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NCLEX-RN original latest material

150 questions · Original · Latest version

Question 1

The nurse receives handoff reports for four clients on a medical-surgical unit. Which client should the nurse assess first?

  1. A. A client with heart failure who has bilateral ankle edema and gained 0.5 kg in 24 hours
  2. B. A client 8 hours after thyroidectomy who reports neck tightness and has a new high-pitched inspiratory sound
  3. C. A client with pneumonia who has a temperature of 38.2°C (100.8°F) and an oxygen saturation of 94% on prescribed oxygen
  4. D. A client 1 day after knee replacement who reports incisional pain of 7 on a 0–10 scale

ANS: Answer: B

Neck tightness and inspiratory stridor after thyroidectomy suggest an expanding hematoma or laryngeal edema threatening the airway. This client requires immediate assessment and emergency intervention. Mild weight gain and ankle edema require follow-up but do not indicate an immediate airway threat. Fever with adequate oxygenation in a client with pneumonia is less urgent. Postoperative pain needs treatment, but airway compromise takes priority.

Question 2

An RN is assigning care to an experienced unlicensed assistive personnel (UAP). Which task is appropriate to delegate?

  1. A. Determine whether a newly admitted client is at risk for falls
  2. B. Teach a client how to use a walker after hip surgery
  3. C. Measure and record urine output for a stable client with an indwelling urinary catheter
  4. D. Evaluate whether a client's dizziness improved after an antihypertensive dose was reduced

ANS: Answer: C

Measuring and recording urine output is a routine task appropriate for trained UAP when the client is stable; the RN interprets findings and follows up on abnormalities. Determining fall risk requires nursing assessment. Initial walker teaching requires professional judgment and evaluation of learning. Evaluating a response to a medication change is also an RN responsibility.

Question 3

A hospitalized client develops frequent watery stools, and testing confirms Clostridioides difficile infection. Which actions should the nurse take? Select all that apply.

  1. A. Wear a gown and gloves when entering the client's room
  2. B. Use soap and water for hand hygiene after providing care
  3. C. Use dedicated client-care equipment when possible
  4. D. Wear a fit-tested N95 respirator for routine bedside care
  5. E. Clean contaminated environmental surfaces with an approved sporicidal product

ANS: Answer: A, B, C, E

C. difficile spreads through spores that contaminate hands, equipment, and surfaces. Contact precautions include gown and gloves, dedicated equipment, and sporicidal environmental cleaning. Soap and water physically remove spores and should be used after care; alcohol-based sanitizer does not reliably kill spores. An N95 respirator is not needed for routine care because C. difficile does not require airborne precautions.

Question 4

A client receiving chemotherapy has an absolute neutrophil count of 300/mm³. During assessment, the nurse obtains an oral temperature of 38.3°C (100.9°F). The client reports feeling chilled but has no other new symptoms. What is the nurse's priority action?

  1. A. Recheck the temperature in 2 hours before reporting it
  2. B. Administer prescribed acetaminophen and reassess at the next routine vital-sign check
  3. C. Immediately notify the provider and initiate the facility's neutropenic fever protocol
  4. D. Obtain a rectal temperature to confirm the fever

Question 5

A client at 30 weeks of gestation calls the prenatal clinic. Which report requires immediate evaluation?

  1. A. Mild ankle swelling that improves after resting with the feet elevated
  2. B. Occasional heartburn after eating a large meal
  3. C. A persistent severe headache with blurred vision
  4. D. Brief irregular uterine tightening that resolves with hydration

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