NCLEX-RN 2025: All-In-One Comprehensive – Expert
Strategies, Full Review of Key Topics, and Practice
Questions for Guaranteed Success
1. A nurse is caring for a client who is 24 hours post-operative
following a cholecystectomy. Which of the following is the priority
assessment?
A) Pain
B) Temperature
C) Skin color
D) Bowel sounds
Answer: B) Temperature
Rationale:
The priority assessment for a client post-cholecystectomy is monitoring
the temperature. A rise in temperature may indicate infection, such as a
wound infection or biliary leakage, which requires prompt attention.
Although pain, skin color, and bowel sounds are important, the
temperature is the most critical to assess initially in the post-operative
period to prevent complications.
2. A nurse is caring for a client diagnosed with a myocardial
infarction (MI). Which of the following interventions is the priority
in the first 24 hours after admission?
A) Administer morphine for pain
B) Assess for signs of bleeding
,C) Monitor serum potassium levels
D) Encourage deep breathing exercises
Answer: A) Administer morphine for pain
Rationale:
The priority intervention for a client with a myocardial infarction (MI)
is the administration of morphine to manage pain and reduce anxiety,
which can help decrease the workload on the heart. Pain management
is essential to prevent further cardiac complications. While monitoring
for bleeding, potassium levels, and encouraging deep breathing exercises
are important, pain management is the priority.
3. The nurse is caring for a client who is receiving warfarin therapy.
Which of the following laboratory values requires immediate
intervention?
A) PT 15 seconds
B) INR 4.5
C) aPTT 30 seconds
D) Platelet count 150,000/mm³
Answer: B) INR 4.5
Rationale:
An INR of 4.5 is elevated and indicates that the client is at an increased
risk for bleeding. The therapeutic INR range for warfarin is typically
between 2.0 and 3.0. An INR of 4.5 requires immediate intervention,
such as administering vitamin K to reverse the anticoagulant effect. PT
and aPTT values are important, but the INR is the primary measure used
for warfarin therapy.
,4. The nurse is preparing to administer a blood transfusion to a
client. Which of the following interventions is the priority?
A) Verify the client's identity
B) Obtain a signed consent form
C) Infuse the blood within 2 hours
D) Take the client's baseline vital signs
Answer: A) Verify the client's identity
Rationale:
The priority intervention before administering a blood transfusion is to
verify the client's identity to ensure that the correct blood type is being
administered to the correct patient. This helps prevent hemolytic
reactions. While obtaining consent, taking vital signs, and infusing the
blood within the appropriate time frame are important, ensuring proper
identification is the priority.
5. A nurse is assessing a client with a history of hypertension. The
nurse should expect the client to exhibit which of the following
findings?
A) Weight loss
B) Headache
C) Hypothermia
D) Tachycardia
Answer: B) Headache
Rationale:
Headaches are a common symptom of hypertension due to the
increased pressure in the blood vessels. Other symptoms of hypertension
may include dizziness, visual disturbances, or shortness of breath.
Weight loss is not typically associated with hypertension, and
, hypothermia and tachycardia are not common findings in hypertensive
clients.
6. A nurse is caring for a client diagnosed with type 1 diabetes
mellitus. The client is experiencing sweating, confusion, and
shakiness. Which of the following is the nurse's priority
intervention?
A) Administer insulin
B) Obtain a blood glucose level
C) Administer a fast-acting carbohydrate
D) Assess the client's neurological status
Answer: C) Administer a fast-acting carbohydrate
Rationale:
The priority intervention for a client exhibiting symptoms of
hypoglycemia (sweating, confusion, shakiness) is to administer a fast-
acting carbohydrate, such as glucose tablets, juice, or soda, to quickly
raise blood sugar. Once the carbohydrate is administered, the nurse
should assess the client's blood glucose level and further monitor the
client’s response.
7. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is receiving oxygen therapy. The nurse should
monitor for which of the following complications?
A) Hypercapnia
B) Hypocapnia
C) Respiratory alkalosis
D) Respiratory acidosis
Answer: A) Hypercapnia
Strategies, Full Review of Key Topics, and Practice
Questions for Guaranteed Success
1. A nurse is caring for a client who is 24 hours post-operative
following a cholecystectomy. Which of the following is the priority
assessment?
A) Pain
B) Temperature
C) Skin color
D) Bowel sounds
Answer: B) Temperature
Rationale:
The priority assessment for a client post-cholecystectomy is monitoring
the temperature. A rise in temperature may indicate infection, such as a
wound infection or biliary leakage, which requires prompt attention.
Although pain, skin color, and bowel sounds are important, the
temperature is the most critical to assess initially in the post-operative
period to prevent complications.
2. A nurse is caring for a client diagnosed with a myocardial
infarction (MI). Which of the following interventions is the priority
in the first 24 hours after admission?
A) Administer morphine for pain
B) Assess for signs of bleeding
,C) Monitor serum potassium levels
D) Encourage deep breathing exercises
Answer: A) Administer morphine for pain
Rationale:
The priority intervention for a client with a myocardial infarction (MI)
is the administration of morphine to manage pain and reduce anxiety,
which can help decrease the workload on the heart. Pain management
is essential to prevent further cardiac complications. While monitoring
for bleeding, potassium levels, and encouraging deep breathing exercises
are important, pain management is the priority.
3. The nurse is caring for a client who is receiving warfarin therapy.
Which of the following laboratory values requires immediate
intervention?
A) PT 15 seconds
B) INR 4.5
C) aPTT 30 seconds
D) Platelet count 150,000/mm³
Answer: B) INR 4.5
Rationale:
An INR of 4.5 is elevated and indicates that the client is at an increased
risk for bleeding. The therapeutic INR range for warfarin is typically
between 2.0 and 3.0. An INR of 4.5 requires immediate intervention,
such as administering vitamin K to reverse the anticoagulant effect. PT
and aPTT values are important, but the INR is the primary measure used
for warfarin therapy.
,4. The nurse is preparing to administer a blood transfusion to a
client. Which of the following interventions is the priority?
A) Verify the client's identity
B) Obtain a signed consent form
C) Infuse the blood within 2 hours
D) Take the client's baseline vital signs
Answer: A) Verify the client's identity
Rationale:
The priority intervention before administering a blood transfusion is to
verify the client's identity to ensure that the correct blood type is being
administered to the correct patient. This helps prevent hemolytic
reactions. While obtaining consent, taking vital signs, and infusing the
blood within the appropriate time frame are important, ensuring proper
identification is the priority.
5. A nurse is assessing a client with a history of hypertension. The
nurse should expect the client to exhibit which of the following
findings?
A) Weight loss
B) Headache
C) Hypothermia
D) Tachycardia
Answer: B) Headache
Rationale:
Headaches are a common symptom of hypertension due to the
increased pressure in the blood vessels. Other symptoms of hypertension
may include dizziness, visual disturbances, or shortness of breath.
Weight loss is not typically associated with hypertension, and
, hypothermia and tachycardia are not common findings in hypertensive
clients.
6. A nurse is caring for a client diagnosed with type 1 diabetes
mellitus. The client is experiencing sweating, confusion, and
shakiness. Which of the following is the nurse's priority
intervention?
A) Administer insulin
B) Obtain a blood glucose level
C) Administer a fast-acting carbohydrate
D) Assess the client's neurological status
Answer: C) Administer a fast-acting carbohydrate
Rationale:
The priority intervention for a client exhibiting symptoms of
hypoglycemia (sweating, confusion, shakiness) is to administer a fast-
acting carbohydrate, such as glucose tablets, juice, or soda, to quickly
raise blood sugar. Once the carbohydrate is administered, the nurse
should assess the client's blood glucose level and further monitor the
client’s response.
7. A nurse is caring for a client with chronic obstructive pulmonary
disease (COPD) who is receiving oxygen therapy. The nurse should
monitor for which of the following complications?
A) Hypercapnia
B) Hypocapnia
C) Respiratory alkalosis
D) Respiratory acidosis
Answer: A) Hypercapnia
