🇺🇸 NCLEX RN Practice Questions
100 Questions • Answers • Detailed Rationales
Trusted by Nursing Students & International Nurses Preparing for NCLEX-RN
Master Clinical Judgment, Pharmacology, Prioritization, Delegation, Patient Safety & other.
🩺 NCLEX-RN Test Information
🔹 Number of Questions: 100 NCLEX-Style Questions
🔹 Scoring: 1 Point per Correct Answer
🔹 Negative Marking: No
🔹 Difficulty Level: Moderate • Challenging • NCLEX-RN Standard
🔹 Detailed Rationales: Included for Every Question
🔹 Topics Covered: Medical-Surgical, Pharmacology, Pediatrics, Maternal-Newborn, Mental Health, Infection Control, Delegation & Patient Safety
🔹 Ideal For: NCLEX-RN Candidates, International Nurses & New Nursing Graduates
🔹 Popular In: 🇺🇸 USA • 🇨🇦 Canada • 🇦🇺 Australia • 🇳🇿 New Zealand
🔹 Scoring: 1 Point per Correct Answer
🔹 Negative Marking: No
🔹 Difficulty Level: Moderate • Challenging • NCLEX-RN Standard
🔹 Detailed Rationales: Included for Every Question
🔹 Topics Covered: Medical-Surgical, Pharmacology, Pediatrics, Maternal-Newborn, Mental Health, Infection Control, Delegation & Patient Safety
🔹 Ideal For: NCLEX-RN Candidates, International Nurses & New Nursing Graduates
🔹 Popular In: 🇺🇸 USA • 🇨🇦 Canada • 🇦🇺 Australia • 🇳🇿 New Zealand
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Question 1
The nurse is caring for a client with acute kidney injury whose latest laboratory results show a serum potassium level of 6.8 mEq/L. Which assessment finding should the nurse prioritize for immediate intervention?
A. Abdominal cramping and diarrhea
B. Generalized muscle weakness
C. Tall, peaked T waves on the electrocardiogram (ECG)
D. Hyperactive deep tendon reflexes
Explanation:
A serum potassium level of 6.8 mEq/L indicates severe hyperkalemia. Tall, peaked T waves on the ECG are a life-threatening sign of cardiac conduction abnormalities that can rapidly progress to fatal dysrhythmias and require immediate intervention.
A serum potassium level of 6.8 mEq/L indicates severe hyperkalemia. Tall, peaked T waves on the ECG are a life-threatening sign of cardiac conduction abnormalities that can rapidly progress to fatal dysrhythmias and require immediate intervention.
Question 2
A client is receiving a continuous intravenous infusion of heparin for a pulmonary embolism. The nurse reviews the activated partial thromboplastin time (aPTT) and finds it is 110 seconds, with a control of 35 seconds. Which action should the nurse take first?
A. Stop the heparin infusion and notify the healthcare provider
B. Obtain a prescription for vitamin K (phytonadione)
C. Lower the infusion rate by 5 units/kg/hr
D. Assess the client for signs of deep vein thrombosis
Explanation:
An aPTT of 110 seconds is critically elevated and places the client at high risk for bleeding. The priority action is to stop the heparin infusion immediately and notify the healthcare provider for further instructions.
An aPTT of 110 seconds is critically elevated and places the client at high risk for bleeding. The priority action is to stop the heparin infusion immediately and notify the healthcare provider for further instructions.
Question 3
The nurse is assigned to care for a client who identifies as transgender and is scheduled for surgery. The nurse notes that the client’s legal name does not match their self-identified preferred name. Which action best demonstrates adherence to clinical equity principles?
A. Utilizing the legal name on all surgical consent forms only
B. Asking the client for their preferred name and pronouns and utilizing them consistently
C. Documenting the client’s gender identity only to mitigate bias
D. Providing the client with a private room
Explanation:
Respecting and consistently using a client’s preferred name and pronouns promotes dignity, trust, inclusivity, and equitable patient-centered care.
Respecting and consistently using a client’s preferred name and pronouns promotes dignity, trust, inclusivity, and equitable patient-centered care.
Question 4
A client is admitted to the medical unit with a suspected diagnosis of pulmonary tuberculosis. Which isolation precautions must the nurse implement immediately?
A. Contact precautions including gloves and a gown
B. Airborne precautions including an N95 respirator and negative pressure room
C. Droplet precautions including a surgical mask and private room
D. Standard precautions only until sputum culture results are confirmed
Explanation:
Pulmonary tuberculosis is transmitted through airborne particles. Airborne precautions require an N95 respirator and placement in a negative-pressure room to prevent transmission.
Pulmonary tuberculosis is transmitted through airborne particles. Airborne precautions require an N95 respirator and placement in a negative-pressure room to prevent transmission.
Question 5
The registered nurse (RN) is planning care for a group of clients. Which task is most appropriate to delegate to the unlicensed assistive personnel (UAP)?
A. Assisting a client who is two days post-operative to ambulate for the first time
B. Measuring and recording the intake and output for a client with heart failure
C. Teaching a client how to use an incentive spirometer
D. Re-applying a dry, sterile dressing to a stable wound
Explanation:
Measuring and recording intake and output is a routine, non-invasive task that may be delegated to a UAP. Assessment, teaching, and sterile procedures remain the nurse’s responsibility.
Measuring and recording intake and output is a routine, non-invasive task that may be delegated to a UAP. Assessment, teaching, and sterile procedures remain the nurse’s responsibility.
Question 6
During labor, the electronic fetal monitor shows decelerations that begin after the peak of a contraction and return to baseline only after the contraction has ended. Which is the nurse’s priority intervention?
A. Perform a vaginal exam to check for cord prolapse
B. Document the finding as a reassuring sign of head compression
C. Position the client on their left side and increase the IV fluid rate
D. Increase the rate of the oxytocin infusion to progress labor
Explanation:
Late decelerations indicate uteroplacental insufficiency. Repositioning the client to the left side and increasing IV fluids can improve placental perfusion and fetal oxygenation.
Late decelerations indicate uteroplacental insufficiency. Repositioning the client to the left side and increasing IV fluids can improve placental perfusion and fetal oxygenation.
Question 7
The nurse is assessing a 6-month-old infant brought to the clinic with vomiting and diarrhea for 24 hours. Which finding indicates severe dehydration?
A. Crying with moist mucous membranes
B. Three wet diapers in the last eight hours
C. Capillary refill time of 2 seconds
D. Soft, flat anterior fontanelle
E. Lethargy with a sunken fontanelle
Explanation:
Severe dehydration in infants is characterized by lethargy, sunken fontanelle, poor skin turgor, dry mucous membranes, and decreased urine output.
Severe dehydration in infants is characterized by lethargy, sunken fontanelle, poor skin turgor, dry mucous membranes, and decreased urine output.
Question 8
A client with bipolar disorder is prescribed lithium carbonate. During a follow-up visit, the client reports blurred vision, coarse hand tremors, and severe diarrhea. Which action should the nurse take first?
A. Administer the next dose of lithium and document the symptoms
B. Encourage the client to increase sodium intake to 3 grams daily
C. Instruct the client to take the medication with a full glass of water
D. Hold the medication and prepare the client for a serum lithium level test
Explanation:
Blurred vision, coarse tremors, and severe diarrhea are signs of lithium toxicity. The medication should be withheld and serum lithium levels checked immediately.
Blurred vision, coarse tremors, and severe diarrhea are signs of lithium toxicity. The medication should be withheld and serum lithium levels checked immediately.
Question 9
The nurse receives arterial blood gas (ABG) results for a client with COPD: pH 7.28, PaCO₂ 55 mmHg, HCO₃ 28 mEq/L. How should the nurse interpret these results?
A. Partially compensated respiratory acidosis
B. Uncompensated metabolic alkalosis
C. Fully compensated respiratory acidosis
D. Partially compensated metabolic acidosis
Explanation:
The low pH indicates acidosis and the elevated PaCO₂ indicates a respiratory cause. The slightly elevated bicarbonate shows the kidneys are attempting compensation, making this partially compensated respiratory acidosis.
The low pH indicates acidosis and the elevated PaCO₂ indicates a respiratory cause. The slightly elevated bicarbonate shows the kidneys are attempting compensation, making this partially compensated respiratory acidosis.
Question 10
A client arrives in the emergency department with sudden-onset right-sided weakness and a facial droop. The client’s spouse states the symptoms began 2 hours ago. After a CT scan rules out a brain bleed, which is the priority nursing action?
A. Assist the client with range-of-motion exercises
B. Prepare the client for the administration of intravenous tissue plasminogen activator (tPA)
C. Schedule the client for an urgent physical therapy evaluation
D. Administer aspirin 325 mg orally
Explanation:
The client is within the therapeutic window for thrombolytic therapy. After hemorrhagic stroke has been ruled out, rapid administration of tPA can restore cerebral blood flow and reduce neurologic damage.
The client is within the therapeutic window for thrombolytic therapy. After hemorrhagic stroke has been ruled out, rapid administration of tPA can restore cerebral blood flow and reduce neurologic damage.
Question 11
The nurse is assessing a client who had a total thyroidectomy 12 hours ago. The nurse notes that the client has a positive Trousseau’s sign. Which medication should the nurse anticipate administering?
A. Potassium chloride
B. Sodium polystyrene sulfonate
C. Calcium gluconate
D. Magnesium sulfate
Explanation:
A positive Trousseau’s sign indicates hypocalcemia, which can occur after thyroidectomy due to accidental injury or removal of the parathyroid glands. Calcium gluconate is administered to correct low calcium levels and prevent complications such as tetany.
A positive Trousseau’s sign indicates hypocalcemia, which can occur after thyroidectomy due to accidental injury or removal of the parathyroid glands. Calcium gluconate is administered to correct low calcium levels and prevent complications such as tetany.
Question 12
A client is being transitioned from an intravenous heparin drip to oral warfarin. The nurse should explain to the client that the heparin must continue for several days after starting the warfarin because:
A. Warfarin takes several days to reach therapeutic levels in the blood
B. Heparin enhances the absorption of warfarin in the gastrointestinal tract
C. The combination of both drugs is required to dissolve existing clots
D. Heparin prevents the common side effect of nausea caused by warfarin
Explanation:
Warfarin has a delayed onset of action because existing clotting factors must be depleted before anticoagulation becomes effective. Heparin provides immediate anticoagulation coverage during this transition period.
Warfarin has a delayed onset of action because existing clotting factors must be depleted before anticoagulation becomes effective. Heparin provides immediate anticoagulation coverage during this transition period.
Question 13
The nurse is teaching a client with a fractured left ankle how to use crutches. Which instruction for stair navigation is correct?
A. “Lead with the left leg when going up the stairs.”
B. “Lead with the crutches when going up the stairs.”
C. “Lead with the left leg when going down the stairs.”
D. “Lead with the right leg when going up the stairs.”
E. “Place both crutches on the same step as the right leg.”
Explanation:
When going upstairs with crutches, the client should lead with the unaffected (stronger) leg first. A simple memory aid is: “Up with the good, down with the bad.”
When going upstairs with crutches, the client should lead with the unaffected (stronger) leg first. A simple memory aid is: “Up with the good, down with the bad.”
Question 14
A nurse is providing care for a client with a confirmed Clostridioides difficile infection. Which hand hygiene practice is mandatory?
A. Using an alcohol-based hand rub before and after client contact
B. Washing hands with soap and water after removing gloves
C. Wearing a surgical mask while providing care to prevent inhalation of spores
D. Double-gloving when handling the client’s bedpan
Explanation:
Alcohol-based hand sanitizers are not effective against C. difficile spores. Handwashing with soap and water is required after glove removal to physically remove spores from the hands.
Alcohol-based hand sanitizers are not effective against C. difficile spores. Handwashing with soap and water is required after glove removal to physically remove spores from the hands.
Question 15
After the morning shift report, which client should the nurse assess first?
A. A client with a new-onset productive cough and a temperature of 102.2°F (39°C)
B. A client with heart failure who gained 2 lbs (0.9 kg) over the last 24 hours
C. A client who is requesting their PRN pain medication for chronic back pain
D. A client who was admitted with a stroke 3 days ago and has a blood pressure of 140/85 mmHg
Explanation:
A new productive cough with a high fever may indicate an acute respiratory infection requiring prompt assessment and intervention. This finding represents the highest priority among the listed clients.
A new productive cough with a high fever may indicate an acute respiratory infection requiring prompt assessment and intervention. This finding represents the highest priority among the listed clients.
Question 16
A client is returning from a thyroidectomy. Which equipment is most important for the nurse to have at the bedside?
A. A sterile dressing change kit
B. An incentive spirometer
C. A tracheostomy tray and suction
D. An extra bottle of intravenous normal saline
Explanation:
Following thyroidectomy, airway obstruction from swelling, hemorrhage, or laryngeal edema is a major risk. Emergency airway equipment, including a tracheostomy tray and suction setup, should be readily available.
Following thyroidectomy, airway obstruction from swelling, hemorrhage, or laryngeal edema is a major risk. Emergency airway equipment, including a tracheostomy tray and suction setup, should be readily available.
Question 17
When educating new parents about infant hydration, the nurse explains that infants are at a higher risk for electrolyte imbalances than adults. Which physiological factor should the nurse include?
A. Infants have a smaller body surface area relative to their weight
B. Infants’ kidneys are more efficient at concentrating urine
C. Infants have a lower percentage of total body water
D. Infants have a more developed Renin-Angiotensin-Aldosterone System
E. Infants have a higher proportion of water in the extracellular fluid compartment
Explanation:
Infants have a larger percentage of body water, especially in the extracellular compartment, making them more susceptible to rapid fluid and electrolyte shifts during illness.
Infants have a larger percentage of body water, especially in the extracellular compartment, making them more susceptible to rapid fluid and electrolyte shifts during illness.
Question 18
A client with heart failure is taking digoxin 0.25 mg daily. Which assessment finding should the nurse identify as a common early sign of digoxin toxicity?
A. Sharp, stabbing chest pain
B. Sudden onset of a dry, hacking cough
C. Bounding peripheral pulses
D. Anorexia, nausea, and vomiting
Explanation:
Early manifestations of digoxin toxicity commonly include anorexia, nausea, vomiting, fatigue, and visual disturbances. Prompt recognition is important to prevent serious cardiac complications.
Early manifestations of digoxin toxicity commonly include anorexia, nausea, vomiting, fatigue, and visual disturbances. Prompt recognition is important to prevent serious cardiac complications.
Question 19
A post-operative client who is heavily sedated has a respiratory rate of 8 breaths per minute. Which acid-base imbalance should the nurse anticipate?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis
Explanation:
Hypoventilation causes carbon dioxide retention, leading to increased PaCO₂ and respiratory acidosis. Sedation is a common cause of decreased respiratory drive.
Hypoventilation causes carbon dioxide retention, leading to increased PaCO₂ and respiratory acidosis. Sedation is a common cause of decreased respiratory drive.
Question 20
Using the “FAST” mnemonic for stroke assessment, which assessment finding is correctly matched to its clinical indicator?
A. F: Face drooping—Ask the client to smile
B. A: Arm weakness—Ask the client to squeeze the nurse’s hands
C. S: Speech difficulty—Ask the client to read a newspaper aloud
D. T: Time—Determine the client’s last meal
E. S: Sensation—Check for numbness in the fingers
Explanation:
FAST stands for Face drooping, Arm weakness, Speech difficulty, and Time to call emergency services. Asking the client to smile helps identify facial asymmetry associated with stroke.
FAST stands for Face drooping, Arm weakness, Speech difficulty, and Time to call emergency services. Asking the client to smile helps identify facial asymmetry associated with stroke.
Question 21
The nurse is caring for a client with chronic hyponatremia. The nurse should ensure the serum sodium level is corrected slowly to avoid which catastrophic complication?
A. Cerebral edema
B. Pulmonary embolism
C. Osmotic demyelination syndrome
D. Acute kidney injury
Explanation:
Rapid correction of chronic hyponatremia can cause osmotic demyelination syndrome (ODS), a serious neurological condition that can result in permanent brain damage.
Rapid correction of chronic hyponatremia can cause osmotic demyelination syndrome (ODS), a serious neurological condition that can result in permanent brain damage.
Question 22
A nurse administers 10 units of Regular insulin at 0800. At what time should the nurse be most alert for signs of hypoglycemia?
A. 0830
B. 1030
C. 1400
D. 1800
Explanation:
Regular insulin peaks approximately 2–4 hours after administration. A dose given at 0800 is most likely to cause hypoglycemia around 1030.
Regular insulin peaks approximately 2–4 hours after administration. A dose given at 0800 is most likely to cause hypoglycemia around 1030.
Question 23
The surgeon is discussing a surgical procedure with a client. What is the nurse’s primary role in the informed consent process?
A. Explaining the risks and benefits of the surgery if the client has questions.
B. Ensuring the client has not eaten anything for at least 8 hours.
C. Discussing alternative treatment options with the client.
D. Witnessing the client’s signature and ensuring they are competent to sign.
E. Providing the client with a copy of the hospital’s patient rights policy.
Explanation:
The healthcare provider explains the procedure, risks, benefits, and alternatives. The nurse’s role is to witness the signature and verify that the client is competent and signing voluntarily.
The healthcare provider explains the procedure, risks, benefits, and alternatives. The nurse’s role is to witness the signature and verify that the client is competent and signing voluntarily.
Question 24
A client is diagnosed with measles (rubeola). Which personal protective equipment (PPE) must the nurse wear when entering the room?
A. N95 respirator
B. Surgical mask and gloves
C. Gown and face shield
D. No PPE is required if staying 3 feet away from the client.
Explanation:
Measles is transmitted through airborne particles. Airborne precautions require the use of an N95 respirator and placement in a negative-pressure room.
Measles is transmitted through airborne particles. Airborne precautions require the use of an N95 respirator and placement in a negative-pressure room.
Question 25
Which client assignment is most appropriate for the licensed practical nurse (LPN) working under the supervision of the RN?
A. A client with a new-onset stroke being evaluated for tPA.
B. A client with stable diabetes requiring a subcutaneous insulin injection.
C. A client in the intensive care unit on a mechanical ventilator.
D. A client with suicidal ideation being admitted to the psychiatric unit.
Explanation:
LPNs are typically assigned stable clients with predictable outcomes. A client with stable diabetes requiring insulin administration is appropriate.
LPNs are typically assigned stable clients with predictable outcomes. A client with stable diabetes requiring insulin administration is appropriate.
Question 26
The nurse is caring for a client with preeclampsia receiving a magnesium sulfate infusion. Which assessment finding requires immediate notification of the healthcare provider?
A. Respiratory rate of 10 breaths per minute
B. Deep tendon reflexes of 2+
C. Urine output of 40 mL/hr
D. Blood pressure of 150/94 mmHg
Explanation:
Magnesium toxicity can cause respiratory depression. A respiratory rate below 12 breaths per minute requires immediate intervention.
Magnesium toxicity can cause respiratory depression. A respiratory rate below 12 breaths per minute requires immediate intervention.
Question 27
The nurse is reviewing the 2026 NCLEX blueprint updates regarding intracranial pressure (ICP) monitoring. Monitoring and maintenance of this device is now classified under which Client Needs subcategory?
A. Reduction of Risk Potential
B. Management of Care
C. Physiological Adaptation
D. Safety and Infection Prevention and Control
Explanation:
ICP monitoring is categorized under Physiological Adaptation because it involves managing complex physiological conditions and monitoring critical changes.
ICP monitoring is categorized under Physiological Adaptation because it involves managing complex physiological conditions and monitoring critical changes.
Question 28
A client with heart failure is prescribed lisinopril. Which side effect should the nurse instruct the client to report immediately as a potential sign of angioedema?
A. A persistent, dry, non-productive cough.
B. Swelling of the lips, face, or tongue.
C. Feeling lightheaded when standing up quickly.
D. Increased frequency of urination at night.
E. A mild, itchy rash on the trunk.
Explanation:
Angioedema is a rare but life-threatening adverse effect of ACE inhibitors. Swelling of the lips, tongue, or face requires immediate medical attention.
Angioedema is a rare but life-threatening adverse effect of ACE inhibitors. Swelling of the lips, tongue, or face requires immediate medical attention.
Question 29
The nurse is preparing to administer NPH and Regular insulin in a single syringe. Which action is correct?
A. Draw up the NPH insulin first, followed by the Regular insulin.
B. Draw up the Regular insulin first, followed by the NPH insulin.
C. Draw each insulin into separate syringes and inject them separately.
D. Shake the Regular insulin vial vigorously before drawing up the dose.
Explanation:
When mixing insulin, draw up clear (Regular) insulin before cloudy (NPH) insulin to prevent contamination of the Regular insulin vial.
When mixing insulin, draw up clear (Regular) insulin before cloudy (NPH) insulin to prevent contamination of the Regular insulin vial.
Question 30
A client with chronic kidney disease has a serum potassium level of 6.2 mEq/L and an ECG showing peaked T waves. Which medication should the nurse anticipate administering first to protect the heart?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Intravenous Regular insulin and dextrose
C. Intravenous Calcium gluconate
D. Furosemide (Lasix)
Explanation:
Calcium gluconate does not lower potassium levels but stabilizes the cardiac membrane, protecting the heart from life-threatening arrhythmias caused by hyperkalemia.
Calcium gluconate does not lower potassium levels but stabilizes the cardiac membrane, protecting the heart from life-threatening arrhythmias caused by hyperkalemia.
Question 31
The nurse is caring for a client who requires physical restraints for safety. Which nursing action adheres to current safety standards?
A. Securing the restraints to the bed side rails with a double knot.
B. Obtaining a PRN order for restraints to use if the client becomes agitated.
C. Checking the client’s skin integrity and neurovascular status every 2 hours.
D. Removing the restraints only when the client promises to remain still.
Explanation:
Clients in restraints must be monitored frequently. Skin integrity, circulation, sensation, and movement should be assessed regularly to prevent injury.
Clients in restraints must be monitored frequently. Skin integrity, circulation, sensation, and movement should be assessed regularly to prevent injury.
Question 32
A nurse is preparing to enter the room of a client with disseminated herpes zoster. Which isolation precautions are required?
A. Contact precautions only.
B. Droplet precautions only.
C. Airborne and contact precautions.
D. Standard precautions only.
Explanation:
Disseminated herpes zoster can spread through airborne particles and direct contact. Both airborne and contact precautions are required.
Disseminated herpes zoster can spread through airborne particles and direct contact. Both airborne and contact precautions are required.
Question 33
A client taking warfarin for atrial fibrillation has an INR of 4.8. Which instruction should the nurse prioritize?
A. “Increase your intake of spinach and broccoli to lower your INR.”
B. “Stop taking the warfarin immediately and wait for your provider’s call.”
C. “Avoid activities that increase your risk of injury and use a soft toothbrush.”
D. “You may need to receive an injection of protamine sulfate today.”
E. “Continue your current dose and return for a repeat blood draw in one week.”
Explanation:
An INR of 4.8 increases the risk of bleeding. Safety measures such as avoiding injury and using a soft toothbrush are essential.
An INR of 4.8 increases the risk of bleeding. Safety measures such as avoiding injury and using a soft toothbrush are essential.
Question 34
The nurse is caring for a client who identifies as non-binary. According to the 2026 Test Plan, which action supports unbiased treatment?
A. Assigning the client to a private room regardless of availability.
B. Utilizing the client’s self-identified pronouns consistently during care.
C. Standardizing care plans to focus solely on physiological needs.
D. Reporting the client’s identity to the ethics committee for guidance.
Explanation:
Respecting a client’s self-identified pronouns promotes dignity, inclusivity, and unbiased patient-centered care.
Respecting a client’s self-identified pronouns promotes dignity, inclusivity, and unbiased patient-centered care.
Question 35
Using the ROME mnemonic, interpret these ABG results: pH 7.52, PaCO₂ 28 mmHg, HCO₃ 24 mEq/L.
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Explanation:
The pH is elevated (alkalosis) and the PaCO₂ is decreased. Using ROME (Respiratory Opposite, Metabolic Equal), this indicates respiratory alkalosis.
The pH is elevated (alkalosis) and the PaCO₂ is decreased. Using ROME (Respiratory Opposite, Metabolic Equal), this indicates respiratory alkalosis.
Question 36
A 4-year-old child is brought to the emergency department with suspected epiglottitis. Which isolation precaution is mandatory?
A. Airborne
B. Droplet
C. Contact
D. Standard only
Explanation:
Epiglottitis is spread through respiratory droplets. Droplet precautions should be implemented immediately.
Epiglottitis is spread through respiratory droplets. Droplet precautions should be implemented immediately.
Question 37
The nurse is preparing to administer digoxin to a client with heart failure. Which assessment is the priority safety measure?
A. Assessing the client’s blood pressure in both arms.
B. Monitoring the client’s weight gain over the last 24 hours.
C. Assessing the apical pulse for a full 60 seconds.
D. Verifying the dose with the hospital’s charge nurse.
Explanation:
Digoxin can cause bradycardia. The apical pulse should be assessed for one full minute before administration and withheld if below the prescribed limit.
Digoxin can cause bradycardia. The apical pulse should be assessed for one full minute before administration and withheld if below the prescribed limit.
Question 38
A client is admitted with a diagnosis of diabetes insipidus. Which laboratory finding should the nurse expect?
A. Serum sodium 130 mEq/L
B. Urine specific gravity 1.002
C. Hematocrit 32%
D. Serum osmolality 270 mOsm/kg
Explanation:
Diabetes insipidus causes excessive dilute urine production, resulting in a very low urine specific gravity.
Diabetes insipidus causes excessive dilute urine production, resulting in a very low urine specific gravity.
Question 39
The nurse is teaching a client about a 3-point crutch gait. Which description by the nurse is correct?
A. Move one crutch and the opposite leg together, then the other side.
B. Move both crutches and the injured leg forward, then the uninjured leg.
C. Move one crutch, then the opposite leg, then the second crutch.
D. Swing both legs forward past the crutches at the same time.
Explanation:
In a 3-point gait, both crutches and the affected leg move forward together, followed by the unaffected leg bearing weight.
In a 3-point gait, both crutches and the affected leg move forward together, followed by the unaffected leg bearing weight.
Question 40
A client on a medical-surgical unit is found to have a serum calcium level of 7.2 mg/dL. Which clinical sign should the nurse expect to find?
A. Shortened QT interval on the ECG.
B. Muscle flaccidity and diminished reflexes.
C. Positive Chvostek’s sign.
D. Severe constipation and abdominal distention.
E. Generalized bone pain and kidney stones.
Explanation:
A calcium level of 7.2 mg/dL indicates hypocalcemia. Positive Chvostek’s sign and increased neuromuscular excitability are classic findings.
A calcium level of 7.2 mg/dL indicates hypocalcemia. Positive Chvostek’s sign and increased neuromuscular excitability are classic findings.
Question 41
The nurse is assigned to four clients. Which client should be assessed first?
A. A client with a potassium level of 3.2 mEq/L reporting muscle weakness.
B. A client with a blood pressure of 158/92 mmHg requesting their medication.
C. A client with new-onset slurred speech and a slight facial droop.
D. A client with heart failure who gained 1 kg (2.2 lbs) since yesterday.
Explanation:
New-onset slurred speech and facial droop are signs of an acute stroke. Immediate assessment and intervention are critical because time-sensitive treatments may be required.
New-onset slurred speech and facial droop are signs of an acute stroke. Immediate assessment and intervention are critical because time-sensitive treatments may be required.
Question 42
A client with alcohol use disorder is admitted with hypomagnesemia. Which cardiac rhythm is this client at the highest risk for developing?
A. Sinus bradycardia
B. Torsades de Pointes
C. First-degree AV block
D. Normal sinus rhythm with occasional PVCs
Explanation:
Hypomagnesemia increases the risk for ventricular dysrhythmias, particularly Torsades de Pointes, which can be life-threatening.
Hypomagnesemia increases the risk for ventricular dysrhythmias, particularly Torsades de Pointes, which can be life-threatening.
Question 43
The nurse is providing care for a client with a confirmed MRSA infection in a surgical wound. Which PPE is required for entering the room?
A. Gown and gloves.
B. N95 respirator and gloves.
C. Surgical mask and face shield.
D. Gloves only.
Explanation:
MRSA wound infections require contact precautions. Healthcare workers should wear a gown and gloves when entering the room.
MRSA wound infections require contact precautions. Healthcare workers should wear a gown and gloves when entering the room.
Question 44
A client is admitted with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Which clinical finding should the nurse expect?
A. Serum sodium 152 mEq/L
B. Urine specific gravity 1.035
C. Serum sodium 128 mEq/L
D. Hematocrit 55%
Explanation:
SIADH causes excessive water retention, leading to dilutional hyponatremia. A serum sodium of 128 mEq/L is an expected finding.
SIADH causes excessive water retention, leading to dilutional hyponatremia. A serum sodium of 128 mEq/L is an expected finding.
Question 45
The nurse is preparing to discharge a client who had a total thyroidectomy. Which instruction is most important?
A. “You should avoid eating dairy products for at least two weeks.”
B. “Report any numbness or tingling in your fingers or around your mouth immediately.”
C. “It is normal to have a persistent dry cough for the first month.”
D. “You may resume your normal high-impact exercise routine tomorrow.”
Explanation:
Numbness and tingling around the mouth or fingers may indicate hypocalcemia caused by accidental parathyroid gland injury during thyroid surgery.
Numbness and tingling around the mouth or fingers may indicate hypocalcemia caused by accidental parathyroid gland injury during thyroid surgery.
Question 46
A client is receiving a continuous intravenous infusion of Regular insulin for diabetic ketoacidosis (DKA). What is the nurse’s priority safety action?
A. Rotating the IV insertion site every 24 hours.
B. Monitoring blood glucose levels every hour.
C. Shaking the insulin bag vigorously before hanging.
D. Shifting the client to an oral hypoglycemic agent within 2 hours.
Explanation:
Frequent blood glucose monitoring is essential during IV insulin therapy to prevent hypoglycemia and guide treatment adjustments.
Frequent blood glucose monitoring is essential during IV insulin therapy to prevent hypoglycemia and guide treatment adjustments.
Question 47
The nurse notes variable decelerations on the fetal heart rate monitor. Using the VEAL CHOP mnemonic, what is the suspected cause?
A. Cord compression
B. Head compression
C. Oxygenation is OK
D. Placental insufficiency
Explanation:
VEAL CHOP: Variable decelerations = Cord compression, Early decelerations = Head compression, Accelerations = OK, Late decelerations = Placental insufficiency.
VEAL CHOP: Variable decelerations = Cord compression, Early decelerations = Head compression, Accelerations = OK, Late decelerations = Placental insufficiency.
Question 48
A client is admitted with severe, prolonged vomiting. Which acid-base imbalance is most likely?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Explanation:
Prolonged vomiting causes loss of gastric acid (hydrochloric acid), resulting in metabolic alkalosis.
Prolonged vomiting causes loss of gastric acid (hydrochloric acid), resulting in metabolic alkalosis.
Question 49
A client with bone metastasis from breast cancer reports severe bone pain. Which laboratory value should the nurse monitor closely for this client?
A. Serum potassium
B. Serum calcium
C. Serum magnesium
D. Serum phosphorus
Explanation:
Bone metastases can cause bone breakdown and release calcium into the bloodstream, leading to hypercalcemia.
Bone metastases can cause bone breakdown and release calcium into the bloodstream, leading to hypercalcemia.
Question 50
Which action by the nurse best demonstrates adherence to the 2026 blueprint regarding patient dignity during personal hygiene?
A. Completing a bed bath as quickly as possible to save time.
B. Keeping the client covered with a bath blanket and only exposing the part being washed.
C. Asking the client’s roommate to leave the room for the duration of the bath.
D. Using only pre-packaged bath wipes to ensure standardized care.
Explanation:
Maintaining privacy and dignity is a core nursing responsibility. Keeping the client covered and exposing only the area being washed preserves dignity and comfort.
Maintaining privacy and dignity is a core nursing responsibility. Keeping the client covered and exposing only the area being washed preserves dignity and comfort.
Question 51
A client with Addison’s disease is admitted to the unit. Which electrolyte pattern should the nurse anticipate?
A. Hypernatremia and Hypokalemia.
B. Hyponatremia and Hyperkalemia.
C. Hypernatremia and Hyperkalemia.
D. Hyponatremia and Hypokalemia.
Explanation:
Addison’s disease causes decreased aldosterone production, resulting in sodium loss and potassium retention. Therefore, hyponatremia and hyperkalemia are expected findings.
Addison’s disease causes decreased aldosterone production, resulting in sodium loss and potassium retention. Therefore, hyponatremia and hyperkalemia are expected findings.
Question 52
A nurse is assigned to a client with an intracranial pressure (ICP) monitor. According to the 2026 Test Plan, monitoring this device falls under which category?
A. Reduction of Risk Potential
B. Management of Care
C. Physiological Adaptation
D. Safety and Infection Prevention and Control
E. Health Promotion and Maintenance
Explanation:
ICP monitoring involves caring for clients with complex physiological conditions and is categorized under Physiological Adaptation.
ICP monitoring involves caring for clients with complex physiological conditions and is categorized under Physiological Adaptation.
Question 53
The nurse is preparing to administer metoprolol to a client with hypertension. Which assessment finding would require the nurse to hold the medication?
A. Blood pressure of 142/88 mmHg.
B. Heart rate of 54 beats per minute.
C. Client report of a dry cough.
D. Serum potassium level of 4.2 mEq/L.
Explanation:
Metoprolol is a beta-blocker that can cause bradycardia. A heart rate of 54 beats per minute should be reported and the medication withheld according to agency policy.
Metoprolol is a beta-blocker that can cause bradycardia. A heart rate of 54 beats per minute should be reported and the medication withheld according to agency policy.
Question 54
A client has a serum sodium level of 162 mEq/L. The nurse should monitor this client for which priority neurological complication?
A. Osmotic demyelination syndrome.
B. Cerebral edema and seizures.
C. Flaccid paralysis of the lower extremities.
D. Acute hemorrhagic stroke.
Explanation:
Severe hypernatremia can cause significant neurological changes. Rapid correction or worsening sodium imbalance may result in cerebral edema and seizures.
Severe hypernatremia can cause significant neurological changes. Rapid correction or worsening sodium imbalance may result in cerebral edema and seizures.
Question 55
The nurse is teaching a client with an ankle injury how to walk down stairs using crutches. Which instruction is correct?
A. “Lead with the uninjured leg first, then the crutches.”
B. “Lead with the crutches and the injured leg first.”
C. “Lead with both legs at the same time.”
D. “Lead with the uninjured leg and the crutches together.”
Explanation:
When going down stairs, the client should move the crutches and injured leg down first, followed by the unaffected leg. Remember: “Up with the good, down with the bad.”
When going down stairs, the client should move the crutches and injured leg down first, followed by the unaffected leg. Remember: “Up with the good, down with the bad.”
Question 56
A client is admitted with suspected meningitis. Which isolation precautions should the nurse implement while waiting for test results?
A. Airborne
B. Droplet
C. Contact
D. Standard only
Explanation:
Suspected bacterial meningitis requires droplet precautions until the infectious cause is identified and treatment has been initiated.
Suspected bacterial meningitis requires droplet precautions until the infectious cause is identified and treatment has been initiated.
Question 57
The nurse is providing care for a client with a living will. Which action by the nurse demonstrates proper clinical judgment?
A. Encouraging the family to override the living will if they disagree.
B. Ensuring a copy of the living will is placed prominently in the medical record.
C. Discussing the living will’s contents with the client’s visitors.
D. Waiting until the client is unresponsive before reviewing the document.
Explanation:
A living will should be readily available in the medical record so healthcare providers can follow the client’s wishes regarding care decisions.
A living will should be readily available in the medical record so healthcare providers can follow the client’s wishes regarding care decisions.
Question 58
A client receiving a continuous heparin infusion for a pulmonary embolism has an aPTT of 125 seconds. Which medication should the nurse have readily available as the antidote?
A. Vitamin K
B. Naloxone
C. Protamine sulfate
D. Flumazenil
E. Calcium gluconate
Explanation:
Protamine sulfate is the antidote for heparin and is used when excessive anticoagulation or serious bleeding occurs.
Protamine sulfate is the antidote for heparin and is used when excessive anticoagulation or serious bleeding occurs.
Question 59
The nurse is preparing to enter the room of a client with measles. Which PPE is required?
A. Surgical mask.
B. N95 respirator.
C. Gown and gloves only.
D. Face shield and surgical mask.
Explanation:
Measles is transmitted via the airborne route. An N95 respirator is required along with airborne precautions.
Measles is transmitted via the airborne route. An N95 respirator is required along with airborne precautions.
Question 60
A client with heart failure is taking furosemide (Lasix). Which assessment finding is a high-priority concern?
A. Serum potassium of 3.1 mEq/L.
B. Blood pressure of 118/76 mmHg.
C. Weight loss of 0.5 kg (1.1 lbs) in 24 hours.
D. Increased frequency of clear urine.
Explanation:
Furosemide can cause potassium loss. A potassium level of 3.1 mEq/L indicates hypokalemia, increasing the risk of cardiac dysrhythmias and requiring prompt attention.
Furosemide can cause potassium loss. A potassium level of 3.1 mEq/L indicates hypokalemia, increasing the risk of cardiac dysrhythmias and requiring prompt attention.
Question 61
A client is hyperventilating due to extreme anxiety. Which ABG result should the nurse anticipate?
A. pH 7.30, PaCO₂ 50, HCO₃ 24
B. pH 7.50, PaCO₂ 30, HCO₃ 22
C. pH 7.48, PaCO₂ 45, HCO₃ 30
D. pH 7.35, PaCO₂ 40, HCO₃ 26
Explanation:
Hyperventilation causes excessive loss of carbon dioxide, resulting in respiratory alkalosis characterized by an elevated pH and decreased PaCO₂.
Hyperventilation causes excessive loss of carbon dioxide, resulting in respiratory alkalosis characterized by an elevated pH and decreased PaCO₂.
Question 62
The nurse is planning care for a group of clients. Which task is most appropriate to delegate to the LPN?
A. Initial assessment of a client arriving from the emergency department.
B. Administering a PRN oral analgesic to a stable post-operative client.
C. Teaching a newly diagnosed diabetic client how to rotate insulin sites.
D. Developing a comprehensive discharge plan for a client with complex needs.
Explanation:
LPNs may administer medications and provide care to stable clients. Initial assessments, teaching, and care planning remain RN responsibilities.
LPNs may administer medications and provide care to stable clients. Initial assessments, teaching, and care planning remain RN responsibilities.
Question 63
A client has a serum calcium level of 12.8 mg/dL. Which clinical finding is consistent with this result?
A. Positive Trousseau’s sign.
B. Muscle flaccidity and constipation.
C. Hyperactive deep tendon reflexes.
D. Prolonged QT interval on the ECG.
Explanation:
A calcium level of 12.8 mg/dL indicates hypercalcemia. Common manifestations include muscle weakness, decreased reflexes, constipation, and lethargy.
A calcium level of 12.8 mg/dL indicates hypercalcemia. Common manifestations include muscle weakness, decreased reflexes, constipation, and lethargy.
Question 64
A nurse is preparing to enter the room of a client with C. difficile. Which action is mandatory according to current infection prevention standards?
A. Using an alcohol-based hand sanitizer upon exiting the room.
B. Donning a gown and gloves before entering the room.
C. Wearing an N95 respirator at all times while in the room.
D. Ensuring the client stays in a room with positive pressure.
Explanation:
C. difficile requires contact precautions. Healthcare workers should wear a gown and gloves, and handwashing with soap and water is preferred.
C. difficile requires contact precautions. Healthcare workers should wear a gown and gloves, and handwashing with soap and water is preferred.
Question 65
A client is caring for a client with severe dehydration. Which vital sign changes are expected?
A. Hypertension and bradycardia.
B. Hypotension and tachycardia.
C. Hypertension and tachycardia.
D. Hypotension and bradycardia.
Explanation:
Severe dehydration decreases circulating blood volume, leading to hypotension and a compensatory increase in heart rate.
Severe dehydration decreases circulating blood volume, leading to hypotension and a compensatory increase in heart rate.
Question 66
A client with bipolar disorder taking lithium reports a fever of 101.4°F and severe vomiting. Why is the nurse concerned about lithium toxicity for this client?
A. Lithium causes increased sweating, which leads to fluid overload.
B. Vomiting and dehydration can cause lithium levels to rise dangerously.
C. Bipolar disorder medications should always be taken on an empty stomach.
D. Fever is a common side effect of therapeutic lithium levels.
Explanation:
Lithium levels increase when dehydration occurs. Fever and vomiting can significantly elevate lithium concentrations and increase toxicity risk.
Lithium levels increase when dehydration occurs. Fever and vomiting can significantly elevate lithium concentrations and increase toxicity risk.
Question 67
The nurse is assessing a newborn in the first week of life. Which factor increases the newborn’s risk for fluid volume deficit?
A. Their kidneys are highly efficient at concentrating urine.
B. They have a smaller body surface area relative to their weight.
C. They have a large proportion of water weight (approx. 75%).
D. They have a fully developed Renin-Angiotensin-Aldosterone System.
Explanation:
Newborns have a high percentage of body water and immature kidneys, making them especially vulnerable to rapid fluid losses and dehydration.
Newborns have a high percentage of body water and immature kidneys, making them especially vulnerable to rapid fluid losses and dehydration.
Question 68
The nurse is caring for a client with a potassium level of 6.6 mEq/L. Which ECG change indicates a life-threatening emergency?
A. Shortened QT interval.
B. Prominent U waves.
C. Tall, peaked T waves.
D. ST-segment depression.
Explanation:
A potassium level of 6.6 mEq/L indicates hyperkalemia. Tall, peaked T waves are a classic ECG finding and may precede fatal dysrhythmias.
A potassium level of 6.6 mEq/L indicates hyperkalemia. Tall, peaked T waves are a classic ECG finding and may precede fatal dysrhythmias.
Question 69
A client is admitted with suspected sepsis. Which isolation precaution is initially required?
A. Airborne.
B. Droplet.
C. Contact.
D. Standard only.
Explanation:
When sepsis is suspected from a potentially transmissible respiratory source, droplet precautions may be initiated until the cause is identified.
When sepsis is suspected from a potentially transmissible respiratory source, droplet precautions may be initiated until the cause is identified.
Question 70
The nurse is preparing to administer warfarin to a client whose INR is 5.5. What is the nurse’s priority action?
A. Administer the dose as prescribed and document the result.
B. Hold the dose and notify the healthcare provider.
C. Administer the dose and monitor for signs of bruising.
D. Prepare to administer protamine sulfate intravenously.
Explanation:
An INR of 5.5 indicates excessive anticoagulation and a high risk of bleeding. The nurse should hold warfarin and notify the healthcare provider immediately.
An INR of 5.5 indicates excessive anticoagulation and a high risk of bleeding. The nurse should hold warfarin and notify the healthcare provider immediately.
Question 71
A client on the medical unit develops sudden angioedema while taking an ACE inhibitor. Which medication should the nurse have ready?
A. Naloxone.
B. Epinephrine.
C. Vitamin K.
D. Protamine sulfate.
E. Flumazenil.
Explanation:
Angioedema can rapidly obstruct the airway. Epinephrine is a first-line emergency medication used to reduce airway swelling and support breathing.
Angioedema can rapidly obstruct the airway. Epinephrine is a first-line emergency medication used to reduce airway swelling and support breathing.
Question 72
The nurse is reviewing a fetal monitor strip and sees late decelerations. What does this pattern indicate?
A. Head compression.
B. Cord compression.
C. Placental insufficiency.
D. Reassuring fetal oxygenation.
Explanation:
Late decelerations occur after the peak of a contraction and are associated with uteroplacental insufficiency, indicating decreased fetal oxygenation.
Late decelerations occur after the peak of a contraction and are associated with uteroplacental insufficiency, indicating decreased fetal oxygenation.
Question 73
A nurse is preparing a client for a procedure. The surgeon has not yet explained the risks of the surgery. What should the nurse do?
A. Explain the risks to the client to save time for the surgeon.
B. Have the client sign the consent form and then call the surgeon.
C. Notify the surgeon that the client has questions about the risks and benefits.
D. Ask the client’s family to explain the risks to the client.
Explanation:
The provider performing the procedure is responsible for explaining risks, benefits, and alternatives. The nurse should notify the surgeon if the client has questions.
The provider performing the procedure is responsible for explaining risks, benefits, and alternatives. The nurse should notify the surgeon if the client has questions.
Question 74
The nurse is teaching a client about the use of crutches with a 2-point gait. Which description is correct?
A. Move both crutches forward together, then swing your legs forward.
B. Move one crutch and the opposite leg together, then the other crutch and leg.
C. Move both crutches forward, then swing the injured leg through.
D. Move one crutch, then the opposite leg, then the second crutch.
Explanation:
The 2-point gait mimics normal walking. One crutch and the opposite leg move forward together, followed by the other crutch and opposite leg.
The 2-point gait mimics normal walking. One crutch and the opposite leg move forward together, followed by the other crutch and opposite leg.
Question 75
A client with heart failure is found to have a serum sodium level of 132 mEq/L. Which is the most likely cause of this finding in a heart failure client?
A. Excessive dietary sodium intake.
B. Dilutional hyponatremia due to fluid volume excess.
C. Excessive use of laxatives and antacids.
D. Rapid replacement of fluid using 3% saline.
Explanation:
Heart failure often causes fluid retention. Excess water dilutes serum sodium, leading to dilutional hyponatremia.
Heart failure often causes fluid retention. Excess water dilutes serum sodium, leading to dilutional hyponatremia.
Question 76
A nurse is caring for a group of clients. Which client should the nurse see first?
A. A client with a tracheostomy requiring routine suctioning.
B. A client with diabetes whose blood glucose is 150 mg/dL.
C. A client reporting a “10/10” pain after a simple sprain.
D. A client with a new-onset facial droop and right-arm drift.
Explanation:
New-onset facial droop and arm drift are classic signs of an acute stroke. Immediate assessment is required because rapid intervention can reduce neurological damage.
New-onset facial droop and arm drift are classic signs of an acute stroke. Immediate assessment is required because rapid intervention can reduce neurological damage.
Question 77
A client on the psychiatric unit has a serum lithium level of 2.1 mEq/L. Which assessment finding is expected?
A. Increased appetite and weight gain.
B. Coarse hand tremors, blurred vision, and confusion.
C. Excessive energy and pressured speech.
D. Fine hand tremors and mild thirst.
Explanation:
A lithium level of 2.1 mEq/L is toxic. Symptoms include coarse tremors, confusion, blurred vision, ataxia, and severe gastrointestinal disturbances.
A lithium level of 2.1 mEq/L is toxic. Symptoms include coarse tremors, confusion, blurred vision, ataxia, and severe gastrointestinal disturbances.
Question 78
The nurse is assessing a 4-month-old infant for dehydration. Which finding is a classic cue of severe fluid loss in this age group?
A. Crying with the presence of tears.
B. A soft, flat anterior fontanelle.
C. Sunken eyes and a sunken fontanelle.
D. Capillary refill of 1.5 seconds.
Explanation:
Severe dehydration in infants commonly presents with sunken eyes, a depressed fontanelle, dry mucous membranes, and poor skin turgor.
Severe dehydration in infants commonly presents with sunken eyes, a depressed fontanelle, dry mucous membranes, and poor skin turgor.
Question 79
A client is admitted with diabetic ketoacidosis (DKA). Which type of insulin can the nurse administer intravenously for this client?
A. NPH insulin.
B. Regular insulin.
C. Insulin Glargine.
D. Insulin Aspart.
Explanation:
Regular insulin is the standard insulin used for intravenous administration in the treatment of diabetic ketoacidosis.
Regular insulin is the standard insulin used for intravenous administration in the treatment of diabetic ketoacidosis.
Question 80
Which isolation precaution is required for a client with disseminated shingles (herpes zoster)?
A. Contact precautions only.
B. Droplet precautions only.
C. Airborne and contact precautions.
D. Standard precautions only.
Explanation:
Disseminated herpes zoster can spread through airborne transmission and direct contact. Airborne and contact precautions are required until lesions are crusted.
Disseminated herpes zoster can spread through airborne transmission and direct contact. Airborne and contact precautions are required until lesions are crusted.
Question 81
The nurse receives these ABG results: pH 7.25, PaCO₂ 35, HCO₃ 18. What is the interpretation?
A. Respiratory acidosis.
B. Metabolic acidosis.
C. Respiratory alkalosis.
D. Metabolic alkalosis.
Explanation:
The pH is low (acidosis) and the HCO₃ is low, indicating a metabolic cause. This ABG reflects metabolic acidosis.
The pH is low (acidosis) and the HCO₃ is low, indicating a metabolic cause. This ABG reflects metabolic acidosis.
Question 82
A client with bone metastasis is lethargic and reporting severe constipation. Which electrolyte imbalance is most likely?
A. Hypokalemia.
B. Hypernatremia.
C. Hypercalcemia.
D. Hypomagnesemia.
Explanation:
Bone destruction from metastasis can release calcium into the bloodstream. Hypercalcemia commonly causes lethargy, weakness, and constipation.
Bone destruction from metastasis can release calcium into the bloodstream. Hypercalcemia commonly causes lethargy, weakness, and constipation.
Question 83
The nurse is planning care for a client with Clostridioides difficile. Which action by the UAP requires intervention by the nurse?
A. Using soap and water to wash hands after providing care.
B. Donning a gown and gloves before entering the room.
C. Using an alcohol-based hand rub to clean hands after removing gloves.
D. Placing the client in a private room with dedicated equipment.
Explanation:
Alcohol-based hand sanitizers do not effectively kill C. difficile spores. Handwashing with soap and water is required.
Alcohol-based hand sanitizers do not effectively kill C. difficile spores. Handwashing with soap and water is required.
Question 84
A client is receiving a magnesium sulfate infusion for preeclampsia. The nurse finds the client’s deep tendon reflexes are absent. Which action should the nurse take first?
A. Administer calcium gluconate as prescribed.
B. Stop the magnesium sulfate infusion immediately.
C. Document the finding as a common side effect.
D. Increase the infusion rate of the maintenance IV fluids.
E. Notify the healthcare provider within 2 hours.
Explanation:
Absent deep tendon reflexes are an early sign of magnesium toxicity. The infusion should be stopped immediately before further interventions.
Absent deep tendon reflexes are an early sign of magnesium toxicity. The infusion should be stopped immediately before further interventions.
Question 85
A nurse is preparing to enter the room of a client with influenza. Which PPE is mandatory?
A. N95 respirator.
B. Surgical mask.
C. Gown and gloves only.
D. No PPE is required if staying 6 feet away.
Explanation:
Influenza is spread through respiratory droplets. A surgical mask is required when caring for affected clients.
Influenza is spread through respiratory droplets. A surgical mask is required when caring for affected clients.
Question 86
A nurse is caring for a client who identifies as non-binary and has expressed a preference for they/them pronouns. Which action demonstrates adherence to the 2026 NCLEX standards for clinical equity?
A. Using the client’s legal name on the bedside identification band only.
B. Consistently using the client’s preferred pronouns during shift report.
C. Asking the client’s family members to confirm the client’s gender.
D. Documenting the pronouns in the chart and then using legal identifiers in person.
Explanation:
Respecting and consistently using a client’s preferred pronouns supports dignity, equity, inclusion, and patient-centered care.
Respecting and consistently using a client’s preferred pronouns supports dignity, equity, inclusion, and patient-centered care.
Question 87
A client with heart failure is taking digoxin. Which electrolyte imbalance increases this client’s risk for digoxin toxicity?
A. Hyperkalemia.
B. Hypokalemia.
C. Hypercalcemia.
D. Hypomagnesemia.
Explanation:
Low potassium levels enhance the effects of digoxin and significantly increase the risk of toxicity.
Low potassium levels enhance the effects of digoxin and significantly increase the risk of toxicity.
Question 88
The nurse is educating a client about lisinopril. Which instruction is the priority for safety?
A. “You may notice your urine turning a bright orange color.”
B. “Report any persistent, dry cough to your doctor.”
C. “Increase your intake of bananas and salt substitutes.”
D. “Limit your intake of high-calcium foods like cheese.”
Explanation:
A persistent dry cough is a common adverse effect of ACE inhibitors and should be reported to the healthcare provider.
A persistent dry cough is a common adverse effect of ACE inhibitors and should be reported to the healthcare provider.
Question 89
A client had a thyroidectomy 4 hours ago. The nurse notes the client has a thready pulse, is diaphoretic, and has visible swelling in the neck. What is the nurse’s priority intervention?
A. Check the client’s serum calcium level.
B. Notify the rapid response team and prepare for emergency airway management.
C. Reposition the client to a side-lying position.
D. Administer a dose of pain medication as prescribed.
Explanation:
Neck swelling after thyroidectomy may indicate hemorrhage causing airway compression. Airway management is the highest priority.
Neck swelling after thyroidectomy may indicate hemorrhage causing airway compression. Airway management is the highest priority.
Question 90
A client on the unit has a serum potassium level of 2.8 mEq/L. Which action by the nurse is correct?
A. Administering potassium chloride IV push immediately.
B. Adding potassium chloride to the current IV bag and giving it over 4 hours.
C. Shaking the potassium vial vigorously before adding it to the IV.
D. Encouraging the client to eat a high-sodium snack.
Explanation:
Potassium must never be administered IV push. It should be diluted and infused slowly according to facility guidelines.
Potassium must never be administered IV push. It should be diluted and infused slowly according to facility guidelines.
Question 91
The nurse is preparing a client for surgery. The surgeon has explained the procedure. What is the nurse’s responsibility when witnessing the signature?
A. Explaining the risks and benefits if the surgeon forgot.
B. Ensuring the client is competent and giving consent voluntarily.
C. Ensuring the client has a living will on file.
D. Providing the client with information about hospital billing.
Explanation:
The nurse verifies that the client is competent, understands the process, and signs the consent voluntarily.
The nurse verifies that the client is competent, understands the process, and signs the consent voluntarily.
Question 92
The nurse is monitoring a client with heart failure. Which change should be reported to the provider immediately?
A. A weight gain of 0.25 kg (0.5 lb) in 24 hours.
B. A weight gain of 1 kg (2.2 lbs) in 24 hours.
C. An intake of 1,500 mL and output of 1,400 mL.
D. A blood pressure reading of 130/80 mmHg.
Explanation:
A weight gain of more than 1 kg (2.2 lbs) in 24 hours may indicate significant fluid retention and worsening heart failure.
A weight gain of more than 1 kg (2.2 lbs) in 24 hours may indicate significant fluid retention and worsening heart failure.
Question 93
A client with a leg injury is using crutches with a 4-point gait. Which description is correct?
A. “Move one crutch, then the opposite foot, then the second crutch, then the remaining foot.”
B. “Move both crutches and the injured leg together.”
C. “Swing both feet forward to meet the crutches.”
D. “Move one crutch and the same-side foot together.”
Explanation:
The 4-point gait provides maximum stability by moving one crutch and one foot at a time in sequence.
The 4-point gait provides maximum stability by moving one crutch and one foot at a time in sequence.
Question 94
A client is admitted with diabetic ketoacidosis. The nurse should expect which acid-base imbalance?
A. Respiratory alkalosis.
B. Metabolic alkalosis.
C. Respiratory acidosis.
D. Metabolic acidosis.
Explanation:
DKA causes accumulation of ketone acids, resulting in metabolic acidosis.
DKA causes accumulation of ketone acids, resulting in metabolic acidosis.
Question 95
Which isolation precaution is required for a client with Neisseria meningitidis?
A. Airborne.
B. Droplet.
C. Contact.
D. Standard only.
Explanation:
Neisseria meningitidis is transmitted through respiratory droplets and requires droplet precautions.
Neisseria meningitidis is transmitted through respiratory droplets and requires droplet precautions.
Question 96
A nurse is preparing to administer heparin subcutaneously. Which action is correct?
A. Aspirate for blood return before injecting.
B. Massage the site vigorously after injection to improve absorption.
C. Use a 25-gauge needle and inject into the abdomen, avoiding the umbilicus.
D. Administer the injection into the deltoid muscle.
Explanation:
Heparin is administered subcutaneously into the abdomen. The site should not be aspirated or massaged due to bleeding risk.
Heparin is administered subcutaneously into the abdomen. The site should not be aspirated or massaged due to bleeding risk.
Question 97
A client is caring for a client with a serum sodium level of 120 mEq/L reporting a severe headache. Which IV solution should the nurse anticipate using?
A. 0.45% Normal Saline.
B. 5% Dextrose in Water (D5W).
C. 3% Normal Saline.
D. 0.9% Normal Saline.
E. Lactated Ringer’s.
Explanation:
Severe symptomatic hyponatremia may require hypertonic saline (3% NaCl) to raise the serum sodium level safely.
Severe symptomatic hyponatremia may require hypertonic saline (3% NaCl) to raise the serum sodium level safely.
Question 98
A client is taking a beta-blocker for hypertension. Which condition in the client’s history requires the nurse to use extreme caution?
A. Hypertension.
B. Chronic kidney disease.
C. Asthma.
D. Osteoarthritis.
Explanation:
Beta-blockers can cause bronchoconstriction and may worsen asthma symptoms, especially nonselective agents.
Beta-blockers can cause bronchoconstriction and may worsen asthma symptoms, especially nonselective agents.
Question 99
A nurse is caring for a group of clients. Which task is most appropriate to delegate to the UAP?
A. Assessing the skin integrity of a client in restraints.
B. Feeding a stable client who had a stroke two weeks ago.
C. Teaching a client how to perform a dressing change.
D. Monitoring a client during a blood transfusion.
Explanation:
Feeding stable clients is an appropriate task for a UAP. Assessment, teaching, and monitoring during transfusions require licensed nursing judgment.
Feeding stable clients is an appropriate task for a UAP. Assessment, teaching, and monitoring during transfusions require licensed nursing judgment.
Question 100
The nurse receives these ABG results: pH 7.32, PaCO₂ 50, HCO₃ 24. What is the interpretation?
A. Respiratory acidosis.
B. Metabolic acidosis.
C. Respiratory alkalosis.
D. Metabolic alkalosis.
Explanation:
The pH is low (acidosis) and the PaCO₂ is elevated, indicating respiratory acidosis.
The pH is low (acidosis) and the PaCO₂ is elevated, indicating respiratory acidosis.
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Disclaimer: These NCLEX-style practice questions are provided for educational and self-assessment purposes only. While every effort has been made to ensure accuracy, some questions may be simplified or adapted for learning purposes and may not exactly reflect current NCLEX exam content, NCSBN guidelines, or local clinical policies. Always refer to your nursing textbooks, instructors, facility protocols, and official NCLEX resources for the most up-to-date information. Exam Objective Nursing is not affiliated with or endorsed by the National Council of State Boards of Nursing (NCSBN).
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