NR 452 VATI RN EXIT EXAM – Practice Questions
& Exam Review | 2026/2027
250-Question Comprehensive Clinical Assessment with
High-Yield Rationales for NCLEX Readiness
1. A nurse is caring for a client who is in labor. The fetal heart rate is
130/min with moderate variability, and there are no decelerations.
Which of the following actions should the nurse take?
• A. Administer oxygen via face mask at 10 L/min
• B. Document the finding as an expected finding
• C. Assist the client to the left lateral position
• D. Notify the provider immediatelya
Rationale: A normal fetal heart rate is 110-160/min. Moderate variability (6-
25 bpm fluctuations) and the absence of decelerations indicate a well-
oxygenated fetus with an intact autonomic nervous system. This is a
reassuring tracing that requires no intervention.
2. A nurse is providing teaching to a client who is at 12 weeks of
gestation. Which of the following statements by the client indicates
an understanding of the teaching?
• A. "I should feel my baby move by 16 weeks of pregnancy"
• B. "I will have an ultrasound done at 28 weeks to check for birth
defects"
• C. "I should expect to have my blood pressure checked once
each trimester"
• D. "I should gain 10 pounds during the first 12 weeks of pregnancy"
Rationale: A primigravida typically feels fetal movement (quickening)
between 16-22 weeks. A multigravida may feel movement as early as 14
weeks.
3. A nurse is caring for a client who has a prescription for vancomycin
,1 g IV bolus. Which of the following actions should the nurse take to
reduce the risk of an infusion reaction?
• A. Administer the medication over 60 minutes
, • B. Infuse the medication with 0.9% sodium chloride only
• C. Premedicate the client with diphenhydramine
• D. Monitor the client's blood pressure every 15 minutes during infusion
Rationale: Vancomycin can cause "Red Man Syndrome" (flushing, rash,
pruritus) if infused too rapidly. To prevent this reaction, the infusion must be
administered over at least 60 minutes.
4. A nurse is caring for four clients. Which of the following clients
should the nurse assess first?
• A. A client who is 3 days postoperative following abdominal surgery
and has a temperature of 38.2° C (100.8° F)
• B. A client who has diabetes mellitus and a blood glucose level
of 160 mg/dL
• C. A client who has a history of asthma and reports shortness of
breath after using a rescue inhaler
• D. A client who is 12 hours postoperative following a
total hip arthroplasty and reports chest pain
Rationale: Chest pain in a postoperative client is a priority finding that could
indicate a pulmonary embolism (PE). This is a life-threatening complication
requiring immediate intervention.
5. A nurse is caring for a client who has a chest tube connected to a
closed drainage system. Which of the following findings should the
nurse report to the provider?
• A. Continuous bubbling in the water seal chamber
• B. Tidaling in the water seal chamber
• C. 200 mL of drainage in the collection chamber in 4 hours
• D. Occlusive dressing over the chest tube insertion site
, Rationale: Continuous bubbling in the water seal chamber indicates an air
leak in the system. This finding requires assessment to locate the leak and
should be reported to the provider.
6. A nurse is caring for a client who is 2 hours postoperative following
a transurethral resection of the prostate (TURP). The nurse notes that
the client's continuous bladder irrigation is infusing slowly. Which of
the following actions should the nurse take?
• A. Check the tubing for kinks
• B. Increase the flow rate of the continuous bladder irrigation
• C. Check the client's vital signs
• D. Administer pain medication
Rationale: The first action is to assess for a simple mechanical issue, such as
kinked tubing, which is a common cause of slow infusion.
7. A nurse is assessing a client who has schizophrenia. Which of the
following findings should the nurse identify as a positive symptom?
• A. Anhedonia
• B. Alogia
• C. Hallucinations
• D. Avolition
Rationale: Positive symptoms are those that add abnormal experiences,
such as hallucinations, delusions, and disorganized thinking. Anhedonia,
alogia, and avolition are negative symptoms (loss of normal function).
8. A nurse is caring for a client who is at 36 weeks of gestation and has
preeclampsia. Which of the following findings is the nurse's priority to
report to the provider?
• A. Urinary output 20 mL/hr
• B. +1 pitting edema of the ankles
& Exam Review | 2026/2027
250-Question Comprehensive Clinical Assessment with
High-Yield Rationales for NCLEX Readiness
1. A nurse is caring for a client who is in labor. The fetal heart rate is
130/min with moderate variability, and there are no decelerations.
Which of the following actions should the nurse take?
• A. Administer oxygen via face mask at 10 L/min
• B. Document the finding as an expected finding
• C. Assist the client to the left lateral position
• D. Notify the provider immediatelya
Rationale: A normal fetal heart rate is 110-160/min. Moderate variability (6-
25 bpm fluctuations) and the absence of decelerations indicate a well-
oxygenated fetus with an intact autonomic nervous system. This is a
reassuring tracing that requires no intervention.
2. A nurse is providing teaching to a client who is at 12 weeks of
gestation. Which of the following statements by the client indicates
an understanding of the teaching?
• A. "I should feel my baby move by 16 weeks of pregnancy"
• B. "I will have an ultrasound done at 28 weeks to check for birth
defects"
• C. "I should expect to have my blood pressure checked once
each trimester"
• D. "I should gain 10 pounds during the first 12 weeks of pregnancy"
Rationale: A primigravida typically feels fetal movement (quickening)
between 16-22 weeks. A multigravida may feel movement as early as 14
weeks.
3. A nurse is caring for a client who has a prescription for vancomycin
,1 g IV bolus. Which of the following actions should the nurse take to
reduce the risk of an infusion reaction?
• A. Administer the medication over 60 minutes
, • B. Infuse the medication with 0.9% sodium chloride only
• C. Premedicate the client with diphenhydramine
• D. Monitor the client's blood pressure every 15 minutes during infusion
Rationale: Vancomycin can cause "Red Man Syndrome" (flushing, rash,
pruritus) if infused too rapidly. To prevent this reaction, the infusion must be
administered over at least 60 minutes.
4. A nurse is caring for four clients. Which of the following clients
should the nurse assess first?
• A. A client who is 3 days postoperative following abdominal surgery
and has a temperature of 38.2° C (100.8° F)
• B. A client who has diabetes mellitus and a blood glucose level
of 160 mg/dL
• C. A client who has a history of asthma and reports shortness of
breath after using a rescue inhaler
• D. A client who is 12 hours postoperative following a
total hip arthroplasty and reports chest pain
Rationale: Chest pain in a postoperative client is a priority finding that could
indicate a pulmonary embolism (PE). This is a life-threatening complication
requiring immediate intervention.
5. A nurse is caring for a client who has a chest tube connected to a
closed drainage system. Which of the following findings should the
nurse report to the provider?
• A. Continuous bubbling in the water seal chamber
• B. Tidaling in the water seal chamber
• C. 200 mL of drainage in the collection chamber in 4 hours
• D. Occlusive dressing over the chest tube insertion site
, Rationale: Continuous bubbling in the water seal chamber indicates an air
leak in the system. This finding requires assessment to locate the leak and
should be reported to the provider.
6. A nurse is caring for a client who is 2 hours postoperative following
a transurethral resection of the prostate (TURP). The nurse notes that
the client's continuous bladder irrigation is infusing slowly. Which of
the following actions should the nurse take?
• A. Check the tubing for kinks
• B. Increase the flow rate of the continuous bladder irrigation
• C. Check the client's vital signs
• D. Administer pain medication
Rationale: The first action is to assess for a simple mechanical issue, such as
kinked tubing, which is a common cause of slow infusion.
7. A nurse is assessing a client who has schizophrenia. Which of the
following findings should the nurse identify as a positive symptom?
• A. Anhedonia
• B. Alogia
• C. Hallucinations
• D. Avolition
Rationale: Positive symptoms are those that add abnormal experiences,
such as hallucinations, delusions, and disorganized thinking. Anhedonia,
alogia, and avolition are negative symptoms (loss of normal function).
8. A nurse is caring for a client who is at 36 weeks of gestation and has
preeclampsia. Which of the following findings is the nurse's priority to
report to the provider?
• A. Urinary output 20 mL/hr
• B. +1 pitting edema of the ankles
