NCLEX Question Bank with Rationales 2025
Study online at https://quizlet.com/_eklwbj
A nurse is planning care for a patient with
anorexia nervosa. Which goal is most
appropriate for the initial plan of care?
A) The patient will express satisfaction
with body image within one week.
B) The patient will engage in social activ-
ities with peers during meal times.
C) The patient will independently plan
and prepare all meals.
D) The patient will gain a specified
amount of weight each week as agreed
upon by the healthcare team.
After a transfusion, the body reacts by
destroying the transfused red blood cells.
What is this reaction? C) Hemolytic
RATIONALE: A hemolytic reaction oc-
A) Rh negative curs when the body destroys transfused
B) antihistamine red blood cells.
C) hemolytic
D) antibody
The nurse prepares to perform the initial
assessment on a school-age client. The
client has an open wound infected with B. Wear gown and gloves.
methicillin-resistant Staphylococcus au- RATIONALE: MRSA requires contact
reus (MRSA). Which precaution will the precautions. The nurse should wear
nurse take? clean, nonsterile gloves and gown when
entering the client?s room and when
A. Wear gloves only. having any contact with the client or with
B. Wear gown and gloves. surfaces that the client touches.
C. Wear gown, gloves, and mask.
D. No precautions are necessary.
D) A client diagnosed with a C6 spinal
The nurse has four phone messages.
cord injury and reporting a headache.
Which message does the nurse return
RATIONALE:
first?
A severe headache is indicative of auto-
nomic dysreflexia in the client who has
A) An older adult client undergoing bow-
sustained a high-level spinal cord in-
, NCLEX Question Bank with Rationales 2025
Study online at https://quizlet.com/_eklwbj
jury. Autonomic dysreflexia is associated
el prep and reporting watery diarrhea.
with a dangerously high blood pressure,
B) A client with a newborn and experi-
and, if untreated, can result in intracra-
encing breast engorgement.
nial bleeding and death. This client is
C) A client who had a cataract extraction
the most unstable and is experiencing
3 days ago and reporting nausea.
a potentially life-threatening issue that
D) A client diagnosed with a C6 spinal
needs to be addressed immediately by
cord injury and reporting a headache.
the nurse.
The adult grandchild of a client diag-
nosed with Parkinson disease tells the C) Warming tray for food
nurse about proposed gift ideas for the RATIONALE: Warming trays can keep
grandparent's birthday in 2 weeks. The food hot, safe, and appealing during the
grandchild asks the nurse which idea is slow eating process of the client di-
best. Which option is the best gift for the agnosed with Parkinson disease. Eat-
nurse to recommend? ing is slow because of overall slowed
body movement, tremors, difficulty chew-
A)Perfume and makeup. ing and swallowing, fatigue, and need
B)Hearing aid with batteries. for rest periods. This choice directly ad-
C)Warming tray for food. dresses a physiologic need.
D)Quilt and soft pillow.
The nurse in the pediatric clinic instructs
the parent of a preschool client diag-
nosed with asthma about preventative
A."My child likes sleeping on the top bunk
care. Which statement by the parent in-
when visiting grandparents."
dicates to the nurse that further teaching
RATIONALE:
is necessary?
Dust mites are a trigger for asthma. Fab-
ric from bedding on the upper bunk can
A. "My child likes sleeping on the top
harbor dust mites. The child is not to
bunk when visiting grandparents."
sleep or lie down on upholstered furni-
B. "My child sleeps on a zippered cov-
ture. Use furniture that can be wiped with
ered pillow and mattress."
a damp cloth such as wood, plastic, vinyl,
C. "My child changes his clothes after
or leather.
playing outside."
D. "My child wears a mask while I vacu-
um the carpets."
The home care nurse evaluates a client
diagnosed with tuberculosis and re-
ceiving isoniazid, rifampin, and pyrazi-
namide. Which client statement requires
further assessment by the nurse?
A) "I have gained 5 pounds since I start-
ed taking the medication."
, NCLEX Question Bank with Rationales 2025
Study online at https://quizlet.com/_eklwbj
C) "I drink a glass of wine with dinner
each night."
RATIONALE:
An adverse reaction of isoniazid is he-
patitis. Instruct a client to avoid ingesting
alcohol when taking the medication.
RATIONALE FOR INCORRECT AN-
SWERS:
"I have gained 5 pounds since I started
taking the medication."
Weight loss is a symptom of TB. Gaining
weight indicates the client is able to eat
and is having minimal GI upset due to the
medications.
"I cover my nose and mouth when I
cough or sneeze."
Covering the mouth and nose when
coughing or sneezing is good hygiene
and prevents the spread of disease.
"I have stopped eating tuna salad sand-
wiches."
A client taking these medications should
avoid tuna, aged cheese, red wine, and
yeast extracts, as they may cause the
adverse effects of flushing, hypotension,
palpitations, and diaphoresis.
B) Charred, waxy, white appearance of
skin on the left leg.
RATIONALE:
This describes a full-thickness burn. All
the skin is destroyed and the muscle and
bone may be involved. The substance
that remains is called eschar and is dry
to the touch. Full-thickness burns do not
, NCLEX Question Bank with Rationales 2025
Study online at https://quizlet.com/_eklwbj
heal spontaneously and require grafting.
All functions of the skin are lost.
RATIONALE FOR INCORRECT AN-
SWERS:
The nurse in the emergency department
assesses a client diagnosed with burns.
A) This describes a partial-thickness
Which observation most concerns the
burn. Only part of the skin is damaged
nurse?
or destroyed. Large, thick-walled blisters
develop, and the underlying tissue is
A) Redness and swelling with fluid-filled
deep red and appears wet and shiny. The
vesicles noted on right arm.
damaged skin is painful with increased
B) Charred, waxy, white appearance of
sensitivity to heat. Healing occurs by
skin on the left leg.
evolution of undamaged basal cells and
C) Reddened blotchy painful areas noted
takes about 21 to 22 days.
on the trunk.
C) This describes a superficial burn. The
D) Blistering and blanching of the skin
skin appears pink and has increased
noted on the back.
sensitivity to heat. Healing occurs with-
out treatment.
D)This describes a partial-thickness
burn.
The nurse providing care for clients with
diabetes mellitus receives report. Which
B) A client with a BP of 90/60 mm Hg and
client does the nurse see first?
whose skin is hot and dry to touch.
A) A female client who reports urinary
RATIONALE:
frequency and burning with urination.
The lower blood pressure and hot, dry
B) A client with a BP of 90/60 mm Hg and
skin indicate dehydration caused by hy-
whose skin is hot and dry to touch.
perglycemia. This is the first stage of dia-
C) A client with a BP of 120/50 mm Hg
betic ketoacidosis (DKA). This client has
and who reports frequent urination and
a circulatory concern and is the highest
thirst.
priority.
D) A client who reports experiencing
constant hunger.
The nurse reviews telephone messages
in the pediatric clinic. Which message
D) Parent states that the umbilical cord
will the nurse return first?
stump of a 5-day-old client is moist at the
A) Parent states the extremities of a
base and slightly red.
2-day-old client extend and return to
the previous position when the crib is
Study online at https://quizlet.com/_eklwbj
A nurse is planning care for a patient with
anorexia nervosa. Which goal is most
appropriate for the initial plan of care?
A) The patient will express satisfaction
with body image within one week.
B) The patient will engage in social activ-
ities with peers during meal times.
C) The patient will independently plan
and prepare all meals.
D) The patient will gain a specified
amount of weight each week as agreed
upon by the healthcare team.
After a transfusion, the body reacts by
destroying the transfused red blood cells.
What is this reaction? C) Hemolytic
RATIONALE: A hemolytic reaction oc-
A) Rh negative curs when the body destroys transfused
B) antihistamine red blood cells.
C) hemolytic
D) antibody
The nurse prepares to perform the initial
assessment on a school-age client. The
client has an open wound infected with B. Wear gown and gloves.
methicillin-resistant Staphylococcus au- RATIONALE: MRSA requires contact
reus (MRSA). Which precaution will the precautions. The nurse should wear
nurse take? clean, nonsterile gloves and gown when
entering the client?s room and when
A. Wear gloves only. having any contact with the client or with
B. Wear gown and gloves. surfaces that the client touches.
C. Wear gown, gloves, and mask.
D. No precautions are necessary.
D) A client diagnosed with a C6 spinal
The nurse has four phone messages.
cord injury and reporting a headache.
Which message does the nurse return
RATIONALE:
first?
A severe headache is indicative of auto-
nomic dysreflexia in the client who has
A) An older adult client undergoing bow-
sustained a high-level spinal cord in-
, NCLEX Question Bank with Rationales 2025
Study online at https://quizlet.com/_eklwbj
jury. Autonomic dysreflexia is associated
el prep and reporting watery diarrhea.
with a dangerously high blood pressure,
B) A client with a newborn and experi-
and, if untreated, can result in intracra-
encing breast engorgement.
nial bleeding and death. This client is
C) A client who had a cataract extraction
the most unstable and is experiencing
3 days ago and reporting nausea.
a potentially life-threatening issue that
D) A client diagnosed with a C6 spinal
needs to be addressed immediately by
cord injury and reporting a headache.
the nurse.
The adult grandchild of a client diag-
nosed with Parkinson disease tells the C) Warming tray for food
nurse about proposed gift ideas for the RATIONALE: Warming trays can keep
grandparent's birthday in 2 weeks. The food hot, safe, and appealing during the
grandchild asks the nurse which idea is slow eating process of the client di-
best. Which option is the best gift for the agnosed with Parkinson disease. Eat-
nurse to recommend? ing is slow because of overall slowed
body movement, tremors, difficulty chew-
A)Perfume and makeup. ing and swallowing, fatigue, and need
B)Hearing aid with batteries. for rest periods. This choice directly ad-
C)Warming tray for food. dresses a physiologic need.
D)Quilt and soft pillow.
The nurse in the pediatric clinic instructs
the parent of a preschool client diag-
nosed with asthma about preventative
A."My child likes sleeping on the top bunk
care. Which statement by the parent in-
when visiting grandparents."
dicates to the nurse that further teaching
RATIONALE:
is necessary?
Dust mites are a trigger for asthma. Fab-
ric from bedding on the upper bunk can
A. "My child likes sleeping on the top
harbor dust mites. The child is not to
bunk when visiting grandparents."
sleep or lie down on upholstered furni-
B. "My child sleeps on a zippered cov-
ture. Use furniture that can be wiped with
ered pillow and mattress."
a damp cloth such as wood, plastic, vinyl,
C. "My child changes his clothes after
or leather.
playing outside."
D. "My child wears a mask while I vacu-
um the carpets."
The home care nurse evaluates a client
diagnosed with tuberculosis and re-
ceiving isoniazid, rifampin, and pyrazi-
namide. Which client statement requires
further assessment by the nurse?
A) "I have gained 5 pounds since I start-
ed taking the medication."
, NCLEX Question Bank with Rationales 2025
Study online at https://quizlet.com/_eklwbj
C) "I drink a glass of wine with dinner
each night."
RATIONALE:
An adverse reaction of isoniazid is he-
patitis. Instruct a client to avoid ingesting
alcohol when taking the medication.
RATIONALE FOR INCORRECT AN-
SWERS:
"I have gained 5 pounds since I started
taking the medication."
Weight loss is a symptom of TB. Gaining
weight indicates the client is able to eat
and is having minimal GI upset due to the
medications.
"I cover my nose and mouth when I
cough or sneeze."
Covering the mouth and nose when
coughing or sneezing is good hygiene
and prevents the spread of disease.
"I have stopped eating tuna salad sand-
wiches."
A client taking these medications should
avoid tuna, aged cheese, red wine, and
yeast extracts, as they may cause the
adverse effects of flushing, hypotension,
palpitations, and diaphoresis.
B) Charred, waxy, white appearance of
skin on the left leg.
RATIONALE:
This describes a full-thickness burn. All
the skin is destroyed and the muscle and
bone may be involved. The substance
that remains is called eschar and is dry
to the touch. Full-thickness burns do not
, NCLEX Question Bank with Rationales 2025
Study online at https://quizlet.com/_eklwbj
heal spontaneously and require grafting.
All functions of the skin are lost.
RATIONALE FOR INCORRECT AN-
SWERS:
The nurse in the emergency department
assesses a client diagnosed with burns.
A) This describes a partial-thickness
Which observation most concerns the
burn. Only part of the skin is damaged
nurse?
or destroyed. Large, thick-walled blisters
develop, and the underlying tissue is
A) Redness and swelling with fluid-filled
deep red and appears wet and shiny. The
vesicles noted on right arm.
damaged skin is painful with increased
B) Charred, waxy, white appearance of
sensitivity to heat. Healing occurs by
skin on the left leg.
evolution of undamaged basal cells and
C) Reddened blotchy painful areas noted
takes about 21 to 22 days.
on the trunk.
C) This describes a superficial burn. The
D) Blistering and blanching of the skin
skin appears pink and has increased
noted on the back.
sensitivity to heat. Healing occurs with-
out treatment.
D)This describes a partial-thickness
burn.
The nurse providing care for clients with
diabetes mellitus receives report. Which
B) A client with a BP of 90/60 mm Hg and
client does the nurse see first?
whose skin is hot and dry to touch.
A) A female client who reports urinary
RATIONALE:
frequency and burning with urination.
The lower blood pressure and hot, dry
B) A client with a BP of 90/60 mm Hg and
skin indicate dehydration caused by hy-
whose skin is hot and dry to touch.
perglycemia. This is the first stage of dia-
C) A client with a BP of 120/50 mm Hg
betic ketoacidosis (DKA). This client has
and who reports frequent urination and
a circulatory concern and is the highest
thirst.
priority.
D) A client who reports experiencing
constant hunger.
The nurse reviews telephone messages
in the pediatric clinic. Which message
D) Parent states that the umbilical cord
will the nurse return first?
stump of a 5-day-old client is moist at the
A) Parent states the extremities of a
base and slightly red.
2-day-old client extend and return to
the previous position when the crib is
