NCSBN TEST BANK - for the NCLEX-RN &
NCLEX-PN, Updated 2025, Complete
Questions & Answers, A+ Guide
Course
NCSBN
1. A client with heart failure is prescribed furosemide. Which finding should the nurse
report to the healthcare provider immediately?
A. Potassium level of 3.2 mEq/L
B. Blood pressure of 110/70 mmHg
C. Heart rate of 88 bpm
D. Urine output of 1000 mL in 8 hours
Answer: A
Rationale: Furosemide is a loop diuretic that causes potassium loss. A potassium level of 3.2
mEq/L indicates hypokalemia, which increases the risk of cardiac arrhythmias.
2. 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."
B. "I can reuse my syringe as long as I clean it."
C. "I’ll store unused insulin in the refrigerator."
D. "I’ll monitor my blood sugar before meals."
Answer: B
Rationale: Syringes should not be reused due to the risk of infection and reduced sterility. The
client requires further education.
3. A nurse is caring for a client who just had a thyroidectomy. Which assessment finding
requires immediate intervention?
A. Hoarse voice
B. Difficulty swallowing
C. Tingling around the mouth
D. Mild neck swelling
Answer: C
Rationale: Tingling around the mouth can indicate hypocalcemia, possibly from accidental
removal or damage to the parathyroid glands.
,4. A client with COPD is receiving oxygen via nasal cannula at 5 L/min. Which action
should the nurse take?
A. Continue the oxygen as ordered
B. Switch to a non-rebreather mask
C. Decrease the flow rate to 2 L/min
D. Notify the respiratory therapist
Answer: C
Rationale: High levels of oxygen in COPD patients can suppress the respiratory drive. Oxygen
should be administered cautiously (1–2 L/min).
5. The nurse is assessing a postpartum client. Which finding is most concerning?
A. Fundus firm and at the level of the umbilicus
B. Lochia rubra with small clots
C. Saturating a peripad in 15 minutes
D. Mild cramping during breastfeeding
Answer: C
Rationale: Saturating a peripad that quickly suggests hemorrhage, which requires immediate
intervention.
6. Which task can the nurse delegate to a UAP (Unlicensed Assistive Personnel)?
A. Administering enemas
B. Teaching insulin injection
C. Monitoring chest tube output
D. Assisting with ambulation
Answer: D
Rationale: UAPs can assist with activities of daily living like ambulation. Medication
administration and assessments are outside their scope.
7. A client receiving heparin has a platelet count of 90,000/µL. What is the priority nursing
action?
A. Continue the heparin
B. Notify the healthcare provider
C. Encourage fluid intake
D. Apply heat to injection sites
Answer: B
,Rationale: A drop in platelet count may indicate heparin-induced thrombocytopenia (HIT), a
potentially life-threatening condition.
8. The nurse is caring for a client with schizophrenia who reports hearing voices. What is
the best response?
A. “You need to ignore the voices.”
B. “I don’t hear anything, but I understand this is real to you.”
C. “Those voices aren't real, so don’t worry.”
D. “Why do you think you hear voices?”
Answer: B
Rationale: This response validates the client's feelings without reinforcing the hallucination,
maintaining therapeutic communication.
9. Which finding is expected in a client with Cushing’s syndrome?
A. Hypotension
B. Weight loss
C. Hyperglycemia
D. Hypokalemia
Answer: C
Rationale: Cushing’s syndrome involves excess cortisol, which raises blood glucose levels.
Hyperglycemia is a common finding.
10. A client with a history of seizure disorder is found unconscious. What is the nurse’s
first action?
A. Check for a medical alert bracelet
B. Turn the client to the side
C. Open the airway
D. Call the healthcare provider
Answer: B
Rationale: Positioning the client on their side prevents aspiration and is the immediate priority
during a post-seizure state.
11. A client is receiving morphine for post-op pain. Which assessment finding requires
immediate attention?
A. Nausea and vomiting
B. Respiratory rate of 8/min
, C. Itching at the IV site
D. Drowsiness
Answer: B
Rationale: Respiratory depression is a life-threatening adverse effect of opioids and must be
addressed immediately.
12. A nurse is reinforcing teaching about digoxin. Which statement by the client indicates a
need for further instruction?
A. “I will check my pulse before taking the medication.”
B. “If I miss a dose, I will double the next one.”
C. “I’ll report any visual changes to my doctor.”
D. “I need to take the medication at the same time each day.”
Answer: B
Rationale: Digoxin has a narrow therapeutic window. Doubling a dose can cause toxicity.
Missed doses should never be doubled.
13. A client with suspected meningitis undergoes a lumbar puncture. Which finding
requires immediate intervention?
A. Headache after the procedure
B. Clear cerebrospinal fluid
C. Positive Brudzinski’s sign
D. Nuchal rigidity
Answer: C
Rationale: A positive Brudzinski’s sign is consistent with meningitis, which is a medical
emergency and may require isolation and antibiotics.
14. A nurse is caring for a client with a NG tube set to low suction. The client becomes
nauseated. What is the nurse’s priority action?
A. Check for tube placement
B. Increase suction pressure
C. Give antiemetics
D. Flush the NG tube with 100 mL of water
Answer: A
Rationale: Tube displacement can prevent proper gastric decompression, leading to nausea.
Check placement first.
NCLEX-PN, Updated 2025, Complete
Questions & Answers, A+ Guide
Course
NCSBN
1. A client with heart failure is prescribed furosemide. Which finding should the nurse
report to the healthcare provider immediately?
A. Potassium level of 3.2 mEq/L
B. Blood pressure of 110/70 mmHg
C. Heart rate of 88 bpm
D. Urine output of 1000 mL in 8 hours
Answer: A
Rationale: Furosemide is a loop diuretic that causes potassium loss. A potassium level of 3.2
mEq/L indicates hypokalemia, which increases the risk of cardiac arrhythmias.
2. 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."
B. "I can reuse my syringe as long as I clean it."
C. "I’ll store unused insulin in the refrigerator."
D. "I’ll monitor my blood sugar before meals."
Answer: B
Rationale: Syringes should not be reused due to the risk of infection and reduced sterility. The
client requires further education.
3. A nurse is caring for a client who just had a thyroidectomy. Which assessment finding
requires immediate intervention?
A. Hoarse voice
B. Difficulty swallowing
C. Tingling around the mouth
D. Mild neck swelling
Answer: C
Rationale: Tingling around the mouth can indicate hypocalcemia, possibly from accidental
removal or damage to the parathyroid glands.
,4. A client with COPD is receiving oxygen via nasal cannula at 5 L/min. Which action
should the nurse take?
A. Continue the oxygen as ordered
B. Switch to a non-rebreather mask
C. Decrease the flow rate to 2 L/min
D. Notify the respiratory therapist
Answer: C
Rationale: High levels of oxygen in COPD patients can suppress the respiratory drive. Oxygen
should be administered cautiously (1–2 L/min).
5. The nurse is assessing a postpartum client. Which finding is most concerning?
A. Fundus firm and at the level of the umbilicus
B. Lochia rubra with small clots
C. Saturating a peripad in 15 minutes
D. Mild cramping during breastfeeding
Answer: C
Rationale: Saturating a peripad that quickly suggests hemorrhage, which requires immediate
intervention.
6. Which task can the nurse delegate to a UAP (Unlicensed Assistive Personnel)?
A. Administering enemas
B. Teaching insulin injection
C. Monitoring chest tube output
D. Assisting with ambulation
Answer: D
Rationale: UAPs can assist with activities of daily living like ambulation. Medication
administration and assessments are outside their scope.
7. A client receiving heparin has a platelet count of 90,000/µL. What is the priority nursing
action?
A. Continue the heparin
B. Notify the healthcare provider
C. Encourage fluid intake
D. Apply heat to injection sites
Answer: B
,Rationale: A drop in platelet count may indicate heparin-induced thrombocytopenia (HIT), a
potentially life-threatening condition.
8. The nurse is caring for a client with schizophrenia who reports hearing voices. What is
the best response?
A. “You need to ignore the voices.”
B. “I don’t hear anything, but I understand this is real to you.”
C. “Those voices aren't real, so don’t worry.”
D. “Why do you think you hear voices?”
Answer: B
Rationale: This response validates the client's feelings without reinforcing the hallucination,
maintaining therapeutic communication.
9. Which finding is expected in a client with Cushing’s syndrome?
A. Hypotension
B. Weight loss
C. Hyperglycemia
D. Hypokalemia
Answer: C
Rationale: Cushing’s syndrome involves excess cortisol, which raises blood glucose levels.
Hyperglycemia is a common finding.
10. A client with a history of seizure disorder is found unconscious. What is the nurse’s
first action?
A. Check for a medical alert bracelet
B. Turn the client to the side
C. Open the airway
D. Call the healthcare provider
Answer: B
Rationale: Positioning the client on their side prevents aspiration and is the immediate priority
during a post-seizure state.
11. A client is receiving morphine for post-op pain. Which assessment finding requires
immediate attention?
A. Nausea and vomiting
B. Respiratory rate of 8/min
, C. Itching at the IV site
D. Drowsiness
Answer: B
Rationale: Respiratory depression is a life-threatening adverse effect of opioids and must be
addressed immediately.
12. A nurse is reinforcing teaching about digoxin. Which statement by the client indicates a
need for further instruction?
A. “I will check my pulse before taking the medication.”
B. “If I miss a dose, I will double the next one.”
C. “I’ll report any visual changes to my doctor.”
D. “I need to take the medication at the same time each day.”
Answer: B
Rationale: Digoxin has a narrow therapeutic window. Doubling a dose can cause toxicity.
Missed doses should never be doubled.
13. A client with suspected meningitis undergoes a lumbar puncture. Which finding
requires immediate intervention?
A. Headache after the procedure
B. Clear cerebrospinal fluid
C. Positive Brudzinski’s sign
D. Nuchal rigidity
Answer: C
Rationale: A positive Brudzinski’s sign is consistent with meningitis, which is a medical
emergency and may require isolation and antibiotics.
14. A nurse is caring for a client with a NG tube set to low suction. The client becomes
nauseated. What is the nurse’s priority action?
A. Check for tube placement
B. Increase suction pressure
C. Give antiemetics
D. Flush the NG tube with 100 mL of water
Answer: A
Rationale: Tube displacement can prevent proper gastric decompression, leading to nausea.
Check placement first.
