NCLEX RN ACTUALL QUESTIONS AND ANSWERS
,1. A client with chronic heart failure is admitted with worsening dyspnea and edema. Which
assessment finding requires immediate intervention?
a) Blood pressure 110/70 mmHg
b) Oxygen saturation 88% on room air
c) Heart rate 90 bpm
d) Weight increased by 1 kg in 3 days
Answer: b) Oxygen saturation 88% on room air
Strategy:
Prioritize airway and breathing issues first. Oxygen saturation below 90% indicates hypoxia needing
immediate attention.
2. A nurse is preparing to administer morphine sulfate 4 mg IV to a client. The medication is
available as 2 mg/mL. How many milliliters should the nurse administer?
Answer: 2 mL
Strategy:
Use the formula: (Desired dose / Available dose) = Volume to administer. Here, 4 mg / 2 mg/mL = 2 mL.
3. Select all that apply (SATA): A nurse is caring for a client with a new colostomy. Which
instructions should the nurse include?
a) Clean the skin around the stoma with warm water only
b) Change the appliance every 5 to 7 days
c) Empty the pouch when it is one-third to one-half full
d) Use adhesive remover sprays to protect skin
e) Allow the stoma to air dry before applying a new appliance
Answer: a), b), c), d)
Strategy:
Colostomy care includes gentle cleaning, regular appliance changes, emptying the pouch before it’s full,
and skin protection. Air drying is not recommended as the skin should be dry but not exposed to air for
extended periods.
,4. A client with diabetes mellitus reports feeling shaky and sweaty. What is the nurse's priority
action?
a) Check the client's blood glucose level
b) Give the client insulin
c) Administer glucagon
d) Provide a high-protein snack
Answer: a) Check the client's blood glucose level
Strategy:
Symptoms suggest hypoglycemia; confirm with blood glucose test before treatment.
5. A client has a new prescription for warfarin. Which lab value should the nurse monitor to
evaluate effectiveness?
a) Prothrombin time (PT)
b) Activated partial thromboplastin time (aPTT)
c) Platelet count
d) Bleeding time
Answer: a) Prothrombin time (PT)
Strategy:
Warfarin affects PT and INR; these are the primary labs to monitor.
6. Case Study:
A 65-year-old male client is admitted with chest pain radiating to the left arm, diaphoresis, and nausea.
ECG shows ST elevation in leads II, III, and aVF.
Question: What is the priority nursing action?
a) Administer aspirin as ordered
b) Obtain vital signs
c) Prepare the client for thrombolytic therapy
d) Place the client on continuous ECG monitoring
Answer: c) Prepare the client for thrombolytic therapy
Strategy:
ST elevation in inferior leads indicates acute MI; timely thrombolytic therapy is critical.
, 7. A nurse is teaching a client about the side effects of lithium therapy. Which of the following should
the client report immediately?
a) Mild tremors
b) Increased thirst and urination
c) Weight gain
d) Diarrhea and vomiting
Answer: d) Diarrhea and vomiting
Strategy:
GI symptoms may indicate lithium toxicity, which requires urgent evaluation.
8. A client with asthma uses a metered-dose inhaler. Which instruction is correct?
a) Inhale quickly and deeply after activating the inhaler
b) Hold your breath for 5 seconds after inhaling the medication
c) Exhale immediately after inhaling the medication
d) Use the inhaler only when symptoms appear
Answer: b) Hold your breath for 5 seconds after inhaling the medication
Strategy:
Holding breath allows medication to settle in the lungs for better effect.
9. A nurse is caring for a client with a Foley catheter. Which action prevents infection?
a) Keeping the drainage bag below bladder level
b) Emptying the bag every 12 hours
c) Washing the catheter with soap and water daily
d) Applying sterile dressings around the catheter insertion site
Answer: a) Keeping the drainage bag below bladder level
Strategy:
This prevents backflow of urine, reducing infection risk.
10. ECG Interpretation (Image provided in original document):
The ECG shows a regular rhythm with a rate of 150 bpm, no visible P waves, and narrow QRS complexes.
,1. A client with chronic heart failure is admitted with worsening dyspnea and edema. Which
assessment finding requires immediate intervention?
a) Blood pressure 110/70 mmHg
b) Oxygen saturation 88% on room air
c) Heart rate 90 bpm
d) Weight increased by 1 kg in 3 days
Answer: b) Oxygen saturation 88% on room air
Strategy:
Prioritize airway and breathing issues first. Oxygen saturation below 90% indicates hypoxia needing
immediate attention.
2. A nurse is preparing to administer morphine sulfate 4 mg IV to a client. The medication is
available as 2 mg/mL. How many milliliters should the nurse administer?
Answer: 2 mL
Strategy:
Use the formula: (Desired dose / Available dose) = Volume to administer. Here, 4 mg / 2 mg/mL = 2 mL.
3. Select all that apply (SATA): A nurse is caring for a client with a new colostomy. Which
instructions should the nurse include?
a) Clean the skin around the stoma with warm water only
b) Change the appliance every 5 to 7 days
c) Empty the pouch when it is one-third to one-half full
d) Use adhesive remover sprays to protect skin
e) Allow the stoma to air dry before applying a new appliance
Answer: a), b), c), d)
Strategy:
Colostomy care includes gentle cleaning, regular appliance changes, emptying the pouch before it’s full,
and skin protection. Air drying is not recommended as the skin should be dry but not exposed to air for
extended periods.
,4. A client with diabetes mellitus reports feeling shaky and sweaty. What is the nurse's priority
action?
a) Check the client's blood glucose level
b) Give the client insulin
c) Administer glucagon
d) Provide a high-protein snack
Answer: a) Check the client's blood glucose level
Strategy:
Symptoms suggest hypoglycemia; confirm with blood glucose test before treatment.
5. A client has a new prescription for warfarin. Which lab value should the nurse monitor to
evaluate effectiveness?
a) Prothrombin time (PT)
b) Activated partial thromboplastin time (aPTT)
c) Platelet count
d) Bleeding time
Answer: a) Prothrombin time (PT)
Strategy:
Warfarin affects PT and INR; these are the primary labs to monitor.
6. Case Study:
A 65-year-old male client is admitted with chest pain radiating to the left arm, diaphoresis, and nausea.
ECG shows ST elevation in leads II, III, and aVF.
Question: What is the priority nursing action?
a) Administer aspirin as ordered
b) Obtain vital signs
c) Prepare the client for thrombolytic therapy
d) Place the client on continuous ECG monitoring
Answer: c) Prepare the client for thrombolytic therapy
Strategy:
ST elevation in inferior leads indicates acute MI; timely thrombolytic therapy is critical.
, 7. A nurse is teaching a client about the side effects of lithium therapy. Which of the following should
the client report immediately?
a) Mild tremors
b) Increased thirst and urination
c) Weight gain
d) Diarrhea and vomiting
Answer: d) Diarrhea and vomiting
Strategy:
GI symptoms may indicate lithium toxicity, which requires urgent evaluation.
8. A client with asthma uses a metered-dose inhaler. Which instruction is correct?
a) Inhale quickly and deeply after activating the inhaler
b) Hold your breath for 5 seconds after inhaling the medication
c) Exhale immediately after inhaling the medication
d) Use the inhaler only when symptoms appear
Answer: b) Hold your breath for 5 seconds after inhaling the medication
Strategy:
Holding breath allows medication to settle in the lungs for better effect.
9. A nurse is caring for a client with a Foley catheter. Which action prevents infection?
a) Keeping the drainage bag below bladder level
b) Emptying the bag every 12 hours
c) Washing the catheter with soap and water daily
d) Applying sterile dressings around the catheter insertion site
Answer: a) Keeping the drainage bag below bladder level
Strategy:
This prevents backflow of urine, reducing infection risk.
10. ECG Interpretation (Image provided in original document):
The ECG shows a regular rhythm with a rate of 150 bpm, no visible P waves, and narrow QRS complexes.
