: High-Fowler’s position promotes lung expansion and
decreases venous return, improving oxygenation. Oral diuretics act
slowly, fluid intake worsens condition, and diagnostics are not priority
over airway and breathing.
2. A client with diabetes mellitus has a blood glucose level of 48 mg/dL.
Which intervention should the nurse perform first?
A. Administer insulin
B. Give 15 g of fast-acting carbohydrate
C. Start IV fluids
D. Notify the provider
Correct Answer: B
Explanation: Hypoglycemia requires immediate correction with fast-
acting carbohydrates. Insulin would worsen hypoglycemia, IV fluids
are not first-line, and notification follows stabilization.
3. A nurse is assessing a postoperative client. Which finding requires
immediate intervention?
A. Pain rating of 6/10
B. Urine output of 20 mL/hr
C. Temperature of 37.8°C (100°F)
D. Mild nausea
Correct Answer: B
Explanation: Urine output <30 mL/hr indicates possible renal
hypoperfusion or shock. Pain, mild fever, and nausea are expected
postoperative findings.
,4. A client receiving heparin therapy has an aPTT of 120 seconds. What is
the nurse’s priority action?
A. Continue infusion
B. Increase dose
C. Stop infusion
D. Administer vitamin K
Correct Answer: C
Explanation: Elevated aPTT indicates risk of bleeding; heparin should
be stopped. Vitamin K is for warfarin reversal.
5. A nurse is caring for a client with COPD. Which oxygen delivery method
is most appropriate?
A. Non-rebreather mask at 15 L/min
B. Nasal cannula at 1–2 L/min
C. Venturi mask at 10 L/min
D. Simple mask at 8 L/min
Correct Answer: B
Explanation: Low-flow oxygen prevents suppression of respiratory
drive in COPD. High oxygen levels can cause CO₂ retention.
6. A client develops sudden unilateral weakness and slurred speech. What is
the nurse’s priority action?
A. Check blood glucose
B. Call rapid response team
C. Administer aspirin
D. Position client flat
Correct Answer: B
Explanation: Stroke symptoms require immediate emergency response.
Rapid response ensures timely intervention such as thrombolytics.
7. A nurse is administering digoxin. Which finding requires withholding the
medication?
A. Heart rate of 58 bpm
B. Blood pressure of 130/80 mmHg
C. Potassium level of 4.0 mEq/L
D. Respiratory rate of 18/min
, Correct Answer: A
Explanation: Digoxin should be withheld if heart rate is below 60 bpm
due to risk of bradycardia.
8. A client with a spinal cord injury at T6 is experiencing severe headache
and hypertension. What condition does the nurse suspect?
A. Hypovolemic shock
B. Autonomic dysreflexia
C. Neurogenic shock
D. Sepsis
Correct Answer: B
Explanation: Autonomic dysreflexia presents with hypertension and
headache due to noxious stimuli below injury level.
9. A nurse is caring for a client receiving morphine. Which assessment is
the priority?
A. Pain level
B. Respiratory rate
C. Blood pressure
D. Temperature
Correct Answer: B
Explanation: Morphine can cause respiratory depression, making
respiratory rate the priority assessment.
10.A client with hyperkalemia shows peaked T waves on ECG. What
intervention is expected?
A. Administer calcium gluconate
B. Give sodium chloride
C. Restrict fluids
D. Provide potassium supplements
Correct Answer: A
Explanation: Calcium gluconate stabilizes cardiac membranes in
hyperkalemia. Potassium supplements worsen condition.
11.A nurse is teaching a client about warfarin therapy. Which statement
indicates understanding?
, A. “I will avoid leafy greens.”
B. “I will double doses if missed.”
C. “I will stop medication if I feel better.”
D. “I will take aspirin for headaches.”
Correct Answer: A
Explanation: Leafy greens contain vitamin K, which reduces warfarin
effectiveness. Other options are unsafe practices.
12.A nurse identifies a medication error after administration. What is the
first action?
A. Notify the provider
B. Document the error
C. Assess the client
D. Inform the supervisor
Correct Answer: C
Explanation: Client assessment ensures safety before reporting or
documentation.
13.A client with asthma is experiencing wheezing and shortness of breath.
Which medication is given first?
A. Inhaled bronchodilator
B. Oral corticosteroid
C. Antibiotic
D. Antihistamine
Correct Answer: A
Explanation: Bronchodilators provide rapid airway relief in acute
asthma exacerbation.
14.A nurse is caring for a client with increased intracranial pressure. Which
position is appropriate?
A. Flat supine
B. Trendelenburg
C. Head elevated 30 degrees
D. Prone position
Correct Answer: C
Explanation: Elevating head promotes venous drainage and reduces
ICP.
