NCLEX-STYLE PRACTICE QUESTIONS WITH COMPLETE
ANSWERS PLUS RATIONALES|A+ GRADED.
1. A nurse is assessing a client with suspected hypoxia. Which finding is an early sign of
hypoxia?
A. Cyanosis
B. Bradycardia
C. Restlessness
D. Hypotension
Correct Answer: C
Rationale: Restlessness is an early indicator of hypoxia due to decreased oxygen to
the brain. Cyanosis and bradycardia are late signs, while hypotension is not an early
indicator.
2. A nurse is caring for a client with heart failure. Which intervention is most important
to prevent fluid overload?
A. Encourage increased fluid intake
B. Monitor daily weight
C. Administer oxygen therapy
D. Provide high-protein diet
Correct Answer: B
Rationale: Daily weight monitoring is the most sensitive indicator of fluid status.
Increased fluids may worsen overload, while oxygen and diet do not directly monitor
fluid balance.
3. A client is prescribed furosemide. Which electrolyte imbalance should the nurse
monitor for?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss, leading to
hypokalemia. The other options are less commonly associated.
4. A nurse is caring for a postoperative client. Which finding requires immediate
intervention?
A. Pain rated 6/10
B. Urine output of 30 mL/hr
C. Respiratory rate of 8 breaths/min
D. Temperature of 37.8°C
Correct Answer: C
, Rationale: A respiratory rate of 8 indicates respiratory depression and requires
immediate action. The other findings are less critical.
5. A nurse is teaching a client about insulin administration. Which statement indicates
understanding?
A. "I will inject insulin into my muscle."
B. "I will rotate injection sites."
C. "I will shake the insulin before use."
D. "I will reuse needles to save cost."
Correct Answer: B
Rationale: Rotating injection sites prevents lipodystrophy. Insulin is given
subcutaneously, not shaken vigorously, and needles should not be reused.
6. A nurse is assessing a client with dehydration. Which finding is expected?
A. Bounding pulse
B. Edema
C. Dry mucous membranes
D. Weight gain
Correct Answer: C
Rationale: Dry mucous membranes indicate dehydration. Bounding pulse, edema, and
weight gain suggest fluid overload.
7. A client with COPD is receiving oxygen therapy. Which action is appropriate?
A. Administer high-flow oxygen
B. Maintain oxygen at 1–2 L/min
C. Discontinue oxygen if saturation improves
D. Use non-rebreather mask
Correct Answer: B
Rationale: Low-flow oxygen prevents suppression of respiratory drive in COPD
patients. High-flow oxygen may be harmful.
8. A nurse is caring for a client with a urinary catheter. Which intervention prevents
infection?
A. Disconnect catheter daily
B. Keep drainage bag above bladder
C. Perform perineal care daily
D. Irrigate catheter routinely
Correct Answer: C
Rationale: Daily perineal care reduces infection risk. The bag should be below
bladder level, and routine disconnection increases infection risk.
,9. A nurse is evaluating pain management. Which indicates effective treatment?
A. Client sleeps frequently
B. Client reports pain reduced from 8 to 3
C. Client avoids movement
D. Client requests more medication
Correct Answer: B
Rationale: A reduction in pain score indicates effective management. Sleep or
avoidance may not reflect true relief.
10. A nurse is caring for a client with hypertension. Which diet is recommended?
A. High sodium
B. DASH diet
C. High fat
D. Low potassium
Correct Answer: B
Rationale: The DASH diet helps lower blood pressure. High sodium and fat worsen
hypertension.
11. A nurse is assessing a client with shock. Which sign is expected?
A. Warm, dry skin
B. Decreased heart rate
C. Hypotension
D. Increased urine output
Correct Answer: C
Rationale: Hypotension is a key sign of shock. Skin is typically cool, heart rate
increases, and urine output decreases.
12. A client is receiving blood transfusion. Which reaction requires immediate action?
A. Mild fever
B. Chills and back pain
C. Slight rash
D. Fatigue
Correct Answer: B
Rationale: Chills and back pain indicate a possible hemolytic reaction, requiring
immediate cessation of transfusion.
13. A nurse is teaching hand hygiene. Which is correct?
A. Use water only
B. Wash for at least 20 seconds
C. Skip between fingers
D. Dry with reusable towel
Correct Answer: B
, Rationale: Proper handwashing requires at least 20 seconds. All surfaces must be
cleaned and disposable towels used.
14. A client has hypoglycemia. What is the priority action?
A. Administer insulin
B. Give 15 g of glucose
C. Encourage exercise
D. Restrict fluids
Correct Answer: B
Rationale: Hypoglycemia requires immediate glucose administration. Insulin would
worsen the condition.
15. A nurse is assessing lung sounds. Which indicates fluid in alveoli?
A. Wheezes
B. Crackles
C. Rhonchi
D. Stridor
Correct Answer: B
Rationale: Crackles indicate fluid in alveoli. Wheezes relate to airway narrowing.
16. A client is on bed rest. Which intervention prevents pressure ulcers?
A. Reposition every 2 hours
B. Massage bony areas
C. Limit fluids
D. Use donut cushions
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers. Massage and donut
cushions can worsen tissue damage.
17. A nurse is administering IV potassium. Which is correct?
A. Give IV push
B. Dilute and infuse slowly
C. Mix with calcium
D. Administer rapidly
Correct Answer: B
Rationale: IV potassium must be diluted and given slowly to prevent cardiac arrest.
18. A nurse is caring for a client with fever. Which intervention is appropriate?
A. Provide warm blankets
B. Increase room temperature
ANSWERS PLUS RATIONALES|A+ GRADED.
1. A nurse is assessing a client with suspected hypoxia. Which finding is an early sign of
hypoxia?
A. Cyanosis
B. Bradycardia
C. Restlessness
D. Hypotension
Correct Answer: C
Rationale: Restlessness is an early indicator of hypoxia due to decreased oxygen to
the brain. Cyanosis and bradycardia are late signs, while hypotension is not an early
indicator.
2. A nurse is caring for a client with heart failure. Which intervention is most important
to prevent fluid overload?
A. Encourage increased fluid intake
B. Monitor daily weight
C. Administer oxygen therapy
D. Provide high-protein diet
Correct Answer: B
Rationale: Daily weight monitoring is the most sensitive indicator of fluid status.
Increased fluids may worsen overload, while oxygen and diet do not directly monitor
fluid balance.
3. A client is prescribed furosemide. Which electrolyte imbalance should the nurse
monitor for?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypercalcemia
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes potassium loss, leading to
hypokalemia. The other options are less commonly associated.
4. A nurse is caring for a postoperative client. Which finding requires immediate
intervention?
A. Pain rated 6/10
B. Urine output of 30 mL/hr
C. Respiratory rate of 8 breaths/min
D. Temperature of 37.8°C
Correct Answer: C
, Rationale: A respiratory rate of 8 indicates respiratory depression and requires
immediate action. The other findings are less critical.
5. A nurse is teaching a client about insulin administration. Which statement indicates
understanding?
A. "I will inject insulin into my muscle."
B. "I will rotate injection sites."
C. "I will shake the insulin before use."
D. "I will reuse needles to save cost."
Correct Answer: B
Rationale: Rotating injection sites prevents lipodystrophy. Insulin is given
subcutaneously, not shaken vigorously, and needles should not be reused.
6. A nurse is assessing a client with dehydration. Which finding is expected?
A. Bounding pulse
B. Edema
C. Dry mucous membranes
D. Weight gain
Correct Answer: C
Rationale: Dry mucous membranes indicate dehydration. Bounding pulse, edema, and
weight gain suggest fluid overload.
7. A client with COPD is receiving oxygen therapy. Which action is appropriate?
A. Administer high-flow oxygen
B. Maintain oxygen at 1–2 L/min
C. Discontinue oxygen if saturation improves
D. Use non-rebreather mask
Correct Answer: B
Rationale: Low-flow oxygen prevents suppression of respiratory drive in COPD
patients. High-flow oxygen may be harmful.
8. A nurse is caring for a client with a urinary catheter. Which intervention prevents
infection?
A. Disconnect catheter daily
B. Keep drainage bag above bladder
C. Perform perineal care daily
D. Irrigate catheter routinely
Correct Answer: C
Rationale: Daily perineal care reduces infection risk. The bag should be below
bladder level, and routine disconnection increases infection risk.
,9. A nurse is evaluating pain management. Which indicates effective treatment?
A. Client sleeps frequently
B. Client reports pain reduced from 8 to 3
C. Client avoids movement
D. Client requests more medication
Correct Answer: B
Rationale: A reduction in pain score indicates effective management. Sleep or
avoidance may not reflect true relief.
10. A nurse is caring for a client with hypertension. Which diet is recommended?
A. High sodium
B. DASH diet
C. High fat
D. Low potassium
Correct Answer: B
Rationale: The DASH diet helps lower blood pressure. High sodium and fat worsen
hypertension.
11. A nurse is assessing a client with shock. Which sign is expected?
A. Warm, dry skin
B. Decreased heart rate
C. Hypotension
D. Increased urine output
Correct Answer: C
Rationale: Hypotension is a key sign of shock. Skin is typically cool, heart rate
increases, and urine output decreases.
12. A client is receiving blood transfusion. Which reaction requires immediate action?
A. Mild fever
B. Chills and back pain
C. Slight rash
D. Fatigue
Correct Answer: B
Rationale: Chills and back pain indicate a possible hemolytic reaction, requiring
immediate cessation of transfusion.
13. A nurse is teaching hand hygiene. Which is correct?
A. Use water only
B. Wash for at least 20 seconds
C. Skip between fingers
D. Dry with reusable towel
Correct Answer: B
, Rationale: Proper handwashing requires at least 20 seconds. All surfaces must be
cleaned and disposable towels used.
14. A client has hypoglycemia. What is the priority action?
A. Administer insulin
B. Give 15 g of glucose
C. Encourage exercise
D. Restrict fluids
Correct Answer: B
Rationale: Hypoglycemia requires immediate glucose administration. Insulin would
worsen the condition.
15. A nurse is assessing lung sounds. Which indicates fluid in alveoli?
A. Wheezes
B. Crackles
C. Rhonchi
D. Stridor
Correct Answer: B
Rationale: Crackles indicate fluid in alveoli. Wheezes relate to airway narrowing.
16. A client is on bed rest. Which intervention prevents pressure ulcers?
A. Reposition every 2 hours
B. Massage bony areas
C. Limit fluids
D. Use donut cushions
Correct Answer: A
Rationale: Frequent repositioning prevents pressure ulcers. Massage and donut
cushions can worsen tissue damage.
17. A nurse is administering IV potassium. Which is correct?
A. Give IV push
B. Dilute and infuse slowly
C. Mix with calcium
D. Administer rapidly
Correct Answer: B
Rationale: IV potassium must be diluted and given slowly to prevent cardiac arrest.
18. A nurse is caring for a client with fever. Which intervention is appropriate?
A. Provide warm blankets
B. Increase room temperature
