NCLEX-RN PRACTICE EXAM Questions

NCLEX-RN PRACTICE EXAM Questions And ( Answers) Plus Rationales 2025 Q&A Instant Download PDF

• A nurse is caring for a client who has heart failure and is receiving

furosemide. Which finding indicates the medication is effective?

• Presence of dependent edema
• Jugular vein distention
• Weight gain of 1 kg
• Clear lung sounds

Rationale: Furosemide is a diuretic that reduces fluid overload. Clear

lung sounds indicate reduced pulmonary congestion.

• A client with pneumonia has a productive cough and is weak. What

should the nurse do first?

• Encourage fluid intake
• Assist the client to sit upright 1 / 4

• Provide a cough suppressant
• Obtain a sputum specimen

Rationale: Sitting upright promotes lung expansion and drainage of

secretions, improving oxygenation.

• Which statement by a client taking warfarin indicates the need for

further teaching?

• "I will avoid drinking alcohol."
• "I will use an electric razor."
• "I will take aspirin for headaches."
• "I will keep my lab appointments for INR checks."

Rationale: Aspirin increases bleeding risk and should be avoided with

warfarin.

4. A nurse prepares to administer regular insulin subcutaneously at 7:30

AM. The nurse should monitor for signs of hypoglycemia at what time?

A. 8:00 AM

B. 9:30 AM

C. 12:00 PM

D. 2:00 PM

Rationale: Regular insulin peaks in 2-4 hours; thus, hypoglycemia is

likely around 9:30-11:30 AM.

• A nurse is caring for a client who is 2 hours postoperative following a

cardiac catheterization. Which assessment is the priority? 2 / 4

• Urinary output
• Peripheral pulses
• Oxygen saturation
• Blood glucose level

Rationale: Monitoring peripheral pulses ensures circulation distal to

the catheter insertion site, preventing ischemia.

• Which finding in a newborn requires immediate intervention?
• Acrocyanosis
• Positive Babinski reflex
• Moro reflex present
• Grunting respirations

Rationale: Grunting indicates respiratory distress and needs prompt

intervention.

• A nurse is teaching a client about a low-sodium diet. Which food

should the client avoid?

• Fresh fruits
• Plain rice
• Baked chicken
• Canned soup

Rationale: Canned soups are high in sodium and should be avoided.

• Which is the most reliable method to verify placement of a nasogastric

tube?

• Inject air and auscultate 3 / 4

• Ask the client to speak
• X-ray confirmation
• Check residual volume

Rationale: An abdominal X-ray is the gold standard to confirm NG

tube placement.

• A nurse finds a client having a tonic-clonic seizure. What is the nurse’s

priority action?

• Insert an oral airway
• Restrain the client’s movements
• Move the client to bed
• Turn the client to the side

Rationale: Turning the client prevents aspiration and promotes

airway patency.

• Which lab result should the nurse report for a client on heparin

therapy?

• Platelet count of 250,000/mm³
• INR of 1.0
• Hemoglobin of 13 g/dL
• Platelet count of 50,000/mm³

Rationale: A low platelet count may indicate heparin-induced

thrombocytopenia, which is life-threatening.

• A nurse is assessing a client with COPD. Which finding requires

immediate intervention?

• / 4