NCLEX-RN Exam 2025 | Real Questions & Verified Answers | 100% Pass
Guarantee | Comprehensive Study Guide & Practice Test
1. Question
While assessing a one-month-old infant, which of the findings warrants further investigation by the
nurse? Select all that apply.
o A. Abdominal respirations
o B. Irregular breathing rate
o C. Inspiratory grunt
o D. Increased heart rate with crying
o E. Nasal flaring
o F. Cyanosis
o G. Asymmetric chest movement
Correct Answers: C, E, F, & G o Option C. Grunting occurs when an infant
attempts to maintain an adequate functional residual capacity in
the face of poorly compliant lungs by partial glottic closure. As
the infant prolongs the expiratory phase against this partially
closed glottis, there is a prolonged and increased residual volume
that maintains the airway opening and also an audible expiratory
sound. o Option E: Nasal flaring occurs when the nostrils widen
while breathing and is a sign of troubled breathing or respiratory
distress.
o Option F: Cyanosis refers to the bluish discoloration of the
skin and indicates a decrease in oxygen attached to the red
blood cells in the bloodstream.
o Option G: Asymmetric chest movement occurs when the
abnormal side of the lungs expands less and lags behind the
normal side. This indicates respiratory distress.
o Option A: Abdominal respiration is normal among infants and
young children. Since their intercostal muscles are not yet
fully developed, they use their abdominal muscles much
more to pull the diaphragm down for breathing.
o Option B: Newborns can have irregular breathing patterns
ranging from 30 to 60 breaths per minute with short periods
of apnea (15 seconds). o Option D: An increase in heart rate
is normal for an infant during activity (including crying).
Fluctuations in heart rate follow the changes in the
, newborn‟ s behavioral state – crying, movement, or
wakefulness corresponds to an increase in heart rate.
• 2. Question
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol)
0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the
order in which the nurse must carry out the following actions prior to the administration of
preoperative medications.
View Answers:
o Place the call bell within reach o Raise the
side rails on the bed o Have the client empty
bladder o Instruct the client to remain in bed
Correct order is shown above.
o Have the client empty the bladder. The first step in the
process is to have the client void prior to administering the
pre-operative medication. If the
client does not have a catheter, it is important to empty
the bladder before receiving preoperative medications to
prevent bladder injury (especially in pelvic surgeries). Else,
a straight catheter or an indwelling catheter may be
ordered to ensure the bladder is empty.
o Instruct the client to remain in bed. Preoperative
medications can cause drowsiness and lightheadedness
which may put the client at risk for injury.
o Raise the side rails on the bed. Raising the side rails on
the bed helps prevent accidental falls and injury when the
client decides to get out of the bed without assistance. o
Place the call bell within reach. Call bells should always
be within the reach of a client.
2. 3. Question
A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data
about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years
ago at 12 weeks gestation. How would the nurse accurately document this information? Fill in
the blanks.
o Answer: Gravida (3) para (1)
,Correct Answer: Gravida 3 para 1
Gravida is the number of confirmed pregnancies and each pregnancy is
only counted one time, even if the pregnancy was a multiple gestation
(i.e., twins, triplets). Para (parity) indicates the total number of
pregnancies that have reached viability (20 weeks) regardless of whether
the infants were born alive. Thus,
for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable
birth (twins).
o 4. Question
Which individual is at the greatest risk for developinghypertension?
o A. 45-year-old African-American attorney
o B. 60-year-old Asian-American shop owner
o C. 40-year-old Caucasian nurse
o D. 55-year-old Hispanic teacher
Correct Answer: A: 45-year-old African American attorney o Option A:
African-Americans develop high blood pressure at younger ages
than other groups in the US. Researchers have uncovered that
African-Americans respond differently to hypertensive drugs than
other groups of people. They are also found out to be more
sensitive to salt, which increases the risk of developing
hypertension. o Option B: The incidence of hypertension in Asian-
Americans does not appear to be significantly higher than the
general population, according to limited US data. o Option C: The
racial disparity in hypertension and hypertension-related
outcomes has been recognized for decades with African-
Americans with greater risks than Caucasians. o Option D:
Hypertension prevalence rates in Hispanics may vary by gender
and country of origin. Hispanic Americans overall have relatively
low levels of hypertension, despite elevated levels of diabetes and
obesity.
• 5. Question
A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes
ago is rushed to the emergency department. Which of these orders should the nurse do first?
, o A. Gastric lavage
o B. Administer acetylcysteine (Mucomyst) orally
o C. Start an IV Dextrose 5% with 0.33% normal saline tokeep the vein open
o D. Have the patient drink activated charcoal mixed with water
Correct Answer: A. Gastric lavage
o Option A: Acetaminophen overdose is extremely toxic to the liver causing
hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting,
abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis
occurs and may lead to death. Removing as much of the drug as possible is the
first step in treatment for acetaminophen overdose, this is best done through
gastric lavage. Gastric lavage (irrigation) and aspiration consist of flushing the
stomach with fluids and then aspirating the fluid back out. This procedure is
done in life-threatening cases such as acetaminophen toxicity and only if less
than one (1) hour has occurred after ingestion.
o Option B: The oral formulation of acetylcysteine is the drug of choice for the
treatment of acetaminophen overdose but should be done after GI
decontamination with activated charcoal. Liver damage is minimized by giving
acetylcysteine (Mucomyst), the antidote for acetaminophen. Acetylcysteine
reduces injury by substituting for depleted glutathione in the reaction that
converts the toxic metabolite of acetaminophen to its nontoxic form. When
given within 8 hours of acetaminophen toxicity, acetylcysteine is effective in
preventing severe liver injury. It is administered orally or intravenously.
o Option C: Intermittent IV infusion with Dextrose 5% may be considered for
late-presenting or chronic ingestion.
o Option D: Oral activated charcoal (AC) avidly adsorbsacetaminophen and
may be administered if the patient presents within 1 hour after ingesting a
potentially toxic dose. Charcoal should not be administered immediately
before or with antidotes since it can effectively adsorb it and neutralize the
benefits.
• 6. Question
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours
after the procedure?
o A. Angina at rest
o B. Thrombus formation
o C. Dizziness
o D. Falling blood pressure
Correct Answer: B. Thrombus formation
A thrombus formation may prevent blood from flowing normally through
the circulatory system, which may become an embolism, and block the
flow of blood towards major organs in the body.
Guarantee | Comprehensive Study Guide & Practice Test
1. Question
While assessing a one-month-old infant, which of the findings warrants further investigation by the
nurse? Select all that apply.
o A. Abdominal respirations
o B. Irregular breathing rate
o C. Inspiratory grunt
o D. Increased heart rate with crying
o E. Nasal flaring
o F. Cyanosis
o G. Asymmetric chest movement
Correct Answers: C, E, F, & G o Option C. Grunting occurs when an infant
attempts to maintain an adequate functional residual capacity in
the face of poorly compliant lungs by partial glottic closure. As
the infant prolongs the expiratory phase against this partially
closed glottis, there is a prolonged and increased residual volume
that maintains the airway opening and also an audible expiratory
sound. o Option E: Nasal flaring occurs when the nostrils widen
while breathing and is a sign of troubled breathing or respiratory
distress.
o Option F: Cyanosis refers to the bluish discoloration of the
skin and indicates a decrease in oxygen attached to the red
blood cells in the bloodstream.
o Option G: Asymmetric chest movement occurs when the
abnormal side of the lungs expands less and lags behind the
normal side. This indicates respiratory distress.
o Option A: Abdominal respiration is normal among infants and
young children. Since their intercostal muscles are not yet
fully developed, they use their abdominal muscles much
more to pull the diaphragm down for breathing.
o Option B: Newborns can have irregular breathing patterns
ranging from 30 to 60 breaths per minute with short periods
of apnea (15 seconds). o Option D: An increase in heart rate
is normal for an infant during activity (including crying).
Fluctuations in heart rate follow the changes in the
, newborn‟ s behavioral state – crying, movement, or
wakefulness corresponds to an increase in heart rate.
• 2. Question
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol)
0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the
order in which the nurse must carry out the following actions prior to the administration of
preoperative medications.
View Answers:
o Place the call bell within reach o Raise the
side rails on the bed o Have the client empty
bladder o Instruct the client to remain in bed
Correct order is shown above.
o Have the client empty the bladder. The first step in the
process is to have the client void prior to administering the
pre-operative medication. If the
client does not have a catheter, it is important to empty
the bladder before receiving preoperative medications to
prevent bladder injury (especially in pelvic surgeries). Else,
a straight catheter or an indwelling catheter may be
ordered to ensure the bladder is empty.
o Instruct the client to remain in bed. Preoperative
medications can cause drowsiness and lightheadedness
which may put the client at risk for injury.
o Raise the side rails on the bed. Raising the side rails on
the bed helps prevent accidental falls and injury when the
client decides to get out of the bed without assistance. o
Place the call bell within reach. Call bells should always
be within the reach of a client.
2. 3. Question
A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data
about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years
ago at 12 weeks gestation. How would the nurse accurately document this information? Fill in
the blanks.
o Answer: Gravida (3) para (1)
,Correct Answer: Gravida 3 para 1
Gravida is the number of confirmed pregnancies and each pregnancy is
only counted one time, even if the pregnancy was a multiple gestation
(i.e., twins, triplets). Para (parity) indicates the total number of
pregnancies that have reached viability (20 weeks) regardless of whether
the infants were born alive. Thus,
for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable
birth (twins).
o 4. Question
Which individual is at the greatest risk for developinghypertension?
o A. 45-year-old African-American attorney
o B. 60-year-old Asian-American shop owner
o C. 40-year-old Caucasian nurse
o D. 55-year-old Hispanic teacher
Correct Answer: A: 45-year-old African American attorney o Option A:
African-Americans develop high blood pressure at younger ages
than other groups in the US. Researchers have uncovered that
African-Americans respond differently to hypertensive drugs than
other groups of people. They are also found out to be more
sensitive to salt, which increases the risk of developing
hypertension. o Option B: The incidence of hypertension in Asian-
Americans does not appear to be significantly higher than the
general population, according to limited US data. o Option C: The
racial disparity in hypertension and hypertension-related
outcomes has been recognized for decades with African-
Americans with greater risks than Caucasians. o Option D:
Hypertension prevalence rates in Hispanics may vary by gender
and country of origin. Hispanic Americans overall have relatively
low levels of hypertension, despite elevated levels of diabetes and
obesity.
• 5. Question
A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes
ago is rushed to the emergency department. Which of these orders should the nurse do first?
, o A. Gastric lavage
o B. Administer acetylcysteine (Mucomyst) orally
o C. Start an IV Dextrose 5% with 0.33% normal saline tokeep the vein open
o D. Have the patient drink activated charcoal mixed with water
Correct Answer: A. Gastric lavage
o Option A: Acetaminophen overdose is extremely toxic to the liver causing
hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting,
abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis
occurs and may lead to death. Removing as much of the drug as possible is the
first step in treatment for acetaminophen overdose, this is best done through
gastric lavage. Gastric lavage (irrigation) and aspiration consist of flushing the
stomach with fluids and then aspirating the fluid back out. This procedure is
done in life-threatening cases such as acetaminophen toxicity and only if less
than one (1) hour has occurred after ingestion.
o Option B: The oral formulation of acetylcysteine is the drug of choice for the
treatment of acetaminophen overdose but should be done after GI
decontamination with activated charcoal. Liver damage is minimized by giving
acetylcysteine (Mucomyst), the antidote for acetaminophen. Acetylcysteine
reduces injury by substituting for depleted glutathione in the reaction that
converts the toxic metabolite of acetaminophen to its nontoxic form. When
given within 8 hours of acetaminophen toxicity, acetylcysteine is effective in
preventing severe liver injury. It is administered orally or intravenously.
o Option C: Intermittent IV infusion with Dextrose 5% may be considered for
late-presenting or chronic ingestion.
o Option D: Oral activated charcoal (AC) avidly adsorbsacetaminophen and
may be administered if the patient presents within 1 hour after ingesting a
potentially toxic dose. Charcoal should not be administered immediately
before or with antidotes since it can effectively adsorb it and neutralize the
benefits.
• 6. Question
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours
after the procedure?
o A. Angina at rest
o B. Thrombus formation
o C. Dizziness
o D. Falling blood pressure
Correct Answer: B. Thrombus formation
A thrombus formation may prevent blood from flowing normally through
the circulatory system, which may become an embolism, and block the
flow of blood towards major organs in the body.
