1
Kaplan NCLEX-RN QBank 2025 | 140 Verified Real
Questions & Answers | NGN Style | A+ Guaranteed Pass
Study Pack
1. A nurse is caring for a client with heart failure who is receiving furosemide.
Which assessment finding requires immediate action?
A. Weight loss of 2 pounds in 2 days
B. Mild leg cramps
C. Serum potassium of 2.9 mEq/L
D. Increased urine output
Correct Answer: C
Rationale: A potassium level of 2.9 mEq/L indicates hypokalemia, which can lead
to serious cardiac arrhythmias. This is a priority finding requiring prompt
intervention.
2. A client is admitted with Clostridium difficile infection. What is the appropriate
infection control precaution?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Neutropenic precautions
Correct Answer: B
, 2
Rationale: C. difficile is transmitted via contact with contaminated surfaces.
Contact precautions, including gown and gloves, are essential.
3. A client with pneumonia is prescribed IV antibiotics. The nurse notes the client
has a penicillin allergy. What is the nurse’s priority action?
A. Notify the healthcare provider immediately
B. Hold the medication for 12 hours
C. Administer the drug with an antihistamine
D. Document the allergy in the chart only
Correct Answer: A
Rationale: The nurse must notify the provider to prescribe an alternative antibiotic.
Administering the drug could cause anaphylaxis.
4. A nurse is caring for a client with cirrhosis. Which finding requires immediate
intervention?
A. Ankle edema
B. Mild confusion
C. Loss of appetite
D. Asterixis
Correct Answer: D
Rationale: Asterixis (flapping tremor) is a sign of hepatic encephalopathy, a
potentially life-threatening complication.
5. Which nursing action is most appropriate when caring for a client with an
indwelling urinary catheter?
A. Cleanse the catheter tubing daily
B. Flush the catheter with saline every shift
C. Maintain the drainage bag below bladder level
D. Clamp the catheter when the client ambulates
Correct Answer: C
Rationale: Keeping the drainage bag below bladder level prevents backflow and
reduces infection risk.
, 3
6. A nurse prepares to administer digoxin to a pediatric client. Which finding
requires withholding the medication?
A. Apical heart rate of 110 bpm
B. Apical heart rate of 60 bpm
C. BP of 92/60 mm Hg
D. Slight nausea
Correct Answer: B
Rationale: In children, digoxin is held if the apical pulse is below 90–110 bpm
depending on age. A rate of 60 bpm is dangerously low.
7. A client with chronic kidney disease reports muscle weakness and irregular
heartbeat. Which lab value is most concerning?
A. Sodium 138 mEq/L
B. Potassium 6.2 mEq/L
C. Magnesium 1.9 mg/dL
D. Calcium 8.9 mg/dL
Correct Answer: B
Rationale: Hyperkalemia can lead to cardiac dysrhythmias and muscle weakness,
especially in CKD patients.
8. The nurse is caring for a client receiving vancomycin IV. Which assessment is
most important?
A. Blood pressure
B. Trough vancomycin level
C. Respiratory rate
D. Bowel sounds
Correct Answer: B
Rationale: Monitoring trough levels ensures the drug stays within the therapeutic
range and prevents nephrotoxicity and ototoxicity.
, 4
9. A client with schizophrenia reports hearing voices telling them to hurt others.
What is the nurse’s priority?
A. Ask the client what the voices are saying
B. Ensure the safety of the client and others
C. Explain that the voices are not real
D. Administer PRN antipsychotic medication
Correct Answer: B
Rationale: Safety is the priority when a client is experiencing command
hallucinations.
10. A client with COPD is receiving oxygen via nasal cannula at 5 L/min. Which
action should the nurse take?
A. Continue oxygen as ordered
B. Reduce oxygen to 2 L/min
C. Change to a non-rebreather mask
D. Elevate the client’s legs
Correct Answer: B
Rationale: High-flow oxygen can suppress the hypoxic drive in COPD clients.
Oxygen should typically be administered at 1–2 L/min.
11. A nurse assesses a client who suddenly becomes confused and restless post-op.
What is the most likely cause?
A. Anxiety
B. Sleep deprivation
C. Hypoxia
D. Medication side effect
Correct Answer: C
Rationale: Sudden confusion and restlessness are early signs of hypoxia, especially
after surgery.
12. The nurse is teaching a client with a new colostomy. Which client statement
indicates understanding?
Kaplan NCLEX-RN QBank 2025 | 140 Verified Real
Questions & Answers | NGN Style | A+ Guaranteed Pass
Study Pack
1. A nurse is caring for a client with heart failure who is receiving furosemide.
Which assessment finding requires immediate action?
A. Weight loss of 2 pounds in 2 days
B. Mild leg cramps
C. Serum potassium of 2.9 mEq/L
D. Increased urine output
Correct Answer: C
Rationale: A potassium level of 2.9 mEq/L indicates hypokalemia, which can lead
to serious cardiac arrhythmias. This is a priority finding requiring prompt
intervention.
2. A client is admitted with Clostridium difficile infection. What is the appropriate
infection control precaution?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Neutropenic precautions
Correct Answer: B
, 2
Rationale: C. difficile is transmitted via contact with contaminated surfaces.
Contact precautions, including gown and gloves, are essential.
3. A client with pneumonia is prescribed IV antibiotics. The nurse notes the client
has a penicillin allergy. What is the nurse’s priority action?
A. Notify the healthcare provider immediately
B. Hold the medication for 12 hours
C. Administer the drug with an antihistamine
D. Document the allergy in the chart only
Correct Answer: A
Rationale: The nurse must notify the provider to prescribe an alternative antibiotic.
Administering the drug could cause anaphylaxis.
4. A nurse is caring for a client with cirrhosis. Which finding requires immediate
intervention?
A. Ankle edema
B. Mild confusion
C. Loss of appetite
D. Asterixis
Correct Answer: D
Rationale: Asterixis (flapping tremor) is a sign of hepatic encephalopathy, a
potentially life-threatening complication.
5. Which nursing action is most appropriate when caring for a client with an
indwelling urinary catheter?
A. Cleanse the catheter tubing daily
B. Flush the catheter with saline every shift
C. Maintain the drainage bag below bladder level
D. Clamp the catheter when the client ambulates
Correct Answer: C
Rationale: Keeping the drainage bag below bladder level prevents backflow and
reduces infection risk.
, 3
6. A nurse prepares to administer digoxin to a pediatric client. Which finding
requires withholding the medication?
A. Apical heart rate of 110 bpm
B. Apical heart rate of 60 bpm
C. BP of 92/60 mm Hg
D. Slight nausea
Correct Answer: B
Rationale: In children, digoxin is held if the apical pulse is below 90–110 bpm
depending on age. A rate of 60 bpm is dangerously low.
7. A client with chronic kidney disease reports muscle weakness and irregular
heartbeat. Which lab value is most concerning?
A. Sodium 138 mEq/L
B. Potassium 6.2 mEq/L
C. Magnesium 1.9 mg/dL
D. Calcium 8.9 mg/dL
Correct Answer: B
Rationale: Hyperkalemia can lead to cardiac dysrhythmias and muscle weakness,
especially in CKD patients.
8. The nurse is caring for a client receiving vancomycin IV. Which assessment is
most important?
A. Blood pressure
B. Trough vancomycin level
C. Respiratory rate
D. Bowel sounds
Correct Answer: B
Rationale: Monitoring trough levels ensures the drug stays within the therapeutic
range and prevents nephrotoxicity and ototoxicity.
, 4
9. A client with schizophrenia reports hearing voices telling them to hurt others.
What is the nurse’s priority?
A. Ask the client what the voices are saying
B. Ensure the safety of the client and others
C. Explain that the voices are not real
D. Administer PRN antipsychotic medication
Correct Answer: B
Rationale: Safety is the priority when a client is experiencing command
hallucinations.
10. A client with COPD is receiving oxygen via nasal cannula at 5 L/min. Which
action should the nurse take?
A. Continue oxygen as ordered
B. Reduce oxygen to 2 L/min
C. Change to a non-rebreather mask
D. Elevate the client’s legs
Correct Answer: B
Rationale: High-flow oxygen can suppress the hypoxic drive in COPD clients.
Oxygen should typically be administered at 1–2 L/min.
11. A nurse assesses a client who suddenly becomes confused and restless post-op.
What is the most likely cause?
A. Anxiety
B. Sleep deprivation
C. Hypoxia
D. Medication side effect
Correct Answer: C
Rationale: Sudden confusion and restlessness are early signs of hypoxia, especially
after surgery.
12. The nurse is teaching a client with a new colostomy. Which client statement
indicates understanding?
