NGN NCLEX RN ACTUAL CASE STUDIES WELL
ANSWERED 2025
Course
Nclex
1. A nurse is assessing a client who is receiving intravenous (IV) fluids. The nurse notices that
the infusion site is swollen and cool to the touch. What is the most appropriate action for the
nurse to take?
A) Discontinue the IV and restart it in another location.
B) Increase the infusion rate to ensure better flow.
C) Apply warm compresses to the infusion site.
D) Notify the healthcare provider about the site reaction.
Answer: A) Discontinue the IV and restart it in another location.
Rationale: Swelling and coolness at the IV site indicate infiltration, meaning the IV fluid is not
infusing into the vein but into the surrounding tissue. The IV should be discontinued and
restarted in a different location to prevent further complications.
2. A nurse is caring for a client who is 6 hours postoperative following a cholecystectomy. The
client is complaining of severe pain at the surgical site. What is the nurse's first action?
A) Administer prescribed pain medication.
B) Assess the client’s vital signs for signs of infection.
C) Reposition the client to promote comfort.
D) Notify the healthcare provider about the pain.
Answer: A) Administer prescribed pain medication.
Rationale: Pain management is a priority after surgery. Administering prescribed pain
medication is the nurse’s first action to alleviate the client’s discomfort.
3. A nurse is educating a client on how to properly take their prescribed medication. Which of
the following statements indicates that the client understands the teaching?
A) "I will take my medication with food to prevent nausea."
B) "I will take two doses if I miss one dose."
C) "I will take my medication every other day for convenience."
D) "I will stop taking my medication if I feel better."
,Answer: A) "I will take my medication with food to prevent nausea."
Rationale: Many medications should be taken with food to reduce the risk of gastrointestinal
upset. It is important to adhere to the prescribed schedule and dosage.
4. A client with a history of asthma presents to the emergency department with shortness of
breath and wheezing. The nurse should administer which medication first?
A) Prednisone (a corticosteroid)
B) Albuterol (a beta-agonist)
C) Salmeterol (a long-acting beta-agonist)
D) Ipratropium (an anticholinergic agent)
Answer: B) Albuterol (a beta-agonist)
Rationale: Albuterol is a short-acting beta-agonist that works quickly to open the airways during
an asthma exacerbation. It is the first choice to relieve acute symptoms like shortness of breath
and wheezing.
5. A nurse is caring for a client receiving heparin therapy. The client’s latest lab results show an
activated partial thromboplastin time (aPTT) of 100 seconds. What action should the nurse take?
A) Continue administering the heparin as prescribed.
B) Discontinue the heparin and notify the healthcare provider.
C) Administer vitamin K to reverse the effect of heparin.
D) Reduce the heparin dose by half.
Answer: B) Discontinue the heparin and notify the healthcare provider.
Rationale: An aPTT of 100 seconds is significantly elevated, indicating a risk for bleeding. The
nurse should discontinue the heparin and notify the healthcare provider to assess the situation
and adjust the treatment plan.
6. A client with congestive heart failure (CHF) is receiving a diuretic. The nurse monitors for
which of the following potential complications?
A) Hyperkalemia
B) Hypertension
C) Hypokalemia
D) Hyperglycemia
,Answer: C) Hypokalemia
Rationale: Diuretics can lead to potassium loss, which can result in hypokalemia. The nurse
should monitor the client’s potassium levels and watch for signs of potassium imbalance.
7. A nurse is caring for a client with diabetes mellitus who is scheduled for a fasting blood
glucose test. Which instruction is appropriate for the nurse to provide?
A) "You should eat a light breakfast before the test."
B) "You can drink water up to 1 hour before the test."
C) "You should refrain from taking your insulin before the test."
D) "You must fast for 12 hours before the test."
Answer: B) "You can drink water up to 1 hour before the test."
Rationale: Fasting blood glucose tests require the client to fast for 8-12 hours, but they can drink
water. Insulin should typically be withheld until after the test unless instructed otherwise by the
healthcare provider.
8. A nurse is caring for a client who is 1 day postoperative following a total hip replacement. The
client is complaining of nausea and vomiting. What should the nurse do first?
A) Administer antiemetic medication.
B) Assess the client’s bowel sounds.
C) Ask the client if they are experiencing pain.
D) Encourage the client to drink clear fluids.
Answer: C) Ask the client if they are experiencing pain.
Rationale: Nausea and vomiting after surgery may be related to pain. The nurse should assess
pain first, as effective pain management could reduce the symptoms of nausea and vomiting.
9. A nurse is teaching a client about the side effects of a new prescription for an antihypertensive
medication. The nurse should include which of the following as a common side effect?
A) Insomnia
B) Dizziness
C) Increased appetite
D) Tremors
, Answer: B) Dizziness
Rationale: Dizziness is a common side effect of antihypertensive medications due to their effect
on blood pressure. Clients should be cautioned to rise slowly from a sitting or lying position to
prevent falls.
10. A nurse is caring for a client with a history of chronic obstructive pulmonary disease
(COPD). The nurse should be concerned if the client has which of the following lab results?
A) Decreased hemoglobin and hematocrit levels
B) Elevated white blood cell count
C) Increased potassium levels
D) Decreased carbon dioxide (CO2) levels
Answer: B) Elevated white blood cell count
Rationale: An elevated white blood cell count can indicate infection, which is a common
concern for clients with COPD due to their compromised respiratory function. Prompt
assessment and intervention are necessary.
11. A nurse is caring for a client who is receiving a blood transfusion. During the transfusion, the
client reports chills and back pain. What is the nurse's first action?
A) Continue the transfusion and monitor the client.
B) Discontinue the transfusion and notify the healthcare provider.
C) Administer acetaminophen for the chills.
D) Slow the infusion rate and notify the blood bank.
Answer: B) Discontinue the transfusion and notify the healthcare provider.
Rationale: Chills and back pain during a blood transfusion may indicate a transfusion reaction.
The nurse should immediately stop the transfusion, notify the healthcare provider, and follow
hospital protocols for managing transfusion reactions.
12. A client with a new diagnosis of type 2 diabetes mellitus is being discharged. The nurse
should include which of the following in the discharge teaching?
A) "You should monitor your blood glucose daily."
B) "You can eat a large amount of sugar as long as you take insulin."
ANSWERED 2025
Course
Nclex
1. A nurse is assessing a client who is receiving intravenous (IV) fluids. The nurse notices that
the infusion site is swollen and cool to the touch. What is the most appropriate action for the
nurse to take?
A) Discontinue the IV and restart it in another location.
B) Increase the infusion rate to ensure better flow.
C) Apply warm compresses to the infusion site.
D) Notify the healthcare provider about the site reaction.
Answer: A) Discontinue the IV and restart it in another location.
Rationale: Swelling and coolness at the IV site indicate infiltration, meaning the IV fluid is not
infusing into the vein but into the surrounding tissue. The IV should be discontinued and
restarted in a different location to prevent further complications.
2. A nurse is caring for a client who is 6 hours postoperative following a cholecystectomy. The
client is complaining of severe pain at the surgical site. What is the nurse's first action?
A) Administer prescribed pain medication.
B) Assess the client’s vital signs for signs of infection.
C) Reposition the client to promote comfort.
D) Notify the healthcare provider about the pain.
Answer: A) Administer prescribed pain medication.
Rationale: Pain management is a priority after surgery. Administering prescribed pain
medication is the nurse’s first action to alleviate the client’s discomfort.
3. A nurse is educating a client on how to properly take their prescribed medication. Which of
the following statements indicates that the client understands the teaching?
A) "I will take my medication with food to prevent nausea."
B) "I will take two doses if I miss one dose."
C) "I will take my medication every other day for convenience."
D) "I will stop taking my medication if I feel better."
,Answer: A) "I will take my medication with food to prevent nausea."
Rationale: Many medications should be taken with food to reduce the risk of gastrointestinal
upset. It is important to adhere to the prescribed schedule and dosage.
4. A client with a history of asthma presents to the emergency department with shortness of
breath and wheezing. The nurse should administer which medication first?
A) Prednisone (a corticosteroid)
B) Albuterol (a beta-agonist)
C) Salmeterol (a long-acting beta-agonist)
D) Ipratropium (an anticholinergic agent)
Answer: B) Albuterol (a beta-agonist)
Rationale: Albuterol is a short-acting beta-agonist that works quickly to open the airways during
an asthma exacerbation. It is the first choice to relieve acute symptoms like shortness of breath
and wheezing.
5. A nurse is caring for a client receiving heparin therapy. The client’s latest lab results show an
activated partial thromboplastin time (aPTT) of 100 seconds. What action should the nurse take?
A) Continue administering the heparin as prescribed.
B) Discontinue the heparin and notify the healthcare provider.
C) Administer vitamin K to reverse the effect of heparin.
D) Reduce the heparin dose by half.
Answer: B) Discontinue the heparin and notify the healthcare provider.
Rationale: An aPTT of 100 seconds is significantly elevated, indicating a risk for bleeding. The
nurse should discontinue the heparin and notify the healthcare provider to assess the situation
and adjust the treatment plan.
6. A client with congestive heart failure (CHF) is receiving a diuretic. The nurse monitors for
which of the following potential complications?
A) Hyperkalemia
B) Hypertension
C) Hypokalemia
D) Hyperglycemia
,Answer: C) Hypokalemia
Rationale: Diuretics can lead to potassium loss, which can result in hypokalemia. The nurse
should monitor the client’s potassium levels and watch for signs of potassium imbalance.
7. A nurse is caring for a client with diabetes mellitus who is scheduled for a fasting blood
glucose test. Which instruction is appropriate for the nurse to provide?
A) "You should eat a light breakfast before the test."
B) "You can drink water up to 1 hour before the test."
C) "You should refrain from taking your insulin before the test."
D) "You must fast for 12 hours before the test."
Answer: B) "You can drink water up to 1 hour before the test."
Rationale: Fasting blood glucose tests require the client to fast for 8-12 hours, but they can drink
water. Insulin should typically be withheld until after the test unless instructed otherwise by the
healthcare provider.
8. A nurse is caring for a client who is 1 day postoperative following a total hip replacement. The
client is complaining of nausea and vomiting. What should the nurse do first?
A) Administer antiemetic medication.
B) Assess the client’s bowel sounds.
C) Ask the client if they are experiencing pain.
D) Encourage the client to drink clear fluids.
Answer: C) Ask the client if they are experiencing pain.
Rationale: Nausea and vomiting after surgery may be related to pain. The nurse should assess
pain first, as effective pain management could reduce the symptoms of nausea and vomiting.
9. A nurse is teaching a client about the side effects of a new prescription for an antihypertensive
medication. The nurse should include which of the following as a common side effect?
A) Insomnia
B) Dizziness
C) Increased appetite
D) Tremors
, Answer: B) Dizziness
Rationale: Dizziness is a common side effect of antihypertensive medications due to their effect
on blood pressure. Clients should be cautioned to rise slowly from a sitting or lying position to
prevent falls.
10. A nurse is caring for a client with a history of chronic obstructive pulmonary disease
(COPD). The nurse should be concerned if the client has which of the following lab results?
A) Decreased hemoglobin and hematocrit levels
B) Elevated white blood cell count
C) Increased potassium levels
D) Decreased carbon dioxide (CO2) levels
Answer: B) Elevated white blood cell count
Rationale: An elevated white blood cell count can indicate infection, which is a common
concern for clients with COPD due to their compromised respiratory function. Prompt
assessment and intervention are necessary.
11. A nurse is caring for a client who is receiving a blood transfusion. During the transfusion, the
client reports chills and back pain. What is the nurse's first action?
A) Continue the transfusion and monitor the client.
B) Discontinue the transfusion and notify the healthcare provider.
C) Administer acetaminophen for the chills.
D) Slow the infusion rate and notify the blood bank.
Answer: B) Discontinue the transfusion and notify the healthcare provider.
Rationale: Chills and back pain during a blood transfusion may indicate a transfusion reaction.
The nurse should immediately stop the transfusion, notify the healthcare provider, and follow
hospital protocols for managing transfusion reactions.
12. A client with a new diagnosis of type 2 diabetes mellitus is being discharged. The nurse
should include which of the following in the discharge teaching?
A) "You should monitor your blood glucose daily."
B) "You can eat a large amount of sugar as long as you take insulin."
