NCSBN TEST BANK - for the NCLEX-RN & NCLEX-PN, Updated 2025, Complete Questions &
Answers, A+ Guide
Course
NCSBN
1. Question:
A nurse is caring for a client with chronic heart failure. Which of the following findings requires
immediate action?
A. Weight gain of 1 kg in 24 hours
B. Peripheral pitting edema
C. A heart rate of 88 beats per minute
D. Bibasilar crackles
Answer: A. Weight gain of 1 kg in 24 hours.
Rationale:
A sudden weight gain of 1 kg in 24 hours is indicative of fluid retention and worsening
heart failure, requiring immediate intervention. Peripheral edema (B) and bibasilar
crackles (D) are expected but should still be monitored. A heart rate of 88 beats per
minute (C) is within the normal range.
2. Question:
The nurse is teaching a client newly diagnosed with type 1 diabetes about insulin administration.
Which statement indicates the need for further teaching?
A. "I will rotate injection sites to prevent tissue damage."
B. "I can skip my insulin dose if I’m not eating."
C. "I will inject insulin into my abdomen for consistent absorption."
D. "I will monitor my blood glucose before meals and at bedtime."
Answer: B. "I can skip my insulin dose if I’m not eating."
Rationale:
Skipping insulin can lead to hyperglycemia or diabetic ketoacidosis. Basal insulin must
still be administered even if meals are skipped. The other statements reflect correct
understanding.
,3. Question:
A client with pneumonia is prescribed IV antibiotics and oxygen therapy. Which assessment
finding requires immediate action?
A. Respiratory rate of 22 breaths per minute
B. Oxygen saturation of 88% on 4 L/min nasal cannula
C. Productive cough with yellow sputum
D. Temperature of 38.3°C (101°F)
Answer: B. Oxygen saturation of 88% on 4 L/min nasal cannula.
Rationale:
An oxygen saturation of 88% indicates severe hypoxemia and requires immediate
intervention. The respiratory rate (A) and fever (D) are expected findings in pneumonia.
Yellow sputum (C) is typical with bacterial infections.
4. Question:
A nurse is assessing a postpartum client 1 hour after a vaginal delivery. Which finding requires
immediate intervention?
A. Fundus is firm and midline
B. Lochia rubra with small clots
C. Saturating one perineal pad in 15 minutes
D. Perineal discomfort rated 6/10
Answer: C. Saturating one perineal pad in 15 minutes.
Rationale:
Excessive bleeding, defined as saturating a pad within 15 minutes, indicates possible
postpartum hemorrhage. The other findings are within normal postpartum expectations.
5. Question:
The nurse is reviewing the laboratory results of a client receiving warfarin therapy. Which INR
value indicates therapeutic range?
, A. 0.8
B. 1.2
C. 2.5
D. 4.5
Answer: C. 2.5
Rationale:
The therapeutic INR range for warfarin therapy is typically 2.0–3.0 for most indications.
Values below this range indicate insufficient anticoagulation, while values above suggest
an increased risk of bleeding.
6. Question:
A client receiving chemotherapy reports new onset of oral sores and difficulty eating. What is the
nurse's priority intervention?
A. Encourage the use of a soft-bristle toothbrush.
B. Advise avoiding spicy and acidic foods.
C. Assess for signs of infection or neutropenia.
D. Suggest frequent mouth rinses with saline.
Answer: C. Assess for signs of infection or neutropenia.
Rationale:
Mucositis is a common side effect of chemotherapy, but it can also indicate infection,
especially in neutropenic clients. Preventative measures like soft toothbrushes and saline
rinses (A and D) are appropriate but not the priority.
7. Question:
Which finding in a client with acute pancreatitis should be reported immediately?
A. Severe epigastric pain radiating to the back
B. Serum amylase 300 U/L
C. Positive Cullen’s sign
D. Nausea and vomiting
, Answer: C. Positive Cullen’s sign.
Rationale:
Cullen’s sign (bruising around the umbilicus) indicates retroperitoneal bleeding, a serious
complication. The other findings, while concerning, are expected in acute pancreatitis.
8. Question:
A nurse is caring for a client with diabetic ketoacidosis (DKA). Which lab finding is consistent
with this condition?
A. Blood glucose of 180 mg/dL
B. Arterial pH of 7.28
C. Bicarbonate level of 26 mEq/L
D. Potassium level of 3.2 mEq/L
Answer: B. Arterial pH of 7.28.
Rationale:
DKA is characterized by metabolic acidosis (pH < 7.35) and hyperglycemia. The
bicarbonate level would typically be low (<18 mEq/L), and potassium may initially
appear elevated or normal but drop with treatment.
9. Question:
A client with a history of asthma presents with wheezing, dyspnea, and a respiratory rate of 32
breaths per minute. What is the nurse's priority action?
A. Administer albuterol via nebulizer.
B. Obtain a peak expiratory flow reading.
C. Position the client in high Fowler’s position.
D. Assess oxygen saturation.
Answer: A. Administer albuterol via nebulizer.
Rationale:
Albuterol, a short-acting bronchodilator, is the first-line treatment for acute asthma
exacerbations. Other assessments and interventions (B, C, D) are important but
secondary.
Answers, A+ Guide
Course
NCSBN
1. Question:
A nurse is caring for a client with chronic heart failure. Which of the following findings requires
immediate action?
A. Weight gain of 1 kg in 24 hours
B. Peripheral pitting edema
C. A heart rate of 88 beats per minute
D. Bibasilar crackles
Answer: A. Weight gain of 1 kg in 24 hours.
Rationale:
A sudden weight gain of 1 kg in 24 hours is indicative of fluid retention and worsening
heart failure, requiring immediate intervention. Peripheral edema (B) and bibasilar
crackles (D) are expected but should still be monitored. A heart rate of 88 beats per
minute (C) is within the normal range.
2. Question:
The nurse is teaching a client newly diagnosed with type 1 diabetes about insulin administration.
Which statement indicates the need for further teaching?
A. "I will rotate injection sites to prevent tissue damage."
B. "I can skip my insulin dose if I’m not eating."
C. "I will inject insulin into my abdomen for consistent absorption."
D. "I will monitor my blood glucose before meals and at bedtime."
Answer: B. "I can skip my insulin dose if I’m not eating."
Rationale:
Skipping insulin can lead to hyperglycemia or diabetic ketoacidosis. Basal insulin must
still be administered even if meals are skipped. The other statements reflect correct
understanding.
,3. Question:
A client with pneumonia is prescribed IV antibiotics and oxygen therapy. Which assessment
finding requires immediate action?
A. Respiratory rate of 22 breaths per minute
B. Oxygen saturation of 88% on 4 L/min nasal cannula
C. Productive cough with yellow sputum
D. Temperature of 38.3°C (101°F)
Answer: B. Oxygen saturation of 88% on 4 L/min nasal cannula.
Rationale:
An oxygen saturation of 88% indicates severe hypoxemia and requires immediate
intervention. The respiratory rate (A) and fever (D) are expected findings in pneumonia.
Yellow sputum (C) is typical with bacterial infections.
4. Question:
A nurse is assessing a postpartum client 1 hour after a vaginal delivery. Which finding requires
immediate intervention?
A. Fundus is firm and midline
B. Lochia rubra with small clots
C. Saturating one perineal pad in 15 minutes
D. Perineal discomfort rated 6/10
Answer: C. Saturating one perineal pad in 15 minutes.
Rationale:
Excessive bleeding, defined as saturating a pad within 15 minutes, indicates possible
postpartum hemorrhage. The other findings are within normal postpartum expectations.
5. Question:
The nurse is reviewing the laboratory results of a client receiving warfarin therapy. Which INR
value indicates therapeutic range?
, A. 0.8
B. 1.2
C. 2.5
D. 4.5
Answer: C. 2.5
Rationale:
The therapeutic INR range for warfarin therapy is typically 2.0–3.0 for most indications.
Values below this range indicate insufficient anticoagulation, while values above suggest
an increased risk of bleeding.
6. Question:
A client receiving chemotherapy reports new onset of oral sores and difficulty eating. What is the
nurse's priority intervention?
A. Encourage the use of a soft-bristle toothbrush.
B. Advise avoiding spicy and acidic foods.
C. Assess for signs of infection or neutropenia.
D. Suggest frequent mouth rinses with saline.
Answer: C. Assess for signs of infection or neutropenia.
Rationale:
Mucositis is a common side effect of chemotherapy, but it can also indicate infection,
especially in neutropenic clients. Preventative measures like soft toothbrushes and saline
rinses (A and D) are appropriate but not the priority.
7. Question:
Which finding in a client with acute pancreatitis should be reported immediately?
A. Severe epigastric pain radiating to the back
B. Serum amylase 300 U/L
C. Positive Cullen’s sign
D. Nausea and vomiting
, Answer: C. Positive Cullen’s sign.
Rationale:
Cullen’s sign (bruising around the umbilicus) indicates retroperitoneal bleeding, a serious
complication. The other findings, while concerning, are expected in acute pancreatitis.
8. Question:
A nurse is caring for a client with diabetic ketoacidosis (DKA). Which lab finding is consistent
with this condition?
A. Blood glucose of 180 mg/dL
B. Arterial pH of 7.28
C. Bicarbonate level of 26 mEq/L
D. Potassium level of 3.2 mEq/L
Answer: B. Arterial pH of 7.28.
Rationale:
DKA is characterized by metabolic acidosis (pH < 7.35) and hyperglycemia. The
bicarbonate level would typically be low (<18 mEq/L), and potassium may initially
appear elevated or normal but drop with treatment.
9. Question:
A client with a history of asthma presents with wheezing, dyspnea, and a respiratory rate of 32
breaths per minute. What is the nurse's priority action?
A. Administer albuterol via nebulizer.
B. Obtain a peak expiratory flow reading.
C. Position the client in high Fowler’s position.
D. Assess oxygen saturation.
Answer: A. Administer albuterol via nebulizer.
Rationale:
Albuterol, a short-acting bronchodilator, is the first-line treatment for acute asthma
exacerbations. Other assessments and interventions (B, C, D) are important but
secondary.
