50 Free NCLEX Practice Questions with Rationales (RN & PN)

Q1. A nurse is caring for four patients. Which patient should be assessed FIRST?

• A) A 45-year-old post-op day 2 after cholecystectomy reporting pain 4/10
• B) A 67-year-old with COPD whose O2 sat dropped from 94% to 88% in the last hour
• C) A 52-year-old with hypertension whose BP is 148/90 mmHg
• D) A 38-year-old requesting their scheduled 8 AM oral medications

Answer: B

Rationale: A drop in O2 sat is an acute respiratory change requiring immediate assessment. COPD patients already have a narrow margin; further decline could indicate hypoxic respiratory failure. Pain 4/10, stable hypertension, and oral meds are lower acuity.

Q2. The nurse is preparing to administer digoxin 0.25 mg PO to a patient. Before administering, which action is the priority?

• A) Assess the patient's blood pressure
• B) Check the patient's serum potassium level
• C) Assess the patient's apical pulse for 1 full minute
• D) Review the patient's most recent digoxin level

Answer: C

Rationale: The priority action before giving digoxin is to assess the apical pulse for one full minute. Hold if HR < 60. While K+ and digoxin levels are important, the immediate safety check before any given dose is the pulse. (NCLEX frequently tests this — don't confuse the order of priority.)

Q3. A patient on heparin infusion has an aPTT of 120 seconds (normal 25–35 sec, therapeutic 60–100 sec). Which action should the nurse take FIRST?

• A) Increase the heparin infusion rate
• B) Notify the provider immediately
• C) Stop the heparin infusion and notify the provider
• D) Draw a repeat aPTT in 4 hours

Answer: C

Rationale: An aPTT of 120 seconds is supratherapeutic (>2.5× normal), placing the patient at high risk for bleeding. The priority is to stop the infusion and notify the provider so the rate can be adjusted. Do not wait and recheck — act now.

Q4. A nurse is caring for a patient in restraints. Which action requires immediate intervention?

• A) The nurse checks on the patient every 2 hours
• B) The restraints are tied to the side rails of the bed
• C) The nurse offers fluids and toileting during assessments
• D) The restraint knots can be released quickly

Answer: B

Rationale: Restraints must NEVER be tied to the side rails — if the rail is lowered, the restraint tightens and can injure the patient. Restraints must be tied to a non-moveable part of the bed frame using a quick-release knot. All other options reflect correct practice.

Q5. A patient returns from surgery and has a respiratory rate of 8 breaths/min and is difficult to arouse. The nurse's PRIORITY action is:

• A) Notify the surgeon
• B) Reposition the patient to promote airway patency
• C) Administer naloxone (Narcan) per PRN order
• D) Increase the IV fluid rate

Answer: C

Rationale: RR of 8 and decreased LOC after surgery indicates opioid-induced respiratory depression. Naloxone is the antidote and is the priority intervention. Repositioning is appropriate but does not reverse opioid toxicity. Notify the surgeon after giving naloxone.

Q6. Which patient is at HIGHEST risk for a fall?

• A) A 72-year-old who is alert and oriented, ambulatory with a cane
• B) A 55-year-old post-op day 1 receiving IV opioids, with a history of falls
• C) An 80-year-old with mild confusion who has a bed alarm
• D) A 68-year-old with a Foley catheter

Answer: B

Rationale: The combination of opioid sedation, post-operative status, and a history of falls creates the highest fall risk per the Morse Fall Scale. History of falls is the single strongest predictor of future falls. A bed alarm mitigates (but doesn't eliminate) risk for option C.

Q7. The nurse is caring for a patient with increased intracranial pressure (ICP). Which nursing action would be CONTRAINDICATED?

• A) Elevate the HOB to 30–45 degrees
• B) Maintain the head and neck in a neutral position
• C) Administer stool softeners to prevent straining
• D) Encourage coughing and deep breathing every 2 hours

Answer: D

Rationale: Coughing, straining, and Valsalva maneuver all increase intracranial pressure. Incentive spirometry is appropriate, but forceful coughing is contraindicated. The other options (HOB elevation, neutral positioning, stool softeners) are all correct ICP-lowering interventions.

Q8. A nurse receives shift report. Which patient should be seen FIRST?

• A) A patient with chronic heart failure whose weight is 2 lbs more than yesterday
• B) A patient with a new-onset temperature of 38.9°C (102°F) 24 hours post-op
• C) A patient 6 hours post-op with urine output of 20 mL over the past 2 hours
• D) A patient with a potassium of 3.4 mEq/L who is on a cardiac monitor

Answer: C

Rationale: Urine output of 20 mL over 2 hours = 10 mL/hr, which is oliguria (normal minimum is 30 mL/hr or 0.5 mL/kg/hr). This suggests acute kidney injury or hypovolemia and requires immediate assessment. The other options are concerning but not immediately life-threatening.

Q9. A nurse is preparing to give a patient their 9 AM medications when the patient states, "I don't want to take that blue pill." The nurse's BEST response is:

• A) "Your provider ordered this medication, so you need to take it."
• B) "Can you tell me more about why you don't want the blue pill?"
• C) "If you don't take it, I'll have to notify your doctor."
• D) "It's very important for your health, so you should take it."

Answer: B

Rationale: Patients have the right to refuse medication. The priority is therapeutic communication — assess the reason for refusal before any other action. The patient may have a history of adverse reactions, allergy, or simply not recognize the pill. After assessing, notify the provider if the patient refuses a critical medication.

Q10. A patient with a chest tube is being transported. Which action by the nurse requires immediate correction?

• A) The nurse keeps the drainage system upright
• B) The nurse clamps the chest tube during transport
• C) The nurse keeps the drainage chamber below chest level
• D) The nurse ensures all connections are secure

Answer: B

Rationale: Clamping a chest tube during transport is dangerous — if air or fluid accumulates, it can cause a tension pneumothorax. Chest tubes should ONLY be clamped by a physician order (e.g., to assess for air leak readiness for removal). All other options are correct transport practices.

Q11. A patient is prescribed metformin 500 mg BID for type 2 diabetes. Which finding should cause the nurse to hold the medication and notify the provider?

• A) Fasting blood glucose of 118 mg/dL
• B) Serum creatinine of 2.1 mg/dL
• C) HbA1c of 7.2%
• D) BMI of 32

Answer: B

Rationale: Metformin is contraindicated in renal impairment (creatinine >1.5 mg/dL in men, >1.4 in women) due to risk of lactic acidosis. Hold metformin and notify the provider.

Q12. The nurse is preparing to administer warfarin. Which lab value is MOST important to review before administration?

• A) aPTT
• B) Platelet count
• C) INR
• D) Hemoglobin

Answer: C

Rationale: Warfarin's anticoagulant effect is monitored by INR. Therapeutic range is 2–3 for most indications (2.5–3.5 for mechanical heart valves). aPTT monitors heparin, not warfarin.

Q13. A patient is receiving IV vancomycin. The nurse notices the patient's face, neck, and upper chest are bright red and flushed. Which action should the nurse take FIRST?

• A) Stop the infusion immediately and call a code
• B) Slow the infusion rate and notify the provider
• C) Administer epinephrine per standing order
• D) Obtain vital signs and document the finding

Answer: B

Rationale: This describes "Red Man Syndrome," a common infusion-related reaction (not a true allergy) to vancomycin caused by too-rapid infusion. The intervention is to slow (not stop) the infusion and notify the provider. Epinephrine is for anaphylaxis, which presents differently (hypotension, bronchospasm).

Q14. Which patient statement indicates the need for further teaching about furosemide (Lasix)?

• A) "I should weigh myself every morning before eating."
• B) "I can take my other medications with grapefruit juice."
• C) "I should eat bananas and oranges while taking this medication."
• D) "I will call my doctor if I notice muscle cramps or weakness."

Answer: B

Rationale: Grapefruit juice interacts with many medications (especially calcium channel blockers, statins, and some immunosuppressants). Option B indicates poor general medication safety understanding that needs clarification. The other statements demonstrate correct understanding of furosemide.

Q15. A patient is prescribed lithium carbonate 300 mg TID. Which symptom requires immediate intervention?

• A) Mild hand tremor at the start of therapy
• B) Polyuria and polydipsia
• C) Coarse hand tremor, ataxia, and confusion
• D) Mild nausea after doses

Answer: C

Rationale: Coarse tremor, ataxia, and confusion are signs of lithium toxicity (serum level > 1.5 mEq/L). Therapeutic range is 0.6–1.2 mEq/L. Early side effects (mild tremor, polyuria, nausea) are common and expected; toxicity requires immediate intervention.

Q16. The nurse is teaching a patient prescribed atorvastatin (Lipitor). Which instruction is MOST important?

• A) "Take this medication in the morning with food."
• B) "Report any unexplained muscle pain or weakness immediately."
• C) "Avoid taking this medication if you miss a dose."
• D) "You may take this with grapefruit juice to improve absorption."

Answer: B

Rationale: The most dangerous side effect of statins is rhabdomyolysis — muscle breakdown that can cause renal failure. Patients must be taught to report unexplained muscle pain, tenderness, or weakness immediately. Grapefruit juice INCREASES statin levels (increases toxicity risk) — do NOT advise this.

Q17. A nurse is administering insulin glargine (Lantus). Which statement is correct?

• A) It can be mixed with regular insulin to save time
• B) It should be administered before meals
• C) It is a basal insulin given once daily with no peak
• D) It should be shaken vigorously before administration

Answer: C

Rationale: Glargine is a long-acting basal insulin — it has no peak and provides steady 24-hour coverage. It should NEVER be mixed with other insulins (it precipitates). It is not a mealtime insulin. Insulin should be gently rolled, not shaken.

Q18. A patient with a severe penicillin allergy is prescribed cephalexin. Which action should the nurse take?

• A) Administer the medication — cephalosporins are safe in all penicillin allergy patients
• B) Hold the medication and clarify the order with the prescriber
• C) Administer half the dose to test for cross-reactivity
• D) Substitute amoxicillin, which has fewer cross-reactions

Answer: B

Rationale: There is a cross-reactivity risk (~1–10%) between penicillins and cephalosporins, especially in patients with a history of severe penicillin reactions (anaphylaxis). The nurse should hold the medication and clarify with the prescriber before administering. Never administer a half-dose "test dose" without a specific protocol.

Q19. The nurse is preparing to administer potassium chloride 40 mEq IV. The patient's current K+ is 3.2 mEq/L. Which is MOST important?

• A) Administer the potassium via IV push over 2 minutes
• B) Ensure the potassium is diluted and administered via infusion pump
• C) Confirm the IV site is patent before administration
• D) Obtain a repeat potassium level before proceeding

Answer: B

Rationale: IV potassium must NEVER be given via IV push — rapid administration can cause fatal cardiac arrhythmias. It must be diluted (typically ≤10 mEq/100 mL) and infused via a pump at ≤10 mEq/hr peripherally (up to 20 mEq/hr centrally). This is a high-alert medication.

Q20. A patient is taking MAO inhibitors. Which food should the nurse instruct the patient to AVOID?

• A) Fresh chicken breast
• B) Aged cheddar cheese
• C) Brown rice
• D) Green leafy vegetables

Answer: B

Rationale: MAOIs combined with tyramine-rich foods (aged cheeses, cured meats, red wine, fermented foods) can cause hypertensive crisis. Fresh, unfermented foods are safe. Aged cheddar is high in tyramine.

Q21. A patient with DKA has a blood glucose of 480 mg/dL and K+ of 2.8 mEq/L. The provider orders insulin. Which action is the nurse's PRIORITY before starting insulin?

• A) Obtain IV access
• B) Replace potassium IV
• C) Start the insulin infusion immediately
• D) Administer a 0.9% NaCl bolus first

Answer: B

Rationale: Insulin drives potassium into cells. If K+ is already low (2.8 mEq/L), insulin will cause severe hypokalemia and potentially fatal dysrhythmias. Replace potassium before starting insulin in any patient with K+ < 3.5 mEq/L.

Q22. A patient with SIADH has a serum sodium of 118 mEq/L. Which order should the nurse question?

• A) Fluid restriction to 1000 mL/day
• B) 3% hypertonic saline IV at 20 mL/hour
• C) D5W at 125 mL/hour
• D) Sodium level check in 6 hours

Answer: C

Rationale: D5W is hypotonic — it would further dilute the already low sodium and worsen hyponatremia. Treatment of SIADH involves fluid restriction and potentially hypertonic saline (3% NaCl) — not free water or hypotonic fluids.

Q23. A patient's ABG shows: pH 7.28, PaCO2 52, HCO3 24. How should the nurse interpret this result?

• A) Metabolic acidosis with compensation
• B) Respiratory acidosis, uncompensated
• C) Respiratory alkalosis with compensation
• D) Metabolic alkalosis, uncompensated

Answer: B

Rationale: pH < 7.35 = acidosis. PaCO2 > 45 = respiratory cause (CO2 is retained). HCO3 is normal (22–26), meaning there is no metabolic compensation yet = uncompensated respiratory acidosis. Using ROME: Respiratory Opposite — CO2 up while pH down = acidosis.

Q24. A patient is receiving 0.9% NaCl at 150 mL/hr post-surgery. The nurse notes crackles bilaterally and O2 sat drops to 91%. Which action is FIRST?

• A) Increase the O2 flow rate
• B) Slow the IV infusion rate
• C) Place the patient in high Fowler's position
• D) Notify the provider

Answer: C

Rationale: The patient shows signs of fluid overload (crackles, dropped O2 sat). The priority nursing action is positioning — high Fowler's improves respiratory mechanics immediately. Then slow the IV, increase O2, and notify the provider. Position change is the fastest non-pharmacological intervention the nurse can independently initiate.

Q25. A patient with a K+ of 6.2 mEq/L is on a cardiac monitor. Which ECG change should the nurse anticipate?

• A) ST elevation
• B) Peaked T waves
• C) Prolonged PR interval
• D) U waves

Answer: B

Rationale: Hyperkalemia classically presents with tall, peaked (tented) T waves on ECG. As K+ rises further: widened QRS → sine wave pattern → VF. U waves are associated with hypokalemia.

Q26. A nurse is caring for a patient with a suspected pulmonary embolism. Which symptom is the MOST classic presentation?

• A) Gradual onset of bilateral leg swelling
• B) Sudden onset pleuritic chest pain and dyspnea
• C) Fever with productive cough
• D) Slow onset hemoptysis over several days

Answer: B

Rationale: Classic PE presentation is sudden onset pleuritic chest pain (worsens with breathing), dyspnea, tachycardia, and anxiety. Hemoptysis is possible but late. DVT symptoms (unilateral leg swelling) may precede PE but are not the PE presentation itself.

Q27. The nurse is caring for a post-op patient who develops sudden onset of confusion, fever of 39.8°C, tachycardia (HR 118), and BP 88/50 mmHg 18 hours after surgery. Which is the PRIORITY action?

• A) Draw blood cultures
• B) Administer prescribed IV antibiotics
• C) Apply oxygen and prepare for fluid resuscitation
• D) Notify the provider

Answer: C

Rationale: This patient has septic shock (infection + hypotension + tachycardia). ABC priority: airway and circulation first — oxygen and IV fluid resuscitation. Notify the provider and draw cultures, but the immediate nursing action is to support perfusion. In NCLEX: treat the life-threatening problem first, then notify.

Q28. A patient with chronic kidney disease asks why they cannot have bananas. The nurse's BEST explanation is:

• A) "Bananas are high in phosphorus, which is hard for your kidneys to filter."
• B) "Bananas are high in potassium, and your kidneys cannot excrete it normally."
• C) "Bananas are high in sodium, which increases blood pressure."
• D) "Bananas increase uric acid, which causes kidney stones."

Answer: B

Rationale: In CKD, the kidneys lose the ability to excrete potassium. Bananas (and other high-K+ foods: oranges, potatoes, tomatoes) must be restricted to prevent hyperkalemia. Phosphorus restriction is also important in CKD, but potassium is the reason to restrict bananas specifically.

Q29. A patient's wound shows a red, moist wound bed with granulation tissue. The nurse interprets this as:

• A) A sign of wound infection requiring culturing
• B) A healthy, healing wound in the proliferative phase
• C) A stage III pressure injury
• D) Evidence of necrotic tissue requiring debridement

Answer: B

Rationale: A red, moist wound bed with granulation tissue is the classic appearance of a healthy healing wound in the proliferative (granulation) phase. Yellow wound beds indicate slough; black indicates eschar/necrosis; red indicates healthy granulation. This wound does not require debridement.

Q30. A patient with heart failure has daily weights recorded: Monday 162 lbs, Tuesday 164.5 lbs, Wednesday 167 lbs. Which action is MOST appropriate?

• A) Document the finding and continue monitoring
• B) Increase the patient's dietary sodium to offset fluid loss
• C) Notify the provider — the patient has gained 5 lbs in 48 hours
• D) Assess for signs of dehydration

Answer: C

Rationale: In heart failure, a weight gain of 2–3 lbs in 24 hours or 5 lbs in one week indicates fluid retention and decompensation. This patient gained 5 lbs in 2 days — notify the provider. Sodium restriction (not increase) is the intervention for fluid management in HF.

Q31. A 150 lb (68 kg) adult sustains burns to the entire front of both legs and the front of the trunk. Using the Rule of Nines, what percentage of TBSA is burned, and which intervention is the HIGHEST priority in the first 24 hours?

• A) 27% TBSA — priority is wound debridement
• B) 36% TBSA — priority is IV fluid resuscitation (Parkland formula)
• C) 27% TBSA — priority is pain management with IV opioids
• D) 36% TBSA — priority is prophylactic antibiotics

Answer: B

Rationale: Rule of Nines — each anterior leg = 9%, both anterior legs = 18%; anterior trunk = 18%; total = 36% TBSA. The highest priority in the first 24 hours of a major burn is aggressive IV fluid resuscitation using the Parkland formula (4 mL × weight in kg × %TBSA burned). Fluid shifts cause hypovolemic shock if not addressed. Pain management is important but secondary to airway and circulation.

Q32. A patient arrives in the ED with sudden onset facial drooping, arm weakness, and slurred speech that began 45 minutes ago. The provider wants to give tPA. Which action is the nurse's PRIORITY before tPA is administered?

• A) Obtain an INR and aPTT
• B) Ensure a non-contrast CT scan of the head has been completed
• C) Insert two large-bore IVs and start IV fluids
• D) Notify the neurology team for stroke consultation

Answer: B

Rationale: tPA (thrombolytics) is only given for ischemic stroke — NOT hemorrhagic stroke. A non-contrast CT scan of the head must be completed FIRST to rule out hemorrhage. Giving tPA to a hemorrhagic stroke patient is fatal. The CT scan is the priority gating action before any thrombolytic therapy.

Q33. A patient with sickle cell disease presents in vaso-occlusive crisis with severe bone pain (9/10), HR 110, and temperature 38.2°C. Which two interventions are the HIGHEST priority?

• A) Oxygen supplementation and antipyretics
• B) IV fluid hydration and IV opioid analgesia
• C) Packed RBC transfusion and antibiotic therapy
• D) Splenectomy preparation and hydroxyurea administration

Answer: B

Rationale: During a sickle cell vaso-occlusive crisis, the two hallmark priority interventions are: (1) IV fluid hydration to reduce blood viscosity and restore flow through occluded vessels, and (2) IV opioid analgesia for severe pain management. Oxygen is given if SpO2 is low, but hydration and pain control are the primary treatment goals for every crisis. Transfusions are reserved for specific indications (aplastic crisis, acute chest syndrome, stroke).

Q34. A patient is 1 day post-op from a right total hip replacement. Which position is CONTRAINDICATED and increases the risk of prosthetic dislocation?

• A) Lying on the unaffected (left) side with a pillow between the legs
• B) Sitting in a high chair with hips flexed to 90 degrees
• C) Crossing the right leg over the left knee
• D) Walking to the bathroom with a walker

Answer: C

Rationale: After total hip replacement, the patient must avoid adduction (bringing the leg past midline) and internal rotation — both of which can dislocate the prosthesis. Crossing the legs is a classic example of adduction + internal rotation. An abduction pillow is often used to keep the legs apart. The other positions are safe and appropriate.

Q35. A patient delivers vaginally and 30 minutes postpartum the nurse notes the uterus is boggy, displaced to the right, and there is heavy vaginal bleeding (soaking one pad in 15 minutes). Which is the nurse's FIRST action?

• A) Increase the IV oxytocin infusion rate
• B) Perform fundal massage and have the patient void
• C) Notify the provider and prepare for a blood transfusion
• D) Insert a urinary catheter

Answer: B

Rationale: A boggy, laterally displaced uterus with heavy bleeding = uterine atony (most common cause of postpartum hemorrhage) + full bladder (displacing the uterus). The FIRST nursing action is fundal massage to stimulate uterine contraction AND have the patient void (or catheterize) to remove the bladder that is preventing uterine contraction. A distended bladder is a key NCLEX-tested cause of uterine atony.

Q36. A patient with schizophrenia tells the nurse, "The television is sending me secret messages about my mission." Which response by the nurse is BEST?

• A) "You know that's not really happening, right?"
• B) "That must be very frightening for you. Tell me more about how you're feeling."
• C) "Don't worry, we won't let the TV hurt you."
• D) "That's a hallucination — it isn't real."

Answer: B

Rationale: Therapeutic communication with delusions: do not reinforce, do not argue/confront, acknowledge the patient's feelings and emotional experience. Option B focuses on the patient's feeling state without validating the delusion as real.

Q37. A patient taking clozapine reports a sore throat and fever. Which action is the PRIORITY?

• A) Administer acetaminophen for the fever
• B) Obtain a CBC with differential immediately
• C) Notify the provider to discontinue the medication
• D) Document the finding and monitor for 24 hours

Answer: B

Rationale: Clozapine carries a black box warning for agranulocytosis (dangerously low neutrophils). Sore throat + fever in a patient on clozapine = possible agranulocytosis until proven otherwise. Obtain a CBC immediately. This is why weekly CBC monitoring is mandatory for clozapine patients.

Q38. Which intervention has the HIGHEST priority for a newly admitted patient who is suicidal?

• A) Establish a therapeutic nurse-patient relationship
• B) Obtain a suicide risk assessment and ensure a safe environment
• C) Begin group therapy within 24 hours
• D) Administer prescribed antidepressants

Answer: B

Rationale: The priority for a suicidal patient is safety. Remove means of harm, assess risk level (ideation, plan, means, intent, timeline), and initiate 1:1 observation per policy. A therapeutic relationship supports treatment but safety comes first.

Q39. A nurse is caring for a patient with anorexia nervosa. Which finding requires the MOST immediate intervention?

• A) Body weight 15% below ideal body weight
• B) Fine downy hair on the trunk (lanugo)
• C) Potassium of 2.6 mEq/L with QT prolongation on telemetry
• D) Patient stating "I still feel fat"

Answer: C

Rationale: Hypokalemia with QT prolongation is a life-threatening cardiac emergency — risk of torsades de pointes and fatal dysrhythmia. While all findings in anorexia are concerning, the cardiac consequence of electrolyte imbalance is the immediate physiologic threat.

Q40. A patient in alcohol withdrawal shows tremors, diaphoresis, and HR of 118. Which medication should the nurse anticipate administering?

• A) Haloperidol (Haldol)
• B) Lorazepam (Ativan)
• C) Naloxone (Narcan)
• D) Methadone

Answer: B

Rationale: Benzodiazepines (lorazepam, diazepam, chlordiazepoxide) are the treatment of choice for alcohol withdrawal — they prevent seizures and delirium tremens (DTs). Haloperidol is for psychosis; naloxone reverses opioids; methadone is for opioid maintenance.

Q41. A 4-year-old presents with sudden onset high fever, drooling, muffled voice, tripod positioning, and refusal to swallow. Which action by the nurse requires IMMEDIATE correction?

• A) Keeping the child calm and upright in a position of comfort
• B) Preparing for emergency intubation and notifying the provider
• C) Using a tongue depressor to visualize the posterior oropharynx
• D) Having IV access established by the most experienced person available

Answer: C

Rationale: These are classic signs of epiglottitis (not croup). In epiglottitis, NEVER examine the throat or use a tongue depressor — stimulating the airway can cause complete airway obstruction and death. Keep the child calm, allow position of comfort, prepare for emergency intubation, and have airway equipment at bedside. This is the #1 NCLEX pearl for epiglottitis.

Q42. The nurse monitoring a patient in active labor notes late decelerations on the fetal heart monitor for 20 minutes. Which action is the FIRST priority?

• A) Prepare the patient for an emergency cesarean section
• B) Reposition the patient to the left lateral position and apply O2 via face mask
• C) Increase the oxytocin infusion rate
• D) Document the finding and continue monitoring every 15 minutes

Answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency — the fetus is not receiving adequate oxygen. The immediate nursing interventions are: (1) reposition to left lateral to relieve aortocaval compression, (2) apply O2 via face mask at 8–10 L/min, (3) stop oxytocin if infusing, and (4) notify the provider. The repositioning + O2 combination is the first nursing action. C-section is a provider decision made after initial interventions fail.

Q43. An 82-year-old patient with no prior history of confusion becomes acutely confused on post-op day 1. Which assessment finding should the nurse investigate FIRST?

• A) Review the patient's baseline MMSE score
• B) Check current oxygen saturation and administer oxygen if SpO2 < 94%
• C) Assess for signs of depression or grief
• D) Reorient the patient to time and place

Answer: B

Rationale: New-onset confusion in an older adult post-operatively is delirium until proven otherwise. The most common reversible causes (per NCLEX) are hypoxia, pain, urinary retention, and medication effects — check oxygen saturation FIRST. Hypoxia is immediately life-threatening and easily treated. Reorientation is appropriate but addresses the symptom, not the cause.

Q44. A patient who is deaf is scheduled for surgery. The surgeon explains the procedure to the patient using written notes. The patient signs the consent form. Which action should the nurse take?

• A) Witness the consent and proceed with pre-op preparation
• B) Request that a qualified sign language interpreter be present for the informed consent discussion
• C) Have a family member who knows sign language interpret for the surgeon
• D) Document that written communication was used and consent was obtained

Answer: B

Rationale: Informed consent requires that the patient fully understand the procedure, risks, benefits, and alternatives. For a deaf patient who uses sign language as their primary communication, a qualified professional sign language interpreter must be provided — written notes alone are insufficient for complex medical consent. Family members should not serve as medical interpreters (role conflict, confidentiality, accuracy concerns). This is a legal and ethical standard.

Q45. A patient who is a Jehovah's Witness has a hemoglobin of 6.8 g/dL after surgery and refuses a blood transfusion. The surgeon insists the transfusion is necessary. What is the nurse's MOST appropriate action?

• A) Administer the transfusion — the surgeon has the authority to override the patient's refusal
• B) Respect the patient's refusal, document the decision, and notify the provider
• C) Ask the patient's family to convince the patient to accept the transfusion
• D) Contact hospital administration and wait for their decision

Answer: B

Rationale: A competent adult has the right to refuse any medical treatment, including life-saving transfusions, regardless of religious beliefs. The nurse must respect patient autonomy, document the refusal thoroughly (including that risks were explained), notify the provider, and explore alternative treatments (IV iron, erythropoietin, autologous transfusion). Administering a transfusion against a competent patient's wishes constitutes battery.

Q46. Recognize Cues

Which findings require IMMEDIATE follow-up? (Select all that apply)

• A) SpO2 of 88%
• B) HR 112 irregular
• C) Weight gain of 10 lbs in 2 weeks
• D) BP 162/94
• E) Bilateral crackles
• F) Temperature 37.0°C

Answer: A, B, C, E

Rationale: SpO2 of 88% is below the acceptable threshold (≥94%) and represents hypoxemia requiring immediate oxygen. HR 112 irregular with known A-Fib and fluid overload needs monitoring. Weight gain of 10 lbs in 2 weeks = significant fluid retention. Bilateral crackles = pulmonary edema. BP 162/94 is elevated but not an immediate emergency in this context. Temperature 37.0°C is normal.

Q47. Analyze Cues

This clinical picture is MOST consistent with:

• A) Pulmonary embolism
• B) Acute decompensated heart failure
• C) Community-acquired pneumonia
• D) Diabetic ketoacidosis

Answer: B

Rationale: Weight gain + orthopnea + S3 gallop + bilateral crackles + SpO2 88% + irregular rhythm in a patient with known HTN and A-Fib = classic decompensated heart failure. PE would present with sudden onset without weight gain. Pneumonia would have fever and productive cough. DKA would have glucose abnormalities and fruity breath.

Q48. Prioritize Hypotheses

The nurse's HIGHEST priority concern is:

• A) Hyperglycemia from missed metformin
• B) Risk for acute respiratory failure
• C) Supratherapeutic warfarin INR
• D) Uncontrolled hypertension

Answer: B

Rationale: SpO2 of 88% represents impending respiratory failure — this is the immediate threat to life. The other concerns are secondary. Airway and breathing always come before circulation and other diagnoses in NCLEX priority frameworks.

Q49. Generate Solutions

Which provider orders should the nurse anticipate? (Select all that apply)

• A) O2 via nasal cannula, titrate to SpO2 ≥ 94%
• B) Furosemide IV 80 mg now
• C) Start D5W at 125 mL/hour
• D) Daily weights
• E) Cardiac monitor
• F) Digoxin 0.125 mg IV push now

Answer: A, B, D, E

Rationale: Correct orders: O2 to correct hypoxemia; IV furosemide (higher dose than oral, and IV works faster for acute decompensation); daily weights to monitor fluid status; cardiac monitor for A-Fib and rate. Eliminate: D5W would worsen fluid overload; digoxin IV push is dangerous and not indicated in acute management without prior levels/K+ assessment.

Q50. Evaluate Outcomes

After 2 hours, the patient's SpO2 is 95%, RR 18, urine output 800 mL. Which assessment finding BEST indicates the interventions are effective?

• A) BP remains 158/92
• B) HR is now 88 irregular
• C) Patient reports decreased dyspnea and can speak in full sentences
• D) Patient's weight is 197 lbs (down 1 lb)

Answer: C

Rationale: Decreased dyspnea with improved functional status is the best clinical indicator of effectiveness. SpO2 and RR have improved, and the patient's subjective experience aligns with objective improvement. A 1 lb weight loss after 2 hours of diuresis is minimal and not the best outcome indicator. The patient's ability to speak in full sentences without dyspnea is the most meaningful outcome.