Clinical Nursing Practice for NCLEX Success

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Sample questions from Clinical Nursing Practice for NCLEX Success

This material has 20 questions with answers and rationales. Here are the first 5.

1. 1.The nurse receives handoff on four clients. Which client should the nurse assess first?

   • A.A. A client with COPD whose oxygen saturation is 90% within the prescribed target and who reports usual breathing
   • B.B. A postoperative client with new confusion, respiratory rate 30/min, and blood pressure 86/48 mm Hg
   • C.C. A client with arthritis reporting chronic knee pain rated 6 out of 10 before a scheduled analgesic
   • D.D. A client awaiting discharge who needs reinforcement of dressing-change instructions

   Rationale: B is correct because the new neurological change, tachypnea, and hypotension indicate acute instability and possible shock. A describes a stable client meeting an individualized oxygen target. C requires pain management but has no stated acute threat. D requires teaching, but teaching is lower priority than immediate physiological instability.

2. 2.A client who received IV morphine is difficult to arouse. Respirations are shallow at 6/min, and oxygen saturation is 96% on supplemental oxygen. Which action is the priority?

   • A.A. Document that oxygenation is adequate and reassess in 30 minutes
   • B.B. Remove the oxygen to obtain a more accurate assessment
   • C.C. Support airway and ventilation, summon help, and prepare naloxone under protocol
   • D.D. Give the next prescribed analgesic early to prevent breakthrough pain

   Rationale: C is correct because severe sedation and slow, shallow breathing indicate inadequate ventilation and possible opioid toxicity. Airway and ventilation support must not wait for naloxone to work. A incorrectly treats a normal saturation as proof of adequate ventilation. B removes needed support without treating the problem. D could worsen respiratory depression.

3. 3.A client with diabetes is awake, can swallow safely, and has a glucose level of 58 mg/dL. Which intervention is most appropriate under the facility's hypoglycemia protocol?

   • A.A. Give about 15 g of rapid-acting carbohydrate and recheck glucose in 15 minutes
   • B.B. Administer scheduled rapid-acting insulin before providing food
   • C.C. Give only a high-fat snack and recheck glucose in 2 hours
   • D.D. Keep the client NPO and wait for the next routine laboratory draw

   Rationale: A is correct for a conscious adult who can swallow safely; repeat treatment if glucose remains low and follow the protocol for subsequent food. B can worsen hypoglycemia. C delays effective carbohydrate absorption and reassessment. D leaves a clinically important low glucose untreated.

4. 4.Ten minutes after a blood transfusion begins, a client develops chills, back pain, and dyspnea. Which action should the nurse take first?

   • A.A. Slow the transfusion and continue observing
   • B.B. Obtain a urine specimen before changing the infusion
   • C.C. Give an antipyretic and complete the unit
   • D.D. Stop the transfusion

   Answer and rationale are in the full material.

5. 5.Which task is most appropriate for the RN to delegate to a trained unlicensed assistive person?

   • A.A. Evaluate whether a newly administered diuretic improved heart failure
   • B.B. Measure and record urine output for a stable client, with instructions to report specified changes
   • C.C. Perform the initial assessment of a client admitted with chest pain
   • D.D. Teach a client how to adjust insulin doses at home

   Answer and rationale are in the full material.