NCLEX-RN Practice Questions and
Answers Latest and Updates 2025
What is the infusion pump setting in mL/hr for heparin sodium at
1200 units per hour from a bag labeled 'Heparin sodium 20,000
units in 250 mL D5W'?
15 mL/hr
Which client should the nurse assess initially? A client on bed rest
with swelling, a client complaining about a late breakfast tray, a
client with pneumonia and bilateral crackles, or a client with a
urinary tract infection and urgency?
A client diagnosed with pneumonia who has bilateral crackles on an exam.
What is the most appropriate initial nursing intervention for a client
experiencing pruritus and restlessness ten minutes after starting a
blood transfusion?
Stop the transfusion at the hub.
Which interventions are appropriate when caring for a client in
disseminated intravascular coagulation (DIC)? (Select all that apply)
Monitor dressings and output for signs of bleeding; Measure abdominal girth
and increased output on dressing at least each shift.
Which finding would NOT lead the nurse to suspect a client is
developing disseminated intravascular coagulation (DIC) after
cesarean delivery?
Temperature of 101 degrees Fahrenheit.
What precautions should a nurse initiate for a school-age child with
leukemia and a platelet count of 40,000/mm3?
Implement bleeding precautions.
When a client diagnosed with deep vein thrombosis complains of
pain and swelling in the legs, what should be the first nursing
intervention?
Elevate the foot of the bed.
,How can the risk of HIV transmission and transfusion reaction be
reduced for a client scheduled for elective surgery?
Autologous blood donation prior to surgery.
What is the most appropriate action for a nurse administering
packed red cells to a client currently receiving lactated Ringer's
solution?
Discontinue the lactated Ringer's solution and start an infusion of 0.9% NaCl
to run with the packed cells.
How many milliliters of heparin should an older adult client receive
if prescribed 5,000 units subcutaneously twice a day, with the
available dose being 20,000 units per 1 mL?
0.25 mL.
What drug should a nurse administer immediately in case of a
serious bleeding reaction for a client receiving a heparin infusion?
Protamine sulfate.
Which laboratory parameters should be monitored for a client
taking warfarin (Coumadin)?
PT (Prothrombin Time).
If a client is instructed to increase his warfarin dose from 5 mg to
7.5 mg and only has 5 mg tablets, how many tablets should he take?
1.5 tablets.
What intervention should a nurse take for a client in a sickle cell
pain crisis who reports severe pain but appears comfortable?
Contact the healthcare provider to request a prescription for patient-
controlled analgesia with a higher dose of morphine.
What is the antidote for heparin in case a client begins to
hemorrhage?
Protamine sulfate.
What should a nurse instruct a client undergoing a percutaneous
liver biopsy to do during the procedure?
Instruct the client to take a deep breath and hold it.
, What is the appropriate action for a nurse if a client is receiving
heparin for DVT prophylaxis and begins to hemorrhage?
Administer Protamine sulfate as the antidote.
What is the significance of monitoring PT for a client on warfarin?
PT indicates the effectiveness of warfarin therapy and helps prevent
complications.
What is the recommended IV solution to use with packed red blood
cells?
0.9% NaCl.
What should the nurse do after a client undergoes a liver biopsy?
Obtain clotting studies post-procedure.
What is the maximum dose of morphine sulfate prescribed for a
client in a sickle cell pain crisis?
The specific dose is not provided, but it is given every 4 hours as needed.
What should a nurse do if a client taking warfarin has a change in
dosage?
Instruct the client on how to take the correct number of tablets to match the
new dosage.
What is the role of fresh frozen plasma in heparin therapy?
It can be used to manage bleeding, but Protamine sulfate is the specific
antidote.
What is the importance of monitoring INR in clients on
anticoagulants?
INR helps assess the anticoagulation level and prevent thromboembolic
events.
What is the risk associated with administering morphine to a client
who appears comfortable but reports severe pain?
Potential under-treatment of pain and risk of addiction if not managed
properly.
What should be done if a client receiving heparin experiences signs
of bleeding?
Assess the client and prepare to administer Protamine sulfate.
Answers Latest and Updates 2025
What is the infusion pump setting in mL/hr for heparin sodium at
1200 units per hour from a bag labeled 'Heparin sodium 20,000
units in 250 mL D5W'?
15 mL/hr
Which client should the nurse assess initially? A client on bed rest
with swelling, a client complaining about a late breakfast tray, a
client with pneumonia and bilateral crackles, or a client with a
urinary tract infection and urgency?
A client diagnosed with pneumonia who has bilateral crackles on an exam.
What is the most appropriate initial nursing intervention for a client
experiencing pruritus and restlessness ten minutes after starting a
blood transfusion?
Stop the transfusion at the hub.
Which interventions are appropriate when caring for a client in
disseminated intravascular coagulation (DIC)? (Select all that apply)
Monitor dressings and output for signs of bleeding; Measure abdominal girth
and increased output on dressing at least each shift.
Which finding would NOT lead the nurse to suspect a client is
developing disseminated intravascular coagulation (DIC) after
cesarean delivery?
Temperature of 101 degrees Fahrenheit.
What precautions should a nurse initiate for a school-age child with
leukemia and a platelet count of 40,000/mm3?
Implement bleeding precautions.
When a client diagnosed with deep vein thrombosis complains of
pain and swelling in the legs, what should be the first nursing
intervention?
Elevate the foot of the bed.
,How can the risk of HIV transmission and transfusion reaction be
reduced for a client scheduled for elective surgery?
Autologous blood donation prior to surgery.
What is the most appropriate action for a nurse administering
packed red cells to a client currently receiving lactated Ringer's
solution?
Discontinue the lactated Ringer's solution and start an infusion of 0.9% NaCl
to run with the packed cells.
How many milliliters of heparin should an older adult client receive
if prescribed 5,000 units subcutaneously twice a day, with the
available dose being 20,000 units per 1 mL?
0.25 mL.
What drug should a nurse administer immediately in case of a
serious bleeding reaction for a client receiving a heparin infusion?
Protamine sulfate.
Which laboratory parameters should be monitored for a client
taking warfarin (Coumadin)?
PT (Prothrombin Time).
If a client is instructed to increase his warfarin dose from 5 mg to
7.5 mg and only has 5 mg tablets, how many tablets should he take?
1.5 tablets.
What intervention should a nurse take for a client in a sickle cell
pain crisis who reports severe pain but appears comfortable?
Contact the healthcare provider to request a prescription for patient-
controlled analgesia with a higher dose of morphine.
What is the antidote for heparin in case a client begins to
hemorrhage?
Protamine sulfate.
What should a nurse instruct a client undergoing a percutaneous
liver biopsy to do during the procedure?
Instruct the client to take a deep breath and hold it.
, What is the appropriate action for a nurse if a client is receiving
heparin for DVT prophylaxis and begins to hemorrhage?
Administer Protamine sulfate as the antidote.
What is the significance of monitoring PT for a client on warfarin?
PT indicates the effectiveness of warfarin therapy and helps prevent
complications.
What is the recommended IV solution to use with packed red blood
cells?
0.9% NaCl.
What should the nurse do after a client undergoes a liver biopsy?
Obtain clotting studies post-procedure.
What is the maximum dose of morphine sulfate prescribed for a
client in a sickle cell pain crisis?
The specific dose is not provided, but it is given every 4 hours as needed.
What should a nurse do if a client taking warfarin has a change in
dosage?
Instruct the client on how to take the correct number of tablets to match the
new dosage.
What is the role of fresh frozen plasma in heparin therapy?
It can be used to manage bleeding, but Protamine sulfate is the specific
antidote.
What is the importance of monitoring INR in clients on
anticoagulants?
INR helps assess the anticoagulation level and prevent thromboembolic
events.
What is the risk associated with administering morphine to a client
who appears comfortable but reports severe pain?
Potential under-treatment of pain and risk of addiction if not managed
properly.
What should be done if a client receiving heparin experiences signs
of bleeding?
Assess the client and prepare to administer Protamine sulfate.
