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NCLEX Readiness Exam| Questions And Correct
Answers (Verified Answers) Plus Rationales
2025 Q&A | Instant Download Pdf
- A client with congestive heart failure reports increased shortness of breath and fatigue. Which assessment finding should the nurse prioritize? a) Peripheral edema b) Crackles in lung bases c) Mild weight gain d) Decreased urine output b) Crackles in lung bases Crackles indicate pulmonary congestion, which can lead to respiratory distress and require immediate attention in CHF.
- Which intervention should the nurse implement first for a client experiencing hypoglycemia? a) Administer insulin b) Give 15-20 grams of fast-acting carbohydrates c) Check blood pressure d) Call the healthcare provider
b) Give 15-20 grams of fast-acting carbohydrates Immediate administration of carbohydrates is the priority to raise blood glucose and prevent neurological damage.
- A client with a new ileostomy expresses concern about skin irritation around the stoma. What is the best nursing response? a) "Try to keep the area dry and clean." b) "Apply an over-the-counter cream on the skin." c) "Use warm water and a mild soap to cleanse the area." d) "Avoid changing the pouch frequently." c) Use warm water and a mild soap to cleanse the area. Gentle cleansing prevents irritation; harsh soaps or creams can worsen skin breakdown.
- When teaching a client about warfarin therapy, which statement indicates the need for further teaching? a) "I will avoid foods high in vitamin K like spinach." b) "I should have my blood tested regularly." c) "I can stop taking the medication if I feel fine." d) "I will report any unusual bleeding immediately." c) "I can stop taking the medication if I feel fine." Clients must not stop warfarin without provider guidance due to risk of thrombosis.
a) Supine with head elevated b) Prone c) Side-lying d) Trendelenburg c) Side-lying Side-lying position promotes drainage and reduces risk of aspiration.
- A nurse is teaching a client newly diagnosed with type 1 diabetes about insulin administration. Which statement indicates understanding? a) "I will inject insulin into a muscle." b) "I should rotate injection sites within the same area." c) "I will only give insulin when I feel symptoms of high blood sugar." d) "I don’t need to monitor my blood glucose if I take insulin." b) "I should rotate injection sites within the same area." Rotating sites prevents lipodystrophy and ensures consistent absorption.
- A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid? a) Apples b) Bananas c) Rice d) Green beans
b) Bananas Bananas are high in potassium and should be avoided in clients at risk for hyperkalemia. 10.A client with asthma uses a metered-dose inhaler (MDI). What is the correct sequence for administering two puffs? a) Shake, inhale, press canister, hold breath b) Shake, press canister, inhale, hold breath c) Press canister, inhale, shake, hold breath d) Inhale, shake, press canister, hold breath b) Shake, press canister, inhale, hold breath Shaking ensures medication mixing; pressing before inhalation delivers the dose properly. 11.The nurse is caring for a client with neutropenia. Which precaution is most important? a) Place client in a negative pressure room b) Encourage visitors with colds to visit briefly c) Use strict hand hygiene and limit visitors d) Administer broad-spectrum antibiotics immediately c) Use strict hand hygiene and limit visitors Clients with neutropenia have high infection risk; strict hygiene and visitor screening are essential.
c) Notify the healthcare provider d) Prepare for intubation a) Reassess oxygen saturation to confirm Confirming the reading rules out equipment error before intervening. 15.A client with a history of deep vein thrombosis is prescribed heparin. What lab test is used to monitor therapeutic effect? a) INR b) PT c) aPTT d) Platelet count c) aPTT aPTT is used to monitor heparin anticoagulation therapy. 16.A nurse is teaching a client about signs of hypoglycemia. Which symptom should the nurse include? a) Increased thirst b) Polyuria c) Sweating and shakiness d) Dry mouth c) Sweating and shakiness Sweating and shakiness are classic symptoms of low blood glucose.
17.Which electrolyte imbalance is a priority concern for a client with chronic diarrhea? a) Hyperkalemia b) Hypokalemia c) Hypernatremia d) Hyponatremia b) Hypokalemia Diarrhea causes potassium loss, increasing risk of hypokalemia. 18.A client with Parkinson’s disease is taking levodopa. Which side effect should the nurse monitor? a) Bradycardia b) Dyskinesia c) Hyperglycemia d) Constipation b) Dyskinesia Levodopa can cause involuntary movements known as dyskinesias. 19.Which action is appropriate when suctioning an adult client’s tracheostomy? a) Apply suction while inserting the catheter b) Limit suction time to 15 seconds
22.Which of the following is a sign of magnesium toxicity? a) Hyperreflexia b) Hypotension and respiratory depression c) Tachycardia d) Diarrhea b) Hypotension and respiratory depression High magnesium depresses neuromuscular and cardiovascular function. 23.A nurse is teaching a client about a low-sodium diet. Which food choice indicates understanding? a) Canned soup b) Fresh fruit c) Processed cheese d) Pickles b) Fresh fruit Fresh fruits naturally contain little to no sodium. 24.Which of the following vaccines is contraindicated in pregnancy? a) Influenza (inactivated) b) Tetanus, diphtheria, pertussis (Tdap) c) Measles, mumps, rubella (MMR) d) Hepatitis B
c) Measles, mumps, rubella (MMR) MMR is a live vaccine and contraindicated during pregnancy. 25.A client is on contact precautions for Clostridium difficile. What personal protective equipment (PPE) is essential? a) Gloves and gown b) Mask and gloves c) Gown and N95 respirator d) Gloves, gown, and face shield a) Gloves and gown Contact precautions for C. diff require gloves and gown; masks are not necessary. 26.What is the priority nursing action for a client exhibiting signs of anaphylaxis? a) Administer diphenhydramine b) Maintain airway and administer epinephrine c) Place client in trendelenburg position d) Monitor vital signs every 15 minutes b) Maintain airway and administer epinephrine Epinephrine is the first-line treatment to reverse anaphylaxis and maintain airway. 27.Which of the following would indicate a positive response to diuretic therapy?
30.What is the correct order for donning PPE? a) Gloves, gown, mask b) Mask, gown, gloves c) Gown, mask, gloves d) Mask, gloves, gown b) Mask, gown, gloves Mask goes on first to protect respiratory tract, then gown, then gloves. 31.A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding indicates the client is experiencing respiratory acidosis? a) Elevated pH, low PaCO b) Low pH, elevated PaCO c) Elevated pH, elevated PaCO d) Low pH, low PaCO b) Low pH, elevated PaCO Respiratory acidosis is characterized by decreased pH and elevated carbon dioxide. 32.What is the earliest sign of hypoxia in a client? a) Cyanosis b) Restlessness and agitation
c) Bradycardia d) Confusion b) Restlessness and agitation Neurological changes like restlessness occur early due to insufficient oxygen. 33.Which of the following interventions helps prevent deep vein thrombosis in a post-op client? a) Encourage bed rest b) Apply sequential compression devices c) Limit fluid intake d) Administer analgesics b) Apply sequential compression devices SCDs promote venous return and reduce clot risk. 34.Which of the following lab values is most important to monitor for a client receiving lithium therapy? a) Serum sodium b) Serum potassium c) Serum lithium levels d) Blood glucose c) Serum lithium levels Monitoring lithium levels is critical to prevent toxicity.
b) Platelet count Petechiae are often caused by thrombocytopenia. 38.What is the most important action when caring for a client with Cushing’s syndrome? a) Monitor blood glucose levels b) Encourage weight loss c) Limit fluid intake d) Increase salt intake a) Monitor blood glucose levels Clients with Cushing’s often have hyperglycemia requiring monitoring. 39.Which of the following is a sign of digoxin toxicity? a) Constipation b) Visual disturbances such as yellow halos c) Increased appetite d) Bradycardia with no other symptoms b) Visual disturbances such as yellow halos Visual changes are classic signs of digoxin toxicity. 40.Which position is best for a client after a lumbar puncture? a) Supine flat b) Sitting upright
c) Trendelenburg d) Side-lying with head elevated a) Supine flat Lying flat reduces the risk of post-lumbar puncture headache. 41.Which of the following is the most appropriate pain assessment tool for a 3 - year-old child? a) Numeric rating scale b) FACES pain scale c) Visual analog scale d) McGill Pain Questionnaire b) FACES pain scale The FACES scale is suitable for young children who cannot use numeric scales. 42.Which food should a client taking MAO inhibitors avoid? a) Bananas b) Aged cheese c) Apples d) Rice b) Aged cheese Aged cheese contains tyramine, which can cause hypertensive crisis with MAOIs.
a) Verify the client’s identity and blood compatibility Patient and blood match verification prevents transfusion reactions. 46.What symptom would indicate hyperthyroidism? a) Weight gain b) Cold intolerance c) Tachycardia d) Constipation c) Tachycardia Hyperthyroidism increases metabolism and heart rate. 47.Which of the following interventions prevents ventilator-associated pneumonia? a) Elevate the head of the bed 30–45 degrees b) Suction the endotracheal tube every hour c) Keep the client supine d) Limit oral care to once daily a) Elevate the head of the bed 30–45 degrees Elevation reduces aspiration risk and pneumonia incidence. 48.What is the correct action for a nurse who notices a fire in a client’s room? a) Rescue clients, activate alarm, contain fire, extinguish fire b) Activate alarm, rescue clients, contain fire, extinguish fire
c) Contain fire, extinguish fire, activate alarm, rescue clients d) Extinguish fire, activate alarm, rescue clients, contain fire a) Rescue clients, activate alarm, contain fire, extinguish fire RACE acronym guides fire response in healthcare. 49.Which lab result indicates that a client is experiencing diabetic ketoacidosis (DKA)? a) Blood glucose 180 mg/dL, pH 7. b) Blood glucose 450 mg/dL, pH 7. c) Blood glucose 90 mg/dL, pH 7. d) Blood glucose 200 mg/dL, pH 7. b) Blood glucose 450 mg/dL, pH 7. High glucose and acidosis (low pH) indicate DKA. 50.Which vaccine is recommended annually for healthcare workers? a) Varicella b) Influenza c) Pneumococcal d) MMR b) Influenza Annual flu vaccination is recommended for healthcare workers to prevent spread.
