NCLEX-RN 2025 Exam
Comprehensive Review
,1 A client is prescribed metoprolol for hypertension. Which assessment finding should the nurse
report immediately?
a) Heart rate 52 bpm
b) Blood pressure 128/78 mmHg
c) Respiratory rate 16 breaths/min
d) Temperature 98.6°F
Answer: a) Heart rate 52 bpm
Rationale: Bradycardia is a common side effect of beta-blockers and should be reported
immediately.
2 A nurse is caring for a client with pneumonia. Which intervention is most appropriate to
prevent aspiration?
a) Encourage the client to lie flat
b) Elevate the head of the bed 30 degrees
c) Restrict oral fluids
d) Administer sedatives as needed
Answer: b) Elevate the head of the bed 30 degrees
Rationale: Elevating the head of the bed reduces the risk of aspiration.
3 Which action should the nurse take first when a client experiences a seizure?
a) Restrain the client
b) Insert an oral airway
c) Protect the client’s head and airway
d) Administer PRN medications
Answer: c) Protect the client’s head and airway
Rationale: Protecting the client from injury and maintaining a patent airway are the first
priorities.
4 A client with diabetes mellitus reports blurred vision. Which action should the nurse take first?
a) Check blood glucose level
b) Administer insulin
c) Notify the physician
d) Provide a snack
Answer: a) Check blood glucose level
Rationale: Blurred vision in a diabetic client may indicate hyperglycemia or hypoglycemia;
checking blood glucose is the first step.
, 5 Which client should the nurse assess first?
a) A client with mild abdominal pain
b) A client with a new onset of confusion
c) A client requesting pain medication
d) A client with a stable blood pressure
Answer: b) A client with a new onset of confusion
Rationale: New confusion is a priority as it may indicate a serious underlying condition.
6 A nurse is preparing to administer a blood transfusion. Which action is most important before
starting the transfusion?
a) Check the client’s identification and blood compatibility
b) Administer premedication
c) Document the procedure
d) Inform the family
Answer: a) Check the client’s identification and blood compatibility
Rationale: Ensuring correct client and blood product is critical to prevent transfusion reactions.
7 A client is receiving IV potassium. The nurse notes the IV site is red and swollen. What should
the nurse do first?
a) Slow the infusion rate
b) Discontinue the IV and restart in another site
c) Apply a warm compress
d) Notify the physician
Answer: b) Discontinue the IV and restart in another site
Rationale: Redness and swelling indicate infiltration or irritation; the IV should be discontinued.
8 A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via
nasal cannula. The nurse should monitor for which complication?
a) Hyperventilation
b) Oxygen toxicity
c) Respiratory acidosis
d) Oxygen-induced hypoventilation
Answer: d) Oxygen-induced hypoventilation
Rationale: Clients with COPD can develop hypoventilation if oxygen is administered at high
concentrations.
9 Which action is most important for preventing the spread of Clostridioides difficile (C. diff)?
a) Handwashing with soap and water
Comprehensive Review
,1 A client is prescribed metoprolol for hypertension. Which assessment finding should the nurse
report immediately?
a) Heart rate 52 bpm
b) Blood pressure 128/78 mmHg
c) Respiratory rate 16 breaths/min
d) Temperature 98.6°F
Answer: a) Heart rate 52 bpm
Rationale: Bradycardia is a common side effect of beta-blockers and should be reported
immediately.
2 A nurse is caring for a client with pneumonia. Which intervention is most appropriate to
prevent aspiration?
a) Encourage the client to lie flat
b) Elevate the head of the bed 30 degrees
c) Restrict oral fluids
d) Administer sedatives as needed
Answer: b) Elevate the head of the bed 30 degrees
Rationale: Elevating the head of the bed reduces the risk of aspiration.
3 Which action should the nurse take first when a client experiences a seizure?
a) Restrain the client
b) Insert an oral airway
c) Protect the client’s head and airway
d) Administer PRN medications
Answer: c) Protect the client’s head and airway
Rationale: Protecting the client from injury and maintaining a patent airway are the first
priorities.
4 A client with diabetes mellitus reports blurred vision. Which action should the nurse take first?
a) Check blood glucose level
b) Administer insulin
c) Notify the physician
d) Provide a snack
Answer: a) Check blood glucose level
Rationale: Blurred vision in a diabetic client may indicate hyperglycemia or hypoglycemia;
checking blood glucose is the first step.
, 5 Which client should the nurse assess first?
a) A client with mild abdominal pain
b) A client with a new onset of confusion
c) A client requesting pain medication
d) A client with a stable blood pressure
Answer: b) A client with a new onset of confusion
Rationale: New confusion is a priority as it may indicate a serious underlying condition.
6 A nurse is preparing to administer a blood transfusion. Which action is most important before
starting the transfusion?
a) Check the client’s identification and blood compatibility
b) Administer premedication
c) Document the procedure
d) Inform the family
Answer: a) Check the client’s identification and blood compatibility
Rationale: Ensuring correct client and blood product is critical to prevent transfusion reactions.
7 A client is receiving IV potassium. The nurse notes the IV site is red and swollen. What should
the nurse do first?
a) Slow the infusion rate
b) Discontinue the IV and restart in another site
c) Apply a warm compress
d) Notify the physician
Answer: b) Discontinue the IV and restart in another site
Rationale: Redness and swelling indicate infiltration or irritation; the IV should be discontinued.
8 A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via
nasal cannula. The nurse should monitor for which complication?
a) Hyperventilation
b) Oxygen toxicity
c) Respiratory acidosis
d) Oxygen-induced hypoventilation
Answer: d) Oxygen-induced hypoventilation
Rationale: Clients with COPD can develop hypoventilation if oxygen is administered at high
concentrations.
9 Which action is most important for preventing the spread of Clostridioides difficile (C. diff)?
a) Handwashing with soap and water
