NCLEX-RN PRACTICE
EXAM
COMPREHENSIVE REVIEW
High-Yield Qs & Answers with Rationales
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
,Section A: Management of Care (QUESTION 1-40)
QUESTION 1
Client Needs: Management of Care
A 78-year-old client with heart failure is admitted with dyspnea, bilateral lower
extremity edema, and a weight gain of 6 lbs in 2 days. VS: BP 160/98, HR 104,
RR 28, O2 sat 88% on room air. The client is receiving furosemide 40 mg IV push
and metoprolol 25 mg PO BID. The nurse must delegate tasks to the unlicensed
assistive personnel (UAP).
Which task can the nurse safely delegate to the UAP?
A. Assess breath sounds and document findings B. Obtain daily weight and
record intake/output C.
Administer prescribed oxygen therapy via nasal cannula D. Evaluate the client's
response to diuretic therapy ANSWER: B
Rationale: The UAP can perform routine data collection tasks like obtaining
weights and recording I&O, which are within their scope of practice. Assessing
breath sounds requires nursing judgment and critical thinking. Administering
oxygen therapy involves medication administration and requires an RN.
Evaluating treatment response requires clinical assessment and nursing
judgment that only an RN can perform.
QUESTION 2
Client Needs: Management of Care
A 34-year-old pregnant woman at 36 weeks gestation presents to labor and
delivery with severe preeclampsia. VS: BP 180/110, HR 96, RR 20, proteinuria
3+. She is receiving magnesium sulfate 2 g/hr IV and has multiple clients
requiring immediate attention. The charge nurse must prioritize care
assignments.
Using the ABC priority framework, which client should the nurse assess first?
,A. A postpartum client with heavy lochia and fundal massage needed B. A
laboring client requesting epidural pain management C. The preeclamptic client
experiencing visual disturbances and headache D. A client in early labor with
ruptured membranes 2 hours ago
ANSWER: C
Rationale: The preeclamptic client with visual disturbances and headache is
showing signs of impending eclampsia, which threatens both maternal and fetal
life (Airway/Breathing/Circulation). This represents the most immediate life-
threatening situation. Heavy lochia requires attention but is not immediately
lifethreatening. Epidural requests and early labor management are important but
not urgent compared to potential seizure activity.
QUESTION 3
Client Needs: Management of Care
A 45-year-old client with terminal pancreatic cancer has an advance directive
stating "no heroic measures." The family is requesting aggressive treatment
including intubation and CPR. VS: BP 80/50, HR 120, RR 32, O2 sat 85%. The
client is conscious but weak.
What is the nurse's most appropriate action regarding this ethical dilemma?
A. Follow the family's wishes since they are the decision-makers B. Honor the
client's advance directive and provide comfort care only C. Consult with the
healthcare provider about aggressive interventions D. Ask the client to clarify
their wishes regarding life-sustaining treatment
ANSWER: D
Rationale: When the client is conscious and competent, they have the right to
make their own healthcare decisions and can modify their advance directive. The
nurse should directly ask the client about their current wishes. Following family
wishes when they contradict the client's documented wishes is inappropriate.
While provider consultation may be needed, the client's current preference takes
precedence over the advance directive if they are competent to decide.
QUESTION 4
Client Needs: Management of Care
, A 16-year-old client requires emergency surgery for appendicitis. The parents are
unreachable, and the client is asking about the procedure. VS: BP 110/70, HR
88, temp 101.2°F, WBC 14,000. The surgeon is requesting informed consent.
What is the nurse's best action regarding informed consent for this minor?
A. Have the client sign the consent form as they are mature enough B. Obtain
consent from the hospital administration or legal department C. Proceed with
surgery under implied consent for emergency treatment D. Wait until the parents
can be contacted before any surgical intervention
ANSWER: C
Rationale: In life-threatening emergencies when parents cannot be reached,
implied consent allows healthcare providers to provide necessary treatment to
save the minor's life or prevent serious harm. Appendicitis with elevated WBC and
fever represents such an emergency. Minors cannot legally provide informed
consent except in specific circumstances (emancipated minors, certain
conditions). Waiting for parents could result in complications like perforation and
peritonitis.
QUESTION 5
Client Needs: Management of Care
A case manager is coordinating care for a 82-year-old client being discharged
after hip replacement surgery. The client lives alone, has limited mobility, and will
need physical therapy, wound care, and medication management. Family lives
300 miles away.
Which referral is the highest priority for safe discharge planning?
A. Outpatient physical therapy clinic appointment B. Home health nursing for
wound assessment and medication compliance C. Meals on Wheels for nutritional
support D. Social services for long-term care facility evaluation
ANSWER: B
Rationale: Home health nursing addresses the most critical post-operative
needs including wound monitoring for infection, medication compliance, and
overall safety assessment. This directly impacts immediate patient safety and
prevents complications requiring readmission. While PT, meals, and social
services are important, the nursing care addresses the most urgent medical needs
that could become lifethreatening if not properly managed.
EXAM
COMPREHENSIVE REVIEW
High-Yield Qs & Answers with Rationales
This Exam Description:
High-Yield Qs
Answers with Rationales
100% Guaranteed Pass
,Section A: Management of Care (QUESTION 1-40)
QUESTION 1
Client Needs: Management of Care
A 78-year-old client with heart failure is admitted with dyspnea, bilateral lower
extremity edema, and a weight gain of 6 lbs in 2 days. VS: BP 160/98, HR 104,
RR 28, O2 sat 88% on room air. The client is receiving furosemide 40 mg IV push
and metoprolol 25 mg PO BID. The nurse must delegate tasks to the unlicensed
assistive personnel (UAP).
Which task can the nurse safely delegate to the UAP?
A. Assess breath sounds and document findings B. Obtain daily weight and
record intake/output C.
Administer prescribed oxygen therapy via nasal cannula D. Evaluate the client's
response to diuretic therapy ANSWER: B
Rationale: The UAP can perform routine data collection tasks like obtaining
weights and recording I&O, which are within their scope of practice. Assessing
breath sounds requires nursing judgment and critical thinking. Administering
oxygen therapy involves medication administration and requires an RN.
Evaluating treatment response requires clinical assessment and nursing
judgment that only an RN can perform.
QUESTION 2
Client Needs: Management of Care
A 34-year-old pregnant woman at 36 weeks gestation presents to labor and
delivery with severe preeclampsia. VS: BP 180/110, HR 96, RR 20, proteinuria
3+. She is receiving magnesium sulfate 2 g/hr IV and has multiple clients
requiring immediate attention. The charge nurse must prioritize care
assignments.
Using the ABC priority framework, which client should the nurse assess first?
,A. A postpartum client with heavy lochia and fundal massage needed B. A
laboring client requesting epidural pain management C. The preeclamptic client
experiencing visual disturbances and headache D. A client in early labor with
ruptured membranes 2 hours ago
ANSWER: C
Rationale: The preeclamptic client with visual disturbances and headache is
showing signs of impending eclampsia, which threatens both maternal and fetal
life (Airway/Breathing/Circulation). This represents the most immediate life-
threatening situation. Heavy lochia requires attention but is not immediately
lifethreatening. Epidural requests and early labor management are important but
not urgent compared to potential seizure activity.
QUESTION 3
Client Needs: Management of Care
A 45-year-old client with terminal pancreatic cancer has an advance directive
stating "no heroic measures." The family is requesting aggressive treatment
including intubation and CPR. VS: BP 80/50, HR 120, RR 32, O2 sat 85%. The
client is conscious but weak.
What is the nurse's most appropriate action regarding this ethical dilemma?
A. Follow the family's wishes since they are the decision-makers B. Honor the
client's advance directive and provide comfort care only C. Consult with the
healthcare provider about aggressive interventions D. Ask the client to clarify
their wishes regarding life-sustaining treatment
ANSWER: D
Rationale: When the client is conscious and competent, they have the right to
make their own healthcare decisions and can modify their advance directive. The
nurse should directly ask the client about their current wishes. Following family
wishes when they contradict the client's documented wishes is inappropriate.
While provider consultation may be needed, the client's current preference takes
precedence over the advance directive if they are competent to decide.
QUESTION 4
Client Needs: Management of Care
, A 16-year-old client requires emergency surgery for appendicitis. The parents are
unreachable, and the client is asking about the procedure. VS: BP 110/70, HR
88, temp 101.2°F, WBC 14,000. The surgeon is requesting informed consent.
What is the nurse's best action regarding informed consent for this minor?
A. Have the client sign the consent form as they are mature enough B. Obtain
consent from the hospital administration or legal department C. Proceed with
surgery under implied consent for emergency treatment D. Wait until the parents
can be contacted before any surgical intervention
ANSWER: C
Rationale: In life-threatening emergencies when parents cannot be reached,
implied consent allows healthcare providers to provide necessary treatment to
save the minor's life or prevent serious harm. Appendicitis with elevated WBC and
fever represents such an emergency. Minors cannot legally provide informed
consent except in specific circumstances (emancipated minors, certain
conditions). Waiting for parents could result in complications like perforation and
peritonitis.
QUESTION 5
Client Needs: Management of Care
A case manager is coordinating care for a 82-year-old client being discharged
after hip replacement surgery. The client lives alone, has limited mobility, and will
need physical therapy, wound care, and medication management. Family lives
300 miles away.
Which referral is the highest priority for safe discharge planning?
A. Outpatient physical therapy clinic appointment B. Home health nursing for
wound assessment and medication compliance C. Meals on Wheels for nutritional
support D. Social services for long-term care facility evaluation
ANSWER: B
Rationale: Home health nursing addresses the most critical post-operative
needs including wound monitoring for infection, medication compliance, and
overall safety assessment. This directly impacts immediate patient safety and
prevents complications requiring readmission. While PT, meals, and social
services are important, the nursing care addresses the most urgent medical needs
that could become lifethreatening if not properly managed.
