NCLEX-RN Practice Questions (50) - Q&A; with Explanations
This practice set contains 50 original multiple-choice questions with correct answers and brief rationales. Use for
study and review. (Not actual NCLEX exam questions.)
Q1. A nurse finds a client with COPD sitting in a tripod position and using accessory
muscles to breathe. Which action should the nurse take first?
a) Encourage the client to perform pursed-lip breathing
b) Obtain arterial blood gas (ABG) values
c) Administer a bronchodilator as ordered
d) Place the client on bed rest and provide oxygen
Answer: c) Administer a bronchodilator as ordered
Explanation: Bronchodilators help relieve bronchospasm and improve airflow; immediate pharmacologic relief is
appropriate for respiratory distress. Pursed-lip breathing is supportive but bronchodilator is priority.
Q2. A client is receiving warfarin for a DVT. Which lab value should the nurse check to
evaluate therapeutic effect?
a) aPTT
b) INR
c) Platelet count
d) Bleeding time
Answer: b) INR
Explanation: INR (and PT) are used to monitor warfarin therapy. aPTT is for heparin monitoring.
Q3. Which of the following is the best indicator of fluid volume status in a postoperative
client?
a) Daily weight
b) Serum sodium
c) Urine specific gravity
d) Intake and output
Answer: a) Daily weight
Explanation: Daily weight provides the most accurate single measure of fluid balance over time; I&O; and labs are
helpful but weight changes reflect total body fluid.
Q4. A client with possible acute MI complains of chest pain. What is the nurse's first
action?
a) Obtain a 12-lead ECG
b) Administer sublingual nitroglycerin as ordered
c) Call for cardiac enzymes
d) Give aspirin chewable
Answer: a) Obtain a 12-lead ECG
, Explanation: A 12-lead ECG must be obtained immediately to identify ischemia/infarction; other interventions follow
rapidly.
This practice set contains 50 original multiple-choice questions with correct answers and brief rationales. Use for
study and review. (Not actual NCLEX exam questions.)
Q1. A nurse finds a client with COPD sitting in a tripod position and using accessory
muscles to breathe. Which action should the nurse take first?
a) Encourage the client to perform pursed-lip breathing
b) Obtain arterial blood gas (ABG) values
c) Administer a bronchodilator as ordered
d) Place the client on bed rest and provide oxygen
Answer: c) Administer a bronchodilator as ordered
Explanation: Bronchodilators help relieve bronchospasm and improve airflow; immediate pharmacologic relief is
appropriate for respiratory distress. Pursed-lip breathing is supportive but bronchodilator is priority.
Q2. A client is receiving warfarin for a DVT. Which lab value should the nurse check to
evaluate therapeutic effect?
a) aPTT
b) INR
c) Platelet count
d) Bleeding time
Answer: b) INR
Explanation: INR (and PT) are used to monitor warfarin therapy. aPTT is for heparin monitoring.
Q3. Which of the following is the best indicator of fluid volume status in a postoperative
client?
a) Daily weight
b) Serum sodium
c) Urine specific gravity
d) Intake and output
Answer: a) Daily weight
Explanation: Daily weight provides the most accurate single measure of fluid balance over time; I&O; and labs are
helpful but weight changes reflect total body fluid.
Q4. A client with possible acute MI complains of chest pain. What is the nurse's first
action?
a) Obtain a 12-lead ECG
b) Administer sublingual nitroglycerin as ordered
c) Call for cardiac enzymes
d) Give aspirin chewable
Answer: a) Obtain a 12-lead ECG
, Explanation: A 12-lead ECG must be obtained immediately to identify ischemia/infarction; other interventions follow
rapidly.
