1.

A nurse is caring for a client who has just returned from a

cardiac catheterization. Which finding requires immediate
action?

A. Small hematoma at insertion site

B. Mild oozing of blood on dressing
C. Dorsalis pedis pulse absent in affected leg
D. Heart rate 98 bpm

2. Which task is appropriate for a UAP assisting with

postmortem care?

A. Remove all tubes if an autopsy is ordered

B. Document time of death
C. Position the body in normal alignment
D. Notify the family

3. A client with a central venous catheter develops sudden chest

pain and dyspnea. What is the nurse’s priority action?

A. Administer oxygen
B. Clamp the catheter
C. Place the client on left side with head down
D. Notify the provider

4. Which finding requires immediate action for a client receiving

IV potassium?

A. Complains of burning at IV site

B. Reports nausea
C. ECG shows peaked T waves
D. Urine output 50 mL/hr
5. Which action by the nurse reduces risk of infection for a client
with a urinary catheter?

A. Irrigate the catheter daily

B. Keep the drainage bag below bladder level
C. Change the catheter every 3 days
D. Clamp the catheter periodically

6. A client with cirrhosis has increasing abdominal girth. Which

is the priority nursing action?

A. Measure abdominal girth

B. Restrict sodium intake
C. Assess respiratory status
D. Document daily weight

7. Which client should be assigned to a private room?

A. Client with HIV

B. Client with varicella
C. Client with diabetes mellitus
D. Client with COPD

8. A nurse receives a new prescription for a client with heart

failure: “Administer 40 mg IV furosemide stat.” Which lab should
be checked first?

A. Hemoglobin
B. Potassium
C. Glucose
D. BUN
9. Which indicates effective teaching for a client taking warfarin?

A. “I will eat more green leafy vegetables.”

B. “I should use a soft toothbrush.”
C. “I can take aspirin for headaches.”
D. “I don’t need to monitor my lab values.”

10. Which client should the nurse see first?

A. Client with angina reporting chest pain 3/10

B. Client post thyroidectomy with hoarse voice
C. Client with pneumonia and productive cough
D. Client with renal colic requesting pain medication

11. A client with COPD has a prescription for oxygen at 6 L/min.

What should the nurse do first?

A. Administer oxygen as prescribed

B. Lower the flow rate
C. Place client in high Fowler’s
D. Notify the provider

12. Which finding is a late sign of hypoxia?

A. Restlessness
B. Confusion
C. Cyanosis
D. Tachycardia

13. A nurse is caring for a client receiving TPN. Which lab

requires immediate action?

A. Glucose 180 mg/dL

B. Potassium 4.2 mEq/L
C. Sodium 142 mEq/L
D. Blood glucose 55 mg/dL

14. A client on digoxin

Absolutely — let’s improve Day 5 with fresh, high-difficulty

NCLEX-style questions (with clear gaps and good spacing). I’ll
rewrite 1–15 now with changed questions and improved flow. If
you like this, I’ll complete all 50 in this style.

1. A client is scheduled for a paracentesis. Which action should

the nurse take first?

A. Ask the client to empty the bladder

B. Position the client flat
C. Insert an IV line
D. Administer pain medication

2. A nurse finds a client lying on the floor who is unresponsive

but breathing. What should the nurse do first?

A. Check for a medical alert bracelet

B. Call for help and stay with the client
C. Start chest compressions
D. Place a pillow under the head

3. A client receiving IV vancomycin reports flushing and itching.

The nurse notes redness of the neck and face. What is the
priority action?
A. Discontinue the IV immediately
B. Slow the infusion rate
C. Administer diphenhydramine
D. Call the provider

4. Which finding indicates an adverse effect of morphine?

A. Respiratory rate of 8/min

B. Itching at the IV site
C. Blood pressure 128/80 mmHg
D. Mild sedation

5. A client has a chest tube with continuous bubbling in the

water seal chamber. What should the nurse do?

A. Clamp the tube

B. Check for air leaks
C. Increase suction
D. Strip the tubing

6. A nurse is preparing to administer 0900 medications when a

client refuses a dose of digoxin. What is the priority action?

A. Document the refusal

B. Explain the importance of the medication
C. Notify the provider
D. Withhold the dose and reassess later

7. A nurse is caring for a client with severe burns. Which finding

indicates possible sepsis?

A. Low-grade fever
B. Blood pressure 120/70 mmHg
C. Urine output 50 mL/hr
D. Confusion and restlessness

8. Which lab result should the nurse monitor closely for a client
on heparin therapy?

A. INR
B. Platelet count
C. Hematocrit
D. Potassium

9. A nurse notices an electrical fire in a client’s room. What is the

priority action?

A. Rescue any clients in immediate danger

B. Pull the fire alarm
C. Extinguish the fire
D. Close the doors and windows

10. A client post-thyroidectomy reports tingling around the

mouth. What is the priority assessment?

A. Assess potassium level

B. Check blood glucose
C. Check for Chvostek’s sign
D. Review thyroid hormone level

11. A nurse prepares to administer insulin to a client with blood

glucose of 60 mg/dL. What is the first action?

A. Hold the insulin

B. Give juice and recheck in 15 minutes
C. Notify the provider
D. Give the insulin as ordered

12. A nurse is planning care for a client with a new

tracheostomy. Which intervention takes priority?

A. Provide humidified air

B. Change the tracheostomy ties daily
C. Keep a suction kit at bedside
D. Clean the inner cannula every shift

13. Which client should the nurse see first?

A. A client with asthma using accessory muscles

B. A client with diabetes requesting snacks
C. A client with a wound needing a dressing change
D. A client asking about discharge instructions

14. A client receiving chemotherapy is at risk for which

complication?

A. Hypoglycemia
B. Hypertension
C. Neutropenia
D. Hyperthyroidism

15. Which action by the nurse helps prevent ventilator-

associated pneumonia (VAP)?

A. Keeping the head of bed flat

B. Frequent suctioning
C. Daily sedation vacations
D. Using sterile gloves for mouth care
16. A nurse is teaching a client with heart failure about daily
weights. Which statement indicates understanding?

A. “I will weigh myself after I eat breakfast.”

B. “I will use different scales if needed.”
C. “I will weigh myself at the same time every day.”
D. “I will wear different clothes each time.”

17. Which is a priority finding for a client with peritoneal dialysis?

A. Clear pale yellow drainage

B. Weight gain of 1 kg
C. Cloudy effluent
D. Mild abdominal discomfort

18. Which prescription should the nurse question for a client

with chronic kidney disease?

A. Low-protein diet
B. Ibuprofen every 8 hours
C. Erythropoietin injection
D. Phosphate binder with meals

19. A client with a DVT is receiving heparin. Which observation

requires immediate intervention?

A. Mild epistaxis
B. Small bruise at injection site
C. Coffee-ground emesis
D. Mild anxiety

20. A nurse is caring for a client with COPD. Which meal

selection is best?

A. Hot soup and crackers

B. Grilled chicken and potato salad
C. Spaghetti with garlic bread
D. Chili and cornbread

21. Which instruction should the nurse give to a client collecting

a 24-hour urine specimen?

A. Keep the urine at room temperature

B. Discard the first void, then start collection
C. Save only the first morning urine
D. Add ice only if it appears cloudy

22. Which symptom indicates digoxin toxicity?

A. Increased appetite
B. Bradycardia
C. Hypertension
D. Tachypnea

23. A nurse assesses a client who had a femoral angiogram.

Which finding is most concerning?

A. Bruising at puncture site

B. Weak pedal pulse on affected leg
C. Mild discomfort at site
D. Pink-tinged drainage

24. Which statement by a client with a new colostomy indicates

correct understanding?
A. “I will eat high-fiber foods immediately.”
B. “I can expect some mucus in the bag.”
C. “I do not need to worry about gas.”
D. “I should avoid drinking fluids.”

25. Which is a priority intervention for a client experiencing

anaphylaxis?

A. Administer IV steroids
B. Apply oxygen
C. Check blood pressure
D. Give epinephrine

26. A nurse is caring for a client with Cushing’s syndrome.

Which finding is expected?

A. Weight loss
B. Hypoglycemia
C. Hypotension
D. Thin fragile skin

27. Which task can the nurse delegate to a UAP?

A. Assess bowel sounds

B. Administer enemas
C. Record oral intake
D. Teach incentive spirometry

28. Which indicates possible fluid overload in a client receiving

IV fluids?

A. BP 110/70 mmHg
B. Lung crackles
C. Skin warm and dry
D. Heart rate 72 bpm

29. Which finding is an early sign of increased ICP?

A. Bradycardia
B. Widened pulse pressure
C. Restlessness
D. Dilated pupils

30. Which finding is most concerning for a client with diabetes

mellitus?

A. Fasting glucose 120 mg/dL

B. HbA1c 7%
C. Foot ulcer with purulent drainage
D. Complaints of thirst

31. A client is receiving TPN via central line. Which action is

appropriate?

A. Increase rate if solution is behind

B. Use a dedicated lumen for TPN only
C. Piggyback medications through the line
D. Flush with tap water

32. A nurse is caring for a client with a potassium level of 2.8

mEq/L. Which is a priority?

A. Monitor for muscle weakness

B. Encourage deep breathing
C. Increase fluid intake
D. Restrict sodium
33. Which action prevents aspiration in a client with dysphagia?

A. Offer liquids with a straw

B. Encourage talking during meals
C. Tilt head slightly forward while swallowing
D. Use large spoonfuls

34. Which indicates a complication of IV therapy?

A. Red, warm area along the vein

B. Fluid flows freely with no swelling
C. Transparent dressing intact
D. IV site is dry

35. A nurse is teaching foot care to a client with peripheral

neuropathy. Which statement shows correct understanding?

A. “I will soak my feet every night.”

B. “I will walk barefoot at home.”
C. “I will check my feet daily.”
D. “I will use hot water bottles in winter.”

36. Which action helps prevent catheter-associated urinary tract

infection?

A. Keep catheter bag on bed

B. Use sterile technique for insertion
C. Clamp catheter when not in use
D. Change catheter daily

37. A client with tuberculosis is placed on airborne precautions.

Which statement by the nurse is correct?
A. “You may leave your room with no mask.”
B. “Staff must wear an N95 respirator.”
C. “Visitors do not need masks.”
D. “The door can remain open.”

38. Which finding in a newborn requires immediate intervention?

A. Acrocyanosis
B. Respiration rate 44/min
C. Nasal flaring and grunting
D. Positive Moro reflex

39. Which client should the nurse assess first?

A. Client with stable vital signs post-op

B. Client with mild incisional pain
C. Client requesting to ambulate
D. Client reporting sudden shortness of breath

40. Which lab result should the nurse report immediately?

A. Hemoglobin 13 g/dL
B. Platelets 50,000/mm³
C. WBC 8,000/mm³
D. Potassium 4.0 mEq/L

41. A client is receiving blood transfusion and develops chills

and back pain. What is the first action?

A. Slow the transfusion rate

B. Check the vital signs
C. Stop the transfusion
D. Notify the provider

42. Which is an expected finding for a client with right-sided

heart failure?

A. Dry cough
B. Crackles in lung bases
C. Jugular vein distention
D. Pink frothy sputum

43. A nurse prepares to give enoxaparin to a client. Which site is

appropriate?

A. Vastus lateralis
B. Deltoid muscle
C. Abdomen
D. Dorsogluteal

44. Which action is most important after a liver biopsy?

A. Place client in high Fowler’s

B. Monitor urine output
C. Position client on right side
D. Encourage fluids

45. Which client statement indicates understanding of low-

sodium diet?

A. “I will avoid processed foods.”

B. “I can eat canned soup daily.”
C. “I will use extra salt when cooking.”
D. “I should eat cured meats for protein.”
46. A nurse is caring for a client with neutropenia. Which
instruction is appropriate?

A. Avoid fresh flowers in the room

B. Use rectal suppositories for constipation
C. Drink only tap water
D. Attend large public events

47. Which is a sign of hypoglycemia?

A. Dry, flushed skin

B. Fruity breath odor
C. Confusion and sweating
D. Deep rapid respirations

48. Which position is best for a client with aspiration risk?

A. Supine
B. Semi-Fowler’s
C. Trendelenburg
D. Prone

49. A nurse is caring for a client with hyperthyroidism. Which

finding requires immediate action?

A. Heart rate 120 bpm

B. Weight loss
C. Diarrhea
D. Temperature 104°F (40°C)

50. Which nursing action helps prevent pressure injuries?

A. Massage reddened bony areas

B. Reposition client every 2 hours
C. Keep bed flat at all times
D. Limit fluid intake